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z <br /> a � <br /> BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 V <br /> 715-349-2109 cn ��g <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED o <br /> WITH THIS APPLICATION 1 <br /> G <br /> Application Information(T pe or Print) <br /> Property OwN me Property Legal Description <br /> GL 1/4 1/4,S �/ r <br /> I� T� ,R W o �1 <br /> Propertywncr's Mailing Add Property Site Address(if different than <br /> SS 33 tvre mailing address) p O <br /> O <br /> City,State 7.ip Code Owner's Phone Number City,State Zip <br /> Lj <br /> In <br /> Code '" n <br /> C <br /> T pe of Building Being Connected: (Check one) R'f own of g <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ <br /> ❑Village pot',t j <br /> S b <br /> ❑ Public ❑ Commercial <br /> Describe uses and design flows for the b ilding being c�j nected: Parcel Identification Number OR Tax ti <br /> /�' ID: °G <br /> ���i�t� ► ,/vlQ(1l(���C�-Y�2c�� Cie Z�� Z <br /> *Reconnection Permit:required when a new or existing <br /> Ty �of Permit*' ]7 <br /> 1/J POWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial Cn <br /> County# 3�18 structure rebuilds,any new structures with plumbing) <br /> State Sanitary Permit <br /> 0 <br /> number in question: *Connection Permit:required when the sanitary permit N <br /> State# 5 5( 2 $1 expired without a structure being connected to the installed k <br /> POWTS. ado a <br /> C7 <br /> Check with Burnett County Land Services Dept.for pQ <br /> further clarification <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: <br /> Fee Rec:15 <br /> l.� � d Check#: <br /> Tank Condition <br /> Baffle Condition Manhole Cover/Riser Condition d <br /> N <br /> CDComments <br /> on <br /> o a L— <br /> W <br /> 03 C <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes n <br /> m N C7 .t C <br /> t7 0 <br /> Page I of 2 d w C <br /> a.rt r <br /> S 3 U <br /> m <br /> Reconnect Permit Application 12/2024 <br />