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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 ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name ��/ Property Legal Description �1 <br /> "a\j "{ M©' � GL I/4 l/4,S 23,T'yCI,R (O(W <br /> Pmperty Owner's Mailing Address Lot Number Block Number <br /> Sa90 Clr�n I -� D- 7+a0 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> r�t1�11 e( , M N I S5q L9 ) <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> 1$[ 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑village�0��IGu�O, 1030C Scho n0 CY <br /> ❑ Public 1A Town of Fire Number O O <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] <br /> oaf OoD <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 /> `jd POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#jsg gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ 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 /> ❑ 1,the undersigned,assume responsibility for the installation of the non-plumbing sanitarysystem for which this permit is issued. <br /> Plumber's/Owner' Name(print) P bet's/ wner' Si tore: MP/MPRS W No.: Business Phone Number: <br /> ?a Bni�ls � oo��o r6 7/s-5ff_ SS33 <br /> Plurfibces Address(Street,City,State,Zip Code): <br /> ail use She_ RE135 , 5.ret,, 5 qg 7 d <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Is in Ag t Si ature <br /> Approved ❑Owner Given Initial Adverse /6. p0 9-Z9—/G <br /> Determination <br /> Comments: <br /> Conditions of:approval/Reasons for Disapproval: <br /> /VOVe — RrSCI' To Ito lepZjIg,el dot %o Aae+aye. <br /> �Fp 9, q�Uf V <br /> Revised 6/7/02 t <br /> BURNETT COUNTY <br /> ZONING <br />