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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIRENS WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION $50) <br /> POWTS RECONNECTION ($25) <br /> POTS REVISION ($25) <br /> Application Information—Type or Print j <br /> Property Owner Name Property Legal Description rt �•1 <br /> If) O�h� Gn L nr� G .0 nt-LW GL NW 1/4 N✓V1/4,S 1 D ,T3y N,R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3bu3 ZioL - NE <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> RID IZGCnC h O /11/Y, c� l l L4 q 1 <br /> Type of Building: (Check one) ❑ State-Owned ❑ciry Ne est Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village &(7lei S <br /> ❑ Public frown of Fire Number <br /> Public Building/Land Use: [Explain the use/purpose or this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit Ty a of Non-Plumbing Device/System/Toilet/Unit: <br /> X Non-Plumbi (envy oilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconne� ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the PO activity for which this permit is issued. <br /> 1A I,the undersigned,assume responsibility for the ins f the non-plumbing sanitary system for which this perinit is issued. <br /> Plumber's/ er's Tint) I Plumb e: MP/MPRSW No.: Business Phone Number: <br /> L ,r. ` (a/)nt ( <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss g Agent Signature <br /> Approved ❑Owner Given Initial Adverse i <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />