Laserfiche WebLink
} IR <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 /> Apptication Information(Type or Print <br /> Property Owner Name f} i1A k e-- Property Legal Description �y <br /> Woo L�4Ke c,4m rF��re_Af /rl F.IJ�S L-LG GL 1/4se 1/4,S-5 T3 Ir7 9N,R V <br /> Property Owner's Mailing Address , Property Site Address(if different than mailing address) <br /> 1`/367 1,1-ke 27-1146) <br /> City,State L Zip Code Owner's Phone Number City,State ' Zip Code <br /> g 410 <br /> Type of Building Being Connected: (Check one) iffTown of wood <br /> ❑ 1 or 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 /> 07 oyd a 38/833 yoyo�o�a«� <br /> T ermit*: *A Reconnection Permit is required when a different building than was intended <br /> OWTS Reconnection WTS 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 /> Plumber's Name(print) Plumber's Signatu : MP/MPRSW No.: Business Phone Number: <br /> lv 14c�e. R aS 3C19-7-286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued �q ssu Agent igna <br /> IOL@pproved ❑Owner Given Reason for 00 1431593 <br /> Disapproval in Writing <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> APPROVID <br /> Revised 3/16/18 <br />