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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 /> �WAOWN/RECOINCTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> PrOT Owner Name �} Property Legal Description <br /> � � ` GL 1 1/4 1/4,S) T N,R(5 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> gag .0 <br /> City,State ZipCodePhone Number Subdivision Name or CSM Number <br /> /jType <br /> — of Building: (Check one)❑ State-Ow 11City N crest a <br /> or 2 Family Dwelling-No.of Bedrooms: d ❑Village v <br /> ❑ Public Town oP'rg s F <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] 0'7 O)a 0E <br /> 001—o 1(0001 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> WTS ReconnectionC ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair ounty# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 19Si19 ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Na a(print Plumbees/Owner's tore: MP/MPRSW No.: Business Phone Number- <br /> Plumbees Address(Street,City,State,Zip Code): <br /> )&0,,y --S—/ e „J 7,-7- <br /> Office <br /> ,2Office Use Only: <br /> CO3Disapproved Permit Fee: CST No. Date Issued Iss n Agen Sig re <br /> Approved ❑Owner Given Initial Adverse /�'D S'3/�/p <br /> Determination <br /> Comments: / <br /> /000.14C /l/ersvt/t/�o %.vK is (/sl�D`o.^ �tc�or,/V'"yl iivL'y- A 'tli A%e4$ <br /> (/'r.�/tr 6t•�rr�! r�url6;.v� �fs. /l`via4er 31 ���'/�vs �ivat fLoars�rar'N '�or <br /> /1 f to�wvte�oi y, <br /> Conditions of Approval/Reasons for Disapproval: <br /> nQ ECE#VEN <br /> Revised 6/7/02 <br /> MAY_j1 2016 <br /> BURN - COUNTV <br />