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04-29-11 ;07;56AM; '763-526-8492 # 2/ 2 <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 CONNECTION/RECONNECTIO ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Propert'f�lvncr Name T/ Property Legal Description <br /> GL 1/4 114,S b ,Tg0N,R 16 W <br /> Property Ownces Mai' gAddress Lot Number Block Number <br /> 990K G <br /> Cil ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> y5303 aFlei verst-Altom s <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Roadp�r� ,n1 <br /> I ort Family Dwelling-No.of Bedrooms: ! . Calld \ ,❑,Village O 1 11 0 <br /> ❑ Public 61,,kh0VS8 Townof A'I FroNumberaga, <br /> Public Building/Land Use: IBxplain the use/purpose for this permit,(i.e., Pel Tax N,t�mbcr(s) <br /> campground,festival,renreationt"tettainment event etc.)] lrC a0-t136 b-0a-106, <br /> o�-Darr a-No-IL-ob�•/s-�-pd.ILmb <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet(UnW <br /> ❑ on-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> POWTS Reconnection ❑ Privy-Vault Toilet(Vault sin: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County 41 99?5-2 112p gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# Nb ❑ Other 4_0 JWi)w 2%,SD y <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> XI,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 111,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber'slOwners Name(print) Plumber's/Owner's Signature: MP/MPRSWNo.: Business Phone Number. <br /> Rlc/__ f/ le" _f `l <br /> Plumbers Address(Sweet,City,State,Zip Code): <br /> ok776o f/t.- 3S� W-e5st,'� r�1 s'WQ53 <br /> Office Use Only: <br /> ❑Disapproved Pemdt Fee: CSTNO. Date Issued Issuin n]Signal <br /> .t Approved O Owner Given Initial Adverse CUJ Away <br /> �)I <br /> Determination J / <br /> - Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/I/02 <br />