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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN,WISCONSIN 54872 <br /> 715-349-2138 <br /> (NOIN-P�LUMB]NGSAN�ITARY PERMIT APPLICATIi�1VLr 1.11U1V <br /> POWTS REVISION OO <br /> Application Information-Type or Print <br /> J <br /> Property 9wner Name _ �� Property LegaICE <br /> Eription <br /> PP111141" S /uL'f� 'rOWAQ" GI�W1/4sJfI14,S1 T N.R W <br /> Property Owner's Mailm umber Block Number <br /> NiAddress Lot Ns; 1 <br /> City,StateZip Code hoIIc Number Subdivision Name or CSM Number <br /> i'1?N t53 -Pm <br /> T pe of Building: (Check one)❑ State-Owned ❑City est Road <br /> I or 2 Family Dwelling-No.of Bedrooms: / ❑village <br /> ❑ Public gown of,51.,&ss Fire Number <br /> 05 <br /> Public Building/Land Use: [Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreationlentertainment event etc.)] <br /> T e of Permit- - lumbing Device/System/Toilet/Unit: <br /> Non-Plumbing Privy oilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconn�C hnvy—vault I otlet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or _cubic yards) ❑ Portable Restroom Unit <br /> 13 Revision State# 15--other <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 /> 1,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> [,P;Iumbc:r's/Owncr s Name(print) Plumbces/Owner's Si MP/MPRSW No.: i Business Phone Number <br /> 209" 6371 <br /> 20 <br /> lumber's Address(Street.City,State.Zip Code): <br /> G s' r Nf- 0e e-1 <br /> f Wov sial <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued nj Agent Signature <br /> pproved O Owner Given Initial Adverse q5U � /a8 O q l�Ij <br /> Determination ff U <br /> Comments: <br /> rn <br /> 00 <br /> Conditions of Approval/Reasons for Disapproval: <br />