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�v -..�+ vvv ,a vv �aa,V [lYN►a1�lUa��lalaVl\ <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN,WISCONSIN 54872 r/ <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> POWT <br /> POWTS REVISION <br /> Application Information—Type or Print Q , <br /> On <br /> Property Owner Name Property Legal Description po <br /> 0109vrY L, TA+e t3 GL lie 1/e,s i(OT .It'y W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6-80 1701-4 5 f Lor / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 15-5-3 5-.;t, <br /> Tam t /h/1/ ( g 5� ) L/1-s ie �/ivtsS 5✓b clivi sr ' <br /> Type of Building: (Check one)❑ State-Owned O City or t Rosd <br /> �®or 2 Family Dwelling-No.of Bedrooms:_ ss0 Village' t <br /> ❑ Public Ip Town of ire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,mcreation/cmenainmem event etc.)] t <br /> 5 r//4e- a*,t- IfeCAeA-J'r"0" 1 Oaf-90�s �1-BUD <br /> Type of Permit: pe of Non! - umbing Device/System/Toilet/Unit: <br /> Non-Plumbing Toilet.Restroom etc.) Privy IML0 Composting Toilet System <br /> ❑ POWTS Reconnection OPrivy au t Toilet(Vault size: O Incinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) O Portable Restroom Unit <br /> ❑ Revision State# O Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) . P]g�Qber's/Owneyc Sig rc: MP/MPRSW No.: Business Phone Number: <br /> ©/54j_Af L�—�\ 9S�—Yy5=F3S60 <br /> Plumber's Address(Street.City,State.Zip Code): <br /> 16 <br /> s8o /roT� s7`C. ,rm�-p/ryM /yl�, ti 3sr <br /> Office Use Only: <br /> O Disapproved Permit Fee: CST No. Date Issued Issui A ni Signal <br /> Approved 0 Owner Given initial Advcrse � f J�St qG 104 <br /> Determination <br /> Comments: 1 <br /> Prrvv Ply dePih .ZD�,_ s.t<.. 4b.3 <br /> 0 <br /> Conditions of Approval/Reasons for Disapproval: <br /> ' 1 <br />