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c b <br /> cr. ga b <br /> <. [J <br /> BURNETT COUNTY LAND SERVICES ;,' cn W <br /> 0 <br /> 7410 COUNTY ROAD K, #120 <br /> SIREN, WISCONSIN 54872 ro <br /> d <br /> 715-349-2109 ,\ <br /> i <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> g' <br /> < <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED ' <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print) Lot 1_am• Vol 33 Pi..I tf S <br /> Property Owner Name ff J I Property Legal Description <br /> AeCkfY\ J 1 cld:Ld Vh10 t"', GL 1/4 1/4,S 13 <br /> T L{t�N,R S(�Property Owner's Mailing Address Property Site Address(if different than ° <br /> �� mailing address) <br /> ag a S t J Fh'r\cefon auii,ei Bo1iwrLae Rct. c <br /> City,State ' Zip Code Owner's Phone Number City,State Zip 'C=1 <br /> *21 <br /> Code <br /> Lau CiGu`ce 1 WI rSLI7C3 ( 7LS) 2t9-1171 . 4.t..bury , u.1T 54-$30 n cA <br /> z ° <br /> Type of Building Being Connected: (Check one) 1E1 Town of o <br /> o <br /> 159 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village ,.o.. ' <br /> ❑ Public 0 Commercial 34C/4 son F <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax .y <br /> t ID: a4 <br /> Lau..'L\ctr9 \ -use o7-01 -,)-Nu-ic-/;-5-isEts-oigtye <br /> Type of Permit*: *Reconnection Permit:required when a new or existing <br /> ® POWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS V\ <br /> (Including but not limited to:structure additions, full/partial Cl) <br /> State Sanitary Permit County# structure rebuilds,any new structures with plumbing) <br /> number in question: "Z I *Connection Permit:required when the sanitary permit N W i <br /> State# 33O3o9' expired without a structure being connected to the installed <br /> POWTS. 5' —1 <br /> Check with Burnett County Land Services Dept.for ln' <br /> further clarification 8' <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z Q <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPONik <br /> REQUEST <br /> Holding/Septic Tank <br /> 0 <br /> Manufacturer/Material/Capacity J Gu ti Preca -}— Effluent Filter Condition: Fee Rec:#73a <br /> CEi\o't N o h i✓ Check#: /61 G 4/�n,� <br /> rn <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition z r^' �'dix.4 "O <br /> 0 <br /> GOO Ctx <br /> Comments <br /> s r <br /> sv <br /> -1 a. Vriv <br /> >• cpw = <br /> o � 3 r— <br /> r. 5m <br /> - o <br /> , or? w + <br /> v 7 N <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes < Si,c w <br /> m <br /> z <br /> Reconnect Permit Application 12/2022 i <br /> b <br />