Laserfiche WebLink
Z <br /> RURNETT COUNTY ZONING ADMINISTRATION • 5 <br /> 7410 COUNTY ROAD K, #102 i <br /> SIREN, WISCONSIN 54872 C <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Chao leS &1/ -fi•,erel GL 1/4 1/4,s3l 7 3f-,✓A) 0-4, <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /03 0o Neva /Zd <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 6ra.41-Sbkvf___14/,ti ery679,o ( ) <br /> Type of Building: (Check one) 0 State-Owned ❑City I Nearest RRead ' <br /> 14 1 or 2 Family Dwelling-No.of Bedrooms: 3 0 Village Nevo /z� <br /> ❑ Public El Town of LI.44 r 4 1 Fire/0Se0O <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> d <br /> campground,festival,recreation/entertainment event etc.)] 1a7.-dbb— 38,17_.7, /01-000 <br /> � <br /> U,daoo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy—Pit Toilet 0 Composting Toilet System <br /> POWTS Reconnection i 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair County#_ gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# I ❑ Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> g'I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 7-76 O ir,-- 3.5— -e-6.s7`-9 r Gt/� -5-7-71g.7 <br /> Office Use Only: •), <br /> D Disapproved Permit Fee: CST No. Dat Issu s jg6nt igpay'T <br /> /r! Approved ❑Owner Given Initial Adverse (r0.06 12.1.814,15'5 2.11A0 <br /> Determination i 7 1J (, 7 2 <br /> Comments: <br /> • Olol &wA.. (noMIreat -9 <br /> C <f c 1?7 51501tV <br /> Conditions of Approval/Reasons for Disapproval: ''� <br /> Stpfic, ► &u.* lot, 1n�Mkea te4C per SPS. 383 I[ �� <br /> % Seph'c 0T-tuec 1- goKX wtusf lot cwt: 1 <br /> All Work PeeArwte& AtLe61- be del"' 1 a- Col hcevoeat ii .,;.g 2 8 20201 j <br /> Revised 6/7/02 <br /> —Etna Etnett County <br /> Land Services Department <br />