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BURNS T T COUNTY ZONING ADMINISTRATION <br /> 7=410 COUNTY ROAD K, #102 � <br /> SIREN, WISCONSIN 54872 � <br /> 715-349-2133 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> ?u H o! ySf�r 1< GL a v4 ug..s 36 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /n Al. 11,575 y3 9 v. la P. <br /> Type of Building.: (Check one) ❑ State-Owned ❑City Nearest Road ✓ <br /> I or 2 Family Dwelling-No.of Bedrooms: x ❑v illa'e K <br /> El Public @1 Town of SG.,Y— Fire Numbed7e,G O <br /> Public Building/Land Use: [Explain the use/purpose for this permit,ti.e., Parcel Tw,'Number(s)� <br /> campground,festival,recreatiorJentertainment event etc.)j <br /> Type of Permit: Type of Non-Piumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ,X POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#" � 1 _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#_r1__ 1 ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ,XI,the undersigned,assume responsibility for the POGNTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this perrrut is issued. <br /> Plumbers/Owner's`Na/me(print) Plumbber'si�Owne/r*s Signature: MP/NIPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fermis Fee: CST No. Date Issued Ibsu' rjg€nl Si . re <br /> Approved ❑Owner Given Initial Adverse /t—D. D� / �„l� <br /> Determination J �P <br /> Comments: <br /> CC rYle-xf //1t°el�Se�,�iao�s 01C S nor /Oor'�* �ront Sfj44'4 <br /> & <br /> Garage ;d,,rvd aia <br /> J � �pCior�o� Garage S%ft• � Ex}ty/s avtt' S�Pfic �iww,E' <br /> ja„ok. V A, �/ �� le {or guest• <br /> Y/tN X%s t,^s [9.v %A,v,(' ,n�sl��� Ao( Tv fly Gra <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/01- <br />