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BURNETT COUNTY ZONING ADNIINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($$0) <br /> POWTS RECONNECTION ($25) f , <br /> POWTS REVISION ($25) w <br /> Application Information—Type or Print " j <br /> Property Owner Nome Property Legal Descripti V <br /> GL /J.J 1/46KJ /4,s'3`f,T-IIN,RISW 0 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> la�la as��h ,5� 5 <br /> City,State Zip Code Phone Number Subdivision Name or CSr I Number <br /> C'h I SGS Ci i rn�) �S o( 3 �s� ' Gsn-, v, 8 Llaa <br /> Tepe of Building: (Check one)❑ State-Owned ❑City Nearest Road <br /> 9? l or2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public Town of 5eJi Fire N' ber <br /> PublicBuilding/Land Use: (Explain the use/purpose for this permit,(i.e., Parcel TaxNumber(s) <br /> campground,fest i cal,recrcation/entertainment event etc.)] <br /> 03 -;�- -G, 204 - pa- bbu <br /> T),jk of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> G r_Non-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ In inerating Toilet Device <br /> ❑ POWTS Repair County# gallons or cubic yards) ❑ P rtable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Rcsponsibilk) .tiWfement: (Check one or both El as appropriate.) <br /> ❑ 1 the undersi-iicd,assume responsibility for the POWTS activity for which this permit is issued. <br /> /, the undersipncd,assume res onsibi try for the installation of the non-plumb' <br /> sanitary system for whic this permit is issued. <br /> PIuw,MWOwner's Namc(print) a's Si P/MPRSW No.: Business Phone Number: <br /> Zs-be G tubers Ni,¢ 2s»xs7 <br /> 114mvA Os-Address(Street,City,State,Zip Code)• <br /> SQ2 A dove <br /> 0f1L•e Use Ou,y: <br /> ❑ Disapproved Permit Fee: CST No. Date Issued issuin t Si re <br /> nl•proved ❑Osma Given Initial Adverse �� ( , r� G7 <br /> U:Icrmination wW / <br /> Comments: <br /> ('. c J itions o 1'.'.p P roval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />