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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 <br /> POWTS RECONNECTION <br /> POWTS REVISION <br /> Application Information-Type or Print <br /> Property Owner Name Property Legal Description <br /> AZO o M A-SO t j GL 1/4 1/4,S lYT40 N,RKS <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 LAld&�s 10C- D2- (9k <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 6A4AIJ Mr-) 1 55fZ3 C'S rn 13c) <br /> T pe of Building: (Check one)❑ State-Owned 0 city yo,,/ ttJOt/E1'��, <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 'Z- ElVillage_T&4< <br /> Public A.Town of Fire Number 3430 <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 /> �l a -yaa5-�S'lao <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 /> �6OWTS Reconnection ❑ POWTS Repair ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑Other: _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Other <br /> Responsibility Statement: (Check one or both 13 as appropriate.) <br /> )A Lithe undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I the undersigned,assume responsibili for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumbees/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> IL14ARn o xl/JS t�.�ta,.y( _ Z258Sr ?ISA46-41s7 <br /> P umber's Address(Street,City,State,Zip Code): <br /> �-r-► a 3S b✓FssR W t. 54893 <br /> Office Use Only: <br /> ❑Disapproved I ipermit Fee- CST Nfl Date su Iss e <br /> Approved ❑Owner Given Initial Adverse 1 t>1 I `— ey()� 4Q <br /> Determination VV <br /> Comments: <br /> l ,,n" <br /> 10Ut1 I ffiZrn�1 �ml % suP q-3-7S <br /> Conditions of Approval/Reasons for Disapproval: <br />