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UO, UU, -UUO 10.cD 04JL100 D 1 Luv11iU fnut U0 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> /1410 COUNTY ROAD K, #102 <br /> 4Q" 3S SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> POWTS RECONNECTION(S25) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner NameA - Property Legal Description <br /> ---17107,0771y, �'�(!L/L '4 % .2. 1/4 1/4 S /7.T q1 N R /SW <br /> Property Ownee'g Mailing Address `` Lot Number Block Number <br /> IZSo -S .�V?eLam- ' <br /> City,State Zip Cade Phone Number Subdivision Name or CSM Number <br /> ;p ,tin eft/ ss yl s z 05rm v.13 p1V <br /> Type of Building: (Check one)❑ State-Owned ❑City Newt Road r t 1 <br /> U- I or 2 Family Dwelling-No.of Bedrooms: A- 0 Village e Num lJ� <br /> ❑ Public .12-Town of s!✓15S Fire Nh1mbeZS <br /> Public Bnilding/Land Use: (Explain the use/putposc for this permit,(i.e., Parcel Tax Number(s) S n ` <br /> campground,festival,recrmtion/rneertainmrnt event etc.)) <br /> /��°Y 63a, �al�-of-Soa ap <br /> Tyye of Permit: Type of Non-Plumbing Device/System/Toilef/Uoit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) .0-Privy-Pit Toilet 0 Composting Toilet System <br /> ❑ POVPPS Reconnection ❑ Privy-Vault Toile((Vault size: ❑ Incinerating Toilet Device <br /> 0 POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both O as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 111,the undersigned,assume respons' or a on e n mbin sari system for which this permit is issued. <br /> PlumberslOwner's Name(paint) P err tit's Signatu MP/MPRsW No.: Business Phone Number: <br /> �vl�/f70�fr� C <br /> Plumber's Address(Stroet,City, late,Zip Code) <br /> Office Use Only: <br /> O Disapproved Permit Fee. CST No. Date Issued I 'n Agent St elute" J <br /> O Approved 0 Owner Given Initial Mveese -3-[�(� `�yr�p <br /> Determination 0" <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 617/02 <br />