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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 S <br /> 715-349-2138 S <br /> a <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> Ott :5 LcAmi f GL /d'a 1/4 1/4,ST N n <br /> Property Own&s Mailing Address IS R/7 <br /> Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> >eec/A wt 1--fqbd o 7/s-) ass-d CSM V. r loll? <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village w p/a FF 4k <br /> ❑ Public VTown of Fire Number <br /> unroh <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 036— e14169-c. �-0100 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> A Non-Plumbing(Privy,Toilet,Restroom etc.) lg Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection Coun # 07 11 Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair ry gallons or <br /> ❑ Revision State# 11 Other _cubic yards) ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> 191,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber's/owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Rlc k �iP�rns /2u ,,d1 d d s-�ri 7isy 8GG-�/�s`7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 7760 /mow �$` Gv2�S7��i G✓Z` ����4� <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin t Si <br /> lar�Approved ❑Owner Given Initial Adverse < �,N14 y dS <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> ®pftEO Iv�h �irv,/ P,r tib• A Y 93.0 ' &4/4 rIA) krt OW) <br /> Revised 6/7/02 <br />