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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 Legal Desc [ion <br /> Property Owner NameC.NC '.Z3 <br /> r. GL 1/4 l/4,S�VT`TflN,R) W <br /> Lot Number Block Number <br /> Property Owner' ailing Address <br /> l sq� 1 -Sf7� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Numb <br /> eu> rrtena� 5�0�7 ( is 3 VIS f�13� <br /> ❑City rest R ad <br /> Type of Building: (Check one) ❑ State-Owned ❑Village C- <br /> • <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: Town of <�40tt:� Fire Number <br /> ❑ Public Parcel Tax Number(s) <br /> Public Building/Land Use: [Explain the use/purpose for this permit, <br /> campground,festival,recreation/entertainment event etc.)] O / — 0 /— q vL�) <br /> Type of Permit Type ofNon-Plumbing Device/System/Toilet/Unit: <br /> ❑ PrivyPit Toilet ❑ Composting Toilet System <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) Priy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Reconnection County# dOO gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ POWTS Repair State# ❑ Other <br /> ❑ Revision <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 undersi ed,assume res onsibili for the tal ion of the non- um in MP MPRSW No.:ry system for which thBus Hess Phone Number: <br /> Plumber's/Owner's Name(print) Plumb O is Sig re: <br /> Plumber's A ress(Street,City.State,Zip Code <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> Approved ❑Owner Given Initial Adverse CID �QO� <br /> Determination �v <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />