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z <br /> BURNETT COUNTY LAND SERVICES N <br /> s <br /> 7410 COUNTY ROAD K, #120 <br /> d <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 Avg 0 <br /> V "'1 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> p n <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED r <br /> WITH THIS APPLICATION ° <br /> Application Information(Type or Print <br /> Property Owner Name Property Legal Description <br /> SCc m �.���U \ ( �Yy�� T l 1/4 1/4,S lb <br /> .J O N,R 13 W t-• <br /> Property Owner's Mailing Address Property Site Address(if different than ° <br /> mailing address) 7y <br /> City,State Zip Code Owner's Phone Number City,State Zip <br /> Code C� <br /> C/) <br /> Type of Building Being Connected: (Check one) XTown of o N <br /> IF 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village n b` <br /> ❑ Public ❑ Commercial <br /> v 1tii o h <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax .� <br /> ID. 3q cas N <br /> Type of Permit*• *Reconnection Permit:required when a new or existing 00 <br /> POWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial v <br /> State Sanitary Permit County#:!AN- 17-7� structure rebuilds,any new structures with plumbing) <br /> number in question: *Connection Permit:required when the sanitary permit N <br /> State# 51'162 O expired without a structure being connected to the installed <br /> POWTS. <br /> 0o 5 <br /> C7 <br /> Check with Burnett County Land Services Dept.for y G <br /> further clarification <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z N <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON <br /> REQUEST <br /> J <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity / I l�� Effluent Filt Condition: Fee Rec: ( <br /> Check#:1�5� <br /> r� <br /> r� <br /> Tank Condition/- Baffle Condi on Manhole Cover/R' r Condition <br /> Comments <br /> 7Cl <br /> o .. <br /> o <br /> C <br /> � psi <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> 07 <br /> Reconnect Permit Application 11/2024 b <br />