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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 Sl <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS RECONNECTION ($50) <br /> POWTS REVISION ($50) <br /> Application Information-'Type or Print <br /> a / <br /> Property Owner Name 1P, Property l<gal Description �I <br /> Me C-145� �� / �fa GK GL d yON,R 16CD <br /> Property O..e,Mailing Address Lot Number Black Number <br /> 30`49 n-L+ Ai/e . S. 4 far <br /> City,State - 55zlwc Phone Number Subdivision Barren,CSM Number, <br /> _— _ - gi PiesoL5 -Mnl y0? , Gil <br /> , 7i8=qin <br /> Tvge of Building: (Check one)ElStato-0tm d Cl Nearest Road <br /> 12 I or 2 Family Dwelling-No.of Bedroom, ❑Village Vfnbgry Lpnp sit <br /> ❑ Public °Taweof0gA),g,j fireN ber _24'f3r <br /> fire V 01.r R <br /> Public Building/Land Use: lecplain the cv/,aT.,c for this perm,,,(�.c, Pared Ta.Namber(s) <br /> c <br /> art,mund,resaval,reerratinn/entenainmevent etc eveetc)I -7-020- 2. - <br /> / 15 - ci3s -6/4000 <br /> fy eof Permit: Ty@C of Nan-Plumbing Device/System/ToileWnit: <br /> .._Plumbing(Privy,Toilet,Restroom etc.) Q'Pri y-Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconneetiov ❑ Privy-Noah Toilet(Vuul[size: El incinerating Toilet Device <br /> ❑ POWTS Repair °nfy# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State ti ❑ Other <br /> Responsibility Statement (Check one or both Cl as appropriate.) <br /> underne <br /> signe <br /> J,assume responsibility for Corthe POWTS activity for which this permit is issued. <br /> 2�1hehe undersi d,assume res onsibl lit for the installation of the non- lumbin sanitary system for which this permit is issued. <br /> Plamber'c/Oxmer's Name(print) Plunibcr's/Owner's Signmurc MP/MPItSW No- business Pbone Number: <br /> Plumher's Address(Scree(,Coy,Scale,Zip Code) <br /> �Office Use Only: <br /> \ ❑Disapprovtl Yertnit Pec: CST No. Dale��ls/ro/ue(� Iss Signature <br /> ppruved ❑Owner(liven Initial Adverse d1)L�)a N"1 rr�aejJ7 <br /> Detcmtinamn i$� �AWI !!JJ <br /> comments: <br /> Conditions of Approval/Reasons for Disapproval: D p/rly rh�nn� D <br /> �U� Z s 203 <br /> Resort 6NO2 <br /> ZONING <br />