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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($150) <br /> POWTS CONNECTION/RECONNECTION ($150) d <br /> Application Information (Type or Print) ATTACH A PLOT RAN WITH THIS APPLICATION <br /> Propert er Name Property Legal Description ��nn /r <br /> otvl � 0-A)� PV' GL SU� ,T '_0N,RW <br /> Propertyrt �Mailing./ruj7s e I l V Lot Number Block Number <br /> I((,ll((JJ/ltC/l ff{{ viU/?r uc Lo� <br /> Ci�tate zip Code Phone Number Subdivision Name or CSM Number <br /> v� fit J/ 550c�y50V-2(0-0% um (', X65 Vii <br /> Type of Building: (Check one)❑ State-Owned ❑City N <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public XTown <br /> 0vvof'' pp Fre <br /> 4LM <br /> Public Building/Land Use: (Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s)�o-�1 12ci(_ <br /> o�campground,festival,recreation/entertainment event etc.)] o l-oa- s os � <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: 0 <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 /> a <br /> ❑ POWTS Repair County# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#_3 J Qca5 ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> X I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume res nsibili for the installation of the non- lumbin sanitary system for which this permit is issued. <br /> Pj,y�bees/Owner's Name(print) P bees/ 's Signature: /MPRSW No.: Business Phone Number: <br /> I'luv c 5chVIf d �(0 7 a �s� a�b �/ ff <br /> P bees Address beet,City,stat zip code): <br /> A) <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss ' t 'gnature <br /> A proved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments:� ��/ / / <br /> �Gli 70W lVle� Ine41 5el- AG/1 5a <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 617/02 <br />