Laserfiche WebLink
BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K. #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print ( � <br /> Property Owner Name Property Legal Description <br /> jN <br /> lclo, '0•a C GL E 1/4 6W114,S T <1,2N,R W C1 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 7391 S, en <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> fill C4/r, 411,,, SSy.3 �� 7 t_1 <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village f< , f.f <br /> ❑ Public ®Tow o ' Fire Num <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertaimnent event etc.)] <br /> dab- X1311 - ��- �� <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> OKNon-Plumbing(Privy,Toilet,Restroom etc.) /18[`Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑POWTS Reconnection El POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑Other: gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ 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 /> 04 I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Dat Iss d Issuin en S a <br /> oved ❑Owner Given Initial AdversertI Q �} 0/ <br /> ) <br /> Determination Yr v / <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: Li <br /> Jul 1 2001 <br /> ,NETT COUNTY <br /> F� <br /> zo&iN111V7y <br /> Imo' � <br />