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b <br />NON -PLUMBING SANITARY PERMIT APPLICATION - Burnett County WI <br />y <br />Applicant Complete All Sections Below This Line °c <br />a <br />Check Type of Non -Plumbing System/Device; Fee is $150 for All Types d <br />A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br />rn� <br />Privy — Pit Toilet (Must be accompanied by one soil boring from a WI Certified Soil Tester) <br />c� <br />❑ Privy - Vault Toilet (Mustspecify volume in gallons: (Minimum 200 gal)) <br />r <br />❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) o <br />❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br />o <br />Property Owner's Name: <br />Property Owner's Mailing Address: L I `"1 `t I '� � q tJ t � � � A kj f-q JS <br />Property Site Address: 4 �3 <br />124 <br />Contact's Telephone Number: (�e Z — � q U — & � <br />Contact's Email: l✓��c� t 1 —fp ( M! p Ad <br />N State sip., pv <br />Legal Description of Property: `` �qq,, <br />Section #:� Town #: `l0 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. <br />Tax ID # (1-5 digit number; found on tax statement): <br />AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br />THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br />Date of staff site visit: �, / /4 ' ( / Initials of site visit staff: L—) 14-k <br />PERMIT APPROVED BY LAND SERVICES OFFICIAL: f,� �/ �� 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 />N <br />0 <br />n <br />0 <br />H <br />Fee Rec: <br />01 <br />N <br />