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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 ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> T <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name 1 ' Property L,e,aa]DesAcr(iFV4,0-1 <br /> tinn t 17 S <br /> G�rA l ln1 l S NGL h �� I/4'v 4,s lvl ,T39N,R19W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1.t1I os& 7 .7G ve—. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one)❑ State-Owned ❑city f, Nearest Road C <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public 'Town of Fire Number �g�1 <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] 07 <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> l,Non-Plumbing(Privy,Toilet,Restroom etc.) .Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County#10PArl gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> e(I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> tel,the undersi ned,assume responsibiltty responsibilityfor the installation of the non-plumbing sanitary system for which this oermit is issued. <br /> Plumber' MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date issued I dng Agent Signature <br /> J$�Approved ❑Owner Given Initial Adverse 13 1 53*7 J <br /> `` Determination —1 V <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />