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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 ( s <br /> SIREN, WISCONSIN 54872 I <br /> 715-349-2138 1 JUL 2 1 2025 <br /> NON-PLUMBING SANITARY PERMIT APPLICA IO <br /> POWTS RECONNECTION Burnett County <br /> Land Services Department <br /> POWTS REVISION 72/3 <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> e. /N S 0 1<1- S GL 1/4 1/4,S/9 T N,R /_50 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ,Qo X 7.:? <br /> City,State Zip Code PhoneS£Number Subdivision Name or E -Nornber <br /> ` <br /> '70a 111 w �-S.s L*ko,- 14c r e- <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest R ad <br /> I or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village WA' <br /> ❑ Public Town of SGJ/.� Fire N tuber <br /> d <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 /> 07 0302 -Z <br /> /-<' 0V3 er/9ood <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> POWTS ReconnectionFStoaut <br /> ty#S1-ZD-(SI ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision #(p Z 308 ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> )Q,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-plumbing sanitary system for which this permit is issued. <br /> Plumber's Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> w� � Iew�s�ioJ/� GJao� .zZ769/ 3y9 7r78� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,SOX <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: JG&+-No. Date Issu d Issuing Agent Signature <br /> Approved ❑Owner Given Initial Adverse 731 fjo 15(a5Lv-7 1 -] 1�j2OZtJ <br /> Determination <br /> Comments: <br /> 4-u weed 2- 6e�wls <br /> Follow a# c Md s*-k rquvAjufl�s <br /> Conditions of Approval/Reasons for Disapproval: <br />