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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 APPLICATI :($50) <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> J/At+ SftVly GL 1/4 1/4,SdgT`ON,R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1613 lark Av a. <br /> Ll <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> l tih i f 2 13tva SS>l D ( (o S/ )Y�`7•N�I <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> O 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village Glrrw r SA <br /> ❑ Public Ia Town of J,,,,,n Fire N umber <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreationtentertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> )kNon-Plumbing(Privy,Toilet,Restroom etc.) ,Q Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair Cou # _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> 13 Revision State State## ❑ 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 /> ❑1,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) Plumb!'s/Owner's Signa rc: MP/MPRSW No.: Business Phone Number: <br /> S /P1 S ?`glN <br /> Plumbers Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> O Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> O Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 617/02 <br />