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026-182-12-1300-LUP-2004-649 � Application for Land Use Permit (*Shoreland*) o o . . County of Sawyer � � ' PO Box 676 - Hayward WI 54843 715/634-8288 � *Property that is located within 300' of a creek, river or stream or within 1000' of a � ' flowage, lake or pond or has any of the above waterbodies located within � ,� : the property's boundaries. ' �\ CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.� , v�� Q� PRINT—USE BLACK INK OR PENCIL � � � �t �� IT o ( M �r (l �P eLl��Ll�--��ie�n�!� � `1 Owner ' 'Tr��!- Builder Q- -=' - -n �� .�' L ��Y 7 7��,,. l.�N ��r �� o� Mailing Address Mailin Address I� O (.c � ,L '�! Q�� .�G L �c?I�� ')f i�� L�!`C-� (.�/� �y�7� �; � � City, State, Zip City, State, Zip � i� �f � - �� .� - � CI � �`15" �� 05 � � Daytime Phone Daytime Phone �. � � � Additional Information: -�Zone District: ,� � l ~ Lot Dimensions: � ��(1 k ( �G � o K � Date lot was created: Acres: � . � � � Is there wetland near the proposed structure? If yes, how far �e S � 9�,� �� o � Building Land Use Floodplain: ( ) Yes (�No � � Q�New O Filling Chippewa Flowage: O Yes (�No � ( )Addition ( ) Dredging Driveway access off of a(Check one): � ( ) Alteration ( ) Grading ( ) Private Rd (� Town Rd. � ( ) Moving On ( ) ( ) County Hwy ( ) State Hwy °Q � ) � ) � � �, r Primary Structure Accessory Building Addition o 0 ( ) Dwelling (?(� Garage-attache etached ( ) Deck � ( ) Year round ( )# of car stalls ( ) Porch �, ( ( ) Seasonal ( ) Storage Building ( ) Enclosed � O Frame built on site O Screenhouse O Living room c� � ( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen � ( ) Mobile/manufactured ( ) Other ( ) Bedroom ( ) Other primary structure ( ) ( ) Relocate/enlarge ' A � � ( ) ( )#ofnew � ( AdditionalInformation: � .� � � I � Type of Construction: ti (�cj Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete , � � ( ) Other �, ,� O �Const:�uction Cost: Primary Stnzcture $ _. _ � Accessory Building: $��, O.s� � Addition: $ � � Deed: Vol ,5.� Pg�_ Certified Soil Test#� z/�- 2�- � � z 4. oq CSM: Vol Pg Lot# Sanitary Permit# / y�—2 n � � � � Plat Envelope Or: � � Condo Vol Pg Year Installed: N � � "Loads and Flows": Vol Pg Owner When Installed: �? � " � Previous office approvals/actions: ' � Variance: # LUP:# y`1� � SP: # CUP: # 1�' Inspection Report: # Change of Zone District: �. � ;a ,�.�� - � �� n I � �,�`� 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 � �_ft. long ft. long ft. long ft. long , . Floor area �j ;�G sq. ft. sq. ft. sq. ft. sq. ft. Hgk from grade ` to peak,� 2 ft. hgt. ft. hgt. ft. hgt. Stories� stories stories stories �. #of bedrooms_�_ � �frc� i � L-L Q Lake/Pond/Flowa e/River/Stream Name � , _ , •_ -- �--1._ --�_ — --_�.�_ �� , __�______.�_ : -�- I 5� �, � t �,Cfj� y �� ✓ � ��7�LS � - � I 1 c�✓o � �,�.� q I, S�P�� 2 � i � � ��e � �.�o �3 � s��u��. � T -�t �. �� : � i � o �'� 1� Fire Number and Name of Road /v-rj � � � ��c �n y' �{�s C /� 1. Enter lot dimensions and indicate north by arrow. Sig ature f Owner.or Au zed Agent' 2. Indicate the location and size of the requested construction � � �' � ��, \ ignature activities. ' �` Print Name: -�Z 3. Also, indicate the location and distance to the well, The above certifies that the listed information an intentions are true and correct.,that all work shall be performed in compliance septic tank and drainfield, wetland areas, lot lines, with the requirements of the Sawyer County Zoning Ordinance and the laws and regulations of the State of Wisconsin, and if centerline of the road and waterbodies. a�t��9 as ow�er�s�a9e�t,has the permission of the owner(s)to perform the work requested on this application. The above personsls hereby give permission for access to the property for onsite inspection. Permit fee: $ � G' P — Total land area within 300' of the waterbody: (A) _i �� G�� Total impervious surface area [including this project] (B) � �.J,�`� � (B)/ (A) x 100 = %Used ��9� (Shall not exceed 15%[or 25% with a conditional use permit].) Shoreline Vegetation Protection Area: Mitigation Required? Yes O No November 10, 2004 -' � Issue Date Signature of Iss ing gent Novmeber 10, 2005 50% Rule: Average Road Setback: Expiration Date Office Comments: �� V�,O�J��'�`e- �� '��( ' S�� N�" I � 100� " qo�� . � ! �� . �, - , � . � ' . � .� • . � � � •. /�'�- ' . ...F�� ; � . . . . ►,,�.� :�.� � , • • • �""'�l'� •��,,� • ' : �'� � , ' ' • � ,.. �-;��i�',�C. '� � : , � � - - �' � 1�l►� � ' - ' ��, � � � • • � . ,. , � • . �.'ri�'..i � .- - •1 .. �� 1 . : � _ . �. , � . '�'��.: ��" . . . . • � . .. . �.�-�� _��- - � - . : /Tii.I�l- �'�. :- � . , - . ., ��A `� � • • � � � - - .�'� • • • • _ r. �� . � . . • ,, , �•�, , , ��- l• `� •- �4 • •• ��-• - � ' • :• • � - �� . J , • � � � F;11� - � �� V . • , � � � � . • � � �f1� � • . � • .. � � . � . � � • � • � � - � . � ♦ . . . � r. �� '� -`•�� ' � : ♦ �t��■■ � �� -. �� : � '� . �_ . � . : ♦ �� /� � � - � . . . 1 � � � . �� t •� . � . 1 _ � � .� �� ♦ _ � . ♦ � � . �� .� �. ♦ ♦ . � � - � `�1 . . � ♦ 1 .. � � � � � . � � : � � � . . . , . . . . ; . . . . . � . . . , . . : e . . . SHORELAND PRESERVATION AGREEMENT � _ � (Non-Intact Shoreline Ve�etation Protection Area) i Land Use Permit No. - � (To be entered b the Zonin Office Index No. - � y � � � ��-� � WHEREAS, (list all owners) -�� ✓� �' ��.i� and Vilma Holm ren _ —' Revocabld Trust � � � owns real estate within Sa er Count that is sub ect to the Sa � � �'Y Y j wyer County Shoreland Regulations, and WHEREAS, in order to secure a Land Use Permit. d � NOW, THEREFORE, the owner(s) hereby certifies that, as a condition of issue of said Land Use Pertnit, that .� the SHORELINE VEGETATION PROTECTION AREA on said real estate shall be restored in accordance �_ with the Mitigation Plan and Implementation Schedule approved by the Sawyer County Zoning Department. � The owner(s) hereby agrees that at all times in the future, the real esta.te subject to this Agreement shall comply � with all shoreland vegeta.tive buffer requirements of the Sawyer County Zoning Ordinance in effect on the date � that the Land Use Permit is issued by the Zoning Office. The owner(s) furkher agrees to allow authorized � representatives of the Governmental Unit to enter onto the owner's property at the following description to � inspect the structure(s) or uses authorized by said Land Use Permit and to determine if the SHORELINE � VEGETATION PROTECTION AREA exists and that it is being preserved. Violation of this Agreement will �authorize, in addition to other penalties and relief required under the Sawyer County Zoning Ordinance, -�. injunctive relief, restoration of said real estate, the revocation of said Land Use Permit and the removal of all � structures approved by the issue of said Land Use Permit and the revocation of any other uses approved by the issue of said Land Use Permit. All parties agree that this Agreement shall be filed with the Sawyer County �-- Zoning Office. � �t Legal Description of Property: Lots 13 and 14 Victory Heights Second Addition � Town of Sand Lake , SawyerCounty WI 026 - 182- 12- 1300 �'` � D d thi �� day of , � e (Owner) (Owner) (Owner) (Owner) (Owner) This instrument was drafted by: Sawyer County Zoning Office