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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) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> William and Bessie Kostecki GL 1/4 i s 7,T40 N,R 15w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6420 W. 166"St 1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Tinley Park, IL 60477 Dinkus Club <br /> Type of Building: (Check one)❑ State-Owned ❑City Nearest Road Seiben Rd <br /> X I or <br /> Public wn 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ PubX Toof Jackson Fire Number 28905 <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.)) 07-012-2-40-15-07-5-15-135-011000 <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 ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# 28906 gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# 458944 ❑ 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-plumbinEsanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's S' nature: MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 11 227691 715-349-7286 <br /> c <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Box 514 Siren, WI 54872 <br /> Office Use Only: <br /> �� ❑Disapproved Permit Fee: CST No. Date Issued Issuin nt Signatur <br /> prcnpproved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />