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50 if505 O <br /> ' APR Z t 2GL5 <br /> BURNETT COUNTY LAND SERVI p <br /> 7410 COUNTY ROAD K #120 Burnett County oQ <br /> , Land Services Department <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION FEE: $150 .� <br /> NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION_ <br /> Application Information(Type or Print) <br /> Property Owner Name Property Legal Description �Q <br /> �►^t L �,�'i CSC 11 ' N'1 <br /> GL 1/4 1/4,S <br /> Property Owner's Mailing Address Property Site Address(if different than mailing address) <br /> 13o(o y.f+1, A.c IV E 7 65-S L a 1)1a hA.c l�r. <br /> City,State M)v Zip Code Owner's Phone Number City,State Zip Code <br /> Calt-W,b« // A4 S sry�1 ( I�e�s�tr� tv S S�3 <br /> Type of Building Being Connected: (Check one) ❑Town of,i 2 <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 0 Village � <br /> ❑ Public ❑ Commercial Oe ICIA,o( <br /> Describe uses and design flows for the building being connected: Parcel Identification Numb r: <br /> p�-p�0-.1- � 0 <br /> Type of Permit*: *A Reconnection Permit is required when a different building than was intended <br /> POWTS Reconnection ❑POWTS Connection for the sanitary system to serve is being connected to the system. <br /> State the sanitary permit [State <br /> uf#27 <br /> -22-13$ *A Connection Permit is required when the sanitary permit expired without being <br /> number in question: $3 connected to the intended use of the sanitary system,and now the building is being <br /> connected. <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 <br /> Holding/ e tic Tank <br /> Manufacturer Material <br /> Capacity <br /> �orlcxt-fie / <br /> Tank Condition Baffle Condition ole Cover/Riser Condition <br /> Comments <br /> Note: Manhole must be securely fashioned in accordance with all NN I Administrative Codes <br /> Page 1 of 2 <br />