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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 <br /> POWTS RECONNECTION (� , <br /> POWTS REVISION w <br /> Application Information—Type or Print <br /> t <br /> POwner'nsN-a�me Property Legal Description <br /> r;�� ��Y�n 1Ve, GL 1/4 1/4,S T3gN,R/5-W <br /> Property Owner's Mailin Address Lot Number Block Number <br /> City,State nn Zip Code Phone Number Subdivision Name or CSM Nu9tber <br /> T e of Building: (Check one)❑ State-Owned FUTown <br /> y Nea st Y`I/A kn Rd <br /> 1 or 2 Family Dwelling-No.of Bedrooms: llage ro <br /> ❑ Public gf„�I�.Ji_ FireN qr�Public Building/Land Use: [Explain the usetpurpose for this permit,(i.e., l Tax Number(s) Icampground,festival,recreation/entertainment event etc.)) <br /> compos- '' 1o ,leI'�- 9n.5o - 0/900 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Sj Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ 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 /> 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 /> ❑1,the un i ned,assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumber Owner' ame(pri PlumbeesQwner's gnature: MP/MPRSW No.: Business Phone Number: <br /> tA7r Bfen&j- 7W,#75-tea <br /> Plumber's Address(Street,City,State.Zip Code): <br /> gc,t, a wt, <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Iss ' t Si <br /> Approved ❑Owner Given Initial Adverse a /Z ids <br /> Determination <br /> Comments: —Thr5 (/NrLc rs Qcca✓&,4/e rr NS-F 4=( <br /> 4 <br /> Conditions of Approval/Reasons for Disapproval: d <br /> CZ <br /> C <br />