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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) <br /> POWTS CONNECTIONBECONNECTION ($50) <br /> r <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner NaProperty C Property Legal Description <br /> 6y- zscm(-b eAz— GL 1/4 1/4,S Z4 ,Ttfb N,Rflq W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3ooB5 ; ,P- -TRRtL, I L ( � <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number W <br /> v'YAG rV)vl 55c7 I ) JI Z,t7 <br /> Type of Building: (Check one) ❑ State-Owned ❑Cjry Barest ad_/l r <br /> Z 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village `- 1 KLA <br /> ❑ Public R Town of 5( Fire Num r <br /> 1231 <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 /> - ozB-4tz�f-o3zto � <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 /> 19 POWTS Reconnection Coun # �J3`11 ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair ty _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# /b ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> R 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.phimhing.sanitary system for which this pennit is issued. <br /> Plumber's/Owner's Name(print) Plu ber's/Owner's Si aNre: MP/MPRSW No.: Business Phone Number: <br /> M&K SEPTIC & EXCAVATI N <br /> P <br /> SPOONER, 54801 <br /> 5-635-7482 <br /> Office Use Only: <br /> , " ❑Disapproved Permit Fee: CST No. Date Issued Iss � Agent Si ure <br /> Ad Approved ❑Owner Given Initial Adverse $50; <br /> Determination _ LLQ <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />