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NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI s: y N <br /> Applicant Complete All Sections Below This Line 0 c I <br /> a c` <br /> Check Type of Non-Plumbing System/Device; Fee $150 f All Types <br /> A PLOT PL M S B INCLUDED TH THIS CATION <br /> WIVE /6,1 <br /> ien 411/// TC71 k"iri ',.1-j Z.11/ Wi i)/-1,7 <br /> tri Privy—Fit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Te t ) '\ <br /> ❑ Privy—Vault Toilet (Must specify volume ingallons: (minimum 200 g+ Y�') �= <br /> o I. <br /> ❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) 1 <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> (-4.4/1d 6rn5 cue / iProperty Owner's Name: u <br /> 1 ej —• <br /> Property Owner's Mailing Address: //^^,, '� V iK?/��l4 <br /> — <br /> P rtY C� tO <br /> City <br /> Property Site Address: ! f # I, ,('/)1 t� Zip`// '/ 1/t, v, <br /> Contact's Telephone umber:/1 .� '' j^ c; <br /> Contact's Email: I'lCjL e), d / / ,l 5367 <br /> **If staff has a question about this application,you will be contacted via email. Make sure your email address is w <br /> legible and your email provider will acce t emails fro the foil wing address: @B ettC untyWl.gov g' <br /> r I Ca 3� t <br /> Legal Descripti n of Property: Q �/ tc y/ <br /> Section#: i t Town#: Lf( N Range#: i 5 W To of: 0 Li' h <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). 2 Zl „ o <br /> o y <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY Eo <br /> . _ <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: d y d <br /> ci?mee1+ ailSd is cis a. N2. I'i— dep-fh v nI- -it Qxceed Sip jinclies, -en( gctluci,k -f-rviLi r c,ix-( P z .. <br /> -11n.��e a I�te y � i t erat -b -N.te Ii,mi-Hai -{ut NI <br /> s <br /> .3 <br /> x <br /> Fee Rec:1300 <br /> m Check#: 5 tj Z <br /> Date of staff site visit: 5 /Z0)2f Initials of site visit staff: GLr,',� <br /> r <br /> rz <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL DATE:514ZCVI < i <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF a a 3 C <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT <br /> Page 1 of 2 2 ;4 w <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2023 y g <br />