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ECE0 E <br /> BURNETT COUNTY ZONING ADMINISTRATI it �, '7! <br /> 7410 COUNTY ROAD K, #102 I APR 1 9 2022 <br /> SIREN, WISCONSIN 54872 -s / <br /> 715-349-213$ Burnett County <br /> Land Services Department <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) Z <br /> -a <br /> '-O <br /> i <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> I <br /> Property Owner Name Property Legal Description C' <br /> &aok Properties GL y 1/4 l/4,Sdi4 /10/tift4if; U <br /> Property Owner's Mailing Address Lot Number Block Number <br /> G2 7 7.25" J etl,osa i L1< Rot <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> t /.e&, fr i4' . 851 ( ) - (9 /We J <br /> Type of Building: (Check one) 0 State-O ned 0 City Nearest Roan /7� 03 <br /> 4 I or 2 Family Dwelling-No.of Bedrooms:4 0 Village Jen,as'N l./ .. <br /> ❑ Public ®Town of061G1ay d Fire Number)'77d.s— <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 /> 1 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy—Pit Toilet 0 Composting Toilet System <br /> la POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device U <br /> ❑ POWTS Repair County#. � gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# 0 Other <br /> Responsibility Statement: (Check one or both 0 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-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: \1 <br /> Plumber's Address(Street,City, Zip Code): <br /> -- //?-76 O ,-- i J'S -e-6 5-7`,- Gt/.1 -5-7-1=-g 7 3 l <br /> Pi <br /> Office Use Only: <br /> 0 Disapproved Permit FeeCST No. ��' Date Issued I uing' nt S �'- , i <br /> A roved 0 Owner Given Initial Adverse 530771 /? v <br /> Determination ' O J Z/��� / , 1 , <br /> Comments: ;\ <br /> l:� <br /> Conditions of Approval/Reasons for Disapproval: Ul <br /> 13". <br /> Revised 6/7/02 <br />