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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 neer Name Property Legal Description <br /> GL 1/4 1/4,S T yd N,R/'6 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> as / s-Yzqfe {�o� 3S ro � s ( t3�:;- 9/(,� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> reffei' C[1_L s r-s61' Joel/ouJa Cc <br /> Cs \ 1 P)a <br /> Type of Building: (Check one)❑ State-Owned ❑City FFirerc <br /> eare t Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village ^ I_ ar� S f— <br /> ❑ Public I� ^ <br /> Town of l r-Lt Number <br /> 81 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> G 2;2o <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 Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# g Ilons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ter <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 /> I,the undcrsi ned assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber' wnerr s Nam (print) Plumber ner's Signature: MP/MPRSW No.: Business Phone Number: <br /> _w <br /> Plumber's Address(Street,City,State.Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. D to Issued Issu'Vip Agent§ignatpre i <br /> Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> e APRaS�Q3 <br /> URNETT <br /> ANG <br />