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e � <br /> 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 CONNECTION/RECONNECTION ($150) <br /> W <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name /' Property Legal Description <br /> V G GL 6 I/4 1/4,S30 ,T N,R16-E) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 7VIO Gouw7�y X x <br /> City,State Zip Code Phone Numbcr Subdivision Name or CSM Number <br /> S;Re,v 5 ( ) <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Roa r <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village ToLdsom <br /> ❑ Public R Town of Fire Number <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 /> OOG <br /> Type of Permit: T pe of Non-Plumbing Device/System/Toilet/Unit: <br /> D Ion-Plumbing(Privy,Toilet,Restroom etc.) Pnvy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection rivy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 'I gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 19 I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumb 's/Owner's Name(print) Plum r'slOwner's Si atom: MP/MPRSW No.: Business Phone Number: <br /> N GI'd1S �'C IS 3r-ani <br /> Plumber's Address(Street,City,State,Zip Code)' <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued =ntt6t ature <br /> Approved ❑Owner Given Initial Adverse /y p <br /> VVV Determination �Ar✓t� <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />