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NON-PLUMBING SANITARY PERMIT APPLICATION—Burnett County,WI a: i <br /> � <br /> Applicant Complete All Sections Below This Line a a N <br /> d <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types ^� <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION "%.1 o <br /> I <br /> ❑ Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> n ib V6► <br /> ❑ Privy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) r Pi0 <br /> ❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) St) nS <br /> ® Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> P. <br /> Property Owner's Name: 11 <br /> Dave Russell <br /> Property Owner's Mailing Address: 942 159 NE Ave Ham Lake MN 55304 -� <br /> City State Zip <br /> Property Site Address: 28875 Brozie rd Danbury 54830 n <br /> Contact's Telephone Number: 763-228-5335 0 <br /> Contact's Email: daverussell@izoom.net o <br /> a <br /> b <br /> Legal Description of Property: SE SE EX PCL DESC IN V 112 P 130,V 404 P 571 E. <br /> .-o <br /> Section#: Town#: N Range#: W Town of: SEE ATTACHED °0 <br /> *Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page.* <br /> Tax ID#(1-5 digit number;found on tax statement): 17806 <br /> cn <br /> -i <br /> 0 <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br /> THIS P RMIT I U�CT TO ALL CONDITIONS LISTED BELOW: <br /> �e . <br /> e a ( a <br /> � <br /> 1 .114 eert4W4tiljfr -F]. ....1 <br /> z <br /> r6')— <br /> Pc <br /> Date of staff site visit:31 1 I Initials of site visi staff: ,/ v, , / Fee Rec. - <br /> T � <br /> / 7/1/h4 Check#: (`e.S <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: � DATE: m <br /> � <br /> 7 -C :=1 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF _ lUN <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT a o 0 <br /> iuvlCV C <br /> Page l of 2 n <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2021 <br /> ° n 0 <br /> a <br /> 3 <br />