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BURNETT COUNTY ZONING ADMINISTRATION � <br /> 7= 10 COUNT' ROAD K, #102 �� <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) �j <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 /> 54^1 13lern�.rd' GL ,5" va 1v4,S�37'go,v R / 74 � <br /> Property Owner's Mailing Address Lot Number Block Number <br /> riL X.r O d.cn V t A1C <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> tja hi Al S-33o V. to r? d <br /> Type of Building: (Check one) ❑ State-Owned ❑City N'earesttRnad f r /�� <br /> 12� 1 or 2 Family Dwelling-No.of Bedrooms:2 ❑Villaee <br /> ❑ Public M Town of (An tout Fire Number g&q3 <br /> Public Building/Land Use: [Explain the use/purpose for de,mi[, i.z., Percel Tax Numbz: ) <br /> campground,festival.recreatiorJentenainmcnt even etc.)) <br /> Type of Permit: Type of Non-Plumbing,Device/System/'ToileUUnft: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet El Composting Toilet System <br /> �POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ IncineratinToilet Device <br /> 11 POWTS Repair County#_ 4369 g <br /> p State# / gallons or _cubic yards) ❑ Ponable Restroom Unit <br /> El Revision ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ,ESI,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-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/✓IPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST N'o. Date Issued Iss _ nrSire <br /> C1 ��Owner Given Initial Adverse D% � d- <br /> Determination 0• <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />