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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(S50) <br /> POWTS RECONNECTION(S25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> S S L P GL NN 1/4/ti61114,S // T39N,R W <br /> Proper,Uwndrs <br /> ¢Mailing/Addddress ��g Lot Number Block Number <br /> Lily,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 'i" /,a S rEd U27-SI ) esm V-6- p }3 a <br /> Type of Building: (Check one)❑ State-Owned ❑Ciy Dearest Roan <br /> N I or 2 Family Dwelling-No.of Bedrooms:_ ❑Village o � + ✓t} T <br /> ❑ Public Town of" Fire Numbe/�Or_ <br /> Public Building/Land Use: [Explain the use/purpose for this peril,(i.e., Parcel Tax Number(s) <br /> campground,festival,mcreationlentenainment event etc.)] <br /> OAU 3111 DI ''�CU <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 /> k POWTSReconnection ❑ Privy—Vault Toilet(Vault size: E3Incinerating Toilet Device <br /> 13 POWTS <br /> Repair County# �� gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# IT—other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ;(l,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,the undersi ne sume responsibility for the installation of the non- lumbin sanitary system for which this Brit is issued. <br /> um Owner's N e(print) Plumbers/Owner's Signature: MPtMS_W No.: Business Phone Number: <br /> /7lu-� amv, a�18-7 y <br /> Plumber's Addrm(SiCity,State,Zip Code): <br /> M&K S PTIC & EXCAVATION <br /> N6228 GOUNTY LINE ROAE) <br /> qpnnNFR WI 54801 <br /> Office Use Only: 715-835-7482 <br /> O Disapproved Permit Fee: CST No. Date Issued Issui S' we <br /> Alf"Approved O Owner Given Initial Adverse e <br /> Deterination 12-09-05 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6(7/02 <br />