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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 />Application Information (Type or Print <br />rerty Owner Name /1 Property Legal Description <br />/JV / 144- K' GL 1/4 1/4, S T N, R W <br />Property Owner's Mailing Address Property Site Address (if different than mailing address) <br />0 S' 07 T/ 9 Pb 8%3a Q✓v, <br />tate Zip Code Owner's Phone Number City, State ' Zip Code <br />3 d <br />Type of Building Being Connected: (Check one) CkTown of P �S <br />.:R, 1 or 2 Family Dwelling - No. of Bedrooms:_ ❑ Village W <br />❑ Public ❑ Commercial <br />Describe uses and design flows for the building being connected: Parcel Identification Number: <br />07- 032-2- eAl- /7-36 d-3 ood-o /vao <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 # *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 />I, the undersigned, assume res onsibili for the POWTS activity for which this permit is issued. <br />Pbjmh—'� lumber's Signar. MP/MPRSW No.: Business Phone Number: <br />Plumber's Address (Street, City, State, Zip Code): <br />77b 0 /,Kcv y Gll,-� <br />Office Use Only: <br />❑ Approved <br />❑ Disapproved <br />❑ Owner Given Reason for <br />Fee Collected: <br />Zp <br />DSPS Cred. No. <br />Date Issued <br />Issuing Agent Signature <br />Disapproval in Writing <br />Comments: <br />je <br />G s s 144� /� . z9�i9 ,T <br />Conditions of Approval /Reasons for Disapproval: <br />Ek��E <br />adc <br />in <br />Burnett County <br />Land Services Department <br />