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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 APPLICATIO ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> Michael Sanderson <br /> GL NEI/4NE1/4,s21 ,T38N,R15w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1349 Wolf Circle <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Lino Lakes, MN 55038 ( ) <br /> OJ <br /> Type of Building: (Check one) ❑ State-owned ❑City Nearest Road X11 <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village [\ 1'1 <br /> ❑ Public X Town of LaF011ette Fire Number Cj <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.)] 07-014-2-38-15-21-1-01-000-011000 IN <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> X Non-Plumbing(Privy.Toilet,Restroom etc.) X 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 <br /> ❑ Revision State# ❑ Other <br /> 1 <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 /> X I,the undersigned,assume responsibility for the installation of the non-glumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumbe�s Signature: MP/MPRS W No.: Business Phone Number: <br /> Michael Sanderson <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued 1 i e i nature <br /> ❑Approved ❑Owner Given Initial Adverse <br /> Determination IJV'Do <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />