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[1,E © En, <br /> CK�b98�v <br /> APR U 5 201'1 <br /> BURNETT COUNTY LAND SERVICES p75a <br /> 7410 COUNTY ROAD K, #120 Burnett County <br /> SIREN, WISCONSIN 54872 Land Services Department <br /> 715-349-2109 't <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION 1 <br /> Application Information(Type or Print) <br /> Property Owner Namur Property Legal Description <br /> Tldn 0e(r c-in GL 1/4 1/4,53 ,T3f N,R4W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) i <br /> / 3*.'D 3 /93 ed ci r•cl e NW 766 <br /> 3 y 5. d,evib Glc 17e,'04e- <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> .-t g /Zt v V V !"'x/11 57-r..?Y 0 ( ) liv4i 7LYk <5-gs3 <br /> Type of Building Being Connected: (Check one) [rTown of <br /> ® 1 or 2 Family Dwelling-No.of Bedrooms: Z 0 Village <br /> 0 Public 0 Commercial /h vYHo n <br /> Describe uses and design flows for the building being connected: Parcel Identification Nu nber: ,AS;!9 03 <br /> &7-ei8-.1‘35/ 4"f"" adroo <br /> ai37p7.c <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> IV POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> � <br /> ( <br /> State the sanitary permit County# 35 7'2-2 *A Connection Permit is required when the sanitary permit expired without being <br /> State# sj fj�'/Y connected to the intended use of the sanitary system,and now the building is being J <br /> number in question: connected. <br /> 4 <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS j' <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 v' <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> 5760. w C4'1,1 6. 360064 I <br /> Tank Condition Baffle Condition p Manhole Cover/Riser Condition Q <br /> 601) Ca es (! 6 v <br /> Comments <br /> APPROVED <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />