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t tLSCEO V E <br /> r <br /> APR %ti 21124 I <br /> 4 URNETT COUNTY LAND SERVICES <br /> C 4t/6b t 7410 COUNTY ROAD K, #120 <br /> Land Services DepartmentBurnett SIREN, WISCONSIN 54872 b <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description <br /> T-p I 1 5 GL 1/4 1/4,S ,T N,R W <br /> Property Owner's Mailing Address Site Address(if different than mailing address) <br /> 2 i °!S1 St).\r;\- 1 kC Ace ys 12l 2 i,,,5-7 ge,„,-- i.,1, /1c,,,k <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> 4 <br /> \----ft/. c q KY) ( ) Free: >�)y S-46'3`7 <br /> Type of Building Being Connected: (Check one) gown of <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> O Public 0 Commercial -1- e. Lice <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> 0' 7- bay-, 37. 1$,-la.-5 OS ^ 00 <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended f] 2,10,0 <br /> ❑ POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# I g 0 S p *A Connection Permit is required when the sanitary permit expired without being <br /> State# connected to the intended use of the sanitary system,and now the building is being <br /> number in question: �-�-0`�� <br /> connected. <br /> P <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> Com' „k/ C y' 00 4-a000 :4 iL\ <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> e.)cc_.-e t -- C>c c,--eAt-e,A- 4 k7.-t( d‘la✓e___ \r-)< <br /> Comments <br /> VV1 <br /> N- 7 r.e, t <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />