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r <br /> NON-PLUMBING SANITARY PERMIT APPLICATION — Burnett County, WI CrN <br /> Applicant Complete All Sections Below This Line °o a <br /> o <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION \ p <br /> ❑ Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> Privy—Vault Toilet (Must specify,volume in gallons: ;-SO (Minimum 200 gal)) <br /> o Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> Property Owner's Name: 149Wk_S I� <br /> id,,.,,,,....7 <br /> Property Owner's Mailing Address: S &t61 G011 )1 y Al AJ S.S 1,1 ' <br /> 2$Z City State Zip <br /> ( 3 - Uss Crr�h S/ocrt�^, VT v <br /> Property Site Address: N( I D <br /> Contact's Telephone Number: b S i -a-7 I-4 -fly, <br /> Contact's Email: 'gnS 14-A ,yq.1r J' o <br /> **If staff has a question about t s applicd(ion,you w l be contacted via email. Make sure your email address is <br /> legible and your email provider will accept emails from the following addresses: @BurnettCounty.org and g• <br /> -o <br /> @BurnettCountyWI.gov °O <br /> Legal Description of Property: 1\ r N v.) <br /> Section#: 3-2` Town#: 3' .J N Range#: I 'V W Town of: eos h. C 001 Li 7 <br /> *Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page.* w <br /> `` o <br /> b <br /> Tax ID#(1-5 digit number;found on tax statement): D 7 o N . -, <br /> R. k <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY (IQo <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: 3730, C-Pe <br /> 0 CTR+ rtii St-Noac -s .-rc J <br /> z <br /> 74 <br /> s <br /> Fee Rec:15/ <br /> ,,^� ,�,,��// rri <br /> o Check#: <br /> Date of staff site visit: /2_3/� Initials of site visit staff: `�T z <br /> rn <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL4W-rtDATE: 51311E < �-2 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF a rp <br /> uI <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT ° <br /> Pagelof2 m o= N o <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2022 14 <br /> m '� w <br /> d �CD <br /> ' I <br /> 3 <br />