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BURNETT 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 ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> GL 1/4 1/4,S 7,T 37N,R/9"W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 131 y8 91st S-�; SE to <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 13ecke„ /YiN .. 5`309 ( ) SUnri:S� }b�'o-L­ <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> 5 1 or 2 Family Dwelling-No.of Bedrooms: of 13Village Sun r t S� <br /> ❑ Public 19T wo of UC Fire Number 6 7d d <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] c 7- 03N-�-37- /$4c?--5_ /-S- <br /> - <br /> -r— -718 - Od / Coo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> is POWTS Reconnection County _q ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ja I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> kle16 -�Ie k_tas / d�S S-� 1-7 hf X66-y/sr <br /> Plumbers Address Street,City,State,Zip Code): <br /> .27760 . 2Z_ <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Is g A ent S' ature <br /> Approved ❑Owner Given Initial Adverse /,SDS 0,0 <br /> Determination G� <br /> Comments: <br /> 5, ff pr%0�'i( Han i/ S:�t. -t%o%Zr1G w.��( A/zJZ AIjt fer, <br /> Conditions of Approval/Reasons for Disapproval: <br /> 6,,,o,1 e Pv,"P At-10'A, A-vW 4,e 6Zel 3 rj',vJt r Pv„111 i s dIVN�r <br /> im <br /> 6G/r/f rR L PL�.,.i,•'V Gedts • E C E�V <br /> nrTO47016 , ID <br /> Revised 6/7/02 <br /> BURNETT COUNTY <br /> ZONING <br />