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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 /> 'b <br /> POWTS RECONNECTION b <br /> POWTS REVISIONti <br /> Application Information—Type or Print 1 <br /> Property Owner Name Property Legal Description c / kI/ <br /> 4Airy Sie,i/t//ne.tZ GL / 1/4 1/4,S /7 T&N,RI7W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 64,/34=/7/2cre5* fir. / .z, <br /> City,State Zip Code Phone Number S taision Name or CSM Number <br /> P-e5noiit/e5 -I- 503// ( ) V/ 7 27 <br /> Type of Building: (Check one) 0 State-Owne 0 City Nearest Road /� k) <br /> O. I or 2 Family Dwelling-No.of Bedrooms: �, <br /> 0 Village , C...9-e?7�0 /'i <br /> O Public p-Town of�.Je s Fii :?1 9y8 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) ray 7 BS <br /> campground,festival,recreation/entertainment event etc.)] 07 006 oZ 38 /7 / <br /> oo/ 0 3200P <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> O Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy—Pit Toilet 0 Composting Toilet System <br /> gPOWTS Reconnection Count # �y g�y 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> y POWTS Repair gallons or cubic yards) 0 Portable Restroom Unit <br /> O Revision State# 5y a yd0 0 Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> CAI,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> tSCI,the undersigned,assume responsibility 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 ignature: MP/MPRSW No.: Business Phone Number: ^' <br /> ed/fd RN A/� % zz��7/ 3 S�9-7,7f <br /> Plumber's Address(Street,City,State,Zip Code): <br /> AI 6.%,/ 5,re#1) GJ Y-57 7. <br /> Office Use Only: N <br /> ❑Disapproved Permit FeeL, CST No. Date Issued Issuin Agent Sign lure �1 <br /> Approved 0 Owner Given Initial Adverse ��qq _ It �'lL1 // /l, (�J, j,/ 2 <br /> Determination �4 1 "�y/[�I/I�TJZ 1 <br /> Comments: <br /> 1i5 totLc 4k Is -ko bt Se.'v((Ace ann <br /> Sized -cbr 3 bmt►-obms. Dks''3^ 'Cc C°5 P01 <br /> Conditions of Approval/Reasons for Disapproval: <br /> (te.1- t h-151-) t15b <br /> jcDv <br /> E 0 <br /> 11 MAR 1 20211 <br /> -Burnett bounty <br /> • Land Services Department <br />