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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 ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description '/ <br /> Q GL 1/4 1/4,S 37 T-39N,RW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 �4-/Dry /41 <br /> City,StateZip Code Phone Number Subdivisi n Name or CSM Number <br /> 4;11S A <br /> Type of Building: (Check one)❑ State-Owned ❑City Nea s Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village �ee /jrN e W <br /> ❑ Public Town of Fire Number <br /> 3(4 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreationlentertainment event etc.)] p7"O34 "3 y' S /6-- tJ71— <br /> QZ6 000 <br /> Type of Permit: Type of Non-Plumbing Device/SystemfFoilet/Ilnit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> P POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as approp'ate.) <br /> 2 the undersigned,assume responsibility for theP WTS a for which this permit is issued. <br /> ❑L the undersigned, <br /> assume res onsibili for the stallat' f the non-plumbing sanity system for which this permit is issued. <br /> Plu es/Owner'ssNNprt) Plumb r' wner ature: MP/MPRS W No.: Business Phone Number: <br /> X39 )/.- Z� <br /> umbb 's Address(Street,City,State,Zip Code) <br /> M /�l aL sl�ZYc <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu'ng A ent Si ature <br /> Approved ❑Owner Given Initial Adverse /SD,0 lO�l� <br /> Determination /0 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> p ECEPSE-D <br /> Revised 1/12/2016 APR 15 2016 0 <br /> BURNETT COUNTY <br /> ZONING <br />