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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 Property Legal Description // <br /> GL 1/4 1/4,S f T VbN,R/4 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> un r 1-0+ 0 Lbnq_,A_kl <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> a <br /> (o5-1-?73--1i1&3 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Ro d <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village OalrtcInd Low <br /> ❑ Public 9r-Tow11 of Fire Number <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.)] 30b <br /> Type of Permit: Type of Non-Plumbing Device/S tysstem/Toilet/Unit: <br /> ANon-Plumbing(Privy,Toilet,Restroom etc.) Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑POWTS 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 /> I,the undeEsigg4uLassumeresponsibility for the iristallgien-afthe4jon-plumbing sanitary s stem for which this Dermit is issued. <br /> Plumbers wrist's Name rint) Plumber' er's Si nature: MP/MPRSW No.: Business Phone Number: <br /> r <br /> Plumber's Ad ress(Street,City,State,Zip ode): <br /> �- llv-oa, <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date I sued Is g A S' <br /> kAPP�ed ❑Owner Given Initial Adverse <br /> Determination 7 <br /> omments <br /> Conditions of Approval/Reasons for Disapproval: <br />