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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 ($150) W <br /> POWTS RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print C �(Q <br /> Property Owner Name Property Legal Description 1 <br /> Richard and Sally Wierstad <br /> GL SW va NW I/a,s 11,T 39N,R 14w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1756 Norfolk Avenue <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> St. Paul, MN 55116 ( ) <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road Martin Lane <br /> X 1 or Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public X Town of Fire Number 26708 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] 024-3111-02-400 <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 /> X POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 27698 gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 434060 p Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume responsibility for Ihe installatio of the non-plumbing sanitary system for which this permt is issued. <br /> Plumber's/Owner's Name(print) er's/ wner's jTgnaturc: MP/MPRSW No.: Business Phone Number: <br /> Kell u FergusonFer uson 224069 715-635-2887 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> W9502 Dock Lake Rd. Spooner WI <br /> Office Use Only: <br /> � � ❑Disapproved Permit Fee: CST No. Date Issued Issui A i Sig e <br /> W Approved ❑Owner Given Initial Adverse 't `tom r <br /> Determination .SU sJfl't 69 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 5/22/08 <br />