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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) i <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner NameProperty Legal Description <br /> �✓a N_�LSab <br /> GL 4 ,/4 1/4.S 7-. 'r 31 N,R/62 W <br /> Property Owner' Mailing Addres Lot Number Block Number <br /> 11,C5 <br /> C <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> r.�a'v, 15`40:99 <br /> Type of Building: (Check one) ❑ State-Owned ❑Ciryearest Road p <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village i <br /> ❑ Public 9]'ownof n ire Number <br /> .25234< <br /> Public Building/Land Use. [Explain the use/purpose for this permit,(i.c., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] 0--7 t91 S -9-37 - 'La -4 — :5- <br /> 0:5- <br /> 05 - 0 O- CSI 9000 <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 /> Id POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POW'I'S Repair County# I-7-7J gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> E7 1,the undersigned, assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑ 1,the undersigned, assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) Plumber's/Owner's ignature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code <br /> X 77 `sq,, u P-r c.E G4h�c " <br /> Office Use Only: <br /> FDet(eri <br /> approved Perinit Fee: CST No. Date Issued Issu Agent nature <br /> Approved ner Given Initial Adverse /�Oination .J <br /> Comments: <br /> �1lLIV� t $ 1'1CGInS S <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />