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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 l <br /> �t <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: 51501 <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> APplication Information(Type or Print <br /> Pro erty er ame Property Legal Description „t4� ,s <br /> Lot I aI,C C I Je�le� 1�- <br /> 71 ., e GL 1/4 i/4,0Z 3Z T �P7,R ttv W <br /> Property Owner's Mail Address Property Site Address(if ifferen han mailing address) <br /> ail Cl ' /1 �Wsq L��� <br /> City,StateZip Code Owner's Phone Number City,S Zip Code <br /> 1`/�f/d 5 t io 62 W fK ( J' to e/, U. S2/55,3 <br /> Type-of-Building Being Connected: (Check one) own of ah <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_L_ ❑Village <br /> ❑ Public ❑ Commercial <br /> Describe,uses and design flows for the buil ing being connected: Parcel Identification Number: <br /> (77-(Z0' <br /> Tye ermit*: *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 permitCounty# �7 y8y *A Connection Permit is required when the sanitary permit expired without being <br /> number in question: [State# connected to the intended use of the sanitary system,and now the building is being <br /> connected. <br /> Responsibility Statement: <br /> I,the undersigned,assume restionsibilittv for t14 PWA activity for which this nermit is issued. <br /> PI bees Name( t Plum e s S' re: MP/MPRSW No.� Business Phone Number: <br /> �� ys <br /> Plumb s Address(Street,Ci ,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred. No, Date Issued Iss ing A ent ure <br /> Approved ❑Owner Given Reason for s0 ! d <br /> Disapproval in Writin <br /> omments: / / /j <br /> copy I r`i,J ��vf f'Ca,w ;S. a,• Cit -5,0;z �vpIt,& e.v P`oY( IOZAP 0 1�. >.41e <br /> &e*f e a fe Tie T.y►i r DM I/ up 7-014le A101 qN <br /> W/ rX 36, e z 4 <br /> Conditions of Approval/Reasons for Disapproval: <br /> ( Revised 1/26/17 <br /> MAY 0 8 2017 <br /> BURNETT COUNTY <br /> ZONING <br />