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Z. <br /> BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 cr• <br /> t <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description <br /> ./ ;t66/4116 fr Ririda Alekkec i GL pi.i yyj ti/4 1/4,s ,T N,R W 1,1150 <br /> Property Owner's Mailing Address Property Site Address(if differe t th mailing address <br /> © re& <br /> .77 0 8 D Au k) 9048 than mailing <br /> � a 1 ►e, V\ <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> 13lrOC 0o.4 / 14P1/4) 561N3 ( ) AUK, WI O 5/3 <br /> Z -016,1 D -23.9,59 <br /> Type of Building Being Connected: (Check one IslTown of Tf(M <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 5_ S� ❑village �� <br /> ❑ Public 0 Commercial ✓✓ �� <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> ba ITOC3tn 6-7-o3y-t�-37-:8 -,26--303-- --otaX <br /> Type��m *A Reconnection Permit is required when a different building than was intended <br /> '6i;'POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> County# 33y Li *A Connection Permit is required when the sanitary permit expired without being <br /> State the sanitary permit connected to the intended use of the sanitary system,and now the building is being <br /> number in question: State# connected. <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 /> COWAV6 i 5 Co Cek-k i oo/goo <br /> Tank Condition Baffle Condition Manhole Cover/RiserC ondition <br /> Goo CO0A 6t� <br /> Comments <br /> 0011412-1 •g\ <br /> iE c rttl:rr Est be securely fashioned in accordance with all WI Administrative Codes n <br /> Page 1 of 2 <br /> Q <br /> MAY Z 3 2024 <br /> Burnett County .,O <br /> Land Services Department <br />