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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 00 <br /> 715-349-2138 0 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) 0 <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> I CmQ.*-j GL 1/4 1/4,SZS T59 N,RW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 0 TO 0 G 1p <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 7r'Y) 3H —7/lZCj <br /> ) <br /> Type of Building: (Check one)❑ State-Owned ❑City Neares Road <br /> NL I or 2 Family Dwelling-No.of Bedrooms: -3 ❑Village wN <br /> ❑ Public JU Town of FireNumber <br /> CC N <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) 7016 A <br /> campground,festival,recreation/entertainment event etc.)] oi6 33-78 -03 �21- <br /> J <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom <br /> �ettcc..)meq ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> M' POWTS Reconnection Count # r-l�I Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair y gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# S !ET ❑ 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-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> At +w+w+7f <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 277 w t jehsyfr w <br /> Office Use Only: <br /> //'' ❑Disapproved Permit Fee: CST No. 1-W <br /> Issuin n[Sig r <br /> 'Approved ❑Owner Given Initial Adverse �[ ��� `OyrDetermination YNY <br /> Comments: <br /> C� <br /> An 2 n <br /> Conditions of Approval/Reasons for Disapproval: <br /> BURNETT COUNTY <br /> ZONING <br /> Revised 6/7/02 <br />