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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 $15 _ <br /> POWTS RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> / <br /> II AA� GL SEV4SVU1/4,S 30,T,3%,RI W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> '5 SS E. 3hadq Ln /�I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Neenah, VUZ 1 5 L 16/- Sao gsb- 3aa <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest goad �I rL h F <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village t� <br /> ❑ Public Town of rte.U.s� Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 0a0 -313o-Da-aoo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ANon-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS RepairFStoaute <br /> ty# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision # ❑ Other <br /> i <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS t ity for hich t permit is issued. <br /> the undersigned,assume responsibility r the install to of the no - I ing sanitary system for which this permit is issued. <br /> Plumber's/ wney <br /> r's Name(print) P u s/O r' nature: MP/MPRSW No.: Business Phone Number: <br /> 1 4 <br /> Plumber's A dress(Street,City,State,Zip Cade. <br /> n <br /> Office Use Only: <br /> ,.,// ❑Disapproved Permit Fee: CST No. Date Issued lssui ent Sign re W <br /> R7 Approved ❑Owner Given Initial Adverse *�C^y9 R. �dour 'g W/�' O u P <br /> Determination Y ✓V �/ O <br /> Comments: <br /> �64 4xc�sfJ�+ li f6p$'r/L Qnvy ^1ow"� u Y 95.Goo. <br /> aohwg !6 i )ndtclEes 5i;6 r- Sal o a a/ep 1r `)o f •s pp <br /> /Vora: fit) �afu��tOa, CoAjed Far �u]� P��t-t• Qr, 1"zf W.,Kal'w on 1,J, (or use At PWTS, <br /> Conditions of Approval/Reasons for Disapproval: <br /> Deqe;j pe-e DeoFh : 4,5 "1, sy.$J N, (BoTu+ OP Gr6) axvdi6ot.t 5 <br /> Revised 6/7/02 <br />