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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 AP ATION ($150) <br /> POWTS CONNECTIO CONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description ,f <br /> GL 3 S {, <br /> Property Owner's Mailin Aildress Lot Number Block Num er <br /> un Q4 9 F <br /> Ci StateZip Code Phone Number Subdivision Name or CSM Number <br /> rdn r 8 qo 7ls) l�3 <br /> Type of Building: (Check one) ❑ State-Owned ❑City arest Road <br /> X I or 2 Family Dwelling-No. of Bedrooms: 2 ❑Village 1-btrn 2d, Ci <br /> ❑ Public X Town 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.)] <br /> a3�) <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: 11Incinerating Toilet Device <br /> El POWTS Repair County# �( gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#:mm ❑ Other <br /> Responsibility Statement: (Check one or both❑ as appropriate.) <br /> X I,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 permit is issued. <br /> Plumber's/Owner's Na e(pant) Plumb 's/0 w` <br /> 's S re: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issueg Agent Signature <br /> )INP I proved ❑Owner Given Initial Adverse Uf <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />