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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 ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Tom Hoffa <br /> GL 1 s 34,T 40N,R 15w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 970 Lake Susan Hills Dr 2 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Chanhassen, MN 55317 ( ) CSM V4 P22 <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> X I or 2 Family Dwelling-No.of Bedrooms: ❑Village Pratt Road <br /> ❑ Public X Town of Jackson Fire Number <br /> 27514 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i e_ Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] 07-012-2-40-15-34-5-05-001-019000 <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 /> X POWTS Recona,,,c1ton ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repai Count # 4861 gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State Septic Tank# 21446 ❑ Other <br /> Responsibility Statement: (Check one or both ❑ as appropriate.) <br /> X 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ 1,the undersigned,assume res onsibil ty 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 /> James Daniels SD 273420 715-866-4157 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 27760 State Rd 35 Webster, WI 54893 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Is i g t Signature <br /> Approved ❑Owner Given Initial Adverse L-7� 0 C) <br /> Determination (VJ O <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />