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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> I <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) O <br /> Application Information (Type or Prior) ATTACH A PLOT PLAN WITH THIS APPLICATION V <br /> Prolmrry OwtnerlNsmo Property f�Leggal Description 1 <br /> CL /N 1/4 #E 1/4.S .T 10 N,R W (74✓.Ll.� <br /> Property Owner's Mailing Address Im Number Black Humber <br /> CW: / r :Phone Number ' Siflsakeionaamear CSM1INernew, - -- —_l <br /> H/I Ji o'.YG J /ry/N rSo ( (rl7 ) 14/ 6' <br /> Tvpe of Building: (Check one)❑ State-Owned ❑City Nearest wad <br /> ❑ 1o 217amily Dwelling-No.of Bedrooms: — ❑Village 04)r <br /> ❑ Public Town of F' e m r <br /> Public Building/Land Than [Bxp]atn the use/pumoec fur this permit,ore- Pmcel'I's,Number(,) <br /> cangtground,feaival,rc/ercmion/mtenainmcnt evrnt em.)] <br /> 07- 020- 240-!(o -0q -1- 0 - � <br /> Type of Permit: 'type of Non-Plumbing Device/System/Toilet/Unit: <br /> _Non-Plu clang(Privy,Toilet,Restroom etc.) Privy-Pit Toilet ❑ Composting Toilet System <br /> ❑ POWfS Reconnectionn,,/ ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ElPOWT$ Repair County NSri l'r'� gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision Stale# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> I,the undersigned,assume responsibility for the PORTS activity for which this permit is mood. <br /> I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumix,sLJOtnxnersfName(Pont) Plumb 's/Owner' Signmurc: I MP/MPRSWNo.: nosiness Phone Number: <br /> rLd ly ✓-, 7 DL Z <br /> Norther,Address(Street.City.Smte,/.ip C'ode): <br /> Office Use Cody: <br /> ❑Disapproved Permit Fee. CST No. Date Issued IssuinK Agent Signawrc <br /> Avnnwed ❑owner urea banal ndtw,aa /S7 /ab/9S0 /� �� <br /> Dercrmination //q.�rC4�v <br /> Comments: s� <br /> No fnrA~NL U49'T /LV 7c 0N$/re' G- W/1!- A ap(f_ CG✓Jspl//)� S?/✓i7 J <br /> SYSiFN+ /a57I1�9. <br /> t 's, <br /> Conditions of Approval/Reasons for Disapproval <br /> /must M44 T PEP7'9f 1`5 8/4r,3i-7SD n;Y fnir- 7,30-4 t Sra eE?v2fTfryr. <br /> l� Add/tw,�D <br /> Reviled 64/02 <br />