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tn b z <br /> cr <br /> 0 <br /> ,. b <br /> BURNETT COUNTY LAND SERVICES N N <br /> 7410 COUNTY ROAD K, #120 <br /> d Q <br /> SIREN, WISCONSIN 54872 ODCD <br /> 715-349-2109 = <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) 3 <br /> 0 <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> 6-4 p <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print) :3c-x..-r..a b )h to r C,..le r itic xf� 0 <br /> -� <br /> Property Owner Name Property Legal Description j...„--r:1 2 <br /> /� GL t 1/4 1/4,S. l2 <br /> Chatles R /(4n t y1 n —i"►-UST Tile N,R/5 W F. <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> mailing address) "ii <br /> Qact -l3 � S,i- e -x'7/3/ dar111e Lki , o <br /> City,State Zip Code Owner's Phone Number State Oe bate r ,,r Zip b <br /> 7/5.781 •' 78 Code cul n <br /> flew Rtchtrl t;J 0 <br /> 5 ,—) ( 7/5)1)6/-19 1 SkSq A <br /> 3 n <br /> v) 0 <br /> -T1 <br /> Type of Building Being Connected: (Check one) ll Town of o <br /> W I or 2 Family Dwelling-No.of Bedrooms: 0 Village $ <br /> O Public 0 Commercial \,CICrK50►1 <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax ,.cy <br /> ID: l Lf 5 frr: <br /> Type of Permit*: *Reconnection Permit:required when a new or existing <br /> ® POWTS Reconnection 0 POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial Cl) <br /> State Sanitary Permit County# structure rebuilds,any new structures with plumbing) <br /> number in question: *Connection Permit:required when the sanitary permit o <br /> State# expired without a structure being connected to the installed V0 <br /> H <br /> POWTS. o H <br /> aro 5 <br /> t7 <br /> Check with Burnett County Land Services Dept.for N' <br /> further clarification 5. <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 xJ 1 V <br /> REQUEST S SLItlyvgLA, I <br /> c>v�� .cy T <br /> Holding/Septic Tank 2-0044 <br /> i3-t <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec: r` � <br /> o Check#: L' <br /> m <br /> r <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition z <br /> 0 <br /> y <br /> m <br /> <, I�1 <br /> Comments m <br /> VD I.- ID <br /> > a .-- <br /> O @c G <br /> 0 <br /> z 3 <br /> r n m c::3 Innl <br /> 'ma . v..> UIJu <br /> CO' <br /> O <br /> rt Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes m Z 2 <br /> o 3rl <br /> - - ` U�U <br /> a <br /> Reconnect Permit Application 12/2021 I JJ <br />