Laserfiche WebLink
BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION (5150) <br /> POWTS CONNECTION/RECONNECTION ($ <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description 4r <br /> V f ey ,%) 5-,71e- Ut.oft/.S GL -SW 1/4N&Ii/4,S ,153 N,R W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ✓may .2 �� <br /> Type of Building: (Check one) ❑ State-Owned ❑City Neaafe t Road <br /> 1 I or 2 Fancily Dwelling-No.of Bedrooms: ❑Villageo)�'N� 5 <br /> ❑ Public 19'rown of Fir umb r <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.c., Parcel Tax Numfb r(s) <br /> campground,festival,recreation/entertainment event etc.)] O 7 OO& ;z _/2 D!l <br /> / 7 ,,�'-7 <br /> 63 coo o// <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,7bilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> IF,POWTS Reconnection County# Q ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# rag ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ❑L. the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume responsibility for the installation of the non-PlUmbing non-Plumbingsanitary system for which this permit is issued. <br /> Plumber's/Owner's ame(print) Plumber's/Owner's S)i4nature, MPIMPRSW No, Business Phone Number: <br /> z z7Z 9/ .2, <br /> Plumber's Address(Street,City,State,Zip Code): or <br /> Office Use Only: <br /> 13 Disapproved unit Fee: CST No. Date Issued Isstting Agen Signature <br /> *Approved ❑Owner Given Initial Adverse / 00 5' <br /> !A/�1�' //�_- <br /> Determination / ��Q l9 -�S 4121 /y, <br /> Comments: fiaJf'.�9 Vr �u6Lt GJ,U t Ma�i.`L e f/o�rte, Te ERisf•',Y9 Stp 'c �A�vKw 9Qh;•v Fr;G�I. <br /> Conditions of Approval/Reasons for Disapproval: ,n <br /> //.v�r �v:C6iw.q seu/Lr �o Exfs rot' 30 ° rFRow� . uiLA�%�Q L,'nz8 <br /> �Il,reAlieosfllProf.�fa,r., Per SPS 38a 30(!I)(c) J . ECEIVE. <br /> Revised 6/7/02 MAY 18 -MDD <br /> BURNETT COUNTY <br /> ZONING <br />