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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 /> Property Owner Name ,; 1'c VAA11—e— Property Legal Description <br /> L"C',j /.eke C�./n r-p, �G��-s��� _ ? <br /> GL 1/4.��; .JJ,�'1/4,S ,TN,Rf. V <br /> Property Owner's Mailing Address j Property Site Address(if different than mailing address) <br /> j yjoy 1-1+ke- D rime- ,vz zz Yz-0 %--515e-,-01 6/ <br /> City,State Zip Code Owners Phone Number City,State Zip Code <br /> Type of Building Being Connected: (Check one) p oo w f <br /> ❑ l or 2 Family Dwelling-No.of Bedrooms: <br /> Public ❑ Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> D 7 ovR a 3S ff133 y cvc os a CK>o <br /> T of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> POWTS Reconnection OWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit !Stoa <br /> unty# *A Connection Permit is required when the sanitary permit expired without being <br /> te# 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 /> Ode- Risr�/6/,, 1 1/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Dat Iss ed ssuing ge t Si 7�A <br /> Approved ❑Owner Given Reason for 160.60 I'Q'LG�3 Q j 1 �)o� <br /> Disa roval in Writing TD J /) o� <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> APP ��� � <br /> Revised 3/16/13 <br /> AUG 12 2019 <br /> Burnett County <br /> Land Services Department <br />