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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 RECONNECTION ($50) <br /> POWTS REVISION($50) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> r\2VI✓1 4JeCY) e-�-l-e eQ�Qi,2 U <br /> GL NEvaN4lua,s a9,r39N,R )fow <br /> Property Owners Mailing Address Lot Number Block,Number <br /> r-1o35 &erwo Cd L„ I <br /> City,State Trp Cade Phone Number Subdivision Name or CSM Number �- <br /> nlopL[ 6rOve ,01Aj 553(0 ( esm V. 90 t9 '713 <br /> Type of Building: (Check one) ❑ Stare-Owned ❑city Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑village <br /> ❑ Public <br /> Town of#AeQnQ� 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.)] <br /> 01 33a9-D3-31,b <br /> Type of Permit: :r-pe of Non-Plumbing Device/Systendfoilet7Unit: <br /> on-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Tioilet System <br /> ❑ POWTS Reconnection — IW Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair k County# 200 gallons or I cubic yards) ❑ Portable Restmom Unit <br /> ❑ Revision State# ❑ Other i <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1 the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> [,the under,; ned,assume responsibility for the installation of the non-plumbing sanitarysystem for which this emu is issued. <br /> Plumber's/Owner's Name(print) Plumber' Owner's Si ure: MP/MPRSW No.: Business Phone Number: <br /> }(�vl N NEpRP� w <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued IS., i en[Si e <br /> Approved ❑Owner Givenlnin.al Adverse fpd AN r t,,IT <br /> Determination O .Zs/lY1Q. µrV <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 66102 <br />