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NON -PLUMBING SANITARY PERMIT APPLICATION — Burnett County, WI <br />Applicant Complete All Sections Below This Line <br />Check Type of Non -Plumbing System/Device; Fee is $150 for All Types <br />A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br />0 Privy — Pit Toilet (Must be accompanied by one soil boring from a WI Certified Soil Test <br />❑ Privy — Vault Toilet (Must specify volume in gallons: (Minimum 200 gal)) <br />❑ Composting Toilet System (Must demonstrate unit is approved for use by WI DSPS) <br />❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br />Property Owner's Name: H <br />Property Owner's Mailing Address: 5 <br />Property Site Address: 21 S i) / <br />Contact's Telephone Number: <br />Contact's <br />e 0C(rc, - q � 7 35;id ke <br />N-,� r 1S 44 Y-- **0 / Tt 1Y <br />© ff Wood ("rk ler <br />city <br />N <br />en7 <br />-����3 7 <br />State Zip <br />Legal Description of Property: �� 1/ y q <br />Section #:b Town #:__3y N Range #: Town of: D'LI' �S <br />*Attach additional page if needed for lengthy description OR attach a copy of the deed OR attach tax system property page. <br />Tax ID # (1-5 digit number; found on tax statement): O 7- e0(c 2, - %-17-2 62 01 -000 -UI I o 0 <br />AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br />THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br />Date of staff site visit: I' Initials of sit isit st <br />PERMIT APPROVED BY LAND SERVICES OFFICIAL: DATE: (p <br />UPON APPROVAL: APPLICANT MUST POST COPY OF <br />SIGNED PERMIT APPLICATION IN PLAIN SIGHT <br />Page 1 of 2 <br />Burnett County, Non -Plumbing Sanitary Application — Rev 3/2018 <br />z <br />L <br />0 <br />r <br />0 <br />9' <br />C <br />or <br />4 <br />F <br />WOR <br />co <br />s <br />N <br />CD <br />Q <br />