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yoiv <br /> E <br /> 1J <br /> BURNETT COUNTY LAND SERVICES MAY 2 1 2024 <br /> 7410 COUNTY ROAD K, #120 Burnett County <br /> SIREN, WISCONSIN 54872 Land Services Department Z, <br /> 715-349-2109 C( -C41 5 l <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) % <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION 'C. <br /> t <br /> Application Information(Type or Print) O <br /> Property Owner Name Property Legal Description <br /> DAil 71/4115Oh GL 1/4 1/4,s 4:1 ,139 N,R'7 W <br /> Property Owner's Mailing Address Property_Site Address(if different than mailing address) <br /> PO5i Croix .S7' Al le..-euhouse- ,3"af t 4i. V <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> /415o,I ws SW o/6 ( ) IN.GSShY✓ w $ t '53 e <br /> Type of Building Being Connected: (Check one) ;Town of <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: ? d Village <br /> 0 Public 0 Commercial Lt►,cot r. <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> /6—3 y o 9'TU X. 1 D 10469 _ <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> 'litl POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# le-5D3 *A Connection Permit is required when the sanitary permit expired without being / r <br /> State# connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS leg i, <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity 01_/a 00 a l' )44N K <br /> S <br /> tA/G p Co n c. dovU S~l <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> Good Gdo G 6c0/ <br /> Comments <br /> SW <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />