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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) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Connie Prose <br /> W 330' SW 1/4 SW vm,s14,T 39N,R16w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6596 N Bass Lake Rd <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Webster, WI 54893 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> XI or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village N Bass Lake Rd <br /> ❑ Public X Town of Meenon Fire Number <br /> 6596 <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.)] (018-3314-02-110) <br /> 07-018-2-39-16-14-3-03-000-012000 <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 ff 10008 _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 20786 ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> X 1,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 Name(print) Plumber's/Owner's Signature: MP/MPRS W No.: Business Phone Number: <br /> - nt @,tee r-�,�. so �� 33 � r5✓-7ss aoa�y <br /> lumber's Address(Street,City,State,Zip Code): <br /> oy ss » d 0.z, <br /> Office Use Only: <br /> ❑DisapprovedPermit Fee: CST No. Date Issued Issui ent Sig e <br /> 51"Approved ❑Owner Given Initial Adverse `�fFJ 'C )l �0 <br /> Determination 'f J /vt <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Subject to filing of a Flows and Loads Affidavit for a 2-bedroom system to allow for 3 bedrooms <br /> Revised 6/7/02 <br />