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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 A CATION($50) <br /> POWTS RECONNECTIO ($25) <br /> POWTS REVISION($2 <br /> Application Information-Type or Print <br /> Property Owner Name) _ Property Legal Description <br /> Ch�.rvs L�QCS()rh GL 5w 1/45E1/4,SOgJ3� ,R16W <br /> Property Owners Mailing Address0Lot Number Block Number <br /> 5858 k ersor, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Vv2bs�er, VU-1- 549g3 '115 860330 <br /> e of Building: (Check one) ❑ State-Owned ❑City N Road Rd <br /> I or 2 Famil Dwellin No.of Bedrooms: ❑Villag <br /> Type <br /> ❑ Public m�nbn <br /> y g' 02 Town of Fire Number 51?S8 <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] 3 G' - <br /> a� <br /> p18- 3 �-I - <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 /> XPOWTS ReconnectionCourt # ❑ Privy-Vault Toilet(Vault size: 13 Incinerating Toilet Device <br /> ❑ POWTS Repair tY gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ 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 undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this pennit is issued. <br /> Plumbees/Owmer's Name(print) Plumbees/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plu berg Address(Street,City,State,Zip Code): <br /> S;ver-. <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued ng Signature <br /> ❑Approved ❑Owner Given Initial Adverse <br /> Determination K7 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />