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{EO W 1 <br /> JUN 24 2024 i 't� <br /> BURNETT COUNTY LAND SERVICES Burnett County , J to <br /> 7410 COUNTY ROAD IC, #120 <br /> SIREN, WISCONSIN 54872 Land Services Department <br /> 715-349-2109 «© ��`_t 12113 <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 u <br /> er6--i l e/eNde, s;s' .1 GL 1/4 1/4,S 3Z,T 4/0N,R' W <br /> Property Owner's Mailing Address ✓ Property Site Address(if different than mailing address) <br /> 27/07/;n wilt Tax a , lqi 13 ' <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> web-Ater lii' 5'073 ( ) <br /> Type of Building Being Connected: (Check one) DrTown of <br /> 1114 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village <br /> ❑ Public ❑ Commercial O k4 , <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> 304 6//d Ns 14P al y 47-070-2-4046 3z5,s c'-o'c, n <br /> Type of Permit*• *A Reconnection Permit is required when a different building than was intended <br /> ES POWTS Reconnection In POWTS Connectionti for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# 2(i)079 *A Connection Permit is required when the sanitary permit expired without being <br /> number in question: State# y py 7lp i-{ <br /> connected to the intended use of the sanitary system,and now the building is being <br /> connected. <br /> 4 <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 'sk <br /> Manufacturer Material Capacity <br /> Narwexo Pleec7ii� /Deo 64 if <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> 0 <br /> Comments <br /> w <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />