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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 /> POWTS RECONNECTION ($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name ��j� h / Property Legal Description ��{ <br /> ,� � Pry svUE� GL I/4 i/4,S13 . :��rr��N.R)F W <br /> Property Owner's Mailing Address Lot Number Block Number -F- <br /> 5� vRc- ' 1'4r/E <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 57- PA`JLL MAJ 1 657164 IKAD WPoID 7K41G_S <br /> T e of Building: (Check one)❑ State-Owned ❑City Neave.t xead <br /> I or 2 Family Dwelling-No.of Bedrooms:_ ❑Village <br /> Public Town of RU7[ Fire Numbero— n�N <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,reereation/emtertaiument event etc.)] <br /> t5 a4-9oso 0,;-' 9m� <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> C Non-Plumbing(Privy,Toilet,Restroom etc.) C Privy-Pit Toilet ❑ Composting Toilet System <br /> )9,POWTS Reconnection C Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> Counts 'j gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Re, Repair State tl C u �- g _ Y ) — <br /> CRevision ❑ Other _ <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 /> the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which thisermit is issued. <br /> Plumber's/Owner's Name(print) PI r's/(hvner' MP/av RSW No.: Business Phone Number: <br /> 1- <br /> Plumber's Address(Street,City,State,Zip Code): <br /> -- STAT6JI <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin ent Si re <br /> Ql APProved ❑Owner Given Initial Adverse *2yrU.7 <br /> Determination �•7 h <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: __i <br /> AUG 2 7 2001 <br /> BURNETT COUNTY J <br /> Revised 6/7/02 <br />