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JAN/16/2020/THU 10: 33 AM Burnett Cty Abstract FAX No, 7153497604 P. 019 <br /> BURNETT COUNTY <br /> SANITARY PER1vLT—TRANSFER BETWEEN OWNER/CHANGE OF FLUMBER <br /> Permit Transfer Date: a//BI 020 FEE; $75.00 <br /> Original Permit Issue Date: 12/16/19 <br /> Expiration Date: 12/15/21 <br /> Previous State Plan ID Number: (p2015( New State Plan ID Number: W01620 <br /> Office Pennit Number: SAN- 19 - 260 <br /> _ <br /> 114 1/2,Section 13 ,T 40 N.,R 15 TOWNS : Jackson <br /> Lot --- Block ---- Subdivision --- Tax ID# 667s <br /> - _ I <br /> TRANSFER BETWEEN OWNERS: <br /> PREVIOUS SANITARY PERMIT HOLDER: NEW SANITARY PERMIT HOLDER: <br /> Name: Karen 5ehmtde Name: Gerard Payne <br /> Address: 28834 Treasure Island Rd. ,Address: 28834 Treasure Island Rd. <br /> City,State,ZIP: Danbury, WI 54830 City, State, and ZIP: Danbury, WI 54839 <br /> Previous Permit Holder Signature: 4 . • 1 <br /> TRANSFER BETWEEN PLUMBERS <br /> *Revised plans must be submitted by installing plumber. <br /> PREVIOUS PLUMBER: *INSTALLING PLUMBER <br /> Name; Name: <br /> Address: Address: <br /> City,State,ZIP: City, State, and ZIP: <br /> Phone: <br /> { <br /> MP/MPRSW#: <br /> I, the undersigned, assume responsibility for installation of the private sewage system that has been <br /> previously approved for this property. <br /> Installing Plumber Signature; <br /> 2/SA0, <br /> issuing Agent Signature: <<.,, �� /, _��` __ Date: ) <br /> f f <br /> Check# i 09a? 7 $1g'° <br /> lE © IEOV <br /> FEB 18 2020 <br /> ..1./0'/i9 <br /> Burnett County <br /> Land Services Department <br />