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Check Type of Non -Plumbing Svstem/Device; Fee is $150 for All Types <br />A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br />❑ Privy — Pit Toilet (Must be accompanied by one soil boring from a WI Certified Soil Tester) <br />19 Privy — Vault Toilet (Must specify volume in gallons: -0 r (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 <br />Property Owner's Mailing Address: IDMA <br />c\ q <br />State <br />17 <br />ka <br />A <br />A <br />Contact's Telephone Number: is-o S 1-? q v o <br />Contact's Email: �,�,, u Q <br />Legal Description of Property: l.. r 1 ` VS kj I E. <br />b <br />Section #:-41, k Town 4:1-N 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. * tj <br />Tax ID # (1-5 digit number; found on tax statement): <br />AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY o N <br />THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br />d <br />Date of staff site visit: /yZ itt- Initials of site visit staff: 1 A - <br />PERMIT APPROVED BY LAND SERVICES OFFICIAL: It- / I 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 1/2019 <br />Fee Rec:_ <br />MU <br />