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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 RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> Pro eerty OwnerName <br /> Property Legal Description <br /> EV� KMnerl GL Sw <br /> Property Own is Mailing Address Lot Number Block Number <br /> 405 tfi h I ' <br /> City,State UZip Code Phone Number Subdivision Name or CSM Number <br /> Ch A_�seh MA) <br /> Type of Building: (Check one) ❑ State-Owned ❑City Ne est Rod <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village .SC�ffnoEd G�] <br /> ❑ Public Town of Fire Number <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 /> vTye of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: J� <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection County# 2.Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair V�Q gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 0 Other D <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ❑ 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 1,the undersi ned,assume resmonsibilitv for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> PIm er's/Owner's Name(print) I Pb Owne 's Si to MP/MPRS W No.: Business Phone Number: <br /> O� u rz <br /> Plu ber's Address(Street,City,State,Zip Cod <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> Approved ❑Owner Given Initial Adverse <br /> De[ertnina[ion �— I v <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />