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c <br /> a g. b <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI g; N <br /> Applicant Complete All Sections Below This Line = a N <br /> Check Type of Non-Plumbing System/Device; Fee is. for All Types <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION O <br /> cl <br /> i'1'40 rivy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) o <br /> v Privy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) <br /> aomposting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br /> • Incinerating Toilet Device Must demonstrate unit is approved for use by WI DSPS) itG <br /> Property Owner's Name: M etirhD )4,,Ye:214 <br /> Property Owner's Mailing Address:a. . 02 �i6P IBX . (f S R3v5) 12-t- <br /> 570`i _ <br /> Ci State Zip <br /> Property Site Address: 7/- , ./2„53.12. G I l G Rc1•/ 6 t'G,n1'sb bot s, v.73. 5 N 8 4 0 n G <br /> Contact's Telephone Number: �, `� 05 / <br /> Contact's Email: 1/14-C'ArG ( ( , r-- )r CCl`Pr 0. N <br /> Legal Description of Property: L 04 11 CS^1 V2.2 915L/ (#3891450 (St,/ N E. 5 <br /> Section#: Z g Town#: 31 N Range#: 1 q W Town of:W eS+ Ma PS 1'11a n J m <br /> *Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page.* <br /> " 1 <br /> Tax ID#(1-5 digit number;found on tax statement): 323 S 6 <br /> v) <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY t 4 3 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: �, Ci. y x <br /> 1 W5 pe-rpiug-- /s. 1 r ie._ Sly Mar cow► o5.iky *4e-I `n d <br /> P Is ‘A) <br /> z w <br /> ,° hVI <br /> AN <br /> Date of staff site visit: Z V 2.0 22Initials of site visit taff: / �/► .-i Fee Rec: ✓ 0"- <br /> % x <br /> Check#:63 55 <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: �'_ , 1 DATE:"/PGl�` e <br /> /1 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF : C <br /> 0) Gal <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHTaa. <br /> n <br /> 3 v�v <br /> Z N U i+v <br /> r• y T <br /> c� <br /> v o L <br /> Page l of 2 _ m <br /> Burnett County, Non-Plumbing Sanitary Application —Rev 12/2021 < 3� N <br /> tm <br /> u 3 <br /> a <br /> ro <br />