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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 CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Ina rt ,I C N1Y t✓ CA, / Ila va,s 3 L 7 q&N R/ <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 47197 4)A ktc.eN C, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑City Ne st Rnad <br /> 1 or 2 Family Dwelling-No.of Bedrooms: -A ❑Village <br /> ❑ Public N Town oqOG[CSbN Fire Ner <br /> m 4, <br /> 84 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/en[enainment event etc.)J <br /> o�-a�.l- -HO-/.S-- s- mdr <br /> v/ 06 <br /> Type of Permit: 'Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit'1'oilet ❑ Composting Toilet System <br /> POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair Court <br /> ty#, _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ,moi,the undersigned,assume responsibility for the POWTS activity for which this perm t is issued. <br /> ❑I,the undersigned,assume res onsi ility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plu�mber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): - <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: p CST No. Date Issuedsuin nt Si re \ <br /> Approved 0 Owner Given Initial Adverse <br /> Determination / <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> ECEov <br /> Revised 617102 nR OCT <br /> BURNETT COUNTY <br /> ZONING <br />