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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 j I �� <br /> 715-349-2138 V <br /> NON-PLU JG SANITARY PERMIT APPLICATION ($5 JUN ? B <br /> POWTS RECONNECTION ($25) ii <br /> POWTS REVISION ($25) sURN67T <br /> Application Information—Type or Print ZONING UNrY <br /> Property Owner Name Property Legal Description (— <br /> Nlw GL MJ 1/45E 1/4,S 10 T3 N,R 1 W C <br /> Property Owner's Mailing Address Lot Number Block Number (� <br /> �,(\ <br /> City,State Zip Code I Phone Number Subdivision Name or CSM Number V <br /> r SStI� 4��- fl69 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Barest oa <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public XTown of f)U� Fire Number <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.)] 400oa4 - 3110T- o3� <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toile[,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System ,�[ <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device ` U <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 POWTS activity for which this permit is issued. <br /> I,the undersigned,assumeres onsibili for the installation of the non-plumbing sanitarysystem for which this permit is issued. J <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Cb„,'- j lvt&- o w <br /> Plumber's Address(Street,City,State,Zip Code): O <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issueddo <br /> Issu' Agent Signature <br /> Approved ❑Owner Given Initial Adverse l <br /> C mments: <br /> 'il <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />