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BURNETT COUNTY LAND SERVICES <br />7410 COUNTY ROAD K, #120 <br />SIREN, WISCONSIN 54872 fl I - <br />715-349-2109 t' <br />POWTS CONNECTION/RECONNECTION PERMIT APPLICATION (FEE: $150) <br />NOTE: A PLOT PLAN IS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION <br />Application Information '1'ype or Print) <br />Proprt Owner Name j Property Legal Description <br />ei-W0 -pt/v- l GL 1/4 114,S3 ;- ,T I �N, R l • W <br />Property Own r s Mailin Address Property Site Address (if different than mailing address) <br />City, State Zip Code Owner's Phone Number City, State Zip Code <br />r2Q .� (.✓,� S�('�'D (�r5 � s�� d�3 rip �� -� �.� 5 `� SAO / <br />TT of Building Being Connected: (Check one) Town of <br />t.t <br />rr 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village % <br />❑ Public ❑ Commercial <br />Describe uses and design flows for the building being connected: Parcel Identification Number: <br />19 .5� cel I , l0 3;- t <br />TT of Permit*: *A Reconnection Permit is required when a different building than was intended <br />L7 POWTS Reconnection ❑ POWTS Connection for the sanitary system to serve is being connected to the system. <br />County # 5-� *A Connection Permit is required when the sanitary permit expired without being <br />State the sanitary permit connected to the intended use of the sanitary system, and now the building is being <br />number in question: State #_ S ���sZ-_ connected. <br />Responsibility Statement: <br />1, the undersigned, assume res onsibilit for the POWTS activity for which this permit is issued. <br />Plu er's Name (pri Plumber's i ature: i MP/MPRSW No.: Business Phone Number: <br />Plu er's Add ss (Street, City, State, Zip Code): <br />10 ax 7 5,42 0,,1 <br />Office Use Only: "k, jo� 6-�-2 7 <br />❑ Disapproved Fee Collected PS Cred. No. Date Issued Q I , mg Agent 'r/,�natulre _ <br />kApproved ❑Owner Given Reason for /5'Q� �0� 920'93 3 /0-/0 p p,Jilfl' <br />Disaooroval in Writine ( `0' /Q r <br />Comments: <br />Conditions of Approval /Reasons for Disapproval: <br />Revised 3/16/18 <br />OCT 0 9 2018 <br />BURNETT COUNTY <br />ZONING <br />]I] <br />