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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($50) <br /> POWTS RECONNECTION(S25) <br /> POWTS REVISION(S25) <br /> Application Information-Type or Print <br /> Pmpaty Owner Name ply �C <br /> Mich fh�kr �3 19N.R <br /> Property Owners Mailing Address GL � 1/4 1/4 S T be R�� W <br /> I.et Number Block Numbs <br /> y Sl r o ajr,_ D/2-1 v 6- <br /> City, <br /> � - Zip CodeS y Z 6/Zl -4186 Subdivision Name or CSM Number <br /> `t sz qz0-4A7 05M v, al p. ao( w <br /> Type of Building: (Check one)O State-Owned O City N Road <br /> O I ort Family Dwelling•No.of Bedrooms: O Vinage�/7A N S LGL KQ K�( a <br /> O Public ATowo of.,m-ake_ Fire Number <br /> Public Building/Land Use: [Explain the usr/purpose for this permit,(i.e., Parcel Tax Nurober(s) <br /> campground,fcadval,reetarion/mtenainman everts etc.)] <br /> -1 bi,3 -3313-oU- 000 <br /> Tr <br /> Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) O Privy-Pit Toilet O Composting Toilet System <br /> POWTS Reconnection County# Privy-Vault Toilet(Vault size: O Incinerating Toilet Device <br /> ❑ Revision <br /> State fi gallons or _cubic yards) O Portable Restroom Unit <br /> O Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> ❑I,the undersigned,assure responsibility for the POINTS activity for which this permit is issued. <br /> 0 I,the undmiloned,assume responsibility for the installation of the r unbin sanitary tem for which this permit is issued. <br /> PlumberslOwner's Name(print) Plumbers) 's Si MP/MPRSW No.: usin��/s Phone Number: <br /> �Ll fGKC-� !tif/LL�/1 �6i <br /> -111810 <br /> Plumbees Address(Seat,City,State,Zip Code): <br /> Ysls C/Hc D,i;-- t tr6 z <br /> Office Use Only: <br /> 0 Disapproved Permit Fee: CST No. Date Issued 'ng Agent Signaum <br /> 0 Approved 0 Owner Given Initial <br /> Comments: Detamusiams <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />