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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 �b <br /> 715-349-2138 -U <br /> l <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> 4n p W k A S GL 540 1/4 1/4,S 1 ,T 38N,R/5 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 17$ 6 VIJOO ave- 3 <br /> City,St to Zip CodePhone Number Subdivision Name or CSM Number a� <br /> (11 12 ) sa -2/'33 C5"'1 # ZZ7 V611_5 fol <br /> Type of Building: (Check one)❑ State-Owned ❑City ear st Road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village r R►+ At <br /> ❑ Public Town ofLA4 f',4,(C Fir 7 u ber <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel el Tax Number(s/)' <br /> campground,festival,recreation/entertainment event etc.)] �v 21 <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 `I pD ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# t-475-11gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ 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 /> M 1,the undersigned,assume responsibility for the installation of the non-plumbing sanitary s stem for which this permit is issued. <br /> ,plumber's/Cn er' Name(print) Plumber'/Ohrngj'�Signature: MP/MPRSW No.: Business Phone Number: <br /> J0kA W A <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing geSignature <br /> Approved ❑Owner Given Initial Adverse /$'0 0 7'o1 9-�S <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> ECERS <br /> JUL 28 2015 <br /> Revised 6/7/02 — 0 <br /> BURNETT COUNTY <br /> ZONING <br />