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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 ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Clark Carter <br /> GL W 1/2 SE 1/4 SW 1/4 S 24,T 39 N R 16 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> PO Box 213 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> New Richmond,WI 54017 <br /> 6/f M7g <br /> t <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> 1 or 2 Family Dwelling-No.of Bedrooms:,__D _ Ifp/aj� j4 ❑Village Peterson Rd <br /> ❑ Public x Town of Meenon Fire Number <br /> 6060 �Jl <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] 018-3324-04-700 <br /> D'I d$ a-39A.--A4-3-04-DOO-0 It 1)0 0 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> X 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 RepairCounty# gallons or cubic yards) ❑ Portable Restroom Unit <br /> State# <br /> 13 Revision ❑ Other C)o <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> 111,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> X I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's wner's�a MP/MPRSW No.: Business Phone Number: <br /> Clark Carter <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ' 1 ❑Disapproved Permit Fee: CST No. Date Issued Issuin t Signa <br /> ffApproved ❑Owner Given Initial Adverse 1 �, <br /> Deterrnination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />