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L(C.44 n16644-) ng/3O <br /> BURNETT COUNTY ZONING ADMINISTRA'- © E i V E <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 SEP 1 4 2021 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($1 I Burnett County . 3 <br /> POWTS CONNECTION/RECONNECTION ($51)). Land Services Department <br /> I <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> NProperty Owner Name Property Legal Description <br /> C L 0,...1 /i I'( GL 1/4 1/4,SC 7-3fA/i? /ri <br /> Property Owner's Mailing Address Lot Number Block Number <br /> AI 43 IA)ynr'otSe Or• \02.32- 1 <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 14relvpi /has !_rs--"/d. ( ) <br /> Type of Building: (Check one) 0 State-Owned 0 City Nearest PR,oari F <br /> II 1 or 2 Family Dwelling-No.of Bedrooms:, 0 Village ��rri�6+C5'4 <br /> ❑ Public ®Town of LKiplofle+r1-Ire 1141 <br /> 7r(4i <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> ft <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 /> ,g POWTS Reconnection Count #_ I 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> y <br /> ❑ POWTS Repair gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both 0 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 Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> - 7-76 O //,-- 3S ---e-6_5 ,-, kti.� S`fS73 <br /> Office Use Only: <br /> 0 Disapproved Permit Fea2 CST No. Date Issued _6.g6 Sig. r ^' <br /> Approved ❑Owner Given Initial Adverse JI / ,d <br /> Determination �� `�� �// �1 �� �'T . /V /' K <br /> Comments: <br /> W. <br /> I1CI, <br /> /v <br /> W <br /> Conditions of Approval/Reasons for Disapproval: tV <br /> Revised 6/7/02 <br />