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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 <br />715-349-2109 <br />POWTS CONNECTION/RECONNECTIOY PERMIT APPLICATION (FEE: $150)Npq-)�_ og <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />AoDiic"stion Information fTvae or Printl <br />flw-u:x Name y�,�)Property <br />PGt-66114W <br />Legal € esctipt"son <br />f l f tic <br />Gl- tra 1A. s 2 0 .T ZIP \. K /G <br />Property Owncrla Mailing Address <br />j" <br />Property� Site Address (if dif errnt burn mailing ad,in � ) <br />61�- L <br />1ppnr►ctt <br />City, e ' <br />-« 1 <br />ZipCode <br />�'�[t� <br />Owner'- Puns Number <br />�9� ,975Z <br />ttitziptodcr <br />&fG1!1y <br />-z �i <br />Tv a of Building Being Connected: (Check tne) Eirr'own of <br />lrl ur 2 Parnily Dwelling -Pio" of flodruonui: 0 villape <br />C1 1'ultli� C 3 (tltntnerct�l <br />Describe tows and design flows for the build'eetg being connected* V. -A. c! lciccn it riac Norte:: <br />T?e of Perndt*' 'A tReceaaection Permit is taqui(cxi w4m a ditacrcut building than was intended <br />t�6 P(3t I N Rectrnnection ❑ Pt)lkA' S Cornccttion for the sanitary symem to seine is being connected to the s)xtem, <br />State the sonitu County r Ot� ;ys "► _ `A Comwe tee Permit is required schen the sanitary permit expired wirboat being <br />ry Permit state h .3) S a 4 coaanected to the intended use of the sanitruy System. jiml now the building is being <br />number in question-, eonrimted. <br />Rtsptz,hsihili#y Ste#cmcn#: <br />1, the undersigned, amume res,ponAbifity for the POWTS activity for wbieb thispermit is issued. <br />PI bee's Plante (print) Plurnier's Sienantrc: MPrMPRSW No.: Business Phone Number: <br />Plumher',sAdddrm,, (Street, City, State, Zip C'e)dc): <br />t?J �sAl �7 /•/�f��fl"ft��L/Z'�d�� w��f J� �,.,,ra7� ��'' { Y�` / <br />Office Use Only: <br />Q Disuppromd <br />Fee Coll xtcd; <br />DSP$ Crctt. !`ro, <br />Ddtc Issued <br />55rri r i <br />1ppnr►ctt <br />0 Owner Given ltmcm for <br />'r 00 <br />DtWproval in Writin« <br />Comments: <br />APPROVED <br />Conditions of Approval lReasons for Disapproval: <br />-111M ,I CCH 1C <br />