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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 ($150) <br /> POWTS CONNECTIONIRECONNECTION ($150) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> I'mlm q Owner Name Property Legal Description 'j <br /> _\ ��n3nv ��IeY1 GL SF— 1/4J�1/4,S �/7,THq,RI_)W <br /> Property Owner's Nlailing Address Lot Number Blo Number <br /> 2--7- -7 - a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑City ��ovl i- <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Villag 1 or <br /> ❑ Public ^Town of Fi <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax N tuber s) <br /> campground,festival,recreation/entertainment event etc.)] 07 -J / <br /> Type of Permit: pe of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) T Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# y gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> !$'I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ($T,the undersigned,assume responsibility for the installation of theon-plumbing sanit s stem for which this permit is issued. <br /> Plumber's/Owner's Name nt) Plumb 's/Owner's Sig MP/MPRSW No.: Business Phone Number: <br /> h lcOti <br /> Plumber's Addre s(Street,City,State,Zip Cole): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Dale Issued Issuing Agent Signature <br /> Approved ❑Owner Given Initial Adverse <br /> Determination f5 131 S37 5 �- � I ' � 6 <br /> Comments: <br /> la <br /> Conditions of Approval/Reasons for Disapproval: ECOVE <br /> E <br /> JUL 1 1 2016 <br /> Revised 6/7/02 D <br /> BURNETT COUNTY <br /> ZONING <br />