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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 /> Pf{rooperty Owner Name Property Legal Description <br /> 10otpl /�r`e I ` 01-e gc-k Y\ GL 1/4 I/4,S /9 ,T 3gN,R /7 10 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 144)-910 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> r4 � wis S"y�yG (7/5-)W-34)/ <br /> Type of Building: (Check one) ❑ State-Owned ❑City N arest Road <br /> CY I or 2 Family Dwelling-No.of Bedrooms: ❑Village g IV 1, ' ' <br /> ❑ Public gKown of /J.cel^ Fire NuAiber <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 /> D�allp-d�N7-1�-'-�-�3�-ill ooa <br /> Type of Permit: Type of Non-Plumbing Device/System/ToileVUnit: <br /> �(Non-Plumbing(Privy,Toilet,Restroom etc.) ivy—Pit'loilet ❑ Composting Toilet System <br /> ❑ POWTS Reconnection County# _ —Vault ElIncinerating Toilet Device <br /> ❑ POWTS Repair gallons or- cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Othe] <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 /> Ot I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> /Owner's Name(print)/ / Signat r i�,fi�/A�fRSIY-ke-„ Business Phone Number: <br /> C(//' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> AJ[A <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Is in Age t nature <br /> Approved ❑Owner Given Initial Adverse p r��/� <br /> Determination �� t <br /> Comments: <br /> Conditions of Approval /Reasons for Disapproval: <br /> JUN 8 2016 <br /> Revised 6/7/02 <br /> ZONING <br />