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RURNETT 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� /so. c a• <br />Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br />Property Owner Name <br />Property Legal Description <br />/0; i ke- Dr- e ) S <br />GL '1 1/4 1/4, s-rx- 7_31iN i?/6 4 <br />Property Owner's Mailing Address <br />Lot Number Block Number <br />6 31Y 8 Fd cie wood /9„e <br />/I <br />City, State Zip Code <br />Phone Number <br />Subdivision Name or CSNI Number <br />woe bkNy lvt N s s / al <br />t <br />Type of Building: (Check one) ❑ State -Owned ❑ City N� est Rog/ // Lk„C <br />23 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village <br />❑ Public Cil Town ofhi a em oN Fire Number <br />Public Building/Land Use: [Explain the use/purpose for this permit, (i.e., Parcel Tax Number(s) _ <br />campground, festival, recreation/entertainment event etc.)] 07 018.— 1” <br />- c>vIf— oJa asa <br />Type of Permit: Type of Non -Plumbing Device/Systen-/Toilet/Unit: <br />❑ Non -Plumbing (Privy, Toilet, Restroom etc.) ❑ Privy — Pit Toilet ❑ Composting Toilet System <br />,K POWTS Reconnection ❑ Privy — Vault Toilet (Vault size: ❑ Incinerating Toilet Device <br />W <br />❑ POTS Repair County #_ I gallons or cubic yards) ❑ Portable Restroom Unit <br />❑ Revision State # ❑ Other <br />Responsibility Statement: (Check one or both ❑ as appropriate.) <br />gl, 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- lumbina sanitary system for which this permit is issued. <br />Plumber's/Owner's Name (print) Plumber's/Owner's Signature: MP/NiPRSW No.: Business Phone Number: <br />J <br />Plumber's Address (Street, City, State, Zip Code): <br />7 '�'6 e� //�- s <br />Office Use Only: <br />❑ Disapproved Permit Fee: CST No. Date Issued Iss in nt Sigya�ire <br />Approved 11Owner Given hiitial Adverse 6- P d0 <br />Determination �S�• �_,� AT?3 4- D w <br />Comments: <br />Conditions of Approval /Reasons for Disapproval: <br />05 2018 <br />BURNETT COUNTY <br />ZONING <br />