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". z <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI is i� <br /> Applicant Complete All Sections Below This Line ' a '' <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types :Ns; C <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br /> P st <br /> o Privy — Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> 1 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 /> • <br /> Property Owner's Name:Aittelevt* ep h Fir(S ? Park-kS` S C <br /> r <br /> Property Owner's Mailing Q Address: U I SO S4-orly al WI/�f ere ci,ti L/W f 5g 7; <br /> Property Site Address: �-7 I be,Vi IS LA '�{ QQ` Abed-� A f j .�jState�g` n ' <br /> Contact's Telephone Number: 1 i - q, 0 1 <br /> Contact's Email: Stan .47j( vz -(V fr,„Vk•IK G(h afl LJJ,ke.�sg. <br /> ""If staff has a question about this application,you will be contacted via em Ma ure your email address is m <br /> legible and your email provider will accept emails from the following address:®BurnettCountyWl.gov 5' <br /> w <br /> Legal Description of Property: GOV /Or C' / . <br /> Section#: � <br /> Town#: V N Range#: /6, W Town of: ark. ('11Q{ <br /> 'Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page.* <br /> Tax ID#(1-5 digit number; found on tax statement): 1a`7 y o <br /> N i <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY w. 0 RITHIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: v �-- a.• <br /> 0 - 5.e- Variance /3 -Corn t 773 3. 0 (A <br /> bn <br /> _ z J <br /> xi <br /> 6` <br /> UFee Rec: Alit <br /> I ' , Check#: - <br /> Date of staff site visit: l f 10p/OvL'q Initials of site visit staff:— E <br /> 0 <br /> PERMIT APPROVED BY LAND SERVICES OFFICI .. <br /> ATE: /zi/zoz <br /> r- <br /> UPON APPROVAL: APPLICANT MUST OST COPY OF ca G I <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT . <br /> civ Z <br /> Page I of 2 ` '< — t <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2023 RI <br />