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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 r <br /> SIREN, WISCONSIN 54872 W <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> POWTS RECONNECTION ($25) _Z, <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> GAets /3an GL 6 1/4 1/4,S.13 Tdl6N,RIGYV <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Sp q( <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> woo®6u r /17N SS/} s' <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> 14 t or 2 Family Dwelling-No.of Bedrooms: ❑Village S, <br /> ❑ Public ®Town of FireNumbl/79 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 0#0 a-432.3 -OW60 <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 /> ❑ POWTS Repair rE <br /> ounty gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision tate# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 0 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- lumbin sanitary system for which thisermit is issued. <br /> Plumber's/Owner's Name(print) Plumbees/Owner's Signature: MP/MPRS W No.: Business Phone Number: <br /> R/c% /5/0 /,—/" s d Jl fmss-- / 715'-Flo-1//J-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> o477(s0 /rC.j, 3S Lried rfri wl Sq 51,73, <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Data Issued Issuin [Sig re <br /> Approved ❑Owner Given Initial Adverse ✓J' <br /> Determination Jc(J " y/} !2/ft1U• <br /> Comments: 5K . <br /> Conditions of Approval/Reasons for Disapproval: <br /> lsi�ts��wj /rrrr/ %anL/ 7) 4ba.%�<.re/.� <br /> Revised 6/7/02 <br />