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NPR'- /q4 7 <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 /> Application Information tType or Print <br /> Property Owner Name Property Legal Description <br /> 5cfx4 J'661t-i!50 1 pr <br /> GL 3 PAEY4 0L- U4.S f T 3?Nr.R i W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> 33q 1'a-Aecr Q La ?' I d470 5A40 br- <br /> City,State Zip Code O"mer's Phone Number City,State Zip Code <br /> 5�i t�V J 44,--r Hn 1 5-5-0 B a ((DTI )of 4 t-(619 vW t�4d, t vi L 5'4 e ct 3 <br /> Type of Building Being Connected: (Check one) 29 Town of r <br /> i; l>r 2 Family Dwelling No.of Bedrooms: ❑Village <br /> ❑ Public ❑ Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> RZotci--&4--oo uJJ,e—, sc& C-.PCI 07- 4i4 -p?- 37-15*-O'-('5'-csf- 3 'OdOot <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> 15 POWTS Reconnection ❑POWTS Connection for the sanitary system to sere is being connected to the system. <br /> State the sanitary permit County# 261 Z L *A Connection Permit is required when the sanitary permit expired without being <br /> number in question State# 301 ofconnected to the intended use of the sanitary system,and now the building is being <br /> cotmected. <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the J47 <br /> activi or which t ' it is issued, <br /> PI her'sName rint) Plumbc Sign r MPf RSW No.: Business Phone Number: <br /> 715-- 416 - ma <br /> Plumber's Address(Street,City,State.Zi ode): <br /> Office Use Only: <br /> ❑Disapproved ee Collected: I3SPS Cred.No. Dat Tssu d �inAg�nl aria ' e <br /> }iroved ❑Owner Given Reason for I l�0 Ob '�►0�5p�3 Q /,� ,2019 <br /> Di--approval roval in Writin= / 40 (1 I <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> APPROVED �� to <br /> Revised 3/16,118 <br /> AUG 1 [ 2019 <br /> Burnett County <br /> Land Services Department <br />