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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 $ 0 <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name ]� Property ALeggaal Descrriipti n <br /> C I L -V f (af I 0— l/ GL /VL 1/4 Jam/ I/4,Sak, J 7N,R/,W <br /> Property Owner's Mjiling Address I Lot Number Block Number <br /> Zeros a <br /> City,State Zip Code Phone Number Subdivision Name or CS Number drl CIO <br /> Fredet-,-c CSm V. Do . 369 *39" <br /> UJ <br /> Type of Building: (Check one) ❑ State-Owned ❑city Nearest Road SU <br /> ❑ I or Family Dwelling-No.of Bedrooms: ❑Village(y]etrjo on �. <br /> ❑ Public `Town of Fire Number <br /> n <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainmcnt event etc.)] <br /> 0) S- 33a -11-ibo <br /> Type of Permit: Type of Non-Plumbing Device/System/ oilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) If Privy—Pit Toilet ❑ C mposting Toilet System <br /> ❑ POWTS Reconnection - ❑ rivy—Vault Toilet(Vault size: ❑ I cinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 111,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume responsibility for the installation of the non- lumbin sanitary system for whi h this penmit is issued. <br /> Plumbces/owner's Name(print) Plumbees/Owner s Si MP/MPRSW No.: Business Phone Number: <br /> Wan l n Cheep & UI <br /> Plumber's Address(Street,City,State,Zip C e): <br /> J <br /> Office Use Only: <br /> 103Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> ❑Approved ❑Owner Givrn Initial Adverse n ,y,,,,, <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />