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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 /> Application Information(Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name�l//�Dr( _O LI W S OA') Property Legal Description <br /> T N I <br /> /(f V Dk7 SOS GL 1/4 I/4,S Tj5N,Rj5W <br /> Property Owner's Mailing AddressLot Number Block Number <br /> J3 877 y77M StrcrT A)- 08 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> STf lv rr Mbi 1550'? �L I (6C (h Li 3q'q - r ur 'S ACrZn�& <br /> Type of Building: (Check one) ❑ State-Owned ❑City ea t Road <br /> a 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village ul" �C, trp/ I <br /> ❑ Public Town oft ISS Fire�1�mb2'23.er <br /> Public Building/Land Use: [Explain the use/putpose for this permit,(i.e., Parcel Tax Number(s) a1�Sj y <br /> campground,festival,recreation/entertainment event etc.)] <br /> �'/-03a-�t-�{I-IS-ZEN-SIS-�(06-013c <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ii4 Non-Plumbing(Privy,Toilet,Restroom etc.) Q Privy—Pit Toilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#_ ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume rresponsibility for the installation of the non-plumbinR sanitary system for which this permit is issued. <br /> Plumbds/Owner'sName(print) Plumb caner' gna 1_jU�6 MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code. <br /> 3277 7h 5J%-«T4. <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued I uing A ent Signature <br /> Approved ❑Owner Given Initial Adverse ISO 131 E3 <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Ip ECEIVE <br /> JAN 9 0 7016 <br /> Revised 6/7/02 <br /> BURNETT COUNTY <br /> ZONING <br />