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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54572 <br /> 715-349-2135 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> 0uµny pancr Pam, o�� /_ Q Properly Ugal Description <br /> No,. b w��9 r p � d IJaf ct5 v+.s /G T vZ /v4 <br /> Progeny owner's Mailing Address Ian somber nlwktsrmber <br /> ,J-00 Ce '+'e/ G l <br /> City.Slit, Zip Code Phone Number 5abdivision Name or Cost Number <br /> -5ee11< U/T 5-48o1 V Iq Q•No <br /> Type of Building: (Check one)❑ State-Owned ❑City N°nrent 'aI r <br /> f.1I or 2 Fnmily Dwelling-No.of Bedroomso_ ❑Villag, rY <br /> ❑ Public 2v l'uwn of �45/e PIaNu�g: <br /> Public Building/Iand Use: tEsphin the melpu:pose for lhi,permit,fi.e.. Pamd Tux S"It,n) <br /> camp-rouna,f.u-l.re<r-mioNermminmemstentem.11 eay 3a�D`�-aw <br /> G .�ase T a a� oa�a3914do-'sos ala <br /> Type of Permit: Type of Non-Plumhing Device/system/(biletfunit: <br /> ❑ Con-Plumbing(Pricy,Toilet,hesitation etcJ ❑ Privy-Pit'1'oiler ❑ Composting Toilet System <br /> -%OWTS Reconnection ❑ Privy-Vault Toilet(Vault size: ❑ (mincraing Toilet Device <br /> (IPONM Repair .Countvi! OJ _gallon or _cubic yards) ❑ Ponablc Restroom Unit <br /> ❑ Rev Lcion State k=� ❑ Other <br /> Responsibility Smtetneute (Check one or both❑as appropriate.) <br /> J 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑L the underuir e ,assume res anelblla,for the insmllaVon of the non-nlumhma sanimr,severs for y.hich this recutt is issued. <br /> PlumbeVJOwner's Namc(,ra) Plum s,f,/0wner's Si_aror, `l P"MPRSNNo.: uusiness Phone Nnmben <br /> Plumbers Address IStmct,City,State.Lp Code): <br /> 77 G ��- t 3.� ��'��51r i G✓1 S ��93 <br /> Office Use Only: <br /> ❑Di>✓PWoved Permit Fee: CST Na Dae sued Iwai .kkm St <br /> � u <br /> S.,ppm,,d ❑Ouner Given Initial Ad, , C z� � f�s <br /> Demnninadmt 70 ' <br /> Comments: QK 8✓l`C/ /O//JG .!)ef/4llC —'i %/�K//f <br /> /- ,L; <br /> (7) ax e' - /Z yB .� ltd � gs� /Z Z7 ��titib Ufa <br /> Conditions of Approval/Reasons for Disapprorel: <br /> p ECOVE <br /> nn JUL 2 2 2013 <br /> LI U <br /> R,tisN dnro� <br /> BURNETTCOUNTY <br /> ZONING <br />