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r Z <br /> -0 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION - Burnett County, WI = N <br /> Applicant Complete All Sections Below This lane j' <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION Ivy <br /> Ny <br /> > Privy- Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> '?'"' "e. ,_ ...,x-- <br /> ❑ Privy — Vault Toilet (Must specify"volume in gallons: (Minimum 200 gal)) <br /> lV <br /> ❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) '- - ;C6 <br /> 0 Incinerating Toilet Device (Must demonstrate unit is approved for use by W1 DSPS) "1"1•- <br /> Property Owner's Name: Kvis D. -J 5(C4 L. OL.satl is <br /> A <br /> Property Owner's Mailing Address: 317Y 5,T{l. 70 $ Hotta i , Ss.° - i (�1 <br /> CityState Zip 1 1 <br /> Property Site Address: <br /> Lin ll�j�, D L> E __.. <br /> G <br /> Contact's Telephone Number: 71033-' Zvi'' 72� o <br /> _ Q/1 <br /> Contact's Email: j(Y(easouCo. i'reKETmeta,e-Cw1 I <br /> **If staff has a question about this application.you will be contacted t is email. Make sure your email address is I <br /> legible and your email provider will accept emails from the following address: (a'BurnettC ountyW l.gov <br /> iJ <br /> Legal Description of Property: LOT It C s,1 '1•70V 5,P/01 (eat LOT 0) z <br /> Section#: 35 Town#: '4 N Range#: /5 W Town of: JAMS 'I 0 <br /> *Attach additional page if needed jar lengthy description OR attach a cops'of the deed OR attach tax system property page_• <br /> Tax ID#(I-5 digit number: found on tax statement): 1002.'1 f — <br /> V. <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY th Q i <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: - <br /> (D iY1.2t+ aU Sr ks 1 L <br /> $Serip <br /> :i+ RCA- -1') -Pxceed I inc,�tuS -POEl U2,t.-k -4Y.QL(t-}�yvt,e,1 t+ <br /> + be u�Cq,�►tip d Irk zll- r SlltC,W2ir,-1-b (atslnc) Mk/ <br /> z <br /> 'N <br /> Fee Rec.: 1573 <br /> ICheck tt: 9 <br /> Date of staff site visit:6/23/Zo2L/ Initials of site visit staff 7-1 If67 L <br /> - <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: DAl F.: ,(i <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF ' a 's <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT - CD 3 <br /> _ G <br /> 0 s. tin E <br /> Page 1 01'2 ' o <br /> Burnett County, Non-Plumbing Sanitary Application - Rex' 12/2023 ;, 3 <br />