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• <br /> • <br /> IECEOVIE --)BURNETT COUNTY LAND SERVICESMAY 2 8 2020 <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN WISCONSIN 54872Burnett County <br /> Land Services Department <br /> 715-349-2109 c4<0 6T6944 5,(5-0 <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 Property Legal Description <br /> go b es--f- Sa v a 5e GL 1/4 1/4,S ,43 ,T YON,R/7 &V <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> ,Z j ff l Y /ti 0'1 5,4- /V6/ Gre v.e /fit- <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> z l YN vh evra r Nl A/ 55-354 ( ) U✓e6SfT✓ Gtj .c Sq.) <br /> Type of Building Being Connected: (Check one) ;lit Town of <br /> 1 or 2 Family Dwelling-No.of Bedrooms: J 12 Village <br /> ❑ Public 0 Commercial L ti r v fr <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> 07—o3b-d-tip.17I3.fos'vaS" <br /> o/,l ode <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# J(O'V 2. *A Connection Permit is required when the sanitary permit expired without being <br /> State# 05j 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 /> _'� `I <br /> Tank Condition Ba C�rf�an r/v — Manhole Cover/Riser Condition <br /> 4e•C <br /> Comments <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />