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c /02-7/a <br /> IECEOVE R <br /> I URNETT COUNTY LAND SERVICES <br /> MAY 2 7 221 J 7410 COUNTY ROAD K, #120 <br /> _ SIREN, WISCONSIN 54872 <br /> umett County 715-349-2109 <br /> Land Services Department <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION ,j <br /> L) <br /> 1 <br /> Application Information(Type or Print) - <br /> Property Owner Name ' ',�/� Property Legal Description Q„ <br /> 14 J<(-A✓l g l � c'i-(--Q J1 s`L"./k GL 1/4 1/4,S35 ,T3 W "N,R I BC <br /> Property Owner's Mailing Address Property SiteSiAddress(if different than mailing address) <br /> 2( (,"--10 g � 4 to O L) .a E�C i c(Q .2 Zit6 Pa Z !rJ 04 vx S6 Q1( Let-a. <br /> City,State Zip Code (Owner's Phone Number City,State Zip Code <br /> CO.e 0 s+-,e c [J.r. s`{S 3 (-z t S1,7-1-/33 5 r-e,_ kt 5‘14-2z, <br /> Type f Building Being Connected: (Check one) .Town of <br /> 2 Family Dwelling-No.of Bedrooms: 'Z, ❑Village ,\ <br /> n' ublic 0 Commercial Me ®,A. N <br /> Describeusesand designJflows for the building <br /> being connected: Parcel Identification Number: <br /> 1 cirl)'Ar&- ) e--(li x'11 0 to 333 56Z-7-.i 0 <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> 0 POWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit County# — *A Connection Permit is required when the sanitary permit expired without being c <br /> State# connected to the intended use of the sanitary system,and now the building is being <br /> number in question: connected. <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS ,, <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/SepticTank2$° <br /> Manufacturer Material Capacity <br /> WC P 694e.c-e_ -e__ -750 6fic(o,ys- <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> ..11."\ <br /> rObOCI Gt9OCI 6490d ?S <br /> Comments <br /> -k- <br /> kl <br /> Note: Manhole must be securelyfashioned o ed In accordance with all R'I Administrative Codes <br /> Page 1 of 2 <br />