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..............03/.................................................................................................................................................01 ...................... <br /> FEB/03/2011/THU 02, 96 PM P. 001/001 <br /> 02/03/2011 12:05 3492166 B C ZDNING PAGE 01 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN,WISCONSIN 54872 <br /> 715-349.2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($150) <br /> POWTS CONNECTIONIRECONNECTION($50) <br /> Application Information(Type or Print) ATTAOU A PLOT PLAN WITH THIS APPLICATION <br /> Pmpmy Owner Nome Poverty Loge)Ia Acilpllon <br /> . _.. ....... . .- ._ .... -_......_ _.... _ ... . . . .. I. <br /> . . .... -.- .. , .. .. .. . . . .. <br /> . .._ .... � _.. _. . _ .. ...GL Iro V4S ,T N,R W - <br /> rry ere oohing Address La,.Number Mock Mlmba <br /> Cay,Stareip Cole Plume Number Subdivision Nome JrC�,b LNwnhw <br /> S3 .c 63 ,ab- <br /> Type of ApBding: (Check one)Cl Stae-OrmedS V ly rev <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: D Tom at Pirc m <br /> ❑ Public <br /> Publio 9u11ding/I.apd Use: Ilfxpdin the umW rpota for this permk.(i.e.. Parcel Tax Nnmha(s) �pU <br /> �nmpgm,rd.fradval, tioNentertninmcnr cvom ou,)I orr—Q32 I)-1b.2 <br /> Ja�IbGl.' 's7. 6Oq-oil Icko <br /> T pe of Permit: Ty$geof Ndn.Plumbing DevicNSystem ffoBeWnit: t <br /> fd Non-Plumbing(Privy,ToildLRatronm eta) -GYPrivy-Pit Toilet f] Composing Toiler Syslcm <br /> Ll'POWTS County ❑ Privy—VaultToila(Vauh>ira 13Inelnwadr,¢TrdirxDtwiee <br /> D POWTS gallons air Wcubic yerdx) O Ponvisic Resbreom Unit <br /> ❑ Revision State 8 p Othcr <br /> J <br /> Responsibility Statement: (Check one or both 0 as oppropriate.) <br /> TXJ. mTS the undersigned.assume responsibility for the POWactivity for which this parmit is Issued, <br /> The Jnderxi bad,Mum;responsibility 1br th ' stall �an of the non-Plumbing saniG system for which this efmit is issued, <br /> Pncruvwner'5 Name(P rQ ser ixnomre MP/MPRSW No.: 9uPesmiPhoneucti. <br /> I[y� <br /> Nombm <br /> Plumbers Addrns(Strout.Guy,State,7Jp Cade <br /> Office se Only: <br /> O DisepvlbvA Permir Per. CSTNo. Data lysed Lux gone Si ww <br /> Approved ❑Owner Given Inival Adrerxe rfo� 3r'6 ( c <br /> Detnnipblion �✓ lv�. <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Ravlscd 6NI02 <br />