Laserfiche WebLink
c05' 1150 <br /> BURNETT COUNTY ZONING ADMINISTRA 0 E 0 N E <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 Z <br /> 715-349-2138 F AUG 2 4 2021 <br /> t <br /> NON-PLUMBING SANITARY PERMIT APPLICATION C. i Burnett County U <br /> POWTS CONNECTION/RECONNECTION ($50) Land Services Department l <br /> kt- zp ‘4223 <br /> y <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name / Property Legal Description M <br /> /�Gh Me' P4:rlrpS GL 1/4 1/4,S d7 %1(a f/2/Gw <br /> Property Owner's Mailing Address (( Lot Number Block Number <br /> /31(010 5henan c1 i- .17. N6 I) <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number (o <br /> Ne.,w• G(< Al h/ I! SS'3 d y �+ <br /> Type of Building: (Check one) 0 State-Owned 0 City Nearest Roa�i <br /> 0 Village /.�tvit'SL/�J�D( <br /> El or 2 Family Dwelling-No.of Bedrooms:_ / <br /> ❑ Public . Town of 0#4401 Fire Number ep 709 §‘ <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/enterainment event etc.)] <br /> i <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 ock .. <br /> POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ 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 /> j .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 Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> .., , ' 77-=/---Y.6 6 e71•/- 7 ph.---\ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> , 7-76 0 1 ,,,- 3_f_ -57‘t-,- Gt--- 5x.573 ,. <br /> Office Use Only: .), 1 <br /> � <br /> 0 Disapproved Permit F� CST No. Date Issued Is;in tt j; <br /> 8 Approved El Owner Given Initial Adverse L`�/r]'y1 Q/ /�) <br /> Determination ��.��//���� u { i i <br /> Comments: / I , <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />