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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 ($25) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> /''%k'_ 7—( /1 °t- A .4W 1/4 56 1/4,S 8 T 1J0N,R /SW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ,A80d3 rl/. Sr�s Llc /?Cj. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W eksl e v WT- Si/ev 3 <br /> Type of Building: (Check one)❑ State-Owned ❑CityNear st Road <br /> ,® 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village �ORe, ✓�� <br /> ❑ Public &TTownof j,,klen Fire Numberd„ g�,y <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> O !A — NdOg—of Sma <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> 10 POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# /3716 _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# egg$ ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> RI,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume res onsibili for the installation of the non-Plumbing sanitarysystem for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> R,e./e flo k,,s I / J,�SS'.S/ 7/.S'X66- '//-r7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ) 776 0 /,4-y3S LI/e6s-/e <br /> Office Use Only: <br /> J ❑Disapproved Permit Fee: CST No. Date Issued Issui t Si ure <br /> tp Approved ❑Owner Given Initial Adverse / <br /> Determination z Go <br /> Comments: 14130Pa4 ds Gray""”- /Aenstiga C*---?1" - x{-35 C, <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />