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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 ON COMPUTER/SCANNED <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> P CTION <br /> POWTS REVI5I0 0 <br /> Application Information-Type or Print <br /> Property Owner Name M ;ch a(• W a I Ez--I n Property Legal Description <br /> tti GL 1/41/4,S�T40N,R 6 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Z25 3S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 011 . 5499; rs <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑VillageQ�" 3S <br /> Public Town of Fie Number <br /> S <br /> Public Building/Land Use: (Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 4 <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 /> ;rPOWTS Reoonnectio ❑ POWTS Repair ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> i�Other: J,,,.G —gallons or _cubic yards) 11 Portable Restroom Unit <br /> 3,,r,,,,.,G �,� ❑ 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 resportsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber's/Owner's Si MP/MPRSW No.: Business Phone Number: <br /> R)1*0np k�nrs Z.75 J5.8b6 ¢/� <br /> Plumber's Address(Street,City,State,Zip Co e): <br /> �77�b 3s A Gr/i. S 89� <br /> Office Use Only: <br /> ❑Disapproved fermit Fee: CST No. Date sued Issul a gna <br /> !PfApproved ❑Owner Given initial Adverse <br /> Determination /O <br /> Comments: <br /> ,Sao- <br /> Conditionsof Approval�ns for�a�l: <br /> X83- i <br />