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e <br /> "'0 <br /> BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION }:3 <br /> Application Information(Type or Print) b'Q <br /> Property Owner Name- Property Legal Description <br /> &) <br /> 5T�f/44I Ly 5 WI AIfe, GL 1/4 1/4,Szy,T 33q N,R/7 W `` <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) N <br /> 700 ' /qk 3c 'la coil 0 w <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> CeAi f O( hl i. 3igz y (612. )31,4$77y Li-Sec w.' Cl/5G 3 <br /> Type of Building Being Connected: (Check one) CQ'Town of <br /> IR 1 or 2 Family Dwelling-No.of Bedrooms: 3 0 Village <br /> 0 Public 0 Commercial AiNCO/"-i <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> Aif it) �7'�U SG 3&A:W*15 07-0/614Y/7-1y y ay Derv-0/zck,v <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> PIS POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. (� n <br /> State the sanitary permit County# 2' *A Connection Permit is required when the sanitary permit expired without being <br /> State# i connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> Q <br /> NOTE:A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> k)i e {� CoNcre ke_ /oao .0 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> gowl e5e)W ,,,,/ , <br /> ...... <br /> Comments <br /> -V <br /> R:I ��,E I be securely fashioned in accordance with all WI Administrative Codes <br /> J V T <br /> DEC 15 2023 Page 1 of 2 <br /> Burnett County <br /> Land Services Department <br /> 0/502L1 Check#/20y' <br />