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BURNETT COUNTY LAND SERVICES Z <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, <br /> WISCONSIN 54872 <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Ppeperty Owner Name / Property Legal Description / C_ <br /> ieA ��U q.ida1 GL 1/4 1/4,S / ,T 55N,R O'7 W <br /> Property Own is Mailing Address Property Site Address(if different than mailing actress) <br /> Z1�-4() 11',� I Z IoZZJ' ( ,b,/,,,1 �' <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> G, aSp Mtn 13 (65-I ) 5 S ) LJ 1,1; F4163 <br /> Type of Building Being Connected: (Check ne) -O'iown of l / <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village (t/Y,o U1 6 <br /> 0 Public 0 Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> LID C6 P D . (.)-`)-vi(.0-z- -tc)-14- I -c&)-b1-brI <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> I7�POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# 12 g 54- *A Connection Permit is required when the sanitary permit expired without being <br /> # connected to the intended use of the sanitary system,and now the building is being <br /> State <br /> number in question: v connected. ‘'''$ <br /> i. , <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 /> 1,-,) Le /ZQ) <br /> Tank Condition i Baffle Co ition Manhole Cover iser Condition <br /> ae--'42.....} / <br /> Comments <br /> ")-e- X eff /Cie...act.,"-1 <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> iiiiiIECIOVE , Page lof2 <br /> MAY 2 9 2020L *'' �5 <br /> - U 'f-Q <br /> Burnett County 7 <br /> Land Services Department t t-I -- <br />