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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($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> P Gtr ¢ �il�/gN �C//��-���✓ GL SE 1/45401/4,S30 Tg?AR/f W <br /> Property Owver s Mailing Address Lot Number Block Number <br /> 29zo C SCo v R.D <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number — r <br /> LllAtv�if� IWAI ..55-39/ (763) Edi/zVo <br /> Type of Building: (Check one) ❑ State-Owned ❑CityNe Call 0 <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Villager�'Se <br /> ❑ Public 'K Town of Fire Number <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.)] 0 7_0 a V_ Z-3 g-�q-30 -q 0) <br /> 000 - 0/119,911 <br /> v 1 <br /> bw of Permit: Type of Non-Plumbing Device/SystemtToileWnit: <br /> A Non-Plumbing(Privy,Toilet,Restroom etc.) X 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 /> p <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this pennit is issued. <br /> I,the undersigned,assume responsibility for the i 559ation o - lumbin sanitarysystem for which this mut is issued. <br /> Plumbers/Owner's Name(print) Plumber' wner's Son <br /> ignature: MP/MPRSW No.: Business Phone Number: <br /> T�oye 1 76-T-6a7-i2yo <br /> Plumber's Address(Strew,City,State,Zip Code): <br /> Z9�0 6sro Dery> ,tow <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issui Agent Signature <br /> proved ❑Owner Given Initial Adverse .)� I� Ob <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6n/02 <br />