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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 RECONNECTION (S50) <br /> POWTS REVISION ($50) <br /> Application Information-Type or Print <br /> Propert}Owncr Name Property Legal Description <br /> GL 1/4 1/4.S 7 .T.3 N.R ILI W <br /> Property Owner's Mailing Address Lot Number 3 Block Number <br /> N Ot J66 nu 1 E Te ek Feed eF 6o-Eb. <br /> Cin',State /_ Code Phone Number Subdivision Namc or CSM Number <br /> 1 �Xw "'sL xR4 147472,dQ <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest,.Road <br /> ❑ I or 2 Family Dwelling-No.of Bedrooms: ❑ Village V �. <br /> ❑ Public PTown of Fire Nupiber <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e.. Parcel Tax Number(-3 <br /> campground,festival,recreation/entertainment event etc.)] o7-cq-23d-1 f-p7-5 15-�,K-013100 <br /> N �1- <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Ultit: <br /> Non-Plumbing(Privy.Toilet,Restroom etc.) EYPrky—Pit Toilet ❑ Composting Toilet System <br /> ❑ PO'AI'S Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ I ncinerating'ioi let Device <br /> ❑ POWTS Repair County# _gallons or cubic yards) ❑ Portable Restroom knit I <br /> ❑ Revision State# ❑ Other .� <br /> 1 <br /> Responsibility Statement: (Check one or both ❑as appropriate. d <br /> ❑ 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> P,<the undersigned,assume responsibility for the installation of the rion-pluiribing non-plumbingsanitary system for which this pentait is issued. <br /> Plumber's/Owner's Name(print) Plumbe /O nRr's9i nature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Sheet Cit),State,Zip Code): <br /> n1 00°I{� <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin ent Si uc <br /> W-Approved ❑Owner Given Initial Adverse 150 e __ 28 J <br /> Determination 7 <br /> Comments: nn <br /> Pertly r"E AIoT To Fcccc� 3.o Q4--6 "i Dk� <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />