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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872i�.�O, <br />715-349-2109 <br />NPP -17-11 <br />J- pelf gD-,5,- <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />Annlication Information (Tvne or Print) <br />Property Owner Name <br />C <br />Q c /► <br />LC�, <br />Property Legal Description 4 0T 3 <br />CSM VL4 1 <br />ALT R , <br />`G V <br />GL ft.' 114 -il4, S � T,T 3 1q N, R 11P W <br />Property Ownef s Mailing Address <br />6$Sq ' -rKC LAKE' ZOO <br />Property Site Address (if different than mailing address) <br />City, we Cor. <br />�"/� �J / - ` <br />V"' e tJ� � 'Gly- Wr. <br />Zip Code ''j <br />� 1 � / � <br />Owner's Phone Number <br />( ) <br />City, State Zip Code <br />Type of Building Being Connected: (Check o e) <br />19 Town of <br />. N <br />01 <br />X 1 or 2 Family Dwelling - No. of Bedrooms: <br />Date Issued <br />❑ Village <br />AApproved <br />❑ Public ❑ Commercial <br />Describe uses and design flows for the building being connected: <br />Parcel Identification Number: <br />/,t�t�isoti = /sb64L �tra�ay <br />o�-dl$ -�-3q-I� Z5-5-oS-oo3 . <br />Type of Permit* • <br />*A Reconnection Permit is required when a different building than was intended <br />POWTS Reconnection ❑ POWTS Connection <br />for the sanitary system to serve is being connected to the system. <br />State the sanitary permit County # AIN/ <br />*A Connection Permit is required when the sanitary permit expired without being <br />number in question: State # 311 O <br />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 responsibility for the POWTS Wivity forwhich this permit is issued. <br />Plumber's Name (print)MP/MPRSW No.: Business Phone Number: <br />o -t"z"e;ezJ"�Mu� U� 1 <br />-1i1-3q?-2L" <br />Plumber's Address (Street, City, State, Zip Code): IV <br />Office Use Only: <br />❑ Disapproved <br />Fee Collected: <br />DSPS Cred. No. <br />Date Issued <br />Is ing Age 9 S' ature <br />AApproved <br />1 ❑ Owner Given Reason for <br />Disapproval in Writing <br />Comments: <br />APPROVED <br />Conditions of Approval /Reasons for Disapproval: <br />nw &4, L� Y <br />Revised 3/16/18 <br />)2.3000 <br />0, %P 3�;- l 1 <br />D ,a ._ ..-.ti doh, :h (tv t --L l-- <br />