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C ' <br /> a g b <br /> NON-PLUMBING SANITARY PERMIT APPLICATION —Burnett County, WI : y N <br /> Applicant Complete All Sections Below This Line = a C.).1, 1 <br /> A p•' <br /> Oj <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION G o <br /> 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: (Minimum 200 gal)) ` 1 <br /> 0 <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) <br /> • <br /> r <br /> Property Owner's Name: -t c•..,e_:i 14 to t' <br /> IN.Property Owner's Mailing Address: 3O 6, .e• Int i CLc w c is E c e- b R-/ Ai Fi12 t(a., i X 7 CCU 6 <br /> City State Zip <br /> .Property Site Address: 23 705 NAB%Z L/Srfit1 i41.1 <br /> /ifv._ -5 9p 7 / n <br /> Contact's Telephone Number: PO6 e.751 0/_5 9 <br /> Contact's Email: J v i,-1 60 3 fe c''jji-,,c.v. C-ct-77 ¢ <br /> **If staff has a question about this applicallbn,you will be contacted via email. Make sure your email address is <br /> legible and your email provider will accept emails from the following address: @BurnettCountyWI.govcm <br /> Legal Description of Property: !0+1 Cs m V 9 ' i 3 P (:4 Cc;V <-v; 7) <br /> Section#: i t, Town#: 3E5 N Range#: / 4 W Town of: 06-�l E W F-0 <br /> W <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): 3)...9 3 0 <br /> N L ►3 <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY k <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: F. d <br /> MR0- ail St-- 4s FkActlf N <br /> t ojlbw visions Privy 1►1sAikilu-c-ion Aye 4 '1&p -+ j <br /> 3 No umi,jnq is aWm r1 4t L ins-kJ-WI i --i e Pr° '-/y t.i t t- , z <br /> a bbau chrvO!►a►l+ Se.f+,'c StjS4e n — <br /> 17, Fee Rec: <br /> • Check#:-4-113 <br /> 5/21 Date of staff site visit: Initials of site visit staff`! T <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: DATE:IO/y/fl zy <br /> UPON APPROV <br /> AL: APPLICANT MUST POST COPY OF a rri ��J <br /> PERMIT APPLICATION IN PLAIN SIGHT z W D 0 <br /> SIGNED , � � <br /> o0 0, <br /> m CD ' O <br /> Page I of 2 2 N c <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 12/2023 0 i, r <br />