Laserfiche WebLink
&PP «- ly <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 />Annlication infarmatinn lTvnn nr Printl <br />Property Owner Name <br />Property Legal Description <br />//�� <br />GL p I/4 YV A S36 ,T' ON, R . 7W <br />Property Owner's Mailing Address <br />Property Site Address (if different than mailing address) <br />Date Issued <br />I; m Age t Si a re <br />City, State <br />Zip Code <br />Owner's Phone Number <br />City, State Zip Code <br />I,t/ -eb V?r ?.V -.T <br />Type of Building Being Connected: (Check one Frown of <br />1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village <br />Public ❑ Commercial 4 <br />Describe usevand design flows for the building being connected: Parcel Identification Number: <br />1_7000 <br />T e of Permit*. *A Reconnection Permit is required when a different building than was intended <br />POWTS Reconnection ❑ POWTS Connection for the sanitary system to serve is being connected to the system. <br />State the sanitary permit County # 110 *A Connection Permit is required when the sanitary permit expired without being <br />State # connected 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 />P7oa, <br />s Name (printj) // Pl s Signature: MP/MPRSW No.: Business Phone Number: <br />(•�l�C�' l 7A -M ?151 i 7/6 -56k020-2- <br />Plumber's Address (Street, City, State, Zip Code): <br />Ole -'70 7?Po,--7c,,j ed w,- 1 <br />Office Use Only: <br />Approved <br />4 <br />❑ Disapproved <br />❑ Owner Given Reason for/ <br />1 Disapproval in Writingli-a-orn17-Jo-IT. <br />Fee Collected: <br />e0 <br />DSPS Cred. No. <br />Date Issued <br />I; m Age t Si a re <br />Comments: <br />PPROVED <br />Conditions of Approval /Reasons for Disapproval: <br />ECEWE <br />i,_.., <br />L i <br />JUL 0 9 2018 <br />BURNETT COUNTY <br />