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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 ($50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION($25) <br /> Application Information—Type or Print <br /> Property Owner Namee,�/l ✓/ Property Legal Descript'on <br /> GL 1/4 /4,S T N,R/6W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 25/6J Coc/i ran£ Or. �F /(oT :V, CSM ✓, 3 /�, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑City N estRoap <br /> � 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village N <br /> ❑ Public 1� own f Fire Nu bet / <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> :( <br /> campground,festival,rccreatioNentenainment event etc.)] p ZU — y33S— 6 /3a cv <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> XPOWTSi..�ttonnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> County# a 5 <br /> ❑ POWTS Repair _gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision Stale# �(e${$,3 ❑ 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 undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> letman k6 1t� �ZS 8S1 IS &�d 1�1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> � ❑Disapproved Permit Fee: CST No. Date Issued Issum Sign <br /> fdApproved ❑Owner Given Initial Adverse <br /> Determination J✓/ J <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />