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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Apptication Information(Type or Print) <br /> Property Owner)Name Property Legal Description <br /> * 7e—res - 1 s GL 1/4 1/4,S T N,R W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> 6 -,;L 3 e o))e 0 e= s ;" 497,9 9 /P get"L 9,te rPa <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> !`kose off kv i J 90A (6s) 7756_;kV ®,?_p.6 � , lv S4/33o <br /> Type of Building Being Connected: (Check one) 19 Town of <br /> 18 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village N <br /> ❑ Public ❑ Commercial U/Y."o,v <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> /_;v '.ri <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> 0 POWTS Reconnection ❑POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# I /3 3- *A Connection Permit is required when the sanitary permit expired without being <br /> State# connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> Responsibility Statement: <br /> I the undersigned,assume responsibility for the POWTS activity for which this permit is issue[' <br /> Plumber's Name(print) P mbees SAlatare•. MP/MPRS W No.:/ Business Phone Number. <br /> 8r,/n. 1"4 Alk K I O ?)L � 7 S SCP <br /> Plumbees Address(Street,City,S te,Zip Code) <br /> 7 6 749.ss, ��� w,' s y 99 <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing A t Si re <br /> .Approved ❑Owner Given Reason for 1 [ Q <br /> Disapproval in WritingJ J 1 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 1/26/17 <br />