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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 5487 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name <br /> /� Property Legal Description <br /> Rene QejjRrlGC GL SW1/4NR" 1/4.S3�- T90N,R46 <br /> Property Owner's Mailing Address Lot Number <br /> Block Number <br /> ,l 73 9q Srcn Ge. IZoP. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> webs{ev- tNt S_ I ( 71-f f —Y4).G <br /> Type of Building: (Check one)❑ State-Owned ❑City I Nearest Road <br /> 1$ 1 or 2 Family Dwelling-No.of Bedrooms: 0�1 ❑Village I LA&sA4Mq 110. Sr <br /> ❑ Public aTown ofOgkIand Fire Number at 7s.�b <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbens) <br /> campground festival,recreationientertainment event etc.)] <br /> pip— Oq3oo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> .R POWTS Reconnection ❑ POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ Other: _gallons or cubic yards) ❑ Portable Restroom unit <br /> ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ®I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume resoonsibility for the installation of the non- lumbin Barri system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumbet'siOwncr's Signa e: MP/MPRSW No.: Business Phone Number. <br /> - 91(1((- //o 1CIrt S 1 7/s- ?G(o -4ls-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu' gent Si re <br /> fir..!pzro <br /> ved ❑Owner Given Initial Adverse y a �f L O <br /> Determination <br /> ents: <br /> Conditions of Approval/Reasons for Disapproval: <br />