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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 Z <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) I <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name'?? Property Legal Description <br /> Ai1J✓'o 0 l c-s1,0 w GL 1/4 1/4,S 01 S 7 yolt/ e?i 4' <br /> N. <br /> Property Owner's Mailing Address Lot Number Block Number <br /> / /7 w,•11 dW LI1 3 o <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Pre.Sco?`� W3" I S`IDci-I ^� <br /> t%8 M. Pr t-- Rd• <br /> Type of Building: (Check one) 0 State-Oyyned 0 City Neares i� <br /> t oadn 1- 17 <br /> 71 <br /> = <br /> 14 1 or 2 Family Dwelling-No.of Bedrooms:L 0 Village l�✓—,k1 Town of,SCd fjL Fire Number /3(08 <br /> ❑ Public <br /> ::-.\ <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.)] p � <br /> 0 .IS -1/0-�y-d`r - <br /> -7k)J <br /> - 05`- ova _ 0 13o5O <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 a.7 <br /> ,i'POWTS Reconnection 5-�pG� 0 Privy-Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair County#_ 3 I gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# 6 Sg8 I I ❑ Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> g-I,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 sanitary system for which this permit is issued. ,�( <br /> mb <br /> Plumber's/Owner's Name(print) Plumber's/Owner' Signature: <br /> MMIPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): d <br /> VI <br /> Office Use Only: <br /> 0 Disapproved Permit Fee: CST No. Date Issued Is/suin nt Si. re <br /> Approved ❑Owner Given Initial Adverse ,41eyi.-1 1 /.p4G44 [J I'' DaLl ��! <br /> Determination v 11YY00 ! t J �tF/ '1 ss��!! <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: C11 61 Jv <br /> D CENE <br /> ct old >SM Y !1tileif/9/1/J 1 APR 0 8 2021 <br /> Revised 6/7/02 <br /> Burnett County <br /> Land Services Department <br />