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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name property Legal Description <br /> Cell CA/�� (SGLI/4 SWI/4,S IS T37N,RlB W <br /> Property wner's Mailing Address Lot Number Block Number <br /> bq C )ed 0 <br /> City,State f, Zip CCood/eO'/ Phone Number Subdivision Name or CSM Number <br /> R01 <br /> pe of Building: (Check one)❑ State-Owne 11 City Nearest Road <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village / 07 C ,�(0 <br /> Public yTown of T/�I& I 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 /> 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# gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision Stater ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ffI,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 sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumb' wner's gna MP/MPRS W No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Is su d Is ing Agent Si nature <br /> Approved ❑Owner Given Initial Adverse �a�d a 3/7 3 ` <br /> Determination 7!! U <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br />