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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 <br /> 11 A' y�, Property Legal Description GG <br /> L/1 V o n1 r ' N CKSCJ 0 01. 56 1/450) 1/4,S )-l T 4d N,R I7 W <br /> Property Owner's Mailing Addrss Lot Number Block Number <br /> City,Sute Zip Code Phone Number Subdivision Name or CSM Number <br /> All v-c,� /yl v 553° 6 )Js7sy rr 1111 <br /> T pe of Building: (Check one)❑ State-Owned ❑Ciry New pad W <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑V dlag° h/O h 91❑ Public Town of a F rc ber Q <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) I <br /> campground,festival,recreatioNenunainment event etc.)) l <br /> U36- yy29-vl - 5-/0 �l <br /> T pe of Permit: pe of Non-Plumbing Device/System/ToileWnit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair [Oue <br /> nty# gallons or _cubic yards) ❑ Portable R stroom Unit <br /> ❑ Revision a # 5--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 undersi ned,assume res nsibilnfor e installation of the non- lumbin sanit s stem for which this ermit is issued. <br /> Plumber's/Owner's Name(print) r's/Owner's Signature: MP/MPR S W No.: Business Phone Number: <br /> Plumber's Address(Street,Ciry,Sute,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Daze Issued Iss Agent Si nature <br /> 13 Approved O Own.Given Initial Adverse <br /> Determination �-/3"C)6 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />