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r <br />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 CONNECTION/RECONNECTION ($50) <br />Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br />PropertyOwnerName <br />Property Legal Description <br />J�1*1/14,6/c'-06k <br />GL 1/4 1/4,S)9 rv0Av,?/64� <br />Property Owner's Mailing Address <br />a 7S";73 Z,HCO/L� 5%1- <br />fCity, <br />Lot Number Block Number <br />City,State <br />ft/' el,� -fc ✓ !�T <br />Zip Code <br />S`f �'g� <br />Phone Number <br />Subdiv ion Np e or CSM Number L <br />2.v� �s �aTiY <br />V <br />Type of Building: (Check one) ❑ State -Owned ❑ City Nearest Roars S� <br />�j I or 2 Family Dwelling - No. of Bedrooms: a ❑ Village <br />❑ Public ® Town of� Fire Numb e,� 75,8'3 <br />Public Building/Land Use: [Explain the use/purpose for this permit, (i.e., Parcel Tax Number(s) of <br />campground, festival, recreation/entertainment event etc.)] <br />ohm - 9170- 0t660 <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 />�,POWTS Reconnection ❑ Privy — Vault Toilet (Vault size: ❑ Incinerating Toilet Device <br />Count #_ a 99 7 <br />❑ POWTS Repair y ' gallons or cubic yards) ❑ Portable Restroom Unit <br />❑ Revision State #_ —7-icl % D ❑ Other <br />Responsibility Statement: (Check one or both ❑ as appropriate.) <br />KI, the undersigned, assume responsibility for the POWTS activity for which this permit is issued. <br />❑ I, the undersigned, assume responsibility for the installation of the non- lumbin anitary system for which this permit is issued. <br />Plumbers/Owner's Name (print) Plumber's/Owner's Si nature: MP/MPRSW No.: Business Phone Number: <br />T'/GIS o� /Zn <br />Plumber's Address (Street, City, State, Zip Code): <br />77d, O // vL- 3' -f- <br />Office Use Only: <br />tAo <br />O Disapproved Permit Fee: O <br />❑ Owner Given Initial Adverse <br />Determination <br />CST No. <br />Date Issued <br />�p '✓17 <br />Issn� nt re <br />Comments: <br />Conditions of Approval /Reasons for Disapproval: <br />Revised 0/7/UZ <br />