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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> lsi <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($150) <br /> POWTS CONNECTION/RECONNECTION ($150) ''SU <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description !��j� � <br /> Ltn 0 /,GC a/t eyn GL a S b T TON RST/ <br /> Property Owners Mailing Address Lot Number Block Number <br /> 6 / X GT l <br /> city,State IZip Code Phone Number Subdivision Name or CSM Number <br /> ason Calx s6 �f0/ 6�/ �0/-0/ C5m 13 <br /> Type of Building: (Check one)❑ State-Owned ❑city Nearest oad <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: ❑VillageX Town of Fir�Number <br /> ❑ Public -C <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.)] Q7,0 2 _ s- 66 l 7o <br /> 619 <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 Reconnection Y Co # ❑ Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repairgallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> X 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume responsibility for the installation of the non- lumbin sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) I Plum's Signature: MP/K4PRSW No.: Business Phone Number. <br /> u,t'e Sod, t z 8 41/ f,/ 7,-5-- 0C' 9 z�} <br /> Plu 's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin ent Sire <br /> termination Approved CO3Owner Given Initial Adverse /S L <br /> 0 fl k _ <br /> Deation �+ <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: - <br /> ECEIVE <br /> Revised 6/7/02 H U <br /> BURNETT COUNTY <br /> ZONING <br />