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Cn C <br /> b <br /> NON-PLUMBING SANITARY PERMIT APPLICATION—Burnett County, WI 17 <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 pQ o <br /> ❑ Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> XPrivy—Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) <br /> o <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: _AL , T L_e, <br /> Property Owner's Mailing Address: 6a 3l� it L W t 1�� <br /> Ic 'q� I� city ( State Zip <br /> Property Site Address: L��b (_ / e., I <br /> Contact's Telephone Number: ��/1s� ( b4` obm o <br /> Contact's Email:�}� -V'I P ( "_ lam( tl � ►�'� o0 <br /> loe -a <br /> o <br /> d <br /> Legal Description of Property: 5 <br /> Section 4:?2 Town#:__3!( N Range#: P21 W Town of: ; e_ <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):0�,3 <br /> 0 <br /> F <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY o <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br /> d <br /> z <br /> X i <br /> Date of staff site visit: / Initials of site visit staff: Fee Rec i`50,60 <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: <br /> r <br /> UPON APPROVAL: APPLICANT MUST POST COPY OFca <br /> G� <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT <br /> IRS <br /> o <br /> Page 1 of 2 <br /> Q <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 1/2019 <br /> Z== <br /> ro <br />