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CUPP-/�-pq <br />BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 <br />715-349-2109 <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />ADnliCation information (Tvne or Print) <br />e <br />PropertTW,el <br />Property Legal Description <br />6 -o� / <br />❑ Disapproved <br />GL y <br />/ <br />1/4 1/4, S T N, R �(�W <br />Property Owner's Mailing Address <br />00 2 �d T� � /- <br />Date Issued <br />Property Site Addres (if different an mailing address) <br />16 7� ��✓ <br />Approved <br />❑ Owner Given Reason for <br />Disapproval in WritingZ' <br />f <br />��iei <br />('i State <br />Zip CodeOwner's <br />Phone Number <br />T <br />City, State <br />Zip Code <br />T e of Building Being Connected: (Check one) Town of <br />1 or 2 Family Dwelling - No. of Bedrooms: Z— Village / <br />Public ❑ Commercial (emev- <br />Describe uses and d flows for the building being connected: Parcel Identification Number: <br />�C-z 4- 'A <br />T e of Permit*: *A Reconnection Permit is required when a different building than was intended <br />POWTS Reconnection ❑ POWTS �C?onnection for the sanitary system to serve is being connected to the system. <br />v <br />State the sanitary permit County # 2 yq *A Connection Permit is required when the sanitary permit expired without being <br />State # 11116-72connected to the intended use of the sanitary system, and now the building is being <br />number in question: connected. <br />Responsibility Statement: <br />1, the undersigned, assume responsibility for the POWTS activity for which this permit is issued. <br />PI is Name (prin)Pl Signature• MP/MPRSW No.: Business Phone Number: <br />g�d� <br />Plumber's Address (Street, City, State, Zip Code <br />27Z2C )?M laidr.t <br />Office Use Only: <br />❑ Disapproved <br />Fee Collected: <br />DSPS Cred. No. <br />Date Issued <br />s g A ent atme <br />Approved <br />❑ Owner Given Reason for <br />Disapproval in WritingZ' <br />omments: <br />nD <br />Conditions of Approval /Reasons for Disapproval: <br />M Ay 2 i 12018, <br />� v <br />t <br />�6 <br />xevisea si i of i a <br />