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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 Z <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION (550) C <br /> C< <br /> .ylplicrtiun ❑dormatinn(I'rpe or PrinU ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Pm'Io, )III cr Na It / ` / Prnpeny Legal Description 'L <br /> C_4ROL ✓ (TvSTIVTS• GL J J ;ITJ N.R1r <br /> Prnpeny Onncr's Mail E AJdrcss Lot Number Bluek Nu rM <br /> 3 e Z S- <br /> Ciel SmteZip Gell Pbnne Number Subdiv&inn Namcnr CSM Number <br /> N=1^' A.06 41W $3Yz7 6f2 9/�j z Z <br /> Type of Building: (Cheek one)❑ Sum-Owned oCiro7AekSru Ncaast a <br /> Y. I or 2 Family Dwelling-No.of m .3 Bedroos: ° K' A <br /> ❑ Public dirt »nl Fine <br /> 7.Public Building/Land Use: [Explain the usc,purposc for this pem,il.(I e.. PilaxNurablos) <br /> ampgrnund.les ival,rcerearonicnlertainment event ac)I <br /> 7oS-xi -olyum <br /> Tr pe of Permit Tyof Non-Plumbing Uevice/Systenerfoilet/Unit: <br /> X Non-P lamb ing( hivy,'Eviler.Restroom etc.) $ Privy-1'it Ioi lel ❑ Composing Toilet Sysem <br /> Cl PONISReconnecnon ❑ Priv Vault Trill-1 Vault siic: ❑ Incinerating']oilet Device <br /> ❑ I'OIVI S Repair County tl ����g _gallons or ( cubic yards) ❑ Portable Rtroom Unit <br /> ❑ Revision Stale q ❑ Other <br /> Respmisihilin'Statement: (Check one or both as appropriate.) <br /> ❑ I,the undenlencd,ussumc responsibility for the POWTS activity for which this permit is issued. <br /> I,the undersigned,assume osponsibilit y for the installation of the non- dumbing sanitary s stem for which this pem it is issued. <br /> I'lumbn'Y ane on in') I�l;mbds/( „ Signature NINNIPRS V No.. Busing y Phone Numtxr_ <br /> G,A�o[ynl2Cot�5�,� CM. <br /> .. Xddec.,,(St.,.city.Sure.Zip Code), <br /> ErCi"srw� soic EST use <br /> Office Ilse Only: <br /> ❑DisapprocW Pmmir Fce: CS'f Nn. hate Issued Issuing Agent Signwul'c <br /> VA,pe,ed ❑o,.ner rm.n ml6al nd,el.e vU JZb/4Sd g'8'/y _ - ei <br /> txmmunat nn <br /> Comments-. <br /> sa/G X57" F12arvt swl/� 33Y/s <br /> Conditions of Approval/Reasons for I)isapproval: <br /> Revised 6/71112 <br />