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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 ($ 0) <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Descriptio `(c JC� d /c <br /> �, �d„� GL 1/4 1 4,S ,T 1 R ( W <br /> Property Owner's Mailing Address Lot Number I Block Number <br /> /703 15l /fire_ <br /> City,State Zip Code Phone NumberSubdivision Name or CSM Number U <br /> /3 rrlei a ( -)5&S-5 Bui Is A-c'r 1 <br /> 0 <br /> Type of Building: (Check one)❑ State-Owned ❑city Near t Road O <br /> El or 2 Family Dwelling-No.of Bedrooms: ❑village (MS <br /> ❑ Public Town of S( tSS Fire Number X35 <br /> Public Building/Land Use: [Explain the use/purpose for[his permit,(i.e., Parcel Tax Numbers) J <br /> campground,festival,recreation/entertainment event etc.)] <br /> 03a-yob or-�o a � <br /> Type of Permit: Type of Non-Plumbing Device/System/T ilet/Unitt <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom OWTS Reconnectietc.) ❑ Privy-Pit Toilet 11Composting Toilet System <br /> on Coun # ( O 13 Privy-Vault Toilet(Vault size: ❑ Inci erating Toilet Device <br /> ❑ Revision State* 33`J�C7 <br /> ❑ POWTS Repair 35 9 —gallons or _cubic yards) ❑ Port ible Restroom Unit <br /> ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersi ed,assume res onsibili for the installation of the non- ]umbin sanit s stem for which is emilt is issued. <br /> P1ua1e's/Owner's Name(print) Plum Owner' e: MP/MPRSW No.: Business Phone Number: <br /> /cr <br /> Plumber's Address(Street,City,State,Zip o <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Is uin t Signa <br /> ❑Approved ❑Owner Given Initial Adverse ` ,/ <br /> Determination �J� J'7 67 <br /> Comments: PlUf))ber wI/I reeoniteGf <br /> bar, ie- 5-fo/"1 (St ,;-i& on �Sa n, f y Cp��1C�i�tr7h� <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />