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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION $50) <br /> POWTS RECONNECTION ($25) <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Qwner Name Property Legal Description <br /> fYllehael /utz22a I GL b va 1/4,S `/Iha,R/4W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> li 3&9 Swalfot") CG✓ AJ w f <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Coon vel ;d 5 m N �s ti 33 ( C Sm V l5 P 5q <br /> Type of Building: (Check one) ❑ State-Owned ❑City N road <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: A ❑Village se d f� <br /> ❑ Public J�i1bwn of Fire Number <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.)] <br /> 006 -y/ 3q-03 C'Ly <br /> Tvpe 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 ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> 11 POWTS Repair County#3agaa 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 POINTS activity for which this permit is issued. <br /> ❑ I,the undersigned,assume responsibility for the installation of the non- lumbin sanitary system for which this perimt is issued. <br /> Plumbees/Owner's Name(print) I Plumber's/Owner's Si amre: MP/MPRSW No.: Business Phone Number: <br /> M 1 c-�te 2 2 22 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved P unit Fee: CST No. Date Issued Iss 'ng Agent Signature <br /> Approved ❑Owner Given Initial Adverse <br /> Determination 5D, fg yGry(/, <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />