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r <br /> b z <br /> a � b <br /> Y. N <br /> BURNETT COUNTY LAND SERVICES N <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 v� 0 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> P <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION o <br /> Application Information(Type or Print <br /> Prop Owner Name Property Legal Description <br /> GL/C� ✓/� J! �' T�N, �, W 1/4,S <br /> Property Owner's Mailing Address Property Site Address(if different than S <br /> mailing address) �2 7,Z/2:> O <br /> City,State ( Zip Code Owner's Phone Number City,State L�f Zip <br /> L.!iv Zi L,-ke 5 1y7/v Code <br /> o <br /> Type of Building Being Connected: (Check one) Town of $ t`1 <br /> ,lam 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village j� /� �a N <br /> ❑ Public ❑ Commercial �/ /��/ 0 <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax d <br /> ID: v Oko 0 <br /> T e of Permit*: *Reconnection Permit:required when a new or existing a IVA <br /> OUTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial CIO <br /> State Sanitary Permit County# �,-� structure rebuilds,any new structures with plumbing) <br /> _ ;q <br /> number in question: *Connection Permit:required when the sanitary permit <br /> State#59q( expired without a structure being connected to the installed <br /> POWTS. y <br /> W <br /> Check with Burnett County Land Services Dept.for CJ -C Zti <br /> further clarification O <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS >Q z <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON <br /> REQUEST <br /> s <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec s 60 <br /> Check#: 7/31 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition z <br /> 0 <br /> Comments \ y <br /> � m W <br /> z C = 1]1►t <br /> r O <br /> j CA 0 <br /> 0 <br /> 100 ti c <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes , w K �r <br /> Page 1 of 2 v CD <br /> a <br /> Reconnect Permit Application 12/2024 <br />