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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 —b <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) f <br /> POWTS CONNECTION/RECONNECTION ($50) v 1 <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION `XD <br /> Property Owner Name Property Legal Description <br /> Tran:S } V: ini Q GL NW 1/4 I%JF, 1/4 S = T37N,R7 W <br /> Property Owners Mailing Addresr Lot Number Block Number <br /> P0 �Nox 3423 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ac Kan 5 aw 1 WZ, Tq 7a <br /> Type of Building: (Check one) ❑ State-Owned ❑City kFireNumley <br /> earest Road <br /> 1 or 2 Family Dwelling-No.of Bedrooms- _ El Village a Qd <br /> 11 Public "IgTownofLinea,) a 9]'7 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) 1 <br /> campground,festival,recreation/entertainment event etc)] 0-7- all,- I -39-/r1-sz- ] <br /> OA- 000 - 0/7000 <br /> Type of Permit: Type of Non-Plumbing Device/System/I'oilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> XPOWTS Reconnection I j t X01 ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#.SS gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#$95- 3oyy17 ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> el,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 /> Plumbers/Owner's Name(print) Plum7bee=gnaturc. WIMPRSW No.: Business PhoneNumber: <br /> Te�v; ut --f':Vld _ `5a 079 <br /> Plumbers Address(Street,City,State,Z e): <br /> I ti/3 414, U 5 i-e}e Poa ef 7 7 -/a X tn.,e r c) w r s',-/e o-13 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued I g Agent Si Lure <br /> ,Approved ❑Owner Given Initial Adverse ' 0 9� <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> p ECEOVE <br /> Revised 6/7/02 <br /> BURNETT COUNTY <br /> 7nNINr2 <br />