Laserfiche WebLink
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 ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description rt <br /> A1&kj4. �rIG�C�6 N GL f 1/4 1/4,Sat0 7901V /ZIs4%) <br /> Property Owner's Mailing Address Lot Number I Block Number <br /> AI ?337 N Shore Do, 1 +1V a La <br /> City,Slate Zip Code Phone Number Subdivision Name or CSM Number <br /> I►'�enOS44- w .S4t9S-,4 V ' <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road LK t!F/� <br /> I or 2 Family Dwelling-No.of Bedrooms:-3 ❑Village <br /> ❑ Public Town oJ4C/<S aN <br /> Fire Numbe�76 yO <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.)] 67,-01d`-J` <br /> �doy , O/S000 <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#. gallons or cubic yards) ElPortable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> gl,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 111,the undersigned,assume res2onsibilia for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber's/Owner's Si `ure, MP/NIPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss iqg' n re <br /> Approved ❑Owner Given Initial Adverse <br /> Determination J (9 <br /> Comments: <br /> Conditions of Approval/R asons for <br /> Disapproval: <br /> �/ �t'Y W l L T •�✓t P C"iGY Pr'. Awl nmol �PL O w�eto <br /> G� iA j A S (�✓/ f <br /> Revised 6/7/02 <br />