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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($50) <br /> 0 — RECONNECTION($2 <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name A 7 Property Legal Description /IIS <br /> �0 GL 1/4 1/4,SSI T—IVN,0W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code I Ph a Number Subdivision Name or CSM Number <br /> M 111,553bq--efo ?�'- 7E;y-s9� <br /> Type of Building: (Check one)❑ State-OwnA <br /> IC 1 or 2 Family Dwelling-No.of Bedrooms:__ Vd��I <br /> ❑ Public own o F)r�1�`'lrtmbeL2 <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.)] <br /> DaG- X331- <br /> Type of Permit: Type of Non-Plumbing Device/System/ToiletfUnit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> X POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#. 5� gallons or cubic ds) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ OtherL . <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑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- lumbing sanitary system for which this permit is issued. <br /> l lumber's/owner' ame(pri Plumber's/Owner's Si ature: MP/MPRSW No.: Business Phone Number: <br /> 10 <br /> Plumber's Address(Street,/City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved P rmit Fee: I CST No. Date Issued Issui Agent Signature <br /> Approved ❑Owner Given Initial Adverse I <ZI �s �� lb-1 <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />