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BU ETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 z <br /> 715-349-2109 z <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) ‘ <br /> K) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION 0 <br /> Application Information(Type or Print) <br /> N' <br /> Property Owner Name Property Legal Description/4)6- <br /> Gr€A-fr 4..1/a'ti L. R 5 c.,4 e Of /f/u, GL SG 1/4_5-47-1/4,S /5,T3YN,R/7w <br /> Property Owner's Mailing Address Property Site Address(if different than maili g address) <br /> y5-4 KR/e,.,,,b4 Ace, 8'2.35 A-ldor A - ted <br /> City,State Zip Code Owner's Phone Number City,Stqe Zip Code <br /> O f5e j6 /v' 553 .2 ( ) S%/"e. A✓." 5-47k7 L2- <br /> Type of Building Being Connected: (Check one) cgTown of <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> 0 Public 0 Commercial Pb-/11/eS <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: d <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> Pik POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. IIIJJJ <br /> State the sanitary permit County# *A Connection Permit is required when the sanitary permit expired without being <br /> number in question: State# connected to the intended use of the sanitary system,and now the building is being <br /> connected. <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibili for the POWTS activity for which this permit is issued. <br /> Plumber's Name(prim Plumber's Signature: MP/MPRSW No.: Business Phone Number: <br /> w i� a,�����/,y, �� z�7� , y‘.-x.95, <br /> Plwnber's Address(Street,City,State,Zip Code): <br /> a K / V �i%' -z) -✓.- .3-S'.5/7Z <br /> Office Use Only: <br /> 0 Disapproved e Collected: DSPS Cred.No. Date Issued t3suin, Qg g ture <br /> Xpproved 0 Owner Given Reason for CO /1 a 02?i�� � <br /> Disapproval in Writing ��V��1 /// Q�Q I <br /> Comments: v <br /> Conditions of Approval/Reasons for Disapproval: <br /> EVAt 1,2 .—41 6Q <br /> Revised 3/16/13 — E C E a v iE -- <br /> D <br /> SEP 1 7 2020 J1 <br /> Burnett County <br /> Land Services Department <br />