Laserfiche WebLink
BURNE T COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 �5 <br /> 715-349-2138 <br /> NON-PI UMBING SANITARY PERMIT APPLICATION <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or PrintLetI L 'L A-"o (oQ qjw v <br /> Z <br /> Property Owner Name ,p Property Legal Description <br /> �00LA 4"t-LLE �� TYF, UL 1 I�I�rYP ,S :!j IN,R/sW <br /> L 1/4 1/4,S a T Y <br /> Property Owner's Mailing Address Lot Number Block Number �. <br /> bats I*+ ,)- I s Ss <br /> City,State Zip Code Phone Numberc� Subdivision Name or CSM Number <br /> W1 Y)AA) SS'-E1� W ��tz 81.1-o[f� �iri*11�n 9 TVOU4 4IrV VW (� S <br /> Ty�of Building: (Check one) State-Owned ❑City NLeateest Bnad . <br /> LY I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village ItI°C Gb <br /> ❑ Public I�fown of�jN/ly�j Fire Numb o J� <br /> Public Building/Land Use: [Exp am the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type rmit: Typ�.of Non-Plumbing Device/System/Toilet/Unit: <br /> B'Non-Plumbing(Privy,Toilet,Restroom etc.) nvy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State 4 ❑ Other <br /> Responsibility Statement: (Che k one or both❑ as appropriate.) <br /> ❑ 1,0<1undersigned,assume respon ibility for the POWTS activity for which this permit is issued. <br /> 11K,the undersigned,assume res on ibility for the installation of the non- lumbing sanitary system for which this permit is issued. �1 <br /> Plu ber's/Owner's Name(print) lumber' Owner's Signatur . MP/MPRS W No.: Business Phone Number: <br /> ohn lvPstr� Sfa r7 014aLq- U <br /> _ 1 <br /> Plumber's Addr s(Street,City,State,Zil,Co <br /> Office Use Only: Q <br /> TO—Disapproved Permit Fee: CST No. Dat Issue gM I <br /> pproved ❑Owner Given I itial Adverse 42�8 S Qj�70Z . <br /> Determination O <br /> Comments: <br /> Al <br /> �G y <br /> Conditions of Approval/Reaso s for Disapproval: 2 <br /> oM <br /> fo <br />