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2011—Mar-24 02:41 PM 3M 6517333356 1/1 <br /> BURNb:TC COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN,WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($150) <br /> POWTS CONNECTION/RECONNECTION($50) <br /> Application information('Type or Print) ��C„KA PLOT PLAN WITH THIS APPLICATION <br /> Property ownerxenx Property l ogd Description <br /> Steven Weinzled SW v4 SW 1/4,s 33,T 41 N,R 16 tv 8 <br /> OL SEI/4SEI/4,s32;r41N.R16W --�-., <br /> Property Owners Mailing Address, Lot Numtwr Rlook Numbs <br /> 641 215s'Avenue 2 <br /> City,State Zip Code Phone Number Subdivision Nam or CSM Number _ <br /> Somerset,WI 54025 <br /> Type of Ruildlug: (Check one)❑ Statc-Owncd ❑City NmuastRoad <br /> ❑ 1 or 2 Fmnily Dwelling•No,ofBedmoms: ❑Village Glendenin <br /> ❑ Public. XTown of SWISS vireNumber o. <br /> 7610 <br /> Public Building/Land Use. (Hxplain the usn(purpos. lbr this permit,(Le, Parcol Tex Numbar(s) <br /> campground,feniva],reciratbnlorraatalmnent event etc.)] 07-032-2-41-16-33-3-0"00-011200 , <br /> Type of Permit: Type of Nun-Plumbing DeAce/System/Toilet/Unit: <br /> X Non-Plumbing(Privy,Toi1N,Restroom etc_) X Privy—Pit Tollet ❑ Compo9ting'1'oi1et System <br /> ❑ POWTSRecomleotion r Crxml N 0 Privy—Vanit'roilet(Vault Sim. 0 locinertrtingTcilctDcvicc <br /> ❑ POW'1'S Repair y gallons or _cubic yards) ❑ Portable Restroom Unit ; <br /> ❑ Revision State(f._ ❑ Other .. ._ <br /> Responsibility Statement: (Chock one or both❑as appropriate.) <br /> ❑1,the undersigned,assume rusponst'bility for the POWTS activity for which this permit is issued. <br /> X 1,the undersigned,assume responsibility for the installation of the ritm-plumb sanitary system for which this permiC is issued. <br /> Plumber's/Owner's Namc(print) Phaalie>'s/owner's siguaN[e MP/MP1tSW Na.: Huslnds Pfione Number: <br /> Steven Welnzierl <br /> Plumber's Address(Street,City.Stst,Zip Code): <br /> Office Use Only: <br /> J E3Disapproved Permit Pee: CST No. Dab:Issued luuL 'ism <br /> r7H Approved ra Owna Given initial Adverse l�r,� ✓� �,5 /,� i 249 111 <br /> Dalmminaliou .•V �'vw� <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised e///02 <br />