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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 ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> T.1„ Thmrnt�n GL 561/4 -fXI14,S36r 4'/N,R /GC_,) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /75'6 17ne �rtrS { /4ue <br /> City,Slate Zip Code Phone Number Subdivision Name or CSM Number <br /> 5f. r~ "Al S-S'1/6 t d s 71 3S7 ll a o P. .tsy <br /> Tvpe of Building: (Check one) ❑ Stare-Owned ❑Cry Nearest Road <br /> O I or 2 Family Dwelling-No. of Bedrooms: ❑Village eu// L/[ e <br /> ❑ Public 19 rowno�w/1 J Fire�wpb�7 <br /> Public Building/Land Use: [Explain the use/purpose for this permit(i.e., Parcel Tax Numbers) oof� <br /> campground festival.recreation/entertainment event etc-)] <br /> 03.2 S-3310 b5 360 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy. "toilet Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet Scstam <br /> 9 POWTS Reconnection ❑ Privy —Vault Toilet(Vault size: ❑ Incinerating Toilet Dcvicc <br /> ❑ POW IS Repair County 4 _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State # ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> 1,the undersigned, assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ <br /> L.the undersigned,assume res onsib ty 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/MPRSW No.. Business Phonc Number <br /> Rif e_ le 1Va,0/C/nS / � {� �JSBS / 7/sffGG-V/ST <br /> Plumbers Address(Street,City,State,Zip Code)_ <br /> 017760 fires 3-s" iNebs><�� 1.✓Zs�S97 <br /> Office Use Only: <br /> J ❑Disapproved Permit Fee- CST No. Date Issued Issu gent Si, ore <br /> a'1 Approved ❑Owner Given Initial AdverseArL <br /> Determination J <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />