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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 U,J <br /> SIREN, WISCONSIN 54872 Z <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION (5150) <br /> POWTS CONNECTION/RECONNECTION (S50) ✓✓✓"" <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name ,`m� Property Legal Description <br /> Vt 4�6 j� Q� d✓ GL ,Z va I/4,s z r37N,Rj& W <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> 0.2,9-7 ArfQoR n <br /> City,Slate Zip Code Phone Number Subdivision Name or CSM Number <br /> rle"'peJ6 WL Sof i_ <br /> T pe of Building: (Check one) ❑ State-Owned ❑City I Nearest Road <br /> I or 2 Family Dwelling-No.of Bedrooms:y� _ ❑Villager 12l <br /> ❑ Public WTown of Fire Numberut,74 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) o34 1$02 o 23 00 <br /> campground,festival,recreation/entertainment event etc.)l <br /> 07-034-2-37-19-OZ-5 o5vo2•ol4ow <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet, Restroom etc.) ❑ Privy-Pit'foilet ❑ Composting Toilet System <br /> 5(POWTS$oconnection Count #3a0g�p ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> El POWTS Repair y gallons or cubic yards) 111 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 /> ❑ I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owners Signature: MP/MPRSW No.: Business Phone Number: <br /> L 4ltA) Is 7 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 2-7 5 k.5 - Rb 8� <br /> Office Use Only: <br /> ./ ❑Disapproved Permit Fee: CST No. Date Issued Issui ent Sig <br /> fa Approved ❑Owner Given Initial Adverse �� 11A '0�Y <br /> Determination /V, �eUwn¢. ZF7I0 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> �vtlQoiy �w�^ -� ult /hsa/aeel tJnoll,�Revised 6/7/02 b/7/02 <br />