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.05;11/2007 12:41 7156534378 DAVE'SPLU46ING RASE 01/01 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD Ky#102 <br /> SIREN, WISCONSIN 54872 <br /> 15-349-2138 <br /> NON-PLUMBING SAKI rARY PERMIT APP CATION(S50) <br /> POWTS I ECONNECTION(I25 <br /> POWTS REVISION($25) <br /> Application Information-Type or Print <br /> Property OIw�n�er Name L�, Prepeny Legal Descnpuon <br /> Lao-,_ 6r"66-5 GL oZ 1/4 1/4,Sa5T'/0N t� W <br /> Property Owners Mailing Addreas Lot Number Bock Number <br /> $ el f'l 1 <br /> Ciq,swe Zip Code Phone Nember Subdivision Name or CSM Number <br /> Lt vl 0 LP J'e_5 (r 5'5D I _l '73 4-Yy L'5rKV ,/b .42 X 23 <br /> Type of Building; (Check one)0 Sore-Owned o city ' � Near�aGRoada <br /> I is 2 Family Dwelling-No.of Bedroom: .�Tv�inrcf;/-//l cart Ere Number <br /> ❑ Public a 9 <br /> Public BuildingtLand Use: IEzplsln the uselpurpow for this pe-rat,(i.e., Parcel Tax Numbe'(s) <br /> campground,Mtival,mresuartcnwrammem event etc,)] <br /> 1 ype of Permit: Type of Non-Plumbing Devlce/SystemrPoiletiUnit: <br /> 0 Non-P)umbing(Privy,Toilet,Resnocrn etc.) ❑ Privy-Pit Toilet O Composting Toilet System <br /> POWTSReconnection 0 Privy-VaultToilet(Vaultsize; 0 Incinerating Toilet Device <br /> ❑ POWTS RrpaiT County# /748L —gallons or _cubic yards) D Portable Restroom Unit <br /> 0 Revision Stale*_2o Z2fj, O Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> the undersigned,assume responsibility for the PO S activity for which this petsnit is issued. <br /> ❑1,the undersigned,assume res osibili for the inset lotion of the non-plumbing aanita s tem for which this permit'1 <br /> issued. <br /> PlumbedsrUwner'aNarne(print) Plumbdd0 z Siy�lure; MP/MPRSW No,: Bwiness Phone Numbar: <br /> D.at,e- lVl l udZ J�- - aarasS" 7�s'4s'3 __ <br /> Plumbed:Address(Street,City,Statc,Zip Code): <br /> .234V 57' . o 'Y%L L Q `L/ <br /> Office Use Only: <br /> —/ ❑Disapproved RrRi For. CST No. Date lowed Issuin t slgnat <br /> 41 Approved ❑Owmr Given Initial Adverse 14,44V O-7 <br /> petermination Y /vW <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6,17/02 <br />