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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 <br /> POWTS RECONNECTION($25) ` <br /> POWTS REVISION ($25) 'N <br /> Application Information—Type or Print <br /> ProprjownerName Property Legal Description <br /> v-'eA.� -1 V 2��, GL 1/4 1/4,S Z, T-SAN,N,R W t� <br /> Property Owner's Mailing Address � A Lot N� Block Number <br /> 4,—ak-ev JJ•-� v2_� <br /> City. State <br /> p / Zip Code Phone Numller Subdivision Name or CSM Number <br /> 1.� Lm is SS/ I o ((�3 <br /> ,T,ype of Building: (Check one)❑ State-Owned ❑City Road <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public Town of R�1� PFircNmber _ <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 /> �c 3S -0/- a00 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> �1 Non-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection Cotm # ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair State# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision ❑ Other f 1 <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 undersigned,assume responsibili for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> bers/Owner's N e(print) Plu ber's/Owner' ign re' MP/MPRSW No.: Business Phone Number: <br /> Z �/ pro,- <br /> 83- 7333 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved rout Fee: CST No. Dale Issued Iss i Aygel <br /> jpproved ❑Owner Given Initial Adverse /�1 q t, �cj&, <br /> Determination t/ 42 GQ� (Y r <br /> Comments: <br /> kJ"Iel//�j)a � y (G72rJ^(•j t a lrovrrh Ct tea_ l <br /> onditions of Approval/Reaso for Disapprov 1: <br />