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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 APPLICATION <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> Q Ve.Al GL SW1/4,S.17T / N,RW <br /> Property Owner' ailing Address Lot Number Block Number <br /> i & <br /> City,State Zip Code Phone Number Subdivision Name or CSM Numbe <br /> Type of Building: (Check one) ❑ State-Owned ❑City Ne est�oadc <br /> �( I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public Town of St�� .S Fire mb r <br /> eej <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] 4'eerea4r aye <br /> U000 /0 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Rf Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS ReconnectionPrivy–Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair [State <br /> ounty# gallons or –/—cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision # ❑ 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 /> the undersi ned,assume responsibility for the installatio of the non-plumbing sanitarysystem for which this permit is issued. <br /> Plu�m)ber's/ow�ner'ss Name(print) Plumbe's/Owne ' ignature: MP/MPRSW No.: Business Phone Number: <br /> fSPiU ''�D <br /> Plumber's Addre (Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issgi Age t Sn ure <br /> Approved ❑Owner Given Initial Adverse •15b1-224,51Determination dot/ <br /> Comments: <br /> nditions of Approval/ asons for Disapproval: <br />