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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 $60) <br /> POWTS RECONNECTION ($25) W <br /> POWTS REVISION($25) (� <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal DescT' ? <br /> C>4'044 SN /4 N�1)11 <br /> 4- <br /> ,S 35,T3 N.R/$w <br /> Property Owners Mailing Address Lot Number Block Number <br /> 11335' iy1 R7%SOAJ Poq-D <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 4kck- , Gtlz 55853 IC7152311ANS <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road <br /> ❑ L or 2 FamilyDwelling No.of Bedrooms: ❑Village `r <br /> n g- IN To"of I ln7 Fire Number <br /> ❑ Public f-p' / <br /> Public Building/Land Use: [Explain the usc/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreation/entertainment event etc.)] <br /> 03(/- 1535- 01-7 <br /> Typpe of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> L�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 undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumbers/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> 5AKAT KiL&001f, <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issw Ageynt tSignature <br /> Approved ❑Ownef Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 617/02 <br />