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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Descrip ion <br /> GL 1/4 IA,S U-1 T .ON,R W J <br /> Property Owner's Mailing Address Lot Number Block Number d <br /> I *J y 1? 1 <br /> City,State V Zip Code Phone Number Subdivision Name or SM Number <br /> 1Vl>a� I�ewooCl ink '/U°I <br /> ( (j5-/ <br /> � �I-��i�s PQ,,d� ts <br /> Type of Building: (Check one)❑ State-Owned �GY vv re✓� O Village E3 City NearesvR�d <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: rFareNumber <br /> ow✓�'iU� <br /> ❑ Public (/(, catof JA 1�'1'ownof �&Q <br /> Public Building/Land Use: [Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> ©'Lo g135roV70 <br /> O <br /> Type of Permit: pe of Non-Plumbing Device/Syste /Toilet/Unit: <br /> 9 Non-Plumbing(Privy,Toilet,Restroom etc.) JW <br /> Privy—Pit Toilet O Zomposting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ ncinerating Toilet Device <br /> ❑ POWTS Repair County# _gallons or _cubic yards) ❑ lortable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> O I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 1,the undersi ned,assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> lumbees/Owner's a(print) Plumber's/O ner's Signature: MP/MPRS W No.: Business Phone Number: <br /> I Cf <br /> Plumber's Address(Street,City,State.Zip Code): ` <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issui ent S' ature <br /> 1)f Approved O Owner Given Initial Adverse �� ►Z/4y _ ! 2 <br /> Determination `t <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> 17R0-f �[t MOST Aoz 6iKCEEO 5 FecE 1n t7 A rt+6 � b� <br /> PUP%%�o l-oG,r vol A-r <br /> 4 <br />