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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 /> J <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION Oc' <br /> Property Owner Name Property <br /> Legal Description <br /> lrL(�/%l V q�r5c, GL I V�V�1/4N�J1/4,SBlock,T N,R W <br /> Property Owner's Mailing Address Lot Number Number <br /> SJ (5-` Cry fel 14 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> GI/p�s / C✓i '�'Y'k_/ 3 1 ('71_5 ) 75 <br /> Type of Building: (Check one) ❑ State-Owned ❑City NeaSest oad <br /> ❑ I or 2 Family Dwelling-No.of Bedrooms: ❑Village "Cd <br /> ❑ Public t (Town of I( Fire um er <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> L7-OGo -38-I�-13- -Oo7-oo� job <br /> T pe of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) VPrivy—Pit Toilet ElComposting Toilet System <br /> WCount <br /> ❑ POTS Reconnection 1 C1 f54 ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair y# 3gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑ as appropriate.) <br /> 111,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 sam.tary system for which this permit is issued. <br /> Plumber's/Owner'sNam (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: CST No. Date Issued Issuin gent Si re <br /> Approved ❑Owner Given Initial Adverse d,1O� / / �� <br /> Determination /J R <br /> Comments: <br /> SOT-rw of �1-6 r be »ovew/d 40 ka-6 k4w 5 ra& Lw 3. <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />