Laserfiche WebLink
a b <br /> <. t, <br /> BURNETT COUNTY LAND SERVICES s: N N <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 F.CD <br /> 715-349-210900 ° <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) c. ,D <br /> o <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED r <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner/Name / Property Legal Description , <br /> RI <br /> 6-k.,Ut: /h/is,4 `-'/q f fit E P 8E14, GL 1/4 <br /> T.37 N,ROA) 1/4,S <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> mailing addresss)) L`�j "4 <br /> a11of D1E� 4"- c,",e, aoldi F/�I+/l �r fC C3 <br /> 0 r <br /> City,State Zip Code Owner's Phone Number City,State 3 yg yo <br /> Zip 'r1 C <br /> Code ! ,ii c 1 <br /> 6-/ /4-k).7:56ulc6- (5-5'8 9 (71-5--) <br /> c537-ITSG-jars5ut<4ad: <br /> cn m 1 ` <br /> .71 <br /> Type of Building Being Connected: (Check one) i$Town of a <br /> or 1 or 2 Family Dwelling-No.of Bedrooms: a Village n <br /> 0 Public 0 Commercial "7A/i-Q '� .----, =' <br /> Describe uses and design flows for the building being connected: ParcelIddentification Number OR Tax ,-LI� (3q62 i3EP/206� Homa-', 0269yoi 1 -A Iiy ' 3,19'73 <br /> Type of Permit*: *Reconnection Permit:required when a new or existing <br /> At POWTS Reconnection 0 POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, fulUpartial cn <br /> p <br /> State Sanitary Permit County# 3 I ,-/9/37 structure rebuilds,any new structures with plumbing) <br /> number inquestion: *Connection ° <br /> Permit:required when the sanitary permit N .— f <br /> State# expired without a structure being connected to the installed o 0 <br /> POWTS. ° H <br /> P al <br /> Check with Burnett County Land Services Dept.for rA ` <br /> further clarification o .V <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z 1' <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON r <br /> REQUEST �— l <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity S KA.Lid_ 75 /6-60 Effluent Filter Condition:` Fee Rec: <br /> lib 1 y/o/ /"tii- 5-7s v Check#: ,3V1/1 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition o ( fga r.1 I It.41 k►'� <br /> O-oo d, 6-co D, <br /> Comments rn <br /> a 0 y <br /> . . M <br /> ni <br /> oW c <br /> o < Cjo!DF %.r & flfr3 SE ,J RE k-� 2 ,r J was-- CD <br /> m• � _ <br /> R ate ) <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes m J <br /> o m <br /> a <br /> LL----------:%Reconnect Permit Application 12/2021 <br />