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c-1 <br /> ! © <br /> OV a1 <br /> URNETT COUNTY LAND SERVICES <br /> JUN 1 6 2020 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> :umett .unty z <br /> Land Services Department 715-349-2109 .� <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> b <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION t <br /> 5 <br /> Application Information(Type or Print) V i ii 4,' L.C4/SMA 4 tjd_,, Lek 1j 2/41 In /1 <br /> Propertyj � Owner Name/ f�l'� Property Legal Description q ,� <br /> 604re'.v4i ' /• "'//L i LL L GL 1/4 1/4,Ss(� ,T 'N,R1Fj& <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> gi <br /> ' INO0v chk /f wy R 7 d jc; , idol 5bee r D <br /> CityState / Zip Code Owner's Phone Number City,State Zip Code <br /> 5/7460-Ci ti.1i cCfig/ (715' ) //D D446,t 1 cv 5W?0 0 <br /> / <br /> Tye of Building Being Connected: (Check one) Town of <br /> Q�_ 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village <br /> Eg Public ❑ Commercial PC/eh/'XI i <br /> Be cribe uses and design flows for the building being connected: Parcel Identification Number: <br /> tOCOi i 4 I,CC cit,,_/ A-Cb /fir„/ Ck "O • 91 i' - !y° 5oO - <br /> T,(ie of Permit*: *A Recondection Permit is required when a different building than was intended <br /> �'POWTS Reconnection ❑POWTSConnectionfor the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County#f 1 / 4 *A Connection Permit is required when the sanitary permit expired without being <br /> State# connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> r <br /> r <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 E. <br /> SKO ki A c P 1 cq1,f'€ /0007 cy <br /> Tanko t <br /> he inteBaffle Condition Manhole Cover Riser Condition <br /> J°C4 eec/S ) e 4Y-el --,_ <br /> Comments <br /> 1(� tI r <br /> `t ( tftp (( jkeck <br /> SPt i'c' q tfir. ti, cif bertg rePAcel <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />