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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 (S50) <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name O� Description ) <br /> (/Tr-^ 'r}(' Property Legal Description(�r� " GL ' 1/4 1/4,S 0 T N,R15W 1 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> I FFF() oA K6(ff►v Ru <br /> City,State I Zip Code Phone Number Subdivision Name or CSM_Number <br /> (°h�lR11vEiJn1Si c�zolX Sa (�13?q9-73 u1S ply 1g3Lfs(o(p <br /> Type of Building: (Check one)❑ State-Owned ❑City N toad <br /> ❑ <br /> ] or 2 Family Dwelling-No.of Bedrooms: O Village IA6 <br /> ❑ Public -Mown of 5LVISS Fire Number t <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,rc(cr�eatior✓rntenainment event etc.)] 0-7-0 3o, 1,-41-15--Iq .5 <br /> R2a a <br /> 0So0 l 0a <br /> 3` 00 <br /> Type of Permit: Typge of Non-Plumbing Device/System/Toilet/Unit: <br /> on-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#hj'1,&EXT gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# (AI` ❑ Othcr <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 /> e undersi ned,assume res onsibili for the installation of the non- lumbin sanit s stem for which this ermit is issued. <br /> Plumber's/Owner's Name(print) rs/Owner' Sigl�alu MP/MPRSW No.: Business Phone Number: <br /> Plumbers Address( treat,City,State,Zip Code): <br /> Oo <br /> On <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. I Date Issued Issuing Agent Signature <br /> ❑Approved O Owner Given Initial Adverse <br /> Determination g`O <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />