Laserfiche WebLink
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($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Mg'rlIl n FI]ck GL 1/4 1/4,S-",3 ,T4UN,RI5W <br /> Property Owners Mailing Address Lot Number Block Number <br /> 18x11 65V1J6LA_S- Dir f�a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Lake HAVAsu C11-111 A-z g(�r�pN pVerland hbh 1v Vu <br /> T of Building: (Check one)❑ State-Owned ❑City Nearest h n I W <br /> 1 or 2 Family Dwelling-No.of Bedrooms: mac. ❑village AWW <br /> ❑ Public Town of-,Ja 0 Fire Number.81 3 f <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] b'i-0 la-A-yb 45-A 3-5-I5"5b0-G$zk 6o0 <br /> Type of Permit: Type of Non-Plumbing Device/System/I'oilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> X'POWTS Reconnection F i ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# �,$�a gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# a �l`f l to ❑ Other <br /> Rponsibility Statement: (Check one or both ❑as appropriate.) <br /> the 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 permit is issued. <br /> Plumb 's/Owner's Name(print) Plumb e's/Owner's Signature: MP/MPPRSW No.: Business Phone Number:7,� a / /,4 D in/ <br /> Plumber's Address(Street,City,State,Zip Code): II <br /> 16✓—b LI' 2 36J'-1- A'VG LLE ( ✓Z �J � <br /> Office Use Only: <br /> �/ ❑Disapproved Permit Fee: CST No. Date Issued Issuing t Signaler <br /> P Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />