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BURNETT COUNTY ZONING ADMINISTRATION 5v,)O�v <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION 41 <br /> POWTS RECONNECTION <br /> POWTS REVISION ) n <br /> Application Information—Type or Print vl 1,1 <br /> Property Owner Name r Property Legal Description lON <br /> Pf- a Ylr,c,� , �je �lZ Z2 <br /> GL 2 1/4 1/4,S Ty/N,R /W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> * !(2! MetIla Pyi Ave <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> AA4k*we&A', MN PIIS_ 6sl- `f�63�7/ <br /> Ty of Building: (Check one)❑ State-Owned ❑Ciry Neare t road <br /> p' 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village <br /> ❑ Public 11B Town of St vt;f Fire grpb(b�bys <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 /> 637_-S-22Z —G ? !DO <br /> T_ yge of Permit: Type of Non-Plumbing Device/System/Toilet/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) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,;pe undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> & the undersigned,assume responsibility for the installation of the non-pjumbing 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 /> *,evt t -0 '3e r 4 LS/ - 42-- 3Y8` <br /> Plumber's Address(Street,Ci ,State,Zip Code): <br /> 25 Cv �d F yLleV/Q w /U 51-12-Z <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Iss uled Issuing gen i na <br /> Approved ❑Owner Given Initial Adverse 7 O/ <br /> Determination <br /> Comments: <br /> h1 _o Asy Ye. c?�,.s 7pm <br /> w t+�i d�„`f- �e �hs�l�Q,�aN o�� a�t�v�'.Sa•=,�y Srs�.�,,- <br /> Conditions of Approval/Reasons for Disapproval: <br />