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• <br /> BURNE T T COUNTY ZONING ADMINISTRATION - <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> Q <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> LS <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> I?ass ell 51;lee► GL 1/4 1/4,S/4 TydN/e/S <br /> -f <br /> Property Owner's Mailing Address ^ Lot Number Block Number <br /> ). � !8 �✓Lr'W► .$Pr/N�f,f /90e <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> Od/S _2.0 I 837/1+ v <br /> Type of Building: (Check one) 0 State-Owned 0 City Nearest.�Zgarl C ' Q <br /> 4 I or 2 Family Dwelling-No.of Bedrooms: 3 0 Village Ce/C 01 - e, <br /> 0 Public 2(Town y 6k.0oh Fire Number yvc /iU' <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 /> n <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 /> fit POWTS Reconnection j 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair ,County#_ gallons or cubic yards) 0 Portable Restroom Unit rt <br /> ❑ Revision State#• I ❑ Other ti <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> A '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: <br /> T'/G-k 7 /0'- /47 S l ll,1 s t )S,3 S> 7-t-4 eii-s <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,")), 7'76 G X/, y J'S1 z - f1-. Gv� -5-772g.7_ <br /> Office Use Only: • 1 <br /> � <br /> 0 Disapproved ermit Feer CST No. Date Issued 1 ,4asi, <br /> ,, <br /> .1a proved ❑Owner Given biitial Adverse `� J5 3 . 5//7/Pa At ;. <br /> Determination i fig., <br /> Comments:1;44 k 5;Ze an� �r e�� ) 5;ted cr a 3 belt/co/1'i <br /> _ 1 <br /> W <br /> ki <br /> 01 we(1 <br /> Conditions of Approval/Reasons for Disapproval: <br /> IECEOVED <br /> Revised 6/7/02 MAY 1 7 2022 <br /> E urnett County <br /> Land Services Department <br /> C K / 1594 i) <br />