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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 , <br /> SIREN, WISCONSIN 54872 ON COMPUTEWSCANNED <c <br /> 715-349-2138 <br /> C <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS RECONNECTION($50) <br /> POWTS REVISION($50) <br /> Application Information—Type or Print <br /> Propert Owner Na e Property Legal Description <br /> e �t �F• 'O� t GL i 1/4 1/4,S 1 T�6 N,R W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 5%3 QS �5 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> jTpeof Building: (Check one)❑ State-Owned ❑city Nearest Road <br /> or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public A(Town of vaol: 5 Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit.(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> f0NIon-POWTlIumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet SystemS Reconnection County# ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> S Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#02" ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non- lumbin9 sanitary system for which this permit is issued. <br /> Plumber's/O er's Na a(print) I Plumber /Owner's S' ture: MP/MPRSW No.: Business Phone Number:010 <br /> Plumbers Address(Street,City,State,Zip Code): <br /> or <br /> �- <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu' nt Si re <br /> 7-Approved ❑Owner Given Initial Adverse �e)Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />