Laserfiche WebLink
a � b <br /> BURNETT COUNTY LAND SERVICES N <br /> 7410 COUNTY ROAD K, #120 7 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $150) L <br /> 0 <br /> G <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED r <br /> WITH THIS APPLICATION N <br /> Application Information(Type or Print <br /> UI <br /> Property Owner Name Property Legal Description , <br /> J icyn <br /> ; � K GL 1/4 1/4,S <br /> no T 141 N,R KIP W r. <br /> Property Owner's Mailing Address Property Site Address(if different than <br /> \ mailing address) <br /> � <br /> 9 16,yfeey N,6 77GY J` 6ag <br /> O <br /> City,State Zip Code Owner's Phone Number City,State y^_ _ 0%4Cn <br /> Zip <br /> Code <br /> IJ�J-� <br /> Type of Building Being Connected: (Check e) Town of ° <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Village <br /> ❑ Public ❑ Commercial <br /> 0 <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax y <br /> ID:0j-03g-a yl-lc--d6- <br /> 15 <br /> Type of Per t*: *Reconnection Permit:required when a new or existing <br /> 121'POWTS Reconnection ❑POWTS Connection structure is to be connected to an existing POWTS <br /> (Including but not limited to:structure additions, full/partial W <br /> structure rebuilds,any new structures with plumbing) <br /> State Sanitary Permit County# fJ-2 N —i <br /> number in question: *Connection Permit:required when the sanitary permit N <br /> State# expired without a structure being connected to the installed <br /> POWTS. <br /> w <br /> t7 <br /> Check with Burnett County Land Services Dept.for v1 (v <br /> further clarification ' <br /> NOTE:A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON <br /> REQUEST <br /> Holding/Septic Tank <br /> i <br /> Manufacturer/Material/Capacity Effluent Filter Condition: Fee Rec:lJr� <br /> -T rv� 1'tQ R� GO o Check#: � <br /> r, <br /> Tank Condition Baffle Condition Manhole Cover/Riser Condition <br /> ©� ©®A <br /> Comments <br /> C <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes tda J U ll <br /> c <br /> Page I of 2 <br /> r,,at rni <br /> Reconnect Permit Application 12/2024u u <br />