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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($50) <br /> POWTS RECONNECTION S25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name <br /> Progeny Legal Description <br /> rl — GL r 1/A 1/0,5 r T'�tJ,R W <br /> Property Owners Mailing Address Lot Number Block Number <br /> x830 F\us�sjc.)L b� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> w�1�Si�(L wI S-qf343 ('1t5- )(,5,- <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> N I or 2 Family Dwelling-No.of Bedrooms: r3 ❑Village <br /> ❑ Public ®Town of���- Fire Number <br /> Public Building/Land Use: (Explain the use/purposc for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreatioNemenainment event etc.)] <br /> oaa- "t ( (7- oa Ltoo <br /> Type of Permit: Type of Non-Plumbing Device/System/foilel/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) 13 Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,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 this it is issued. <br /> Plumber's/Owner's Name(print) P1 be's/Owner's S- turc: MP/MPRSW No.: Business Phone Number: <br /> GJ'4`�p v �,� 7 7&19/ <br /> Plumber's Address(Street,City,Sure,Zip Code): <br /> Office Use Only: <br /> O Disapproved Permit Fee: CST No. Date Issued Is uing Agent Signature <br /> O Approved 13Owner Given Initial Adverse <br /> DI 1L} v� <br /> etermination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised-7/02 <br />