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04 <br />ICON -PLUMBING SANITARY PERMIT APPLICATION — Burnett County, WI <br />Applicant Complete All Sections Below This Line <br />Check Type of Non -Plumbing System/Device; Fee is $150 for All Types <br />A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br />/Privy <br />— Pit Toilet (Must be accompanied by one soil boring from a WI Certified Soil Tester) <br />❑ Privy — Vault Toilet (Must si)ecify volume in gallons: (Minimum 200 gal)) <br />❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br />❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br />Property Owner's Name: �Gtl_,o,I <br />Property Owner's Mailing Address: <br />/ City StateZh) <br />Property Site Address: 2 <br />Contact's Telephone Number: / 2Z; " 4� 2c—,C:) <br />Contact's Email: <br />Legal Description of Property: I <br />Section #:�m_ Town #:___j42N Range #:_ W Town of: <br />*Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page. <br />Tax ID # (1-5 digit number; found on tax statement): /3 78-c/ <br />AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br />THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br />_-mss <br />v'l 1 ') <br />1 <br />Date of staff site visit: Initials of site visit staff: <br />PERMIT APPROVED BY LAND SERVICES OFFICIAL DATE <br />UPON APPROVAL: APPLICANT MUST POST COPY OF <br />SIGNED PERMIT APPLICATION IN PLAIN SIGHT <br />Page 1 of 2 <br />Burnett County, Non -Plumbing Sanitary Application — Rev 3/2018 <br />C_ <br />r - <br />w <br />0 <br />N <br />O <br />r <br />co <br />