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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 b <br /> Application Information(Type or Print <br /> Property Owner Name Property Legal Description <br /> �V• `/���1(�l� GL 1/4 1/4,S f7jrN, W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> Type of Building Being Connected: (Chec e) VTown of <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Villag <br /> ❑ Public ❑ Commercials <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> POWTS Reconnection ❑POWTS Connectionfor the sanitary system to serve is being connected to the system. <br /> A <br /> State the sanitary permit County# "6 *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 for the POWTS activity for which this permit is issued. <br /> Plmnbe ame(p�� Phu ignature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Co <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Dat ss d m gen Si atur <br /> Approved ❑Owner Given Reason for <br /> Disa royal in Writing <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> APPROVED <br /> Revised 3/16/18 <br /> SEP 16 2019 JD <br /> Burnett County <br /> Land Services Department <br />