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NON-PLUMBING SANITARY PERMIT APPLICATION - Burnett County, WI y; N <br /> Applicant Complete All Sections Below This Line ] " w <br /> CI. <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types -F, <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION o <br /> Privy- Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> ' <br /> ❑ Privy-Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) <br /> ❑ 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 /> r. <br /> Property Owner's Name: 3bA' <br /> 1 (4- S 01,.. C-e^ 1C4-C1(--...,_ <br /> Property Owner's Mailing Address: `44,0 A.)06 S r-- ?4, CAD', /w/1,, <br /> k <br /> CC -" ,�� ��""_� Rd <br /> � City �+, State Zi � <br /> Property Site Address: Pas S $A w� I dKok ,artalwie"(. y LA „s y n <br /> r X <br /> Contact's Telephone Number: 7( - S 53 O' Z? c <br /> Contact's Email: / iv% Lc I'�. CC I".SJ1f i•� �. DvI-boy( . C1561---, g <br /> **If staff has a questidh about this application,you will be Contacted via email. Make sure your email address is b <br /> w <br /> legible and your email provider will accept emails from the following addresses: @BurnettCounty.org and 5' <br /> @BuettCountyWl.gov cm rn <br /> Legal Description of Property: 01 - Ott. — -4 40 - !. - 12.-Z, 0( ^000 - 011000 <br /> Section#: )2— Town#: 1"10 A) N Range#: 14 W Town of: Scot' <br /> *Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page.* v, <br /> Tax ID#(1-5 digit number;found on tax statement): II `3' N <br /> AREA BELOW THIS LINE FOR L.ANI)SERVICES STAFF COMMENTS/CONDITIONS ONLY d `I C <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: G. <br /> - M 4 t-�- ck U. Se_-I-6ac kS e <br /> - W i(lcL r t 1uxnb i rt, 'IS i rtS-i-titeid ‘IA altke..l,l. ►r -414..i1 a tU.4e tb WI z -.0 <br /> CM e. COiTj 2liani- 4 c 3..(c-}fM1 LA,iU ii ed 4-o bx invattoc( bki o to z <br /> Li wise(' eittin6vr <br /> x <br /> y Fee Rec: /50- <br /> 5 Check#:3 g <br /> �Date of staff site visit: 110/710z3 Initials of site visit staf . <br /> PERMIT APPROVED BY LAND SERVICES OFFICIALC L DATE: /o/2 z3 ''-_J <br /> M <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF H co <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT v o o <br /> Page l of 2 a' <br /> Burnett County, Non-Plumbing Sanitary Application -Rev 12/2022 al a, Inn <br /> 5 <br />