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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 ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> 0. 41- 7t ?eG GL V Wl/4 SC 1/4,S ZI,,T N,R (luW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> WIZ ` o\k SX Ae I - W <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number 41 <br /> SSoI• ( 3 -1'37-0 3496 Uol ZI 43-1 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village ) <br /> ❑ PublicA ai1mvn of Fire Number <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 /> Zt� -Il Vf <br /> -Soo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) 8"Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> 11 POWTS Repair County# 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 /> 191,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) tum is/Owner's Signature: MP/MP�RSW No.: Business Phone Number: <br /> S <br /> e /A lsl•731-47-1 �^ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 91�S SL A)E -\a.wil ole <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss g ent Signa re <br /> Approved ❑Owner Given Initial Adverse . <br /> Determination tel/ <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />