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zy <br /> BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 p `� <br /> d <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 N <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print L-ot 3 1 awc ,,mx" L v* <br /> Property Owner Name Property Legal Description <br /> � O1aS L (V 1/4,S <br /> � (v <br /> � Lkt ��e�.I� TON,R I`IC� r <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> mailing address) O N <br /> to ao ar"a S ctt �g34s H��nsc1 vv�lake �' <br /> O <br /> City,State Zip Code Owner's Phone Number City,State Zip "n <br /> Oil <br /> Codr,etib�ry <br /> ITI <br /> Type of Building Being Connected: (Check one) 54 Town of } S <br /> f� 1 or 2 Family Dwelling-No.of Bedrooms: q <br /> ❑Village SGoi I <br /> ❑ Public ❑ Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax b <br /> �oo Ub \ Mt 1D: <br /> S C' <br /> 07 -27 s a 3,2b o <br /> Type of Permit' 'Reconnection Permit:required when a new or existing <br /> [A POWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (including but not limited to:structure additions, full/partial rn <br /> State Sanitary Permit County# 1. (j iE�LA� structure rebuilds,any new structures with plumbing) <br /> o <br /> number in question: 2 G 'Connection Permit:required when the sanitary permit N � <br /> State# J O expired without a structure being connected to the installed '� w <br /> POWTS. y <br /> oa <br /> C7 <br /> Check with Burnett County Land Services Dept.for Q <br /> c+ , <br /> further clarification o' J <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON N <br /> REQUEST <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec:_50 0 <br /> Nvc w�Sc P1asc KloQ a l oLN S ►�'oi�e Check#: 113 Z 7 <br /> r <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> [['' v <br /> Gad C-, d Gdpd <br /> Comments <br /> Q <br /> 0 9 SS C V V <br /> C <br /> C.= <br /> t" M <br /> ao � o <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes a F3 <br /> v C <br /> a CD <br /> Reconnect Permit Application 12/2023 r. �0 <br />