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• <br /> -4 t IE 1W E <br /> BURNETT COUNTY LAND SERVICE 1 JUN 2 Z 2020 <br /> 7410 COUNTY ROAD K, #120 - _____I <br /> SIREN, WISCONSIN 54872 Burnett County <br /> 715-349-2109 Land Services Department <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 Name1111 Property Legal Description (4,+' CSM'/1 el 2.51 <br /> t,3tt_LI�► 1 1 S#i2(1,rnt GL 2- 1/4 114,S341 ,T4DN,R(gW c- <br /> Property Owners Mailing Ad Property Site Address(if different than mailing address) <br /> I3ab 13utt> ke 17A., ISE 2-1483 %t AgLt. LAini_ <br /> Cit State Zip Code Owner's Phone Number City,State Zip Code r <br /> ILDr- e-s4'6tr fin 55- 0‘,D ( ) 5 oo ne�r. L,.7.i 543%O t <br /> Type of Building Being Connected: (Check one) 'Town of <br /> Ei 1 or 2 Family Dwelling-No.of Bedrooms: 2, 0 Village <br /> ❑ Public ❑ Commercial Scott Q <br /> Describe uses and design flows for the building being connected: Parcel Identification Number:174,,, (SgZ( <br /> 6.1A -0qt.-FaATg *Roo^A- o-7-oze-2-do-i(-}-3'I-S o5-ooz-ollono <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> PI POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# 27 27 O *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 /> number in question: State# `t�� Iq connected. <br /> a,2i :36 g+�t.u1.4.Avtc.p A 5) 20 0 3 <br /> NOTE:A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 dl1► <br /> N <br /> Holding/Septic Tank <br /> Manufacturer Material <br /> Capacity <br /> .S),--144.1.3 pr.eCAST l..tTl'tc-rd€ 750/500 pu.N.13 �J <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> Q00d1/4 giood .c 1.WR) OZDCFC N l5z Pip <br /> Comments <br /> Vz4,,15 `fin -T,,,K @ 043 ec ec Liv& I00-(,,,'s <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />