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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 ($50) <br /> 0QO- Y3/s-oa- yob <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Propert�^0 eer N(am,a Property Legal Description <br /> GL SE 1/4SOJ1/4,S /S TI/ON,R)kW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a $qss� 2d <br /> City,State / Zip Code Phone Number i <br /> vl bU It 55/830 �ls)b1�4-</d'J N b'�`Ic L� Ya Sf 5L4 Ex F W3j` <br /> -Type of Building: (Check one)❑ State-Owned ❑City Near Road P-d <br /> . 1 or 2 Family Dwelling-No.of Bedroorns: ❑village n <br /> ❑ Public AT.of OaKW Fire Numbera��s� <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 0016- g3Is-60- 4/)0 <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 /> $( POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# a a/a gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 3 3p3 b� p Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ;9�I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Sire: MP/MPRSW No.: Business Phone Number: <br /> Ukzdz �c sl�o-� ow 3 340 3ye, - 7a�� <br /> Plumber's Address <br /> P oX (Street,City,State,Stat;e,IrZip�Code): <br /> sly 7& <br /> 9/ <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issd gen[Sign <br /> Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />