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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) d <br /> POWTS RECONNECTION ($25) �I <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> Trr, -4- GL 1/4 1/4,S T N,R /.71O <br /> Property Owner' Mailing Address Lot Number Block Number <br /> o n QI orot 1 <br /> City,State Zip CodePhone Number Subdivision Name or CSM Number <br /> m ori, <`r15a �►� csn, 3� �5 �� P, gal <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> ➢S( 1 or 2 Family Dwelling-No.of Bedrooms: t_� ❑Village <br /> ❑ Public li(TownofOgn�esFire Nu b <br /> 40 <br /> Public Building/Land Use: [Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s`)' <br /> campground,festival,recreation/entertainment event etc.)] (706��'I 17 0 0 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> 13 Ikon-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet 13 Composting Toilet System <br /> W PO WTS Reconnection County#�� E311m Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair. _gallons or _cubic yards) Portable RestrooUnit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> DVthe undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ 1,the undersigned,assume responsibility for the installation of the n - lumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Ownei s Signature'r MP/MPRSW No.: Business Phone Number: <br /> s2/ U "-L3s= 60 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ffice Use Only: <br /> ❑Disapproved P rmit Fee: CST No. Date Issued Issui Agent Signature <br /> Approved ❑Owner Given Initial Adverse , UO „l? <br /> Determination J' <br /> C mments: <br /> Orii,ja j &n�j "ami 653 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br /> a 'd 9829SE99ILT JNIHWf11d AIN390J d9a :60 ir0 22 OmC <br />