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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 /> PO S RECONNECTIO <br /> POWTS REVISION <br /> Application Information—Type or Print <br /> Property Owner Name ) Property Legal Description <br /> o / iC C✓'man GL tjjr114 NEI/4,S/o Tq6N,R/&09 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> IS-7 farmout Alle- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S{. Pawl MAI. SS/OS' 30.5tleAFX <br /> Type of Building: (Check one)❑ State-Owned ❑city Nearest Road <br /> RI 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public ®Town of Fire Nu b0 <br /> Public Building(Land Use: (Explain the usetpurpose for this permit,(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <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 /> ®POWTS 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❑as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I the undersigned,assume responsibility for the installation of the non- lumbing sanitary system for which this permit is issued. <br /> Plumbees/Owner's Name(print) Plumbees/Owner's Signa e: MP/MPRSW No.: Business Phone Number: <br /> re-I+ZrXlo PQPV.1jf5 22s'gsf $6�- 4t <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 10/:66 <br /> Office Use Only: <br /> 1 <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issu' t S' ture <br /> Approved ❑Owner Given Initial Adverse <br /> Determination <br /> Comments: o' <br /> Q <br /> Conditions of Approval/Reasons for Disapproval: ' <br /> #0 <br /> 20 COU <br />