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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description TOcPiUSt}tP Nb/I/, <br /> A611/6-0 46 wGSj 5'><O770ai JY <br /> S + F I}1VG�$' b(/1LL1lqnf GL 1/4 1/4,S T N,R W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 43 (a /—4 K a= Thi 0 &)15 N <br /> City,Statet�lZip Code Phone Number Subdivision Name or CSM Number <br /> r n M1Ntu �S -130-304' 1 "Ivir— <br /> vkz 6s► ) 40yoY <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: (3' ND 60tL 0 t VV ❑Village t — 14 14 V Nz d/ <br /> ❑ Public Ory S.t 1'E 0 o IV b Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcell Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] Ctt lytic yyrf�C,;,� <br /> YG� <br /> � RSoti�3i. �twT,( 06s_al 5-00 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> XNon-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑POWTS Reconnection ❑ POWTS Repair .Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑Other: O gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> the undersigned,assume responsibility for the installation of the non-plumbing sanitary system 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 /> lr W S W W (Z 3" 3707 <br /> Plumber's Address(Street,City,State,Zip Co 11\, 5 t 'Y 30 — 304 <br /> 6 L C i::-1 0 o N.. p air OK 2 <br /> Office Use Only: <br /> ❑Disapproved Pe it Fee: CST No. Date Is uedIssu' Age Sig t <br /> Approved ❑Owner Given Initial Adverse /.[)1 �2"b O� <br /> Determination "CC (iLJ z <br /> Comments:'` <br /> Conditions of Approval/Reasons for Disapproval: za I� <br /> � l <br /> SEP 1 u ZU01 I <br /> ���'��.TT COUNT C" <br />