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Aug 20 02 12: 04p S lvestre Construction 6128610190 p. 1 <br /> 'e`lb BURNETT COUNTY GOV CENTER <br /> 171534921 D2 P.01/01 <br /> BURNS T COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> POWTS RECONNECTION <br /> POWTS REVISION � l'2102— <br /> Application Information—Type c r Print I Ltd Z A, `n,,o &-,�4 t9m <br /> 2 <br /> Propc y Owner Name pC Pro city Legal Descriptign e— e <br /> �+ Pa 1i4M1 114,Sa !N.R/5W <br /> Property Ownct's Meiling Address Lot Number Mock Narnber <br /> s5'z' -�.- 14+x``{LP,- L*, 14`E' - 1585 <br /> city,State I zip Code Phant Number Subdivision Num or CSM Number <br /> W1 6 PAA) 5'SH w 6`1 &%z <br /> �je �irr.�+c� IS Tka,4 4* IS <br /> Typt6C Building: (Check one)Q Smte•Own�d ❑City NcacalBaad. 2 <br /> 14' l or 2 Family Dwelling-No,of Bedrooms: O village VtFG Cts <br /> Q Public <br /> GYfown of 4 A 1pd;, Firc Numb <br /> Public BulldinglLand Use: (Expl in the use/purpose for ibis permit,(te, Parcel Tax Numbcr(s) <br /> campground.festival,recrcation/cmcrtaintent event etc)] <br /> Typ rmit: Ty f Non-Plumbing Devi"JSystem/Toilet/Unit: <br /> on•Plumbing(Privy.Toilcl,Res oom cic.) rivy—Pit Toilcl ❑ Composting l'ailat Syslem <br /> 0 POWTSReconnection M Privy—VaultToilet(Vaultsi= D tncincratingToilctDcvicc <br /> ❑ POWTS Repair Coun 'k _gallons or _cubic yards) ❑ Ponnblc Restroom Unit <br /> ❑ Revision Smote ❑ Othcr <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> O f,,htrundcrsigned,assume responsibility for th It this perrnit is issued. <br /> M.the undersi nod,assume responsibilityf e Inst ati f th non lum sanitary a stem for which rhis armit is issued. <br /> WinniMi 510wriv's Name(print) er's S utu /MPRSW No.. dussness Plsnne Number: <br /> �6k A S tis Ltz-Fd�l �tP,� <br /> Plww6s3AdJress(Street,City,Suit,Zip o <br /> Office Use Only: <br /> ❑Duapproved Permit Fee;. CST No. nc Issued Issuing Agent Signature <br /> O Approved D Owner Given In tial Adverse S[7a3r <br /> Determination <br /> Comments: <br /> Conditions of Approval/Rt&somi for Disapproval: <br /> 02`�� c. <br /> S,C6) <br /> ala- 8� <br /> TOTAL P.01 <br /> i <br />