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BURNETT COUNTY ZONING ADMINISTRATIO <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) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name + �/, Property Legal Description <br /> Sh P i. i'�`A5 I GL 3 1/4Z /4 S 'ZT yJN R/$W <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> Io35 mercxry Or lU U 17'4 2Zy060 W <br /> City,State Zip Code Phone Number Subdivision Name or CS Number (l <br /> �tacBU:evv f1W 4 5512-10 651 9-71-7 LL* Z M V q p� Y�1 <br /> TWpe of Building: (Check one) ❑ StaoaOwtned ❑city a earest Road - 1 <br /> TW <br /> 1 or 2 Family Dwelling-No.of Bedrooms: t.. eve�J- g FireNumber�y�..7 <br /> ❑ Public �— �'[ownofrAcksaN <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.)] <br /> vet-ol2-z-y�-l5-zv-5 �5-fxr3 b1� u� � <br /> Tye�of Permit: County# Type of Non-Plumbing Device/Syste oilet/Unit: <br /> PfNon-Plumbing(Privy,Toil State# L9-rnvy-Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit 0 <br /> ❑ Revision ❑ Other 'J <br /> Responsibility Statement: (Check one or both❑as appropriate.) 7� <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. tp <br /> LH-fhe undersigned,assume responsibility for the installation of the non- lumbin sanitary system for which this etmiI is issued. f� <br /> Plumbees/Owner's Name(print) P Owner's Si tune: MP/MPRSW No.: Business Phone Number: - <br /> Je( S.aG„wi . <br /> Plumber's Address(Street,City,State,Zip C ). <br /> I-�3S" /Yterc..rY D� W_ S{wre.0:Gy✓ Mrx SS""IZ6 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued in t Signature <br /> Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comment/ <br /> s:: d <br /> nN Pv� <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />