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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 <br />715-349-2109 3 <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 />Property Legal Description <br />Q <br />6 n <br />GL 1/4 1/4,S T N, R W <br />Property Owners Mailing Address <br />Property Site Address (if different than mailing address) <br />�9Amnqr& <br />/9xov"4r"& Ad <br />City, State <br />Zip Code <br />Owner's Phone Number <br />City, State Zip Code <br />w2 <br />1J."Iry-6 <br />1,40 <br />&&c 5'y-Py,0 <br />Type of Building Being Connected: (Check one) <br />Approved <br />Town of <br />p �r <br />moi! <br />J& 1 or 2 Family Dwelling - No. of Bedrooms: <br />Date Issued <br />- I g <br />❑ Village <br />Comments: <br />❑ Public ❑ Commercial <br />Describe uses and design flows for the building being connect e <br />Parcel Identification Numbe : <br />Zoo CPO Gera e. �, <br />pp 61 <br />07-VqX-.1-391 -/g-3y- D� OoS- <br />Type of Permit*: <br />*A Reconnection Permit is required when a different building than was intended <br />i( POWTS Reconnection ❑ POWTS Connection <br />for the sanitary system to serve is being connected to the system. <br />^ <br />County #-ZTT %A <br />*A Connection Permit is required when the sanitary permit expired without being <br />State the sanitary permit <br />State # <br />connected to the intended use of the sanitary system, and now the building is being <br />number in question: <br />connected. <br />Responsibility Statement: <br />I the undersigned, assume res onsibili for the POWTS activity for which this permit is issued. <br />Plumber's Name (print) Plumber's gnature' MP/MPRSW No.: Business Phone Number: <br />or? I Da 7 R AP <br />Plumber's Address (Street, City, State, Zip Code): <br />Office Use Onh: <br />Approved <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Disapproval in Writin <br />Fee Collected: <br />pf% <br />S0' <br />I DSPS Cred. No. <br />X1083 3 111-13 <br />Date Issued <br />- I g <br />ss 'ng Signature <br />Comments: <br />Cond'ti s ROVEDfor Disapproval: <br />Revised 3/16/18 <br />