Laserfiche WebLink
BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 �V-��k� <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICA'rION ($150), <br /> PONNTS CONNECTION/RECONNECTION (S50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> I'minvtyOmer Name Property Legal lkseription q <br /> Gi- IN IN.S ,T N,R1*9W <br /> I'rnpny x is ailing Addass n ' Lvt Number Hoek Number <br /> I 1 (k <br /> l;iry,Stmc %ip 'Me Yhnnc Numncr SuMlirision Namc or CSM NumMr <br /> W 17— 03y—/S?/-04- <br /> Type of Building: (Check one) ❑ State-Owned ❑City t Nr'rGs! oad <br /> ❑ I or 2 family Dwelling-No.of Bedrooms: ❑Village t r <br /> X Publicl�'1'oxn of Fire Number <br /> Puhlic Building/Land Use: Ilisplain me usuPurposef rthis pcmtit.(i.e.. Parcel I.,Number(,) <br /> aopgn,und.Raidal.renvatioNcmcamirr'm e'cnu cmdl 07-03 V-2 • 31•104k- T. 05"ou2C& IIp C - <br /> _ o Hoop <br /> W <br /> Trpe of Permit: Type of Non-Plumbing Device/Svsten✓1'oilet/Unit: <br /> rye-Non-Plumbing(Privy,'I oilet,Restroom etc.) kID Privy-Pit Toilet El Composting I oilet System <br /> ❑ POW'TS Reconnection �/ ❑ Privy-Vault Toilet(Vault size' ❑ Inenomting Toilet Device <br /> ❑ <br /> POW IS S Repair County tl. !— _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision Stale q ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ I,the undersigned,assume responsibility for the POW IS activity for xhich this permit is issued. <br /> the undersi ned,assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> V mM1u(sllJwme{'r�/s((Name(pIa,)( t' tuber' U,arr's Signature Mr/MrItSW No.: Business Phone Number <br /> l fsl0.t.�%V1 <br /> Plumlxre AJ res,c(Strec,City.Scare.Zip Cede): <br /> Office Use Only.. <br /> ❑}� oisamm�,al rer,nit tee: CS r No. Dam L,aed Iso- n Signarere npnrn.m ❑ownerGi en modal Ad,11, g 7't3 �/Zl <br /> I� I>rterminaeon )SD.Op <br /> Comtnen Ls: <br /> Conditions of Approval/Reasons for Disapproval: <br /> AUG 6 2013 <br /> Revised 617,02 Hn <br /> BURNETT COUNTY <br /> ZONING <br />