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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, 4102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 ljJ <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) —� <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Legal Description <br /> r8500 <br /> rty Owner Name <br /> Folle Avoine GL 3 1/4 v4,s 24 ,T 40 N,R 17w <br /> Lot Number Block Number <br /> rty Owner's Mailing Address <br /> County Rd U <br /> StateZip Code Phone Number Subdivision Name or CSM Number <br /> bury, WI 54830 <br /> (715) 866-8890 <br /> ❑City Nearest Road <br /> Type of Building: (Check one) ❑ State-Owned ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: Union <br /> Fire Number <br /> XTown of <br /> ❑ Public Parcel Tax Number(s) <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e.. 03E_4424-02-200 <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> X Priv Pit Toilet ❑ Composting Toilet System <br /> m <br /> X Non-Plumbing(Privy,Toilet,Restrooetc.) y— <br /> ❑ POWYS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> County# gallons or _cubic yards) (3 Portable Restroom Unit <br /> ❑ POWYS Repair _State# ❑ Other <br /> ❑ Revision <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 /> X I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit <br /> stPhona Number: <br /> Plumber slOwner's Name(print) <br /> Plumber's/Owner's Signature: MP/MPRSW No.: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Pe it Fee: CST No. Date Issued Issng Agent Signature <br /> proved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Privies for Karlsborg School & Historical Indian Village <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />