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-9 Z <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI N N <br /> Applicant Complete All Sections Below This Line = a c/a <br /> :- „p. <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types <br /> o <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION O <br /> e,! <br /> N Privy— Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) F <br /> 0 <br /> ❑ Privy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) • <br /> c <br /> 0 Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br /> C <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> l' <br /> Property Owner's Name: Itiwf5 4V 'l L-Z. C I <br /> Property Owner's Mailing Address: i 70 Ali Q Cite' h <br /> � City State Zip <br /> Property Site Address: 3 3y2 l�h� /1111 K2, 0B)9j ��jJ _ <br /> Contact's Telephone Number: (5'z4r/ l/ 7 0 <br /> Contact's Email: rAd h / 0K 6-5 Q xaktoo. cowl o <br /> E.**If staff has a question about this application,you will'be contacted via email. Make sure your email address is S ..,1w <br /> legible and your email provider will accept emails from the following addresses: ci BurnettCounty.org and o• <br /> @BurnettCountyW I.gov o0 <br /> Legal Description of Property: L4d.I COI /4/55 V 7 Pno (6,0✓Jo.1) -it zls Teo <br /> Section#: Town#: No N Range#: T 1 W Town of: C0`11'f O <br /> *Attach adclitiona7 page if needed for lengthy description OR attach a copy of the deed OR attach tray system property page.* v7 <br /> Tax ID#(l 5 digit number; found on tax statement): 18zL/ <br /> C —.1) o d <br /> C <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY o d <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: a. <br /> �he -{-all 5e+194.4 is f 5 1-cQ 744;terneied37'a <br /> i c� <br /> Fee Rec: <br /> U Check#: <br /> Date of staff site visit:6 li/2 _3 Initials of site visit staff: r y <br /> z <br /> 436/.. .,:, a <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: ' DATES/P-3 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF > r- FEI <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT ° <W 0 <br /> 252. o liiiii <br /> Page l of 2 r, o o0 co o <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2022 < m r <br /> G w etna <br /> CCD <br /> D <br /> -o <br />