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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 RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> Arthur and Lisa Ide <br /> GL 2 1/4 v4,s 22,T 37 N,R 18 w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3424 Zenith Ave S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number �1 <br /> Minneapolis, MN 55416 (651)374-3795 <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest Road 00 <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village Pine Lake Road <br /> ❑ Public X Town Trade Lake Fire Number <br /> 11605 <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,reereation/entertainment event etc.)] 034-1522-01-610 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: t <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> X POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 24020 gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 362736 ❑ Other <br /> Responsibility Statement: (Check one or both ❑ as appropriate.) <br /> X 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 /> Plumber's/Owner's Name(print) Plumber's/Owners Signature: MP/MPRSW No.: Business Phone Number: <br /> An%ls 1441--* O �� /160 /s3yg-Ss33 <br /> Plumber's Addr ss(She Cis, Mate 7io Code): <br /> Po grz 7-LG . S1y" w72 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued I uing ent Signature <br /> Ip Approved ❑Owner Given Initial Adverse 9 <br /> (` Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />