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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, 111102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 -� <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) t <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> W <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION C� <br /> Property Owner Name Property Legal Description qq <br /> ,VAJ ,�v r-/�resCl�ir�J "'�' GL 1/4 1/4,SZj ,T1 N,R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Y ,,o4 zj 7 <br /> City,State Zip Code Phone Number 641�11 + h�^�e or CSM Number <br /> Y� <br /> e of Building: (Check one)❑ State-O}nv.d El City Neasgst-Dad, <br /> 1 or 2 Family Dwelling-No.of Bedrooms: V v)k1)wsc_ El Village ! JL <br /> ❑ Public 7Town oflk&rtlwtil Fr yc <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Fax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—pit'I'oilet ❑ Composting Toilet System <br /> ;K�OWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#. 35a,.)O gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# Ij_g�_ _ ❑ 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 /> Plumber's/Owner's Naige(pri t / Plumber's/Owner's Si e: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 164.-1ir1y <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. ^7 Date Issued Issuing Agent Signa re <br /> Approved ❑Owner Given Initial Adverse 5 0 1 3 1 5 3 /5 —a l 16 <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />