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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/5'0) <br /> POWTS RECONNECTION ebb) <br /> POWTS REVISION(BSD) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> GL o2. 1/4 1/4,S�;?(,,T y[ N,R /)W <br /> Property er' ailing Address Lot Number Block Number <br /> '1351 / 9 no a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 00 a7 -3/ 0-5m V, <br /> Type of Building: (Check one)❑ State-Owned ❑City Ne Road <br /> 17 I or 2 Family Dwelling-No.of Bedrooms: ❑Village Fb+ <br /> ❑ Public Town of Suv LSS Fire Number rwrtt `` <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) W <br /> campground,festival,recreation/entertainment event etc.)] <br /> S£,4son_AL RF,Ck,i✓A-rjW t3a-Saab- D3- 9o � <br /> Type of Permit: Tvpe of Non-Plumbing Device/System/Toilet/Unit: <br /> J Non-Plumbing(Privy,Toilet,Restroom etc.) X Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair Cour # gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other ('r` <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ ,theundersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> the undersi ed,assume responsibility for the installation of the non-plunabing non-plumbingsanitary system for which this permit is issued. <br /> Plumber's/Owner's Nam (pri [) Plumber's/Ownei s Si lure' MP/MPRSW No.: Business Phone Number: <br /> dM� 2 tZA lJ Z <br /> Plumber's Add ss(Street,City,State,Zip Code): <br /> Office Use Only: 1<7 <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin t Sign <br /> it Appmved ❑Owner Given Initial Adverse <br /> Determination "/�Q, v <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Privy T be- 16CekeO4 CvA,l; /U ret of 50V &" s 101G4ed o-t, <br /> sotL Evelv.�rsh Plo-� ���. <br /> Revised 6/7/02 <br />