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o <br /> a @ `d <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI g: . <br /> Applicant Complete All Sections Below This Line = a I <br /> O <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types • o R,. <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br /> ❑ Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> o I <br /> •Privy—Vault Toilet (Must specify volume in gallons: `5 UJ (Minimum 200 gal)) r <br /> 0 <br /> o Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> • <br /> Property Owner's Name: ,ry Cilrt� <br /> Property Owner's Mailing Address:6 , fit• J fvt IC�tn� � `. ti7CYk5' LT\ <br /> 7O i City State Zip <br /> Property Site Address: / J 01 5 QLk p, Ti- Mc riL-, (i3i ri <br /> Contact's Telephone Number:�+ (t7 oS- (.062 1 3 vs 4 <br /> Contact's Email: �C�C. Ok (�S l:+C. 9 w 1.tot,‘ a <br /> Legal Description of Property: v iiJ L0-� <br /> g p L ' T 5 C Sill .� 161 i�O 1 2A P , <br /> ro <br /> Section#: 123 Town#: -bc‘ N Range#: 1(f W Town of: MQ 00 C.r-O e S <br /> *Attach additional page if needed for lengthy description OR attach C <br /> h a copy of the deed OR attach tax system property page.* \ � <br /> Tax ID#(1-5 digit number; found on tax statement): 6:'2 56 "\ <br /> 0 <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY 0 W <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: , <br /> Mecf a l l 5e�-bac -f��k 7,07tero<rifS 4 s - p (V_ <br /> q. `w1 <br /> w <br /> y <br /> K <br /> z (.1 <br /> r-- <br /> iS` <br /> Date of staff site visit: t /el 9 7d-,c)- . <br /> Initials of site visit staff: i-if i Fee Rec:/'V` <br /> • II Check#: (tf�S/, <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: DATE: �/11/4 �� rz <br /> r <br /> z o ` <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF 'es Q <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT ' d- - <br /> ' aril <br /> z (11 vo m <br /> Page l of 2 c) '�' <br /> Burnett County,Non-Plumbing Sanitary Application—Rev 12/2021 2 IM <br /> cA )) <br /> a <br /> b <br />