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F Phi 7" <br /> b <br /> BURNETT COUNTY LAND SERVICES a <br /> 7410 COUNTY ROAD K, #120 a <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <br /> PO WTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION <br /> Application information(T or Print) <br /> Property Owner Name Pr<vPDY Legal Ikscription <br /> 11)414 i;L 1r4 1'4,SOR I <br /> r N,R17W <br /> Property Owner's Mailing Address Pioperty Sue Address(if dittcrmt than .� <br /> n mailing address)brlVe., <br /> z. <br /> C ity,State Zip('ode Owner'S Phone Number City,State 7ip <br /> Code <br /> �� r � Uj-T �"� 7�- <br /> (7t�) �7-8�97 S <br /> T%pe of Building Being Connected: (Check ne) 8 Town of ro <br /> A I or 2 Family Dwelling-No.of Bedrooms: ❑village �f+t•7� 5 <br /> ❑ Public ❑ Commercial <br /> Describe uses and design flows for the bulldl R ng connected: Parcel Identification Number <br /> e �p <br /> gelr�,� /'L°Srde, 11.a R lac4ditJL In: <br /> Type of Permit*: 'Reconnection Permit:required when a new or existing <br /> a POWTS Reconnection ❑P(jWTS Corineclitin structure is to be connected to an existing POWTS <br /> -f (Including but not limited to:structure additions, full/partial y� <br /> state Sanitary Permit County k C 141 structure rebuilds.any new structures with plumbing) <br /> number in question: N o i <br /> Connection Permit:required when the sanitary permit <br /> State# expired without a structure being connected to the installed <br /> POWTS. <br /> ro o <br /> Check with Burnett County Land tiers ices Dept.for Q <br /> �' J L'U further clarification •l�� <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 UPONvq M LA v <br /> REQUEST `f <br /> II old ing/Scptic Tank <br /> Manutacturcr/Material/Capacity Effluent Filter Condition:G 'A Fee Rec: <br /> r» <br /> Check#: <br /> Tank Condition Baffle Condition Manhole CoveriRiser Condition z <br /> GOA �ooc �A Il�d �e t�,�jbz <br /> Comments <br /> a)m j <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> - _ ro C ^? <br /> Page 1 of 2 v 7 <br /> "0•t 3 <br /> Reconnect Permit Application 12/2024 .0.� <br />