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BURNETT COUNTY ZONING ADMINISTRATION e <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 /> ,C+e( &/'�()n GL S 1/4 1/4,S qJ3 FN,R <br /> N,R W <br /> Property Owner's Mailing Address O 2 0 2 Lot Number Block Number <br /> 4 <br /> City,State SIREN w r Zip Code S' i,p7Z Phone Number Subdivision Name or CSM Number <br /> ('7/S 349 ?,?z:7 CSrn v. (- to asy <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road (� <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village L AFU�ie+ -J) <br /> ❑ Public [`Mown of Fire Number a L4.3 <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 /> o �� � aao�- v3-hod <br /> Ty a of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit Q <br /> ❑ Revision State# ❑ Other �l <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. <br /> ❑1,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber' Owner's Signature: MP/MPRSW No.: Business Phone Numb r. <br /> -liter 8LkV Ion <br /> Plumber's Address(Street,City,State,Zip Code): �p <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing Agent Si nature <br /> ❑Approved ❑Owner Given Initial Adverse <br /> Determination �rJ <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />