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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 APP ATION ($50) <br /> POWTS RECONNECTION $25) <br /> POWTS REVISION ($25) (N <br /> Q� <br /> Application Information-Type or Print n 1 <br /> Property Owner Name // Property Legal Description <br /> 0-tthan -- L61s K(tl GL 1/4 1/4,S T `6 N,R/ W <br /> Property Ownces Mailing Address Lot Number Block Number <br /> Q $65 _ bL4 VI n 6-f-. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1JGtrIb� rL V0 3M9Yellow Lake ✓{ttobile lto✓/e lIel <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road D u by <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: _ ❑Village <br /> ❑ Public Town of Oak(okld Fire Numbtt b715� <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.)) <br /> Type of Permit: Type of Non-Plumbing Device/Systeni/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> 0 Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# o _ _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumbees/Owner"Signa rc PRSW No.: Business Phone Number: <br /> feof- P fh`l� tl ��f A � I '11S-`l63 34�� <br /> Plumber's Address(Street,City,State,Zip Code): V <br /> ,p / r I t� <br /> wt r,E� f Iw. ti Pot t�X OS lS -,,L wS S I�yv <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> ❑Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />