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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> Timothy Brandenbur er GL 1/4 1/4, s 24,T 41N,R 16W <br /> Property Owners Mailing Address Lot Number Block Number <br /> 589 Cheri Lane 11 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number �t- <br /> Fridley, MN 55421 (612)669-9188 Griff Acres <br /> Type of Building: (Check one) ❑ State-Owned ❑city Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village Griff n Lane 7(` <br /> ❑ Public X Towof U <br /> .Swiss Fire Number <br /> 6505 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number <br /> campground,festival,recreation entertainment event etc.)] 032-9105-02-100 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> X Non-Plumbing(Privy,Toilet,Restroom etc.) It Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device �1 <br /> ❑ POWTS Repair County# _gallons or cubic yards) 11 Portable Restroom Unit fib_ <br /> ❑ Revision State# ❑ Other n <br /> S <br /> Responsibility Statement: (Check one or both❑as appropriate) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. W <br /> ❑I,the undersigned,assume res onsibi ityfor the installation of the non- lumbin sanitary system for which this permit is issued. -� <br /> Plumbers/Owner's Name(print) Plumbers/Owner's Signa MP/MPRSW No.: Business Phone Number: <br /> Timothy Brandenbur er — i!///k /(/✓A <br /> Plumbers Address(Street,City,State,Zip Code): <br /> 0x <br /> Office Use Only: <br /> O <br /> �/' ❑Disapproved PermFee:it CST No. Date Issueedd/ Lssuing Signa 1(� <br /> yl Approved ❑Owner Given Initial Adverse <br /> Determination `RZJ <br /> Comments: <br /> S/s,1rn,, Cyst,Y Pti6-) 37 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />