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a b <br /> N <br /> BURNETT COUNTY LAND SERVICES s:• N CA <br /> 7410 COUNTY ROAD K, #120 <br /> d <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 -t.. 0 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) Ni <br /> o ; it <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION ° N <br /> Application Information(Type or Print) <br /> ProperyyOwner Name Property Legal Description Z <br /> GL 1/4 1/4,S <br /> 4) ICL? Ocvsbb) , T N,R /`) w t-' t . <br /> Property Owner's Mailing Address Property Site Address(if different than ° 1✓) <br /> mailing address) 'M Q• <br /> L 14° 1124 ( ti b2 Cera 4 <br /> z <br /> City,State Zip Code Owner's Phone Number City,State Zip o <br /> Lv /`�l/1 S��v c (�' ) $r5 ZZ)3 Code 4 <br /> , <br /> v� C�ooe Veb 0, sy.8P3 A <br /> cn o <br /> til <br /> -71 <br /> Type of Building Being Connected: (Check one) Ei Town of o <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: d 0 Villa e $ <br /> ❑ Public 0 Commercial 1.611 00 A. <br /> Describe uses and design flows for the building being connected: Parcel Identification/ Number OR Taxon <br /> Ca/aS e 6i u�' 6vev' l sn 6,ec'XfID: es [7 /z <br /> Type of Pe mit*: *Reconnection Permit:required when a new or existing <br /> E YOWTS Reconnection 0 POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial cn <br /> State Sanitary Permit County# structure rebuilds,any new structures with plumbing) <br /> number in question: * o <br /> Connection Permit:required when the sanitary permit Np <br /> State# expired without a structure being connected to the installed o d k <br /> POWTS. <br /> ea <br /> tl <br /> Check with Burnett County Land Services Dept.for H <br /> further clarification <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON z <br /> REQUEST <br /> Holding eptic Tank <br /> Manufacturer/Material/Cap city Effluent Filter Condition: N Fee Rec: /5-6°J <br /> Ste --- 6 Check#: z/7g, <br /> Tank Condition Baffle Condition Manhole Cover/R'ser Condition z <br /> ((��, Cl, <br /> / <br /> (90 b 1 re5ei1 <br /> Comments ' ^ ' <br /> w <br /> 1 = gilla X" <br /> o -.o <br /> 7 �D <br /> r�rl 1C_ �� <br /> , fill <br /> i <br /> Pi Cr . . <br /> G <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes o <br /> cn <br /> C7 ry ^ <br /> Reconnect Permit Application 12/2021 b (.1,-. <br /> _ .2) <br />