Laserfiche WebLink
NPP--20 -03 <br /> APEOVEn . <br /> BURNETT COUNTY LAND SERVICES flE2o2o2oj ,I <br /> [-") <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 Burnett County <br /> 715-349-2109 Land Services Department <br /> 1SO 10 530 aq <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) -Ouni4,(5 <br /> Ploy.614s <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description Lo t 1 CSM V 5,P aI <br /> (11 e I-1 i s c.k e r GL 2 1/4 1/4,S,)to,T/ON,R I yW <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> L-I L4 9 Sf cte Rd' 3S- ! 3s 3 a-U.nvi-y Pct <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> U16( � I Stig53 (71S )Ssy-?213 Spooner, \.JL S48o1 <br /> Type of Building Being Connected: (Check one) 11 Town of - <br /> (qa 1 or 2 Family Dwelling-No.of Bedrooms: I 0 Village <br /> 0 Public 0 Commercial SGo <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> Desi c�h Row - so Tea 07-0 as-2-yo-ly ab-s os-a0.2-018003 <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# 2 S g9 7 *A Connection Permit is required when the sanitary permit expired without being <br /> State# (Q q a q o(,, connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> S'Kau) C r cre-e 1 2 5 0 / 7 Se <br /> Tank Condition Baffle Condition 1 r/ <br /> Manhole Cover/Riser Condition <br /> .al-/ $-147*C 7a)c, <br /> Comments <br /> / / <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />