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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 RECONNECTION($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> P Owner Name Property Legal Descriptiory <br /> y Sw <br /> �� GL //4 1/4,S ,T S4 N,R/ W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Sf'lai <br /> Type of Building: (Check one) ❑ State-Owned ❑City N s Road r A` <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village ( v <br /> ❑ Public ow f Fire Numbgp <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.)] -41 <br /> 332 —d/ — y'CJ� <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ,0"I on-Plumbing(Privy,Toilet,Restroom etc.) ❑ Priv —Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection I Coun # id-Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair n' _gallons or _cubic yards) ❑ Portable Restroom Unit <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 permit is issued. <br /> the undersi ed,assume responsibility for the' llation o e non-plumbing sanitarysystem for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumb Owner' i ature: MP/MPRSW No.: Business Phone Number. <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> Disapproved <br /> ❑ApprovPermit Fee: CST No. Date Issued Issui gent Signature <br /> ed ❑Owner Given Initial Adverse ; <br /> DetenninaGon ��—)l_�—C) <br /> Comments: <br /> a' <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />