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BURNETT COUNTY ZONING ADMINISTRATION \n, <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 �1 <br /> Property Owner Name y� /� Property Legal Description <br /> N e7t L-- 1� i �• „ GL 05V�t/4/VEI/4,S Z�T N,R�(OV <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,Stale Zip Code Phone Number �.3 Subdivision Ne or CSM Number <br /> M N' `�?-1 ( tog- 9 I-�'T'7 MSM i� T7 P l4-Z <br /> Type of Building: (Check one) ❑ State-Own-�*` ❑City est R d � <br /> 1 i f3- Qo. ❑Village r <br /> ❑ Public ` " .Town of 5UjtCS Fir N ber <br /> R Mg/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] D�-� — Z�'�/—�6— �•—d <br /> PiZ�v-bt'�e- (nro 0 W N�1Z C'I.A►1�l(fit I�sCs- f�Z Q.a.a <br /> We of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> on-Plumbing(Privy,Toilet,Restroom etc.) 'Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection Coun # ElPrivy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> t <br /> ❑ POWTS Repair gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> )CI;the un ned,assume res onsibili for the installation of the non-plumbing sanitarysystem for which this permit is issued. <br /> Alwvber's/ er' ame(print) ignagtre: MP/MPRSW No.: Business Phone Number: <br /> tllj C_1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Pe it Fee: CST No. Date ssued Issuin% ent Si t <br /> `41pproved ❑Owner Given Initial Adverse(� Cyd 5-1 <br /> Determination <br /> Comments: i <br /> q,0 ®�Prv� P, . <br /> Conditions of Approval/Reasons for Disapproval: <br /> V <br />