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BURNETT COUNTY ZONING ADNHNISTPJ TION <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 D scription <br /> =RT IC / GL 1/ 1/1 S Zf TYCN,R) < W <br /> Property Owner's Mailing Address Lm Number <br /> Bock Number <br /> l3/U <br /> City Sate Zip Code Phone Numbe Subdivision Nam, m CSM Number <br /> Nc ' Sqt]/ s <br /> Type of Building: (Check one)❑ State-Owned O City N� nerd <br /> © 1 or 2 Family Dwelling-No.of Bedrooms: 3 O Village <br /> O Public BTown of Fi Number <br /> Public Budding/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Num s) <br /> campground,festival,recreation/mustainment event etc.)] <br /> ozu-eliz, 7-02 - 31 <br /> Type of Permit: Type of Non-Plumbing Device/Sys entffollet/Unit: <br /> O Non-Plumbing(Privy,Toilet,Restroom etc.) Cl Privy—Pit Toilet 3 Composting Toilet System <br /> Of POWTS Reconnection Coun # 0 Privy—Vault Toilet(Vault size: Incinerating Toilet Device <br /> ❑ POWTS Repair ty _gallons or _cubic yards) I Portable Restroom Unit <br /> ❑ Revision State# p Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the NWTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume res nsibili for the nstallation of the non-plumbing sanitaryem forwhich this 't is issued. <br /> Plumbefs/Owner's Name(print) Plumbe— .Owner's Sigruturo: MP/MPRSW No.: Busini s Phone Number. <br /> Plumbees Address(Street,City,State,Zip Code): <br /> OfPce Use Only: <br /> O Disapproved P it Fa: CST No. Date Issued Agent Signature <br /> ved O Owner Given Initial Adverse <br /> Determination ---PPPPPP 4-3-o <br /> Comments: <br /> Conditions of Approval/Reasons for Disapp oval: <br /> Revised 617/02 <br />