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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 tki <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) 0 <br /> POWTS CONNECTION/RECONNECTION ($50) W <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description ‘mt\1 <br /> 8 u Las <br /> Jo GL 1/4 1/4,S // ]''fON/2/s <br /> Property/ S/Owners Mailing Address < Lot Number Block Number <br /> 181,0 ?ell �`" ✓ /> #.1.4-3 4, ,f 9-06, CGwid/nf6 <br /> City,State IZip Code Phone Number Subdivision Name or CSM Number VJ <br /> %a y/o v'f FF. i'5 Me! S.S`o 8'1 <br /> Type of Building: (Check one) ❑ State-Owned 0 City j N rest Roa ' <br /> Z 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village -�� / �h b e w T <br /> ❑ Public El Town of ae./GS0 Fire NumberL. <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) 0 <br /> campground,festival,recreation/entertainment event etc.)] ? 1 11 9 * 74 50 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy-Pit Toilet 0 Composting Toilet System <br /> POWTS Reconnection County#_ I 0 Privy-Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) �\ <br /> KI,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-plumbinj sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Si_ alur <br /> e <br /> : <br /> MP/MPRSW No.: Business Phone Number: <br /> / <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 7'76 tr y-- 3-_C-- Lv-e-_sr`m',- Lt/� S 174.-C73 <br /> Office Use Only: <br /> � 0 Disapproved Permit Fee: CST No. Date Issued - suin glint igpayge �4— <br /> .!�"Approved 0 Owner Given Initial Adverse , f 50� I 77I 5l iii�3 <br /> Determination ✓ <br /> Comments: <br /> ECEllVE-R <br /> Conditions of Approval/Reasons for Disapproval: APR 2 8 2023 ii) <br /> Burnett County <br /> Land Services Department <br /> li 150 I <br /> Revised 6/7/02 <br /> ClIA Lt 50S70 <br />