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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 <br /> Application Information—Type or Print <br /> Property Owner Name <br /> Property Legal Description <br /> /fy <br /> /rl 'GI.-,e*:- 1/4-% 1/4,S;?.,SrT N,R W <br /> froperey Owner's Mailing Address Lot Number Block Number <br /> 52 a 0_ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Scotr W s1-50 21 15 )262 5�s <br /> T of Building: (Check one)❑ State-Owned ❑city N est oad <br /> i or 2 Family Dwelling-No.of Bedrooms:As 11 Village <br /> ❑ Public own of�t u( k Fire Numbery� 2- <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.e., Farcel Tax Numbers) 6J <br /> campground,festival,recreation/entertainment event etc.)] <br /> 1 074 372 03 3M <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 /> ,JdXOWTS 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 /> ❑1,the undersigned,assume responsibili for the installation of the non- lumbin sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumbees/Owner's Signature: MP/MPRSW No.: Business Phone Num�^b-w <br /> lumber s A dress Street City,State,Zip Code)' <br /> 2 _ {48 3 <br /> Office Use Only: <br /> ❑Disapproved it Fee: CST No. Date Issued Issu- g e <br /> pperm <br /> rove <br /> ❑Owner Given Initial Adverse <br /> Determination �'7'w '--ed ~ <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />