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NPp-tq <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) \j <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(TVDe or Print <br /> Prop Owner Name Property Legal Description <br /> GL 1/4 1/4,SOZ <br /> Property Owner's Mailin Address Property Site Address if d" Brent th mailing address) <br /> City,State Z C,,Ie Owner's Phone Number City,S to Zip Code <br /> � � ( <br /> Type of Building Being Connected: (Check one) ErTown of <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ _ ❑Village <br /> ❑ ublic ❑ Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: 1�tz CEO $l <br /> b)-cs - Z- -o - cjs-t,' 141Ll-b <br /> T���f Permit*: *A Reconnection Permit is required when a different building than was intended <br /> 3 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 responsibility fot the P WTS activity for which this ermit is issued. <br /> Plumber's Name(print) Pl ber's gnature: MP/MPRSW No.: Business Phone Number: <br /> r kd,43, - - <br /> Plumbers dress(Street,City,State,Zip Code): fr <br /> OUT <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date su su g Age�9L� <br /> proved ❑Owner Given Reason for r! �� <br /> Disapproval in Writing77VV C <br /> Comments: <br /> 1 1° � <br /> Conditio A r "easons for Disapproval: <br /> Revised 3/16/18 0EONC <br /> SEP ? 1 I'll <br /> Burnett County <br /> Land Services Department <br />