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SD2- 829 - 01b1 <br /> • <br /> _ e A..leo ly 11 J E © IE El l <br /> NOV 15 20 1 <br /> BURNETT COUNTY LAND SERVIC S _ <br /> 7410 COUNTY ROAD K, #110Burnett County <br /> Land Services Department <br /> SIREN, WISCONSIN 54872 c ltg 012556 '4 Z <br /> 715-349-2109 b <br /> k <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 /> PropertypeOwner/�Name <br /> /� Property Legal Description ,�; <br /> A(Of,` .i/art " di GL 1/4 1/4,S t ,'I' N,I'c , <br /> Property Owners Mailing AAress Property Site Address(if different than mailing address) <br /> `<-a /iii /1/-e- - ff/s7 -k 51 <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> 57 Li frtA) s-s--/0 0,2 ;CW-00; 4., ,../4 1.442:._ <br /> 5c/eyd <br /> Xype of Building Being Connected: (Check onc) Town of <br /> 1 or 2 Family Dwelling-No.of Bedrooms:—UL El-Village ) / <br /> 0 Public 0 Commercial (� 1, G�'' <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax ID: <br /> 49errrtr,Y (-,Ii.: t<scv • 0Y-O2o-2-Y4).6°6-5-- /S 'Go 69,WO6 <br /> T pe of Permit*: *Reconnection Permit:required when a new or existing structure is to be <br /> POWTS Reconnection 0 POWTS Connection connected to an existing POWTS(Including but not limited to:structure additions, <br /> �`` full/partial structure rebuilds,any new structures with plumbing) <br /> State Sanitary Permit County#/f,-/(_e <br /> Connection Permit:required when the sanitary permit expired without a <br /> number in question: structure being connected to the installed POWTS. <br /> �.i�f State# <br /> Check with Burnett County Land Services Dept.for further clarification <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION IF <br /> THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON REQUEST <br /> Holding/Septic Tank J <br /> Manufacturer/Material/Capacity Effluent Filter Condition: ,-- <br /> / <br /> -/ZOO fq/ 54 to -?rt 4i K$40 // <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> vi7 Cct�fr CC-,w.O <br /> Comments <br /> c--..\ <br /> Aff 117�//C/ ; A \I Z C.►/t <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />