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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> pCJA e S GL 1/4 1/4,S Zo TLlQN,R I W <br /> Property Owner's Mail' g Address Lot Number Block Number <br /> 2 2 Z 1$1' I.c <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Cl L e WI: I sq ( 715 4(3308 1 -7 P22 (o <br /> Type of Building: (Check one)❑ State-Owned ❑City Nest Road <br /> 53,"1 or 2 Family Dwelling-No.of Bedrooms:�� ❑VJillage P c <br /> ❑ Public �4own of Q4KiaWAFire Num er <br /> Public Building/Land Use: [Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] p <br /> 02.0 9180 02 ZOO <br /> T�Cpe of Permit: Ty a of Non-Plumbing Device/Syoilet/Unit: <br /> j(Non-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet j Er3romposting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: 4961ricinerating 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 /> ❑] 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- lumbing sanitary system for which this permiI is issued. <br /> Plumber's/Owner's Name(print) P her Signatu e: MP/MPRSW No.: Business Phone Number: <br /> Kw ( D -3027 <br /> Plumber's <br /> Plumber's Ad ress(Street,City,State,Zip Code): <br /> t W Z 5400 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss Agent 'gnature <br /> yy Approved ❑Owner Given Initial Adverse •60 <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />