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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> 4 NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION($25) <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> r 0v GL R u46C1/4,S3 ,T3 N,R /tW <br /> Property Owners Mailing Address Lot Number Block Number <br /> R clou 1<�� I il <br /> City,Stale Zip Code Phone Number Subdivision Name or CSM Number t <br /> ,Yz ( / 39 -Q57 ;a bti D2c� 3 `2' �w <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest <br /> 13t or 2 Family Dwelling-No.of Bedrooms: ❑r�Village 'til <br /> d O <br /> RK Public ULTown of Fire Number / p <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] `I61 PI14: e>7-01$-2-3`1- 7b -3y-6- <br /> 06-Co 1 -01 LOGO <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> M,Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection �f.Priry-Vault Toilet size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# (E gallons or _cubic yards) ❑ Portable Restroom Unit j <br /> ❑ Revision State# ❑ Other <br /> Siz O. J <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 /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbinE sanitary system for which this Remit is issued. <br /> Plumbees/Owner's Name(print) Plu ces/ er' S' ature: MP/MPRSW No.: Business Phone Number: <br /> Vrnc}+ n Fra. 7i N Z/ 7 � <br /> Plumbers Address(Street,Chy,State,Zip e): <br /> Z [o K S,*'1v^ W,= �} <br /> r <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued I inA ignaturc <br /> ❑Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: VV <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 617/02 <br />