Laserfiche WebLink
BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> Property Owner Name y . JProperty Legal Description <br /> d1 � 3W rXS GL NU 1/45 "/4,S-�'7,TsNR/ <br /> W <br /> Property Owners Mailing Address Lot Number Block Number <br /> IDC) ( N R IVC/�Sf <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number W <br /> Dorno <br /> Type of Building: (Check one) ❑ State-Owned ❑Cityh Nearest Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village /"h ee�Q <br /> ❑ Public Town of Fire Number <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 /> bl £s - 3UI-cjDD J <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) Q Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection C # `Privy—Vault Toilet(Vault size: El Incinerating Toilet Device <br /> ❑ POWTS Repair County —gallons or cubic yards) ❑ Portable Restroom Unit O <br /> 11Revision State# ❑ Other Dq <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> the ondersi ed,assume responsibility for the POWTS activity for which this permit is issued. <br /> I, and ed,assume responsibility for the installation of the non-plumbing sanitary system for which this ermit is issued. <br /> P bers/O er's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> um s A7dress(Street,City,State,Zip Code): <br /> 130n <br /> Office Use Only: (31, <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issui Agent Signature <br /> Approved ❑Owner Given Initial Adverse ��{{�� r,)3- <br /> D�Determination ��l...t,J <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />