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cr <br /> L. . e, b <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI <: <br /> Applicant Complete All Sections Below This Line a ¢ 1 `� <br /> A d ,1T <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION \ o <br /> ;l Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) p <br /> ❑ Privy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) R I. <br /> ❑ 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) 7 <br /> Property Owner's Name: i D d 1 e. U kD f L n ct I ` JAI){ 190 WELL <br /> Property Owner's MailingAddress: cG 90 Slaje CD q C,h. I R , IV SitL i-ivgrTK YNhl 5—0 2U --I <br /> City State Zip <br /> Property Site Address: oZ 3 <br /> _OS"O rid/W 6/9KS r."4 6-1M1/T5eo 6 LOT s ygyb n <br /> C.t LL Illi <br /> Contact's Telephone Number: 65/ - y /t1 7 Z1 <24/1//2 L l NE /,Z 5/.• Y t//6 <o <br /> Contact's Email: A 6 LO C 11S Up h airP10 11 , GO WI 8 Iv <br /> **If staff has a question about this application,yer6 will be contacted via email. Make sure your email address is 'ta <br /> legible and your email provider will accept emails from the following addresses: @BurnettCounty.org and g' le <br /> @BurnettCountyWl.gov m <br /> Legal Description of Property: / 5 E. Sk"--- Is O T 7 N <br /> o <br /> Section#: 3 a Town#: 3 7 N Range#: i`J W Town of: Ohl Y►'1 ARS(,' Lis r//1 <br /> V <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): D(o .v N � = <br /> w a <br /> ' K <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY d H 5 <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: Ut. <br /> mPe+ q,« Se4oa S �,' <br /> Pi+ e* no4- -to -ek teeel q ind.t.i5 -f- j2ctM � ad.ipla.-1-e z v 2 <br /> -f eu TARATt— <br /> s <br /> Fee Rec: <br /> (SAC <br /> d Check#: <br /> Date of staff site visit: G1 7, �ZK Initials of site visit staff: (&L4'I-T z <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL 1 DATE:-.1 )2/21/ C:::) <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF <br /> „ CDC Z t <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT 2 3 <br /> u u u n <br /> O <br /> 00 <br /> Page l of 2 43 S ¶ c <br /> r. <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2022 `1 3�` MI' <br /> t) <br /> o = <br /> cn <br />