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BURNETT COUNTY ZONING ADMINISTRATION - <br />7410 COUNTY ROAD K, #102 <br />SIRE N, WISCONSIN 54872 Qto <br />715-349-213 - -------- <br />NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br />POWTS CONNECTION/RECONNECTION T 4/SO) <br />Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br />Property Owner Name <br />Property Legal Description <br />41! `-etN 0(Se rt <br />GL ( 1/4 1/4, S / 7-37Iv /?19 w1 <br />Property Owner's Mailine Address <br />Lot Number Block Number <br />309 9fa s;, A.{ s. <br />sm g nt ie re <br />City, State Zip Code <br />Phone Number <br />Subdivision Name or CSNI Number <br />5. S t 34,_1 /)l Al s'3'67 S' <br />Conditions of Approval /Reasons for Disapproval: <br />'APPROVED <br />nP E C' ;1` E 0 V E F <br />Revised 6/7/02 <br />Type of Building: (Check one) ❑ State -Owned ❑ City Nearest Road <br />4 1 or 2 Family Dwelling - No. of Bedrooms: 3 ❑ Village S f L I � 14,,c5 S <br />❑ Public Town of�rw(,�t Z� e Number d /tel 8S— <br />Public Building/Land Use: [Explain the use/purpose for this permit, (i.e., Parcel Ta; Number(s) S -OS- vo l <br />campground, festival, recreation/entertainment event etc.)] O 7 bay" of '3 7" <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 a Ob <br />❑ Privy — Vault Toilet (Vault size: ❑ Incinerating Toilet Device <br />❑ POWTS Repair County #_ % 9 gallons or cubic yards) ❑ Portable Restroom Unit <br />❑ Revision State #_ 3�U (0 �I� ❑ Other <br />Responsibility Statement: (Check one or both ❑ as appropriate.) <br />KI, the undersigned, assume responsibility for the POWTS activity for which this permit is issued. <br />❑ I, the undersigned, assume res onsibilit for the installation of the non- lumbinI sanitarysystem for which this ermit is issued. <br />Plumber's/Owner's Name (print) Plumber's/Owner's Signature: MP/NIPRSW No.: Business Phone Number: <br />Z1/,f-_k 2LL, I <br />Plumber's Address (Street, City, State, Zip Code): <br />Office Use Only: <br />oved <br />❑ Disapproved <br />C1 Owner Given Initial Adverse <br />Determination <br />Permit Fee:CST <br />� <br />No. <br />Date Issued <br />'7 <br />sm g nt ie re <br />Comments: /Qs, roeM t�onft� . <br />4-0.VAee�o �/f�lSTi� .Sa�/iTa� y S/�/►?� <br />�r <br />2ano GQL ///" <br />Conditions of Approval /Reasons for Disapproval: <br />'APPROVED <br />nP E C' ;1` E 0 V E F <br />Revised 6/7/02 <br />APR 16 2018 <br />BURNETT COUNTY <br />