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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 RECONNECTION ($50) O <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> Property Owner Name WYe9er cam Pgrbovi Property Legal Description <br /> .3d "4 Ut °4 <br /> I «av rve n- W fi va va,S 2/ ,T N,R L5W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 642 33s-64 Ave 1 <br /> City,State Zip Code Phone Number SobdiuicicoNaxwer CSM Number <br /> �rw6rlG W1 54-837 ) OL /Z Age. 203 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Roa <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village 4• B <br /> Nr Public WTown of 5Kaxs0n 1 062 01 <br /> Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreationtentertainment event etc.)] 07-012_2_q0_jJ(•z(_/ <br /> eam/ground ,27 Stferf 5kwr d .&&C;t 09 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> []'),on-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ® POWTS Reconnection C ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 3/9L gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 4220+9221 ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ❑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- lumbin sanitary system for which this permit is issued. <br /> PI mber's/Owner's Name(print) P Owne ' Signa[u MP/MPRSW No.: Business Phone Number <br /> : <br /> eNA�� E- �n �a ���0 pis-�yG{3So <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 167/3 5 abic k*( 35 Dan6w)( W1 540,5o -90 <br /> ,36 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin nt Signatu <br /> Approved ❑Owner Given Initial Adverse 4///4 <br /> i 4 <br /> Determination R a JJ�7 ZVIZ <br /> Comments: <br /> Conn.6£Ww o� �Nts CehrQgf Sf�s Zro E„rsE� &)T.5, "h,,,4 fr aAtw4(yj1W( & <br /> aOceMf"�Ao. cua” wz{vr '".> vndeW Wes 383 CvKelea <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />