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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 ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name ^`')�'' ) Property s D�,p n Q 70 <br /> ED_ _ �` �^' �U GL 1 1/4 1/4,S( 7T N,R7 W 7 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1 oci4,o A-u lb 3 agt(o c * <br /> l State /� Zip Code Phone Number Subdivision Name or CSM Number <br /> C�t2ev� /1, T 309 ( 63 qat s8a <br /> Type of Building: (Check one)❑ State-Owned ❑City Ne est Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ErVillage cam' TT I LO" 40 <br /> ❑ Public ❑Town of Fire Numbe" n <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) 00 <br /> campground,festival,recreation/entertainment event etc.)] O� D<3l -0 3- d U <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> LPI"Non-Plumbing(Privy,Toilet,Restroom etc.) Pprivy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection County# �j(tT ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair ty gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State 4__U '1" . ❑ Other <br /> Responsibility Statement: kCheck one or both❑as appropriate.) <br /> ❑ktbe undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this pcmrit is issued. <br /> Plumber's/Owner's Name(print) Pl a /Owner' Si tur : MP/MPRSW No.: Business Phone Number: <br /> goo eo a/A40us 731-71;i <br /> Plumber's Address(Street,��State, <br /> +Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu ent Si ure <br /> Approved ❑O mer Given Initial Adverse � 9..�Ut'HP�C 4 <br /> Determination ``YY <br /> Comments: <br /> ?cloy Qif. 5a&*a EL: 94 l C 3 rvet 61A, g too&) <br /> Conditions of Approval/Reasons for Disapproval: <br /> �l <br />