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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information-Type or Print <br /> Property Owner Name <br /> /� Property Legal Description <br /> Rene, 13 e114n�� GL SW1/4NR_ 1/4,S3X T90N,RUP <br /> Property Owner's Mailing Address Lot Number Block Number <br /> )173 9q 57`oneGu vc lZoP• <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> webs{er- Wr I sweej lis P -V9*L& <br /> Type of Building: (Check one)❑ State-Owned ❑City I Nearest Road <br /> I$ 1or2Family Dwelling-No.of Bedrooms: oL ❑Village W.s/,to Ifs.. Sf <br /> ❑ Public a Town of 0Ak14nd Fire Number ot73'4,6 <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 /> 0,�0—17,4S-Og300 <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 responsibility for the installation of the non- lumbinjz sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signa e: MP/MPRS W No.: Business Phone Number: <br /> R (C J{e 1610 S 7/s- fl l& -W-s-,7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> I+�7 6 O CeIW �J L✓-�6 S?��C r //✓�' -S�f 8� <br /> Office Use Only: <br /> --// ❑Disapproved Permit Fee: CST No. Date Issued Issui gent S <br /> l- i <br /> Approved ❑Owner Given Initial Adverse �v r <br /> Determination <br /> Comments: <br /> �U 01j�B <br /> Conditions of Approval/Reasons for Disapproval: 9N C 200 / <br /> pp pproval: <br /> 0/q, ON <br />