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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 /> Application Information(Type or Print) <br /> Property <br /> Owner Name Property <br /> /o / Property Legal Description —7 <br /> 'j—, , /v`� sd � GL 1/4 1;4,S ,tom ,Rlp- <br /> Property Owner's Mailing AdIlress Property Site Address(if different than mailing address) <br /> S 1'-H L� fie- � L07 1 Csm t P �23 <br /> City,State/ Zip Code Owner's Phone Number City State Zip Code <br /> T pe of Building Being Connected: (Check one) ❑Town of <br /> 1 or 2 Family Dwelling-No.of Bedrooms:__ 7V Ila <br /> ElPublic ElCommercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> Type of Permit*' *A Reconnection Permit is required when a different building than was intended <br /> ❑ POWTS Reconnection ❑POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# *A Connection Permit is required when the sanitary petntit 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 eermit is issued.. <br /> Plumber's Name(print) Plumber' Signature: MP/MPRSW No.: Business Phone Number: <br /> , �y �j� z���p/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued MIssugent Lure <br /> Approved ❑Owner Given Reason for H <br /> Disapproval in WritingJYD •e ego <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 1/26/17 <br />