Laserfiche WebLink
BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> GL 1/4 1/4,S ,T N,R W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest oaa <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village q <br /> ❑ Public Town of Fir�Nu <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) oC <br /> campground,festival,recreation/entertainment event etc.)] <br /> 0A -o - <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> �ROWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS RepairCounty# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 11Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ 1,the undersigned,assume responsibility for the installation of the non-plumbin&sanitary system for which this permit is issued. <br /> Plumber's/Owner's Na a(print) Plu b 's/Owner's Signatu MP/MPRSW No.: Business Phone Number: <br /> e tied/,-•, XI �z76q/ 3 v/c?_,:?!2_04 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved P rmit Fee: CST No. Date Issued Issuin en[Si ure <br /> pproved ❑Owner Given Initial Adverse �o/-� -,`/ O <br /> Determination v/V J`l''u�Jpr <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />