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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 ( i1 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS RECONNECTION($50) <br /> POWTS REVISION($50) <br /> Application Information—Type or Print <br /> Property Owner Nam//eProperty Legal Description <br /> 14o_1 /1 Cw GL Y1 L 1/4 .5L]1/4.S ,T qa,RI W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> i5- 95-0 6L a-S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ffhstl � s 1 MIAJ �s D37 CSW _40V6 <br /> ,2 9F <br /> T pe of Building: (Check one)❑ State-Owned ❑City Nearest Bgad <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 1- ❑Village (( <br /> ❑ Public Z Town of,J60 <br /> 1 ' Fire Number i <br /> Public Building/Land Ilse: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) f <br /> campground festival,recreation/entertainmen(event etc.)] tY/•QZ8'z'�-l�'^T•svJ•IN`t•0270d0 <br /> �j2$ / 900 <br /> Type of Permit Tjpe of Non-Plumbing Device/System/Toilet/Unit: <br /> 6A Non-Plumbing(Privy,Toilet,Restroom etc.) Xjvy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS ReconnectionPrivy-Vault Toilet(Vault size: 11 Incinerating Toilet Device <br /> ❑ POW7'S Rcpair County# �1 gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ 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 /> XI L the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbers/Owner'sme(print) Plumb is/Owne's Signature: MP/MPRSW No.: Business Phone Number: <br /> ii,`_t� Ufo,i� 3l 5 I Y( °- 073 <br /> Plumber's Address Street,City,State.Zip Code): <br /> � l 9 /tib <br /> Office Use Only: <br /> ❑DisapprovedPermit Fee: CST No. Date Issued Iss g enl Si tore <br /> Approved ❑Owner Given Initial Adverse 1/6 <br /> _�(�� <br /> Determination JJ ,JG�/DI <br /> Comments: <br /> G'Rot ,/ 6eaa 0V_1 99.00 <br /> fir,r roaf of Fal, : t 93.90 <br /> h6 dol�A <_ 5./0 peis �i <br /> Conditions of Approval/Reasons for Disapproval: <br /> D EC EUV <br /> SEP 7 2010 <br /> Revised 617/02 <br /> BURNETTCOUNTY <br /> ZONING <br />