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BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <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 N me Property Legal Description <br /> efF'_4" 144J e titl'CS G �- GL 1/4 1/4,S ,T N,R W <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> City,State Zip Code Owner's Phone Number City,State Zip Code <br /> Type of Building Being Connected: (Check one) E Town of <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public 0 Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <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# *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 /> 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 /> Tank Condition / Baffle Condition Manhole Cover/Riser Condition <br /> G C� O C/1 7e_' 5 6-0 b G( <br /> Comments <br /> Note: Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />