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BURNETT COUNTY ZONING ADMINISTRATION , Z. <br /> 7410 COUNTY ROAD K, #102 -gyp <br /> SIREN, WISCONSIN 54872 i <br /> 715-349-2138 w <br /> l <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) -P <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION J, <br /> Property Owner Name Property Legal Description �1 <br /> 5 4-CV( B 0 /l y W7 GL 1/4 l/4,S y v ,z/.s w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ? 1`I / 1)1,5t tvw <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number W <br /> NeW i r ► hf ah MA/ SSI0-- ,S7,o1 ( ) V. .Z P 6 q <br /> Type of Building: (Check one) 0 State-Owned 0 City I Nearest�OuFla�l <br /> m <br /> 14 I or 2 Family Dwelling-No.of Bedrooms: 0 Village s <br /> ❑ Public 2 Town ofL4, re/re4ire Number Ail 711p ,..�� <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.)] 'j -025G n <br /> Type of Permit: Type of Non-Plumbing Device/Systern/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy—Pit Toilet 0 Composting Toilet System 0 <br /> POWTS Reconnection 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair County#" gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State# 0 Otheri'' <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> 'I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner'smb Name(print) Plumber's/ wner's Signature MP/MPRSW No.: Business Phone Number: <br /> Z: /G lC 44 //I7_5. /� � Z ,5'�. l 7��8' 1l/-< <br /> Plumber's Address(Street,City,State,Zip Code): <br /> c% <br /> Office Use Only: <br /> 0 Disapproved Permit Fee: CST No. Date Issued f sumo . g€nt e f� <br /> Approved ❑Owner Given Initial Adverse 4)50 J53o771 5111 f 23 I� I a�W ?"Determination <br /> Comments: 'p <br /> R <br /> ECEINE <br /> ti j <br /> Conditions of Approval/Reasons for Disapproval: APR 7 B 2023 <br /> Burnett County <br /> Land Services Department <br /> Revised 6/7/02 <br />