Laserfiche WebLink
1 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 U <br /> l <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name,,/ Property Legal Description <br /> ('P r <br /> /¢r0h• G p,rh,*r%L GL 1/4 1/4,S 7 ,T 9A,R/k® <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Su vision Name or CSM Numb <br /> aa, s-felY c�� ) bo9•a19P ar ' <br /> Type of Building: (Check one) ❑ State-Owned ❑CityNegress7� /i/&. <br /> 9 1 or 2 Family Dwelling-No.of Bedrooms: at El Village <br /> ❑ Public ®Town of461</t../ FireNB�'O <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) dd <br /> campground,festival,recreation/entertainment event etc.)] O 7' Oaa .4—yo_ I6-07p—,S /,- <br /> •3'40., oygova <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 /> Iq POWTS Reconnection ❑ Privy–Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ty# <br /> ❑ POWTS Repair Coun33 <br /> gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> M 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-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Pluumber'ss/OwnneerIss Si nature: MP/MPRSW No.: Business Phone Number <br /> /Z,c(G he /C I n 1 /G�ur.,(�/7 �� �b'.S/ 17eX--A; /S 7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> d 7 70 e lfc - 3�" GJ1-e 6s><Y,- wi S 0P5;3 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued 1 g Agent S ature <br /> Approved ❑Owner Given Initial Adverse <br /> Determination ��o <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />