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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 /> Daniel Bilot <br /> GL 6 I/4 1/4,s36,T40N,R15 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2416 Dupont Ave S 5 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Minneapolis, MN 55405 615-817-8108 <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> X I or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village Mallard Lake Rd <br /> ❑ Public X Town of Fire Number <br /> 3770 <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.)] 07-012-2-40-15-36-5-05-006-014000 <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 /> X POWTS Reconnection County# 18092 ElPrivy—Vault Toilet(Vault size: 13 Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> 11 Revision State# 228410 ❑ Other <br /> a <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> X 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 111,the undersigned,assume responsibility for the installation of the non-2lumbinE sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's SignaNre: p PRSW pNo.: Business Phone Number: <br /> / ` <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /6 4- <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss g Agent Signature <br /> pproved ❑Owner Given Initial Adverse I _ <br /> Determination ��, (� -b�� <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />