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BURNETT COUNTY LAND SERVICES I w <br /> 7410 COUNTY ROAD K, #120 7 i� a Ow <br /> SIREN, WISCONSIN 54872 i s <br /> 715-349-2109 i ' N F <br /> SI <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $1501 - `QJ <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION - XI <br /> 1") <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description <br /> ,� ,/� GL $(A) 1/4 /Jul/4,S 1 <br /> _�'t J <br /> J.'1 �7' j"tI''kg 12(YJ c(%t ' THO Wtti N,R _ S <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> mailing address) 123 ,,) <br /> ')-7(6a0 ail RA 4- os <br /> 0 p <br /> City.State Zip Code Owner's Phone Number I City,State Zip 41 <br /> W W 1 yC6g (7fs-)Litti-lZgy ! Code <br /> — — - - o <br /> tIS <br /> Type of Building Being Connected: (Check one) Town of <br /> 9 <br /> WI 1 or 2 Family Dwelling-No.of Bedrooms: a11011 Village Ci�b <br /> tt no <br /> ❑ Public 0 Commercial c� _ <br /> F. <br /> Describe uses and design flows for the building being connected: Parcel identification Number 9.$Tax re <br /> ID:07-028- ) 4o-1 f.-28- n <br /> I <br /> 10 3--COO—© i,000 <br /> T pe of Permit*: *Reconnection Permit:required when a new or existing a <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 iN <br /> State Sanitary Permit County#3(0 271 structure rebuilds,any new structures with plumbing) <br /> number in question: ;Connection Permit:required when the sanitary permit IV ° <br /> State#6 S Z expired without a structure being connected to the installed i I g <br /> POWTS. 5' -) <br /> 5 <br /> d <br /> Check with Burnett County Land Services Dept.for v <br /> further clarification • Q -A— <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z "+ al <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON W NIm <br /> REQUEST - <br /> -C <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity Effluent Filter Condition: g Fee Rec:f52)-- <br /> Sci f o,.LfG�C, fo09‘jion S Ci=4^ 6 Check#:.tea <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition i <br /> 6. <br /> 1)14 6OP) cow c0 <br /> Comments <br /> FA' i ifia <br /> ___. .t-4' li <br /> iffil <br /> BC CCl{ � ' mg 0 <br /> Note:Manhole must be securely fashioned in accordance with all IlA d 1 < <br /> Reconnect Permit Application 12/2022 L DEC 1 2 2023 a Lt..... ' l <br /> Burnett County J <br /> Land Services.Department <br />