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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION � b <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> gr"q&-), V GL 1/4 1/4,S/7 11{0 N,R/7 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ^ib r /5--fT6 37/2 ArvelTD 0345 eg300 <br /> Type of Building: (Check one)❑ State-Owned ❑city Nearest Road <br /> CT 1 or 2 Family Dwelling-No.of Bedrooms:—Z— ❑Village <br /> ❑ Public ID To <br /> V;T oof� Fire Number9�b <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 /> 036 q#17 a <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 /> ®POWTS Reconnection ❑ POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑Other: _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ 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 undersigned,assumeresponsibilf for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbeess/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> tG ,w r Z / a4Z- <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin nt S' re <br /> li Approved ❑Owner Given Initial Adverse <br /> Determination 'rl 3 r�ylG b <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: -7, <br /> QUG - 220W I <br /> BURNETT Couyly <br /> 4UNING <br />