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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 ($50) <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property <br /> Property Legal Description ,/ (� _ <br /> 1/llam / 1/nom. C..� L) L, 4216e 'LINL 1/4 NE 1/4,S 7 T31 N,R/7!/ l <br /> Property Owner's Mailing Address Lot Number Block Number /3-` <br /> ov,Yiy Nez. Pe c-e 5 is- <br /> City,State Zip Code Phone umber Subdivision Name or CSM Number .� <br /> N6r'h &ACA , MA/ SSd�(P lPsl �y-g�� <br /> Type of Building: (Check one)❑ State-Owned ❑City tA25 Barest Road <br /> ;Er- 1 or 2 Family Dwelling-No.of Bedrooms: C22 ❑Village T.w e r rPPit J4n_/? <br /> 13 Public ❑Town of np- Fire Nu ber <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 /> p a y-3011—Oa-No <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> J9 Non-Plumbing(Privy,Toilet,Restroom etc.) ff Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <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 /> 14,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> ++-.e+„ocr•s�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 /> -� G G✓c C_ G <br /> Office Use Only: Ae <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu gent Sure <br /> Approved ❑Owner Given Initial Adverse af,L—j� D� O�� r <br /> o <br /> Determination TJ <br /> Comments: DatvY ?o l�Cs Sltfd05c�w? <br /> T <br /> ill 0607M -K, 66 <br /> Conditions of Approval/Reasons for Disapproval: <br /> CD <br />