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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 S <br /> POWTS RECONNECTION($25) <br /> POWTS REVISION(S25) <br /> Application Information-Type or Print <br /> Property Owner Namek _ Ply Lea Description ��}} ! <br /> V�er GL 3 1/4 1/4,S,3TAR/J6W <br /> Owners Mailing Addr Lot Number Block Number <br /> 2� ( 7(0 (e_V- t20( a <br /> City.State Zip Code Pion Number Subdivision Name ar CSM Number <br /> (n) `0i5�er us l szt t3 7+S ! Sa CSm ✓. 3 p l5 l <br /> Type of Building: (Check one)❑ State-Owned a city_ m e��n N Ray <br /> ❑ l or 2 Family Dwelling-No.of Bedrooms: ta&e ' <br /> ❑ Public �Y"fown of Fire Nmber <br /> Public Building/Land Use: (Explain the usupurpose for this permit.(i.c. Parcel Tax Numbw(s) <br /> campground,festival,recrestionlentanainmrnt event etc.)] <br /> 018- 33o3-a5 00 <br /> T of Permit: Type of Non-Plumbing DevicelSystem(foileNUnit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) 13 Privy—Pit Toilet C3 Composting Toilet System <br /> ❑ W l Reconnection Privy—Vsuit Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic <br /> ❑ Revision State# ❑ Other yards) ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,asamrc responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing rani for which this pertnit is issued. <br /> PlumbeeslOwner's Name(print) Plum downer's MPIMPRSW No.: Business Phare Number. <br /> j e ef- i2D2 k 9 <br /> Plumbers Adders(Sueu,City,Sunc.Zip <br /> eco n t� -rc(e,e- <br /> Office Use Only: <br /> I]Disapproved Permit Fa: CST No. Date issued bluing Ageru S� iDts <br /> ❑Approved O owner Gives Initial Adverse C <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />