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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) 6 <br /> POWTS CONNECTION/RECONNECTION($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name/' Property Legal Description <br /> Jl�O /t k,& / GL 1/4 114,S 33 ryo v R(b <br /> Property Owners Mailing Address Lot Number Block Number <br /> 10,3 Tvy 1vOr^, 6,f 7 I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> w0ew(11e Wl S9oa$ (?rS )(�y8--3®,(� /Qfbrrf lGklbe<k�,�tth, �eU��sla <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest R„ad .c<!�'z <br /> 14 1 or 2 Family Dwelling-No.of Bedrooms: ❑village <br /> ❑ Public ®Town of0pfjk1an1 FireNumber <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e.. Parcel Tax Number(s) <br /> }� <br /> campground,festival,recreation/entertainment event etc.)] p�IO 907-J fes/ (p OQ <br /> o7-Da0-a-�fcrl(o-�-s-15-DIS-a <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 /> ,,'POWTS Reconnection ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair -County#_ 81'1 i-[.� gallons or cubic yards) ❑ Portable Restroom Unit <br /> 13 Revision Other <br /> Revision State# tJ,S(y23 her <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> 91,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- lumbino sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's SSiiiggnature: MP/MPRSW No.: Business Phone Number: <br /> Plumbers Address(Street,City,State,Zip Code): <br /> 3 S u S7`e i Gt/1 S ��93 <br /> Office Use Only: <br /> � ❑Disapproved Permit Fee: CST No. Date Issued lssui nt Si <br /> SApproved ❑Owner Given Initial Adverse V yD / �ZOIL, <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: 1- <br /> bvgift's Sew" -6o le. In5v1a4.(/ vh(GSS .'Sea.5aK4 um_ 1s m4e_vr � <br /> Revised 6/102 _/^/C�� <br />