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CK.I- 07a 5µc$/' O <br /> BURNETT COUNTY ZONING ADMINISTRA kF © E EN E <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 AUG 2.4 2021 <br /> 715349-2138 <br /> Burnett County <br /> NON-PLUMBING SANITARY PERMIT APPLICATIOT ($1540 Services Department <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Act-Ni 2 D \tit-V6 .Y_ <br /> t <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> t <br /> Property Owner Name Property Legal Description <br /> 6 n) l.e Teik< GL i 1/4 1/4,S /i r' etie'' ' 1' ' U <br /> Property Owner's Mailing Address Lot Number Block Number <br /> L/(1, 113 X, n,neS Ln /V <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> PIyr,OtAf1, rv(,v 5:5 LId. ) M <br /> ` 0Cit I Ne e t Rqa i <br /> Type of Building: (Check one) 0 State-Ownedy t i, R rrt U <br /> 14 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village I <br /> ❑ Public ®Town of f<o# Fire Nylnbe (� <br /> d d �8 k.j <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) ki <br /> campground,festival,recreation/entertainment event etc.)] N. <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy–Pit Toilet 0 Composting Toilet System <br /> ,rit POWTS Reconnection ❑ Privy-Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair County#_ � gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> gI,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ifs <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 Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> 72/G-/Z. {/a-�/Li s /?4,/^ 1/7/04,1 (;731`5.-- -r-/ 7'/':-ge his <br /> Plumber's Address(Street,City,State,Zip Code): <br /> "71 7 ' /'v ; 3.5- 1/ti- _'7`.e-, Gt/- -5 1 7.1 –` <br /> Office Use Only: .), <br /> � <br /> 0 Disapproved Permit Fee: OP CST No. Date Issued •nt Si •or.' <br /> a proved ❑Owner Given Initial Adverse 50 7 �� <br /> Determination ✓`' ���" ' <br /> Comments: // <br /> ‘40 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />