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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 ($5C) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Propertweer Name /�. Property Legal Description <br /> 0b�f �(�/� /1 c/ GL 1/4 1/,,S/_'5--,T N,R W <br /> Properly Owner's Mailing Address Lot Number Block Number <br /> 7(3 .u-e S4- <br /> City,State Zip Code Phone Number Subdivision Name or CSM umber <br /> T s �.i S`I oa s n'S_ z2z�g / >4, , v;`114 <br /> Type of Building: (Check one)❑ State-Owned ❑Ciry N crest Road <br /> ❑Village <br /> - I or 2 Family Dwelling-No.of Bedrooms: ( -mown of Fire Num er <br /> ❑ Public <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 /> O/Z -T37 -�� -�oJ � <br /> Type of Permit: Type of Non-Plumbing Device/System/T ilet/I)nit: <br /> .Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet 1_91�Co posting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ incinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ Portable Restroom Unit .� <br /> ❑ Revision State# ❑ Other -� <br /> Y <br /> c <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> the under ' ned,assume responsibility for the installation of the non- lumbin sant system for whic th7n �it is issued. <br /> Plluum7ber' wner's ame(print) P er's/Owne' ature: MP/MPRSW No.: Business Phone Number: q <br /> KO P�IC1A - /S-ZZZ-oSS6l <br /> s Address(Street,City,State,Zip Code): / <br /> OD <br /> Office Use Only: J <br /> ❑DisapprovedPermit Fee: CST No. Date Issued Issu' gent Si ore <br /> M--Approved ❑Owner Given Initial Adverse /� <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />