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BURNETT COUNTY ZONING ADNIINISTRATION <br /> 7410 COUNTY ROAD K, #102 - - <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> JINVLUMBIN PPLICATION 10) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> l> Ay GL 1/4 1/4,S-7 T qo N,R/6 W <br /> Property Owners Mailing Address Lot Number Block Number <br /> City,State Zip Cade Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one) ❑ State-Owned ❑City r/� Nearest Road <br /> ❑ Public Family Dwelling-No.of Bedrooms: JaTorll llvn of OAnp4 Fire Number / Z81` <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 /> Ke of Permit: Type of Non-Plumbing Device/Sy tem/Toilet/Unit: <br /> on-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet Composting Toilet System <br /> OWTS 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 /> 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,assum&,Wponsibility for the' stallation of umbin sanitarysystem for which this permit is issued. <br /> Plumber PI MP/MPRS W No.: Business Phone Number: <br /> DMA r <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued I ur g Agent S' ature <br /> Approved ❑Owner Given Initial Adverse �SD <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> APR 2'8 2016 <br /> Revised 6/7/02 <br /> BURNETT COUNTY <br /> ZONING <br />