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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 CONNECTION/RECONNECTION ($50) <br /> T <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name ^ A Property Legal Description <br /> 'I ' 1 111 /!�^/1 (]/ /` GL 1/4 1A,S 5,T 41 N,RIto W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> s a� � 's <br /> Crty,State Zip Code Phone Number Subdivision Name or CSM Number <br /> g3 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Barest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public Town of cc��'' FireNumber <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 /> 07-0a-d-Ll1-I 0-3S-3-03-01)-Ot5ODD <br /> TFe of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) �Q Privy—Pit Toilet El Composting Toilet System <br /> POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair rs <br /> ounty# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision ate# ❑ Other <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 /> ❑ 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 Si ure: MP/MPRSW No.: Business Phone Number: <br /> W i A 7 ? rHeh <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> � // ❑Disapproved Permit Fee: CST No. Da a Issued Issui cut Sign <br /> &Approved ❑Owner Given Initial Adverse � y� <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />