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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 nom\\ <br /> Property Owner Name Property Legal Description % <br /> l7esin/`s GLA 1/4 1/4,S3'f T44N.R4w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> SYd ! Ave , fo , L-F 8 �e <br /> Ci ,State Zip Code Phonc Numbe 6 a, Subdivision Name or CSM Number 0 <br /> �✓;nr:�a v(l's , /�?tJ S�t7 -3)9ao CSK v (3 , P ag( <br /> Type of Building: (Check one)❑ State-Owned ❑Ciry Sp oc9vtNt— Nearest Road <br /> 8 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village e Lgne <br /> ❑ Public <br /> ❑Town of.st tt Ft�7m 2 <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.)] OR.S 'Y /3q <br /> Y '3q Q!;� 900 <br /> Type of Permit: Ty e o n-P ing Device/System/Toilet/Unit: <br /> ld Non-Plumbin (Privy,Toilet,Restroom etc.) rivy—Pit To ❑ Composting Toilet System , <br /> ❑ POWTS Reconnection ❑ Privy— ault Toilet(Vault size: ❑ Incinerating Toilet Device U <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ®1,the undersi ned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber Owner Name(print) Hit rrtlistner Signalure: MP/MPRSW No.: Business Phone Number: <br /> U <br /> Plumber's Address(Street,City,State.Zip Code): <br /> San,¢ 0q£ n � ovc <br /> Office Use Only: <br /> ❑Disapproved Permit Fee/ee:,, CST No. Date Issued Issu' gcnt Si ure <br /> (?Approved ❑Owner Given Initial Adverse <br /> S�vU �J q b? <br /> Determination <br /> Comments: �Rwy �rt D6r7YH Shall 11d �xee:er,F 3�7tx+ltar t$e a�..� <br /> q � CNN <br /> �n <br /> Conditions of Approval/Reasons for Disapproval: <br /> Ilk <br /> �u C E ite ate/ <br /> Palm <br /> l f� <br />