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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 /I,, <br /> GL 1/4 1/4,S �b T`/6N,R16 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1 asp five, a 3 <br /> City tate Zip Code Phone Numbey', _ Subdivision Name or CSM Number <br /> ` Af SSBI y (�6 ��03 bn z L ca.&---,,, <br /> Type of Building: (Check one)❑ State-Owned ❑City <br /> _ pet <br /> do <br /> f <br /> Ior2Famil Dwelling ❑Village <br /> Town of 1M <br /> Fire Number <br /> Public <br /> Public Building/Land Use: tExplain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreabon/entertainntent event etc.)] <br /> 6a0-93 FD -03-3&0 <br /> T 7pe of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet X Composting Toilet System <br /> POWTS ReconnectionCount #t ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair y gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> XI,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume res onsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumber' wner's Nam (print) Plumb r' O MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee. CST No. Date Issued Issuing Agent Signature <br /> XApproved ❑Owner Given Initial Adverse t-75 -�9-0a A x.. <br /> Determination J <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />