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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 ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> �^ `Z / �<- ✓�l"J S GL S u 1/4 N E 1/4,S 7 I ,T3 9 N,R / W <br /> Property Owner's Mailing Address //�� Lot Number Block Number (� <br /> 3 r 3 2 . // ve- ZS O /� &C ,Y aQ M1 4 <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number �f <br /> be✓�ti raQ W � 8-74 (7ti—S22- 8o6 Q� <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nest Road Q� <br /> I ,t <br /> 1 or 2 Family Dwelling-No.of Bedrooms: / ❑Village fea.Ver Da✓n P-Town of SK Fire NumbeW <br /> 11 Public r a�36 1 I <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.)] 6 at{- 31 31-0 1'3 b o <br /> fv r 141 . 1 , w5 Ca , .p- <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> O <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) N Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or _cubic yards) ❑ Portable Restroom Unit P <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> I,the undersigned,assume res onsibilit 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/MPRSW No.: Business Phone Number: <br /> David <br /> Plumber's Address(Street,City,State,Zip Code): <br /> J <br /> Office Use Only: 15-57 <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issui A t Si re <br /> Approved ❑Owner Given Initial Adverse �I <br /> Determination 77U <br /> Comments: ; <br /> ppluy ?)b Dom fo be <br /> Ga«>wo GsvAl (2� 31 ; '957.90 s E .r fz6ve ruiJ 9A 90 �aR �!?�") <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />