Laserfiche WebLink
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 /> 1 <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) I <br /> Proerty Owner Name //�� r Property Legal Description ,4)4---- Q <br /> C) (��./ t lam-r//Z / <br /> GL 4.)L 1/4 A/4.)1/4,S,27 ,T.SN,Rag �\ <br /> Property Owners Mailing Address Property Site Address(ifslifferent than mailing address) <br /> 46„6 707 ,,,?5'5'99 S;rIIe.,3 c,),-,,,,is Tr/ <br /> City,StateZip Code Owner's Phone Number City,State Zip Code <br /> &Je she-r CAL -T :5-M3 657 )y85 352 41 e_45p 4,-vT 5 4,673 <br /> Type of Building Being Connected: (Check one) Iii,,Town of //ke,�/mel itJ <br /> I or 2 Family Dwelling-No.of Bedrooms: e,2,_ 0 Village <br /> 0 Public 0 Commercial <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: (,v C� <br /> 0 7 cr/£� 3Y / --??-z <br /> e/°") <br /> /?/32 04,23C3e <br /> Type of Permit: *A Reconnection Permit is required when a different building than was intended <br /> lak POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# `I'5 a/6 *A Connection Permit is required when the sanitary permit expired without being <br /> number inuestion: State# i',..d 79/3 connected to the intended use of the sanitary system,and now the building is being <br /> qconnected. <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> Plumber's Name(print) Plumber's Signature: MP/MPRSW No.: Business Phone Number: <br /> A/ AiLi c��ii-? /t/e4,--Z— % % .zz7G >/ 3 .-Zze‘ r...„, <br /> Plumber's Address(Street,City,State,Zip Code): N <br /> QoX %4/ S'r! 'ew; e.d _5"-W7-2 <br /> Office Use Only: ; <br /> k‘ <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> Tpproved 0 Owner Given Reason for / 1). $4 Q�/ �,/ e•Z I , 1. 144 �7 <br /> Disapproval in Writing O ] V LcJ <br /> Comments: <br /> ti <br /> Conditions of Approval/Reasons for Disapproval: <br /> s) <br /> Revised 3/16/18 IECEI1VED <br /> II APR 14 2021 <br /> BURNETT COUNTY <br /> 7(11\11A10. <br />