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Ct41o5 1 161) <br /> DC © EI1V <br /> BURNETT COUNTY LAND SERVICES <br /> AI If; 0 3 2023 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> Burnett County 715-349-2109 <br /> Land Services Department <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $150) k <br /> rt- <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION C)N <br /> Application Information(Type or Print) <br /> Property Owner Name �i Property Legal Description <br /> rN <br /> t 7e/'A —.5c1 5afr1 ./a/-7/-e_ GL 1/4 1/4,SS/0,T1/04IN,R/4 W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> qi/Nl 4dbo7'--AVe So. /40/5 XV ss '/o 15)2 -5ykes rd. <br /> City,State Zip Code Owner's Phone Number City,State Zip Code 3 <br /> , iso/s /Pk SS WO (o/2)3r5--375'1 S'aa, , i 'r. 5.9(5-0/ <br /> Tye of Building Being Connected: (Check one) [;a'iown of � <br /> LW 1 or 2 Family Dwelling-No.of Bedrooms: C.) �ib1,1roe11tA.. 0 Village 5C" .kr(- <br /> ❑ Public 0 Commercial VI <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> Pc Z 4 c s,1 v z p // eo<< tc..t Pt4 <br /> TType.o�f Permit*: *A Reconnection Permit is required when a different building than was intended <br /> ( 4 OWTS Reconnection ❑POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# *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 F, <br /> number in question: connected. N <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 �' <br /> � � � Gam► ' <br /> Holding/Septic Tank4. ,4i kaAdtc , <br /> 'i, <br /> Manufacturer Material Capacity 0 <br /> 6 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> Comments <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />