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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 ($150) (� <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION 1j) <br /> Property Owner Name Property Legal Pescription <br /> `Jas �e-� GL 1)/4iVE1/4,5 T.9N,R <br /> Property Owner' M mg Address Lot Number Block Number <br /> a - <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Ro d <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public �"n ofD Fir Num]1er <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Numbers) <br /> campground,festival,recreationientertainment event etc,)l <br /> 0-7 <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 /> YT,POWTS Reconnection Countv�I 11 Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> y <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State" 3T ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,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- lumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's Signatu MP/MPRSW No.: Business Phone Number: <br /> o <br /> P yrs- l <br /> Plumber's Address(Street,City,State,Zip Code): <br /> V i �� t14 5—M <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued issdnl g Agent Si ature <br /> Approved ❑Owner Given Initial Adverse & eg -1 -7-17 ~/�hK- <br /> Determination �� '�S <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> D MER <br /> JUL 17 2015 <br /> Revised 6/7/02 — 0 <br /> BURNETT COUNTY <br /> ZONING <br />