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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 CONNECTION/RECONNECTION (850) <br /> application Information(I'ype or Pring ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> I'rogdy Uwner Name Pm'"'Legal Description <br /> Anthony lic,,ch,n <br /> GL 1 S 12.T39N.It 14 W <br /> Property O.mersltailing,Wdres, Lat Numher Black Number <br /> 1295 Kanb take Circle 3 <br /> Cib,SmtcLip Phone Number Sabdi,i,wa Nan,or CSbf Numher <br /> order Hills.AIN S?1Code 12 (.SM V.24 P.24 <br /> " � — I�IU4U-1280 � "--- • <br /> l'spe of uilding: (Check one) ❑ Suite-Owned ❑City Neerest Road <br /> ❑ I or 3 Pami l y Dwcl l ins-No.of Bedrooms: ❑Village Brad,lyra <br /> ❑ Public <br /> XTnwnnf Rask <br /> Public Building/Land Use: [Explain the use1pumose for thi.pemtit,(i.e. Parcel 9'a=Number(,) <br /> camp'.and,fc'u,al,recrcmioplamem ahem event etc.)[ 07-024 2-39-14-12-5-05-001-01 IE00 <br /> Type of Permit:—� 7\pe of Non-1'Ilnnbing Derice/Systelnlfnilet/Ilbie <br /> S Nan-Pluntbiny'Pnry,T,ilal,Restmprc1c) XP...a-Pit Toilet ❑ Compostingl'oilet Svstem <br /> ❑ POWI'S Rcconnaetmn ❑ Priry—Vault TmIct(Vault sin: ❑ Incinerating'Poilet Device <br /> ❑ PORT'S Repair�t•al�'" County# _gallons or _cubic yards) 11Portable Restroom Unit <br /> '❑ Recision� --- Store'� ❑ Other <br /> Responsibility 5tatentent: (Checkoneorboth❑asappropriatc.) <br /> ❑ I,the undersigned,assume responsibility for the POW PS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume "pon,ilb,litv for the installation ofthe non- luntbing suniuiry system him v,hich this pannit is issued. <br /> Plumbar's2O.maC,Santa(mut Plwnbcr'slOwncr's Signature: N111/M I'RSW No.: Business Phmtc Numhce <br /> Plumber,Address(Stoat.City.State.Zip Codc): <br /> 011lce Use Oniv: <br /> ❑DisapprovN Permit Pcc: CS I'No. Ilnta lssuW Insding em Sigwmre <br /> k�npnro..o ❑Owinati.en miral ndser>e i't ccOD -a'I-13 U/ <br /> ll 0 0...inmion <br /> Continents: U o <br /> Condition,of Appro%al/Reasons for Disappras'al: <br /> p ECUSE <br /> Re.bra(,n/oz JUN 21 2013 <br /> J Lk <br /> BURNETT COUNTY <br /> ZONING <br />