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- FIFCEINED <br /> ii MAY 2 4 2023 BURNETT COUNTY LAND SERVICES <br /> Burnett County 7410 COUNTY ROAD K, #120 -No <br /> Land Services Department SIREN,WISCONSIN 54872 t <br /> GPI253q 11St) 715-349-2109 W <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) Cli <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner Name l Property Legal Description a <br /> 6r 1t.//{,/' GL 1/4 1/4,S ZI ,T5e N,R I7w <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) \ <br /> 8501 Ccerria96 /lla sg113 aiukoin 11l <br /> City,State Zip Code Owner's Phone Number City,State Zip Code tV <br /> 6CMV /A/ 65378 (6/Z )950-6.1,5 (CN IN 5416772- W <br /> Type of Building Being Connected: (Check one Town of <br /> ' 1 or 2 Family Dwelling-No.of Bedrooms: /•( 0 Village <br /> ❑ Public 0 Commercial faiN 1e'47 <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: <br /> 67-Cr6-i45-/7-21-5 t)-C'6 -otlCe <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> ng POWTS Reconnection CI POWTS Connection for the sanitary system to serve is being connected to the system. A <br /> State the sanitary permit County#5N 44 10,„, *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 9 <br /> number in question: cotn►ected. <br /> NOTE:A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> ---)k <br /> Holding/Septic Tank _ <br /> Manufacturer Material Capacity <br /> In t ee 6mcrek, IZSO lir <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> ‘o 606d 600d <br /> Comments NZ <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> Page 1 of 2 <br />