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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 <br />715-349-2109 <br />SPP-L��a� <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />Application Information (Type or Print) <br />Property Owner Name< <br />�O <br />Property Legal Description <br />15 <br />G� JY:OV✓ <br />GL 1/4 1/4,S ,T N, R <br />y wnees Mailing Address <br />F; Qox 6 17 <br />Property Site Address (if different than mailing address) <br />� Sa J <br />City,, State L <br />W S'Tcr 1/�% <br />Zip Code <br />$ 9 3 <br />Owner's Phone Number <br />j �' 7 l �' y j j <br />City, S to Zip Code <br />w <br />*A Connection Permit is required when the sanitary permit expired without being <br />connected to the intended use of the sanitary system, and now the building is being <br />connected. <br />$lav <br />T'pe of Building Being Connected: (Chec one <br />1 or 2 Family Dwelling - No. of Bedrooms: �',s <br />❑ Public ❑ Commercial <br />Town of <br />❑Villa e <br />sovl <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Disapproval in Writing1 <br />1jee Collected: <br />j s� O O <br />Describe uses and design flows for the building being connected: <br />LDate Issued`, <br />5 - L1- p <br />Parcel Identification Number: <br />O <br />Type of Permit* • <br />POWTS Reconnection ❑ POWTS Connection <br />*A Reconnection Permit is required when a different building than was intended <br />for the sanitary system to serve is being connected to the system. <br />County #�%3 <br />State the sanitary permit <br />number in question: State # 3 9 y O <br />*A Connection Permit is required when the sanitary permit expired without being <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 activity for which this permit is issued. <br />Plumber's Name (print) Plumber's Signature:MP/MPRSW l Business Phone Number: <br />�,vilex1 }�a�saY, �e.c �,,k j` � io1Ls 7 7.3 )S- yI a -q )o <br />Office Use Only: <br />Approved <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Disapproval in Writing1 <br />1jee Collected: <br />j s� O O <br />DSPS Cred. No. <br />J 3) S 3' S <br />LDate Issued`, <br />5 - L1- p <br />Iss ing Agent Signature <br />— <br />Comments: <br />Conditions of Approval /Reasons for Disapproval: <br />Revised 3/16/18 <br />