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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 Du <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 /> We ✓ a GL SE 1/4—':'E 1/4,S (7 ,T N,R I LW <br /> Property Own is Mailing Address Lot Number Block Nu ber <br /> 26 y if 14b/XJ Ave S . ICU, 8m q <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> { � iS 5"W3 /S -y39 <br /> Type of Building: (Check one)❑ State-Owned ❑City I Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village . a5 <br /> ❑ Public -Town of M Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] <br /> alOn <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> on-Plumbing(Privy,Toilet,Restroom etc.)) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection C #3 Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ozen <br /> ❑ POWTS Repair ty tp _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑is appropriate.) <br /> ❑ 1,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 sanitary system for which this permit is issued. <br /> -A& rMwCs/Owner's Name(print) E�strr's/Owner's Signature: A006PR6W-Na; Business Phone Number: <br /> JawCS FL rricKSoL, �z2 ��- 7/I X66-`z 3S l <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 6 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu' gent Si re <br /> IP(Approved ❑Owner Given Initial Adverse `D 19II OG� O� <br /> Determination J �— <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />