Laserfiche WebLink
BURNETT COUNTY LAND SERVICES <br /> 7410 COUNTY ROAD K, #120 b <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 IS <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) O) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description <br /> /1 -k 7/5dt'1 GL 1/4 1/4,So/4 ,Tt"141,R/47W <br /> Property Owner's Mailing Address _ Property Site Address(if different than mailing address) <br /> 1S(o.Sa /3reezy Form Dr /Ve ?01cS MIrlerVA Daw+ Rol <br /> City,State Zip Code Owner's Phone Number �Ciity,State Zip Code C <br /> CAI yvh,,hl inN Boyd ( ) !/Anb,,,.ry w. Ste 36' <br /> Type of Building Being Connected: (Check one) 5tTown of <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> 0 Public 0 Commercial ,SGv i Si <br /> Describe uses and design flows for the building being connected: Parcel Identification Number: -S/s- 3S/ <br /> p7-b 3�1-,�'Lil-!b-307 olio6.6rks-C 1,,.,,�4 4+ 4-0 r le,* <br /> T of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> PeOWTS Reconnection 0 POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the Sanitary permit County# 13056 *A Connection Permit is required when the sanitary permit expired without being <br /> number in question: connected. <br /> State# connected to the intended use of the sanitary system,and now the building is being `� <br /> 1_ <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS 'j <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 N <br /> Holding/Septic Tank <br /> Manufacturer Material Capacity <br /> 14,((5{✓ CGn C /00 0 <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition �` <br /> 6e' I 609J Got, <br /> Comments <br /> 071//9 ft <br /> i...) <br /> Eoz,: 1ih61 be securely fashioned in accordance with all WI Administrative Codes <br /> D <br /> MAY 10 2024 Page 1 of 2 <br /> Burnett County <br /> Land Services Department <br /> $$i)150 cu ck #5cy13 <br />