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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(S50) <br /> POWTS RECONNECTION(S25) <br /> POWTS REVISION($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Dmngm <br /> Trend B1azeL Gt.S 1/4 Iu,S93 yON,R/7W <br /> Property Owners Mailing Address Lot Number Block Number W <br /> L939571;y,Wlect. brt-kx (I$ o^ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number r,1 <br /> (,Woodbun, , mN S-sia� f6s[-ws� .gxr CSM v. iu .ay W <br /> Type of Building: (Check one)❑ State-Owned O City non Ne YRo,d <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: O Village U /DVC/ i-. <br /> ❑ Public own of Fire Number <br /> Public Building/Und Use: [Explain erre uWpurpow for this pomik,(i.e., Parcel Tu Number(s) <br /> campground,&stival,recreatioiventenamir ent event etc.)) 0 3 & -qw a 3 -05-L/3 D <br /> Type of Permit: Type of Non-Plumbing Device/Systetrt/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet, Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System J <br /> _ ❑ POWTS Reconnection F Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device 1 <br /> ❑ POWTS Repair County p 95—W gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State M ❑ Other <br /> f <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 4 the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> L the undersi neer,auume rcs nsibit* for the installation of the non-plumb'n sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumbers/Owner's Sigmture: MPIMPRSW No.: Business Phone Number: <br /> IfeNr <br /> N <br /> Plumbers Address(Street,City,State,Zip Code): (� <br /> \f\ <br /> V� <br /> Office Use Only: <br /> 0 Disapproved Permit Fee: CST No. Due Issued Issuing Agent Signuurc <br /> O Approved O Osnrz Given Initial Adverse -p-O S lrr n Aod,�a <br /> Determination / /�(3- <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 67/02 <br />