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z <br /> NCA-PLUMBING SANITARY PERMIT APPLICATION—Burnett County, WI <br /> Applicant Complete All Sections Below This Line c <br /> Check Type of Non-Plumbing System/Device; Fee is $150 for All Types �J <br /> A PLOT PLAN MUST BE INCLUDED WITH THIS APPLICATION <br /> ❑ Privy—Pit Toilet(Must be accompanied by one soil boring from a WI Certified Soil Tester) <br /> 0 <br /> Privy—Vault Toilet (Must specify volume in gallons: 3 Qp (Minimum 200 gal)) <br /> o � <br /> ❑ Composting Toilet System (Must demonstrate unit is approved for use by WI VkSPS) <br /> ❑ Incinerating Toilet Device (Must demonstrate unit is approved for use by WI DSPS) <br /> Property Owner's Name: PI C 0/4 R Q W R I G/4 7— <br /> M G d FV j ,vlti/ <br /> Property Owner's Mailing Address: i <br /> Property Site Address: 1 2 '1� z� ? mow% L/ City State Zip <br /> Contact's Telephone Number: ins ! ,Z <br /> Contact's Email: o <br /> 0 <br /> Legal Description of Property: L1,7� I All L Z (� <br /> p- <br /> Section#: 2� Town#:=N Range#: W Town of: Q I` <br /> *Attach additionalpage if neededfor lengthy description OR attach to copy of the deed OR attach tax system property page.* <br /> Tax ID#(1-5 digit number;found on tax statement): <br /> 0 <br /> AREA BELOW THIS LINE FOR LAND SERVICES STAFF COMMENTS/CONDITIONS ONLY <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW: <br /> rjQ <br /> z � <br /> Date of staff site visit: �5D(� S <br /> Initials of site visit staff: <br /> Fee Rec: " <br /> PERMIT APPROVED BY LAND SERVICES OFFICIAL: JJJATE: <br /> a <br /> 0 <br /> UPON APPROVAL: APPLICANT MUST POST COPY OF m <br /> � w <br /> SIGNED PERMIT APPLICATION IN PLAIN SIGHT a S N <br /> p y n tJJ <br /> rz 00 <br /> Page 1 of 2 CD'` c� <br /> Burnett County, Non-Plumbing Sanitary Application—Rev 1/2019 lug <br /> 0 <br /> H <br />