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4- <br />BURNETT COUNTY LAND SERVICES N?P - lQ -Dl <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 <br />715-349-2109 <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />Application Information (Type or Fruit <br />Property <br />y Owner Name /7 A, Property Legal Description <br />W �.1�11V1 LamW: XA-T 1L-'--[—A' 1l1�V GLS— 1/4 1/4,S27,T L//N,R(� W <br />Property Owners Mailing Address Property Site Address (if different than mailing address) <br />City, State Zip Code Owner's Phone Number City, State Zip Code <br />-5-H U PIG V IL-W <br />T pe of Building Being Connected: (Check one) Town of <br />1 or 2 Family Dwelling - No. of Bedrooms: �- ❑ Village c ` <br />❑ Public ❑ Commercial Ski I _,.� <br />Describe uses and design flows for the building being connected: Parcel Identification Number: <br />MnnIG�il WA,�i - W 0-7. 03 _z--91-1, -z - ds. <br />11100 <br />Type of Permit*: 'A Reconnection Permit is required when a different building than was intended <br />POWTS Reconnection ❑ POWTS Connection for the sanitary system to serve is being connected to the system. <br />County# 558 6 ) 5 ;A Connection Permit is required when the sanitary permit expired without being <br />State the sanitary permit State # NA connected to the intended use of the sanitary system, and now the building is being <br />number in question: connected. <br />Responsibility Statement: <br />1, the undersigned, assume responsibility for the POWT$)aetivity jor which this permit is issued. <br />Plumbers Name (print) Plum s Signata MP+ff'R8W No.: Business Phone Number: <br />COKY J .�l4 i'�' - /L I ` �,c13 '� 715�fr��i � ` 9 <br />Plumbers Address (Street, City, State, Zip Code): <br />'306 BLAeK EKOCK K,p. W 1 f,,J� t5-z%5�'7 <br />Office Use Only: <br />,fJ! Approved <br />XApproved <br />❑ Disapproved <br />❑Owner Given Reason for <br />Fee Collected: <br />K <br />DSPS Cred. No. <br />1 / 11.3 <br />Date Issued <br />Issuing A�t Signature <br />Disapproval in Writingb <br />Y <br />Comments: ll <br />_ <br />Conditions of Approval /Reasons for Disapproval: <br />Revised j/ 16/ 18 11 L.-W <br />it <br />MA; 2 9 204 <br />Land Services <br />