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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 <br /> p � N <br /> /_ 1L rCr'1 tJsSYI GL I/4 1/4,S8 TVNjq1d <br /> Property Owner's Mailing Address Lot Number Block Number <br /> J-9 / L. Iden ed <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> a�� �� V P <br /> Type of Building: (Check one)❑ State-Owned ❑City e,.,�p N rest Road <br /> 'l ❑Village D --J. rn <br /> I or 2 Family Dwelling-No.of Bedrooms: �r <br /> ❑ Public ❑Town of 101�)/l4+p Fire Number <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 /> a/19-- 63 /aoo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) A Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑POWTS Reconnection ❑ POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑Other: gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Other <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 /> I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) PI bet's/ wrierSi to MP/MPRSW No.: Business Phone Number: <br /> Ad 4 rei] /Ue/50•n <br /> Plumber's Address(Street,City,State,Zip Code <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued [ssui gent <br /> Approved ❑Owner Given Initial Adverse jt /� /c <br /> Determination �1".�(J 1 ` <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />