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D 0IE FYIE <br /> BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 APR Z 9 204' � <br /> SIREN, WISCONSIN 54872 <br /> Burnett County <br /> 715-349-2109 Land Services Department <br /> 4 <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 NameProperty Legal Description �1 u <br /> GL 1/4 1/4,S L ,T N,R 1 W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) tC <br /> City,State <br /> �',� VAZip Code Owner's Phone Number City,State Zip Code <br /> �JXD1�" (L1B ) <br /> Type of Building Being Connected: (Check o e) Town of <br /> +� I or 2 Family Dwelling-No.of Bedrooms:_ ❑Village r <br /> ❑ Public ❑ Commercial u <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> 070242_3q 1 1+1T202_A0 01300o <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> POWTS Reconnection ❑POWTS CIonnectioonp for the sanitary system to serve is being connected to the system. <br /> County#,l-Z2- �0 *A Connection Permit is required when the sanitary permit expired without being Oj <br /> State the sanitary permit State#b N 3 yy) 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 <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/200D <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> W Qr DOD 9 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> Comments <br /> p�I <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />