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z <br /> NON-PLUMBING SANITARY PERMIT APPLICATION— Burnett County, WI y- N <br /> Applicant Complete All Sections Below This Line <br /> a <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types a o D <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION --0 0 <br /> g <br /> ❑ Privy—Pit Toilet (Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> o <br /> 0 Privy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) <br /> I <br /> de Composting Toilet System (Must demonstrate unit is approved for use by I D PS) X) <br /> SQ/7/11/92e "SP4CEssi' " itiWNS7' s; — '� ' <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) a <br /> 01441-e / 1141cGia d <br /> o4vi a , <br /> Property Owner's Name: / /� j L <br /> Property Owner's Mailing Address::1�JU 62 `/0/"�`'- `A was i �/�s"w4 t /"t/" c�6� -INN._ <br /> (ip p I I C.UI i am ir..J/ r 7 1 City State Zip <br /> Property Site Address: f // (� / ! 1,�� <br /> Contact's Telephone Number: (6'6)' ` w o '� <br /> Contact's Email: 474'6?G , c(4/�- Y/1---4j7 . CO`4 •, <br /> a <br /> Legal Description of Property: p2�ce7 7�h�70( �� {Coe ,-2/, ,e-4--7/7.6q`--.7zG 5 sl <br /> 2 'V Piit g'� b 1 <br /> Section#: 3 Town#: 3 9 N Range#: /'7 W Town of: � r <br /> *Attach additional page if needed for lengthy description OR attach apcopy of the deed OR attach tax system property page.* �, <br /> Tax ID# (1-5 digit number;found on tax statement): 5� o 1/7 iP <br /> cm <br /> 0 <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY o ° - <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br /> cro —I <br /> W. <br /> 5 <br /> H <br /> n <br /> z <br /> Date of staff site visit: (J! A/a-I Initials of site visit s afI': "' <br /> / Fee Rec: (`-d Q <br /> /!/� = rte. s3 <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: / DATE: m <br /> r <br /> Zr.2 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF < --� —� <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT litil <br /> a 0 W n <br /> v _ G) <br /> 2CD2 5W <br /> cm <br /> 0o c= <br /> Page l of 2 -mo <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2020 < 3` •= <br />