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ON COMPUTER/SCANNED <br /> 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) f <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Q Property Legal Description <br /> !l i S GL.SY SP/4 iV va,S20 ,T'y04,R/ W <br /> Property Owner's Mailing Address/ Lot Number Block Number <br /> u.v . U <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Ro <br /> El or 2 Family Dwelling-No.of Bedrooms: / ❑Village <br /> lYPublic Cw;r-e — • y1r (Town of ugvia,_a Fire umber <br /> 7 m2 <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.)] 04F-000— <br /> Cafe /3isl�re u„ ,( 1 Bei(rOeA+ APG4 Mf'Wf 4/4!000 <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 /> 03oPOWTS Reconnection ` ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#� Lgallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> I�esponsihility Statement: (Check one or both❑as appropriate.) <br /> the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> I,the undersigned,assume res onsibi ity for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRS W No.: Business Phone Number: <br /> P 7mber's7A/ddress(Street,City',State,Zip Code). )L <br /> Office Use Only: <br /> ❑Disapproved Pe it Fee: CST No. Date Issued Iss ' A Aiture <br /> {p Approved ❑Owner Given Initial Adverse <br /> Comments: , <br /> P` Determination I L <br /> Aiinovtta� Ezr�� �-f'��u f><�C s�p��rA4v/l� /�tpin�tmev�of ffA�� APprdvt'G� <br /> /oaa yell u/,?str Go.vara1e Grease S.vtilerQtar. �xif1;Nj /000gat[ SRacv Cow+crtt <br /> /,f/4 S Ct,FI j v plann, <br /> Conditions//of Approval/Reasons for Disapproval: 1 <br /> fl/i�,� 7qt dfe Lpa,vyt front a kes; ,vlial w,,shWaer "ow — !o a Gi�n4r/lr6is� <br /> ,I <br /> At <br /> Revised 6/7/02 <br />