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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 ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name fin( Property Legal Description <br /> /I ,5 GL.Sy $E 1%4 it/ 1/4,S 20 ,T�(/D_N,R/a W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> u A;� . U <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Qa,vdvP W1 Sy893 ( ) <br /> Type of Building: (Check one)❑ State-Owned ❑City Near t Ro <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: / ❑Village <br /> Town ofKIc3v� Fire umber <br /> eY <br /> [ PUblic C,*Ae — - yAr + 7 41PZ <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.)] 497-azo-2-y,9-16-Zip-/ O!f—pGO' <br /> Cafe &S. ro 4„'4,( j je,lroe,N AP 14WI R f G/rleoo <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> K�POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# o ❑ Other <br /> sponsibility Statement: (Check one or both❑as appropriate.) <br /> the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 1,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbefs'Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> S S/ 73y�1/ 7c� sGG v/s 7 <br /> P mbe>s Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss ' Ag-rSiture <br /> (I7 Approved ❑Owner Given Initial Adverse <br /> Y� Determination < e <br /> Comments: Al�no✓Ga Ex s� 71'a gaLE S�tCC Sepfrc rAN�S; AtPl4tf n+FAirl o IC 5'147'e 40orvile <br /> /40o3411 cv.�slrCo.varefe Gteafl I�vfe�Grptorr �"Xtd�iN� /040gat1 S�'awLo�vcrl�CTa,vk <br /> 6t/ss lPc/ ;v p�aC[, <br /> Conditions of Approval/Reasons for Disapproval: <br /> iqt vfe c�a#vje -Fro,n a A-es;A*A *Z �vat�iwa�rr LLow - %o a G•.»intrt:.l <br /> ,r <br /> Revised 6/7/02 <br />