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JUN-07-2002 0j;0b BURNETT COUNTY UOl CENTER 17153492102 P.01i01 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN, WISCONSIN 54872 ON <br /> 715-349-2138 COMPUTERtSCgNN <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($50) <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION(S25) <br /> S t?s �0� 0- n./ z ?s <br /> Application Information—Type orPrint 6001 f of 3 of SectSz^' 2/r 7Zw.v5�i� i$ <br /> Property Ow=NsmCU e=e 17 W ( ;/u l(J vJ t JO <br /> / Property tegel Descripti�G2 S,k(r 1/r G t ��- a5 i4 `� SicS�N J • �f5[� er OL IA V4,SQ11 T39N.R1W <br /> Property Owners Mailing Addmis � Lot Number Block Number <br /> JJ� Ulre 60V - 'IT3 70 Qf <br /> Clltty,,1soft Zip Code Phone Number Subdivision Name or <br /> _ CSM Number 7 C'"d"v <br /> � <br /> 31 ( 7/s- )73z-cb { <br /> 3.F- J+-vf 33'z/ t c.� r/. /4S� <br /> Typo of Building: (Cheek one)D StateOwned ❑City Meares�ggo <br /> D l or 2 Family Dwelling-No.of Bedrooms O Village O I,7W 3 S <br /> 13Public aTownof QctUje/g Fire <br /> Pubik Bailding/iand Use: [Explain the uselputpoec for this permit,(i.e., Parcel T Numbers) 5 tf <br /> campground,festival,recreanoNentenainment event etc.)] O - P/ - C) � - 6 CJD <br /> 0© 6 -�tI - -loo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit- <br /> X1 NotrPlumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS ReconnectionCry# w privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS RCPau 202 gallons or _____cubic yards) ❑ Portable Restroom Unit <br /> R Revision State k-( r ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> Q I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> I•the undersigned.assume responsibility for the installation ofthe non-plumbnon-plumb4a sari em for which this ermit is issued. <br /> Plumbot'slOwner's Name(print) Plumber er s rgnalure: MPIMPRSW Nu.: Business Phone Number: <br /> Plumber's Address(Street City.Stare,Zip Code): <br /> Of ke Use Only: <br /> ppqq�cnn�'''' ❑Disapproved A Fee: CST No. I d Issui en ' <br /> f ved ❑Owner Given Initial Adverse r(} 22 y �i O Z <br /> 1/ Dermnination <br /> Comme is; �L=� <br /> f <br /> Conditions of Approval/Reasooa for Disapproval: <br /> V 1 . <br /> JUN 1 3 2002 <br /> BURNETT COUNTY <br /> ZONING 7kyLIV <br /> TOTAL P.01 <br />