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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 ($150) C(3 <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> CjakjciArc= L G,- t&,AA -xs7, GL 1/4 1/4,5 11 735d /?14w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 4d.13 9,-& o! Rupi 7 <br /> City,State "Zip Code Phone Number Subdivision Name or CSM Number <br /> �tiormulcy, MN SS/,l6 ) F P <br /> Type of Building: (Check one) ❑ State-Owned ❑City Ne :`R",d <br /> 9 1 or 2 Family Dwelling-No.of Bedrooms ❑Village a/—ev 4m <br /> ❑ Public 0 Town of ��49k Fire Number X17/ <br /> Public Building/Land Use: (Explain the use/purpose for thie permit,0,e„ Parcel Tax Numbers) <br /> campground,festival,recreation/cmertainment event eta)] Ody-q03S-01-7GI) <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 /> A POWTS Reconnection ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#. : a?�� gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#:'�4s/,7g7q ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> 91,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume res2onsibility for the installation of the non-plumbing sanitary system for which this perruit is issued. <br /> Plumbers/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> T'/&,k o- /Z/1 I �)S1-S'/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 77 G �/µ 3S /tisf�. �✓� S�frS93 <br /> Office Use Only: <br /> � ❑Disapproved Permit Fee: CST No. Date Issued Is m ntre <br /> SApproved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />