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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, 4102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) 4 _ <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> A)w0 Etr GL 1/4 1/4,S /8 TN,R/S <br /> ey <br /> Property ner's Mailing Address Lot Number Block Number <br /> :57,7 Cf�, C0.Sti wa <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> 04"n 14. N/l Sy b'30 G�4 Ss z <br /> /VC rt'1 <br /> Type of Building: (Check one)❑ State-Owned ❑City Nene.et RnnA <br /> 19 1 or 2 Family Dwelling-'No.No.of Bedrooms: .? ❑Village <br /> ❑ Public m Town of$a.rf S Fire Number S9 9d <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 /> Type 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 /> 11POWTS Repair County# gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ OT_ Ither <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> IM I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this ermit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> RIC 114 #&Vpler'n S 12e a 04A5-fSI lis- 06 - 4. F <br /> Plumber's Address(Street,City,Stare,Zip Code): <br /> 776 O <br /> Office Use Only: <br /> // ❑Disapproved Permit Fee: CST No. Date Issued Issu' ent Si <br /> Approved ❑Owner Given Initial Adverse 5-O l3 •09 <br /> Determination •v ` <br /> Comments:/ / <br /> tio+wtc��T�. r�2 <br /> OYrpolne(,f)/ fr eosex (.y #4 , <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />