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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) 'd <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION { <br /> Property Owner Name I Property Legal Description <br /> Veww>=rta J .f L ots MA P,uet--, GL S2-9,T1/ON,R/_5 W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Z IZ SOaTl4u.,o0la <br /> City,State Zip Code Phone Number Subdivision Name or CSM Nu her <br /> CAN t4aQ C-A It . 1V1 N S506 ( G5t) 3 9'5L6 Gl"✓, S ky X re-5 <br /> Type of Building: (Check one)❑ State-Owned ❑vitl ge a Nearest <br /> st Road <br /> l<4 <br /> X I or 2 Family Dwelling-No.of Bedrooms: X Towne Fire Number <br /> ❑ Public <br /> JracKS0r'l 03t-7-7`1 4 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) p <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> X POWTS ReconnectionCounty# ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> State# 2/-6 6 y <br /> ❑ Revision ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> X I,the undersigned,assume responsibility for the P WTS ac' i for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the' lati ahe non-plumbing sanitarysystem for which this permit is issued. <br /> Pluryi is/Owna.:&NamG(print) Plumb s wner' afore: MP/MPRSW No.: Business Phone Number: <br /> Plumbets Address(Street,City,State,Zip Code): / <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. � Date Issued Is 'ng Agent Signat re <br /> Approved ❑Owner Given Initial Adverse ' S O 13 (S 3 _S J- ( [- 6 <br /> Determination t (� ((�� <br /> Comments: c amco%% �J`1 0 n�n�l. M�51�vt �� of ofd (VY)S . <br /> Conditions of Approval/Reasons four D' approval: 1 <br /> ti l L c.4 l s rrv� r o� <br /> Revised 6/7/02 <br />