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C b z <br /> a g b <br /> <. ... , <br /> BURNETT COUNTY LAND SERVICES so to <br /> �^ <br /> 7410 COUNTY ROAD IC, #120 v <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2109 1---) <br /> POWTS CONNECTION/RECONNECTION PERMIT APPLICATION(FEE: $150) ► ., cl)_ <br /> lIl <br /> NOTE:A PLOT PLAN IS REQUIRED TO BE SUBMITTED rn �' G <br /> WITH THIS APPLICATION j S N <br /> N <br /> Application Information(Type or Print) r <br /> Property Owner Name Property Legal Description <br /> SI�/�/1 (/ GL 1/4 1/4,S 13 <br /> C A w /V C_ `pc`-' / T'/aN,R(1/4 <br /> Property Owner's Mailing Address Property Site Address(if different than F. <br /> mailing addres) W <br /> l(5 9 L /02 rd S 7L. 173 / 6.. Li• 0e, 0 <br /> po -C <br /> 0 <br /> City,State Zip Code Owner's Phone Number City,State Zip ':1 <br /> Code A r) <br /> 8/00/1A ; ' ,0 j�✓l,� 5"S'y,� ( 7G�) y 5 9 c((i3 prodo-<r- vT s K96i! n o <br /> tT <br /> e of Building Being Connected: (Check one) 14 Town of o <br /> o <br /> Tf 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village a. <br /> 0 Public 0 Commercial S C.. 4-1--- 127. <br /> o <br /> Describe uses and design flows for the building being connected: Parcel Identification Number OR Tax d <br /> ID: °° <br /> Re- -e 17( ;( -12 (w.C , l9 0y0 <br /> Type of Permit*: 'Reconnection Permit:required when a new or existing <br /> 14 POWTS Reconnection ElW <br /> POWTS Connection structure is to be connected to an existing POTS <br /> (Including but not limited to:structure additions, full/partial "Tl rn <br /> State Sanitary Permit County# structure rebuilds,any new structures with plumbing) m <br /> number in question: 'Connection Permit:required when the sanitary permit N W o <br /> a <br /> State# expired without a structure being connected to the installed o a <br /> POWTS. ' <br /> w C <br /> C7 <br /> A !0 Pe�',,� • c �- C.- Check with Burnett County Land Services Dept.for O. G ---0�V further clarification R o -1-- o <br /> NOTE: A SOIL BORING IS REQUIRED TO BE SUBMITTED WITH THIS z -C <br /> APPLICATION IF THE SYSTEM WAS INSTALLED BEFORE 1/1/2000 OR UPON z <br /> a <br /> REQUEST <br /> i, <br /> Holding/Septic Tank <br /> Manufacturer/MateriallCapacity Effluent Filter Condition: N Fee Rec:.9,60 l�, <br /> / �q��N� r bcteLLAi 5 t,c . o Check#:��I(l1� <br /> • <br /> Tank Condition / Baffle Condition Manhole Cover/Riser Condition ri <br /> 0 <br /> Gb6 I 6 0E Si a ) � U <br /> Comments I _ J <br /> O Ldiu <br /> Note:Manhole must be securely fashioned in accordance with all WI Administrative Codes rl <br /> `''Pagelof2 <br /> _] <br /> Reconnect Permit Application 12/2024 <br />