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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> 1 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION �� <br /> Property Owner Name Property Legal Description <br /> lVrAo'eW GO11N7�q GL W !1N NW A,S Zq T 4O N,R/5-0 <br /> Property Owner's Mailing Address p Lot Number Block Number <br /> 7'//o G..6 /a s <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 5 r e,A0 GvL 6"4g'7�t, ( ) <br /> Type of Building: (Check one) ❑ State-Owned ❑City Nearest ad <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village -Z d sox 'V!gAleli I/ <br /> .4 Public Town of Firebe <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 /> 000- O&WO <br /> pe of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> Non-Plumbing(Privy,Toilet,Restroom etc.) Privy-Pit Toilet ❑ Composting Toilet System <br /> POWTS Reconnection County#kf <br /> (�p Privy-Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> El POWTS Repair 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 POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume res onsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plibees/Owner's Name(print) Plu ber's/Owner's Signature: MP/MPRS W No.: Business Phone Number: <br /> lumber's Adares (Street,City,State,Zip Code): <br /> 41 D C37 <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu g en ig ture <br /> Approved ❑Owner Given Initial Adverse <br /> Detennination <br /> Comments: <br /> Conditions of Approval/Reasons for Di <br /> s <br /> approval: <br /> Revised 6/7/02 <br />