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T <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K,SIRENN, WISCONSIN 548722 C'I(� �( �boylN Z <br /> � 3 l <br /> 715-349-2138 <br /> 1 <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 /> S . LE6aL} <br /> Pm eny\O.vwner Name +, Property LegDcsvriplion PLL <br /> GL 1/4 II4.5 <br /> ny Owners Maiing AJ s Lot Number Bluck Number <br /> VC �S <br /> Cay.Sure Lip We Phone N ber Subdivision Name or CSM Number <br /> t. Ccokt 115 5 �� (115 ,N83XA <br /> Type of Building: (Check one)❑ Stme-Ownnl ❑City .'eyrtsi hti <br /> ❑ lor2 Family Dwelling-No.of Bcdnwms: ❑Village <br /> ❑ Public Town f F '4 <br /> Public Building/Land Use: IE.aplain NeusdpurWaerdtlhiscemil.(ia. Pmcel Taa Number(s) <br /> campyouW.ficairal.mrcmimrVmvMinment evenretc)) o9-a-lo-amt-,n-ora-of-a-eo( <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> 'A Nem-Plumbing(Privy,Toilet,Restraem eta.) ❑ Privy—I'it Toilet ❑ Composting Toilet System <br /> ❑ POWTS Repair lion � Privy—Vauo Toilet(Vault size: ❑ Portable eToilet Device <br /> County <br /> ❑ POwTS Repair � 0gallonx or _cubic yaNs) ❑ Portable Restroom Unit <br /> )[ Revision !f ❑ Other U P6[, ,.o{= /xnk 1-se Ftv,� ' <br /> Responsibility Statement: (Check one or both 0,,,.,p...prizar) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for wh' ihis permit is attract, <br /> ❑I,the undersi ned,assume rex onsibilit for the installation ofilm - Inmbin,,amm x stem f r which thisermit is issued. <br /> Pam i(b enema xr �'s Sl'ca "MulSse No: Business Phone Number: <br /> vJts�,-g� s�1Dk� z�� o9� 71��am�agss <br /> Plumber's Addu ss(Sorer.Cas.State.Zip CW.e1: <br /> 0 `I — <br /> Office Use 0.1, <br /> ❑DiappmvcA Permit Fye: CST No D;ec Issue) Issuing Am Signature <br /> 1�AppnrveA ❑Owua Glvvl total AJvaee <br /> Delenn�nalmn <br /> Comments: <br /> -75P X41 holy SLS hZ le de gLU P^� L ✓t possdLe z �u <br /> ,h Tu*.l2 air <br /> Conditions of Ap"ppro+'alL/Reasons for <br /> o�r Diusampp�ryoivafl: <br /> IQ <br /> 5to <br /> /V,, .eq h/.11f>e4t*e✓nGCf c.�WrnAa®�s>�u/'fO�reLS x✓r/./D�n^ E <br /> SCrJrOME <br /> DReyixW aroma AUG27 2014 <br /> BURNETT COUNTY <br /> ZONING <br />