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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 4 <br /> SIREN, WISCONSIN 54872 61) <br /> 715-349-2138 0 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION <br /> POWTS RECONNECTION(S25) CJ <br /> POWTS REVISION($25) <br /> Application Information-Type or Print <br /> Property Owner Name <br /> ,� ` nA �Tp Property Legal Description '/ / <br /> Wa ���AC _ (� � GL 1/4 1/4,S T`0N,R(6 w <br /> Progeny nets Mailing AddressLot Number Block Number <br /> S4-S T4'11t Lq t-.e A)I/J ( Z <br /> City,State nZip Code _ Phone Number Subdivision Name or CSM Number <br /> CGor.. /ZCi�t't�L� I^V�Vt�J] %3733-1S%2 <br /> Type of Building: (Check one)❑ State-Owned ❑City Veast R n <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: PY i V ❑Village //�� 1,� 'IJn <br /> ❑ Public / ❑Town of i0AWr Firc Number�p <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) 1 <br /> campground,festival,recreationlentertainment event etc.)] <br /> 02O-9065 •-02- 20O <br /> Type of P mit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> .Q Non-Plumbing(Privy,Toilet,Restroom etc.) N Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ IncineratingToilet Device <br /> 13 POWTS Repair County# gallons or <br /> ❑ Revision State# ❑ Other _cubic yards) ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> 11fj,the undersigned,assume responsibility for he installation of the n- bin "nit system for which this ermit is issued. <br /> Plumber's/Owner's Name(print) Plur's/Owner's MP/MPRSW No.: Business Phone Number: <br /> (��a •tee rt: l�2�� 1� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> �/ <br /> 13 Disapproved Permit Fee: CST No. Date Issued Issui ent Si <br /> a7 Approved ❑Owner Given Initial Adverse /L'!xr"rp <br /> Determination �j <br /> Comments: <br /> B& A-r 072. A&t16 .90 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />