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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) <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 /> Kenneth Erickson and Terrance Erickson <br /> GL NE 1/4 NE 1/4,s29,T39N,R16w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Box 614 2 <br /> City,Stale Zip Code Phone Number Subdivision Name or CSM Number <br /> Webster, WI 54893 ( 715) 866-4803 CSM V19 P55 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> 'W I or 2 Family Dwelling-No.of Bedrooms: ❑Village State Rd 35 <br /> ❑ Public X Town of Fire Number <br /> 25597 <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.)] 07-018-2-39-16-29-1-01-000-012000 <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 /> X POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 11066 gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appro riate.) <br /> X I,the undersigned,assume responsibility for the P WT c ity for which this permit is issued. <br /> ❑ 1,the undersigned,assume res onsibilit for the' tall o fthe non-plumbing sanitary system for which this permit is issued. <br /> Plum is/Owner's Na (print) Plumbe wn i na[ur MP/MPRSW No. I Business Phone Number: <br /> Plumberf Address(Street.City,Stine,Zip Code): <br /> 9 v <br /> Office Use Only: <br /> ❑DisapprovedPermit Fee: CST No. Date Issued Issui en[Si amre <br /> e Approved ❑Owner Given Initial Adverse Or <br /> Determination �l�r <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />