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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> LL C, GL Z 1/4 114.S 3STqON,R( W <br /> Property Owner's Mailing Address Lot Numbe Block Number <br /> 222- 1st v lew <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Clea L 5 0(i t-7i s 2 3-- � `�-7O V3 24 2 <br /> Type of Building: (Check one)C1 State-Owned ❑City Ne rest Rot,d <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: �.� ❑Vim'M <br /> C3 Public age I,` <br /> gown of Dp 4a Fire Numbeff <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,rweation/entertainment event etc.)) <br /> 020 y333 03 t CO <br /> T pe of Permit: Ty a of Non-Plumbing DevicelSy;tcr>,t_/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet, Restroom etc.) Allativy—Pit Toilet I tLd-Uomposting Toilet System <br /> POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: 1 cinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) tCPortable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 01,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this ennit is issued. <br /> Plumber's/Owner's Name(print) P=ns/O nature MF/MPRSW No.: Business Phonr Number; <br /> g«jne 7 � soh '715 z63-308-7 <br /> Plumber's Ad ess(Street,City,State,Zip Code) <br /> 2 sIr A u e W C ea r La Z S1100 <br /> Mee Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss gent Si lure <br /> Approved ❑Owner Given Initial Adverse y <br /> Determination 5U•�v 5�?-a 3 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />