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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 /> POW"REVISION <br /> Application Information—Type or Print <br /> Property Owner Name <br /> Legal Description <br /> GL 1/4 1/4,5/s T N,k/T W <br /> Property Owner's Mailing Address <br /> ^� Lot Number Block Number <br /> 374/ 66 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> mone2 &LT 7/S - <br /> Type of Building: (Check one)❑ State Owned a city Ness f� <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 7- Q village <br /> Public Ia'lownof �tSK Fue <br /> Public Bugdin L 7 <br /> g/I and Use: [Explain the usetpiapose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entemtainment event etc.)[ <br /> Type of Permit Oz�-3lis-oz 800 <br /> ❑Non-PlumbingType of NOD-Plumbing Drvice/5ystem/Toilet/Unit: <br /> (Privy,Toi Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> fl Other: S Rectmnection fl POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> O� or _cubic Surds) ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> jo I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume res onsibili for the installation o e non- lumbin sani s stem for which this t is issued. <br /> �' (��AVATI �' er'sSi SW o.: Business Phone Number: <br /> as�879 <br /> SPOON R$ 54$ 1 <br /> Office Use Only: <br /> 0 DisOwner <br /> Permit Fee: CST No. Date I mture <br /> Approved - O Ownerr Given Initial Adverse t Sig <br /> IX Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> BUgN ` In0� l <br /> F <br /> 20N C Ujvr <br />