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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 <br /> GL 1/4 1/4,S T 37N,R/8 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> g E L- S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Num er <br /> (05ai <br /> Type of Building: (Check one)❑ State-Owned ❑City Neare Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village / 2 <br /> ❑ Public o Fire N e <br /> i <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 /> 634- 905-01-200 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> KNon-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# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> I,the undersigned,assume res onsibilit for the installation of the non-plumbing sanitarysystem for which this permit is issued. <br /> Plumber's/O er' me(pont) �}� tuber' nZiiatu P/MPRSW No.: Business Phone Number: <br /> �N vl <br /> Plumber's Address(Street,City, ate,Zip od : <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date I ued Issuin gen t <br /> proved ❑Owner Given Initial Adverse "V n'i/brp �� O <br /> Determination b'aK 7 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />