010-941-31-4310-LUP-2005-087 Application for Land Use Permit (*Non-shoreland) o o . -�
County of Sawyer � �
PO Box 676 - Hayward WI 54843
715/634-8288 �
*Property that is not located within 300' of a creek, river or stream or within 1000' of a
flowage, lake or pond or does not have any of the above waterbodies located within � �
the property's boundaries. r
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. 1
PRINT—USE BLACK INK OR PENCIL
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Owner Builder �
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MailinQ Qddress Mailing Address � O
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City, State, Zip City, State, Zip
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Daytime Phone 71,5 ,5�37-3/7( Daytime Phone f-�s'�U —3 Z 2 -lo�S� � �
Additional Information: �one District = � � �
Lot Dimensions: 7U � x 7 v � � �
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Date lot was created Acres • �� � a`
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Is there wetland near the proposed structure? If yes, how far 1Vv �
Building Land Use
( )New ( ) Filling Floodplain: ( ) Yes �No # �
QD Addition O Dredging Driveway access off of a(Check one): �
( ) Alteration ( ) Grading ( ) Private Rd (Xi Town Rd. �Kr��e� �
( ) Moving On ( ) Commercial ( ) County Hwy ( ) State Hwy � �
� ) � ) �
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Primary Structure Accessory Building Addition °
( ) Dwelling ( ) Garage-attached/detached ( ) Deck
( ) Year round ( ) # of car stalls ( ) Porch
( ) Seasonal ( ) Storage Building ( ) Enclosed
O Frame built on site O Screenhouse O Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen �� �
( ) Mobile/manufactured ( ) Other ( ) Bedroom
(Xj Other primary structure ( ) ( ) Relocate/enlarge '
( ) Single family or multi-unit ( ) ( ) # of new �
Additional Information: �v/'/�,�� � N{.w � /►�P�'l" �?'`,o ai'"' p
-2X-S�Y�:Ny S:�e tJJ- a�, �dh�vfv�. Tr�-y�er- Co►�p. v,
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Type of Construction ro
( ) Frame ( ) Log (f�Pole/metal ( ) Block ( ) Concrete �
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( ) Other � ��,, �
Construction Cost: Primary Structure $ � � � -
Accessory Building: $ Addition: $ �02..5,�D0 .�p �
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Deed )el 35Z `l�S Certified Soil Test# �Z -O`� 's j z
CSM Vol 5 Pg ..3�G1 Lot# � Sanitary Permit# 4�GYcY OZ ^CSGi W � �
I s.
Plat Envelope Or: � � --�
Condo Vol Pg Year Installed n Q
Owner When Installed: � � �
Aff of ex septic Vol Pg �
Previous office approvals/actions:
V ariance: LUP: SP: CUP:
Inspection Report: Change of Zone District: �IZ�,Ip f
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Describe the construction using these columns. List the dimensions of each structure in a separate
column. List each story, each addition, each alteration in a separate column. �
#1 . #2. #3. #4.
Size �7 �� ft. wide ft. wide ft. wide ft. wide
�7G ft. long ft. long ft. long ft. long
Floor area ��0 sq. ft. sq. ft. sq. ft. sq. ft.
Hgt. from grade to peak ft. hgt. ft. hgt. ft. hgt.
Stories stories stories stories
# of bedrooms
� 3 Rear Lot Line
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Fire Number and Name of Road G � � y K!" U � ��
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1 . Fill in lot dimensions and indicate north by arrow. Sign re Own o Authorized Agent:
2. Indicate location and size of existing and new structures. �
Signature
3. Indicate location of well, septic tank, drainfield. /lil¢' D� l�� � f l� w
Print Name:
4. Indicate distance to existing structures, lot lines, septic system./�- The above certifies that the listed information and intentions are
true and correct., that all work shall be performed in compliance
5. Indicate distance to the ordinary high-water mark of any lake, �- With the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
acting as owner'(s) agent, has the permission of the owner(s) to
pond, river, stream, creek, and name the body of water. Pe�ro�, tne Wo�k requested o� m�s application. The above
personsls hereby give permission for access to the property for
6. Indicate vegetative buffer zone. o�Sae ��spe�t�o�.
7. Indicate size and location of all impervious surfaces.
8. Indicate any grading or clearing in excess of the construction site. Permit Fee: �7s
9. Indicate distance to any wetland. '��s� �$�i2-s
Apr i 1 2 6 , 2 0 0 5 ��i����;�-G �
Issue Date Signature of Issuing Agent
April 26 , 20Q6
Expiration Date
Office Comments:
Total % impervious surface: Mitigation required:
Restrictions and other information:
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PREV[OUS TA% PARCEL MAPS, htA'Pih14 ?VRPOSES.
ADD[TIONA� SURVEY OR RESEARGH MAY HE REPU[RED•
,vo��� GRAPHIC SCALE Tax ASSESSMENT PURPOSI
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Surveying, Consulting, "�''� advisory. Map accuracy is limi
lannin services NO�TH quality of the public records f
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WI54843 -715/634-9422 ( IN FEET ) substitute for an accurate ie �
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