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� b <br /> c � � <br /> g. rd <br /> BURNETT COUNTY LAND SERVICES s <br /> 7410 COUNTY ROAD K, #120 a Q <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED <br /> WITH THIS APPLICATION <br /> Application Information(Type or Print <br /> I <br /> Propem•Owner Name Property Legal Description <br /> 114,S <br /> u A To!lAJ JO ` ' T! N,R/S'W LQT '-/ <br /> 3 <br /> Properly Owne ,wiling Address Property Site Address(if different than <br /> mailin address) .� <br /> 3(-o7C 5TA )o 9h. 3 58AVr Ore. o w <br /> City,State VM Zip Code Owner's Phone Number City,State Zip �1 <br /> ,-• Code 5[ ow A i vn <br /> f EA A�To(,�N ,Ss /d �?/G )Yd8-7oY8 A06 u Y l M o <br /> Type of Building Being Connected: (Chet A ne) X1 Town of <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑village zt <br /> ❑ Public ❑ Commercial s(U io <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax d <br /> ID: 4 79(42 <br /> cn <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 <br /> (Including but not limited to:structure additions, full/partial <br /> State Sanitary Permit County# SM q structure rebuilds,any new structures with plumbing) <br /> 1 �a3 <br /> number in question: *Connection Pemdt:required when the sanitary permit N 'J <br /> State# expired without a structure being connected to the installed <br /> POWTS. <br /> d � <br /> Check with Barnett County Land Services Dept.for <br /> further clarification tA N <br /> J <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z o0 <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON <br /> REQUEST -- <br /> Holding/Septic Tank <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec: >SO�Q — <br /> #: <br /> Si k`fr Check�' �/�L� TiME - �rorx� <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> Cs-Oo Q &00 /J &00 0 <br /> z <br /> Comments ` ����N �` /vAE W _ r <br /> ,5 <br /> HA5 c�N `/ l'f a� Hour FXO IV- �'FTF/- SE Y :K <br /> 91 <br /> z <br /> .:i-CD vy S <br /> w <br /> r 1� <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes <br /> V. D <br /> y _S <br /> Reconnect Permit Application 11/2024 �� <br />