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BURNETT COUNTY ZONING .ADNWdSTR.ATION <br />7410 COUNTY ROAD IK, #102 <br />SIREN, WISCONSIN 54872 i <br />715-349-2135 1 <br />POR'T'S CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $I58 <br />© E <br />T B �. <br />NOTE: A PIAT PLAN IS REQUIItF,Il SUBMITTED WITH THIS APPLICATION <br />Anniirgfimr infarmstkrn tT vnp nr PAntl <br />Property Owner Name <br />IV Aloe, LC <br />y Leo Decaaptira� <br />U d& <br />Dow � <br />GL V4 114 5, T W <br />Property Owners Mailfng Address <br />L <br />is <br />PtWesty Site Address ff &fhmat than mailing address) <br />Afa 6...4tiv.,,eI4 D <br />/0 q`qc- Lant <br />rv�. <br />City, Sade <br />fil � 1 <br />Tap Code <br />sqq%. <br />Owner's P�h(areNmnber <br />"f <br />City, State Zip CodeoS <br />bil 7'f b-30 <br />ti <br />* <br />Type of Bnc"fding Being Connected: (Check one)a Village <br />�' R G <br />@r 1 or 2 Family DweTing -No. ofBe&oonM .--i <br />O Public ❑ C inimemiai <br />Describe ares and design ftm for the bandFugbeing muftted: Pared Ide adfisatiat Nambsr: <br />07-0 <br />Type of Permit*: *A Rteonueefim Pearedt is regpred when a dil%rta bmkbng than was mtmded <br />4 POWTS Revomnection ❑ POWLS Connection for tTbe sanitary systew to serve is beings to the system <br />Sats 9 P Cou>ity # 6a r 8 *A Counectim Permit is rewired when Ste sanitary permit equed wiflicutbeing <br />#. 0 oto the mtmded ase of Ste MARYMARYsystt�, and now the bedding is being <br />mimber in question: <br />i <br />Responsibiitty Stf►tement: <br />the as sme fertile POWTS for which this ern+it is issued. <br />Phimws Name (pt/JInt) Pbmo*e0; Signatars~/� M ARPSW No.: IBasiuess PhorctNmnber <br />14 <br />Pl=W3 Address PUVM City. Slaty Mp Co&): <br />d ?7Ge 4y 3S` AL9d5fr�- hvy—S t`9' 3 <br />office Use Only: <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Fee Cobeded: <br />✓S p L V� <br />DSPS Cored. No- <br />�3 /, 3�,3'S <br />lasered <br />'� <br />is -'Agent Signaaae <br />Comments: <br />I <br />Coiditiions of Approval /Reasons for Disapproval: <br />i <br />l <br />Revised uzwrI <br />