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Ln ro Z <br /> BURNETT COUNTY LAND SERVICES s ti <br /> 7410 COUNTY ROAD K, #120 <br /> 4 See 0 ac-R d <br /> PPPLt c. 710x/.l� SIREN, WISCONSIN 54872 <br /> 715-349-2109 0 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print <br /> Property Owner Name Property Legal Description <br /> l�ev t r GL I/4 1/4,S �8 <br /> c) � T N,R jj2y <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> mailing address) ,y <br /> City,State Zip Code Owner's Phone Number City,State Zip <br /> CodeLn <br /> C) <br /> o <br /> Type of Building Being Connected: (Check one) I$Town of Swiss o <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village �a <br /> ❑ Public ❑ Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax o <br /> ID: <br /> T pe of Permit*' *Reconnection Permit:required when a new or existing <br /> WPOWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial <br /> State Sanitary Permit County# structure rebuilds,any new structures with plumbing) <br /> number in question: *Connection Permit:required when the sanitary permit ° <br /> State# expired without a stricture being connected to the installed °N <br /> POWTS. <br /> d � <br /> Check with Burnett County Land Services Dept.for y tN N <br /> further clarification tQ <br /> NOTE: A SOIL BORING IS REQ1 ED TO BE SUBMITTED WITH THIS z -C <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON <br /> REQUEST <br /> (A <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec: <br /> urp-4t o Check#: <br /> sK�-w C God m <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition z <br /> v <br /> Comments <br /> m <br /> y <br /> ..J <br /> a <br /> z <br /> z <br /> r <br /> -C <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> m <br /> Page 1 of 2 v <br /> a <br /> Reconnect Permit Application 12/2024 <br />