010-941-33-1301-LUP-1990-064 � �
' Application for Land Use Fermit FkO
County of Sawyer �
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7'tie undersigned hereby makes application for a Land Use Permit and aqrees
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that all work shall be done in accordance with the requirements of the Sawyer �
County Zoning Ordinance and the laws and regulations of the State of Wisconsin. \ O
PRIN'P - USE ONLY ➢LACK iNK/FENCIL
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Owner Builder
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mailing address mailing address
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cit}�, state, zip city, state, zip
�uilding Land Use Zone District �— I
( ) New ( ) Filling .
(� Addition ( ) Dredging Lot size �98;r ..3�8�//G/� s �
( ) Alteration ( ) Grading m n
( ) Moving on ( ) Acres ��J�
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New Construction ' �
Size � fC wide ft wide /,
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�r ft long ft long � �
Floor area �z� sq ft sq ft �
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Total hgt /L , to peak to peak 1 � x'°
Stories �_ l��l .
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No. of bedrooms � rear lot line or w�.terline
(��Par rout�a or (seasonal) i '� �
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Type of bldg or addition � � �
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( ) Dwelling � , � i
( ) Garage (1) (2) car i � p' S'
O Storage building � /g� • i C r*
( ) 6oatliouse � ��.,' � ~�
� � i N�
� ( ) Livingroom ��
I 7
( ) Bedroom �
� Kitchen-dining � �'¢, � � �i �
O Porch - enclosed/roofed i �� �--t- ��`""'�""'�Ji 0
( ) Deck - open � .. ''� �':.� 1� I
( ) i �� i AI�
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Type of construction � j �j� �� � �
pQ Frame ( ) Block �� J�/o� _� .��\ tiL �/OU'� � Iz(y�
( ) Log ( ) Concrete �i � / � —1'
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( ) Pole ( ) Steel i �; - -�---1� � p �..
( ) Metal ( ) � ! � � �-- � '
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Construction cost $ 7�G'�,— i S� �
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Cer. Soil 1'est CJ� -��7j i �98// � r�
�w� �� CL road I o5'� O
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Sanitary Permit �j4-�L{--] �
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� ""�`�"�'" APPLICATION FOR SANITARY pEkMIT A
� DILHR SAIVYER '
.COUNTY F,,
oeaar+nnenroF (P�B 67) ONIFORMSANITARV 'ERMIT �f A
inwsrv�,�aeoa s ruman ae�ranons
CST 84 - 183 57444
—Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the sYstem, on paper not less than 8'-Sx 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PR RTY OWNER MAILI G ADDRESS
� . 1�.1 ;- Sr'���
PROPERTY LO AT CITV: /
VILLAGE:
S 1/4 �1/4, S , T , N, R f�#ar) W Towry oF: Y c�.
LOT NUMBER BLOCK NUMBER SUBDR'ISI N NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. ."vU�BER
��}y � So�
TYPE OF BUILDING OR USE SERVED
7 or 2 Family Number of Bedrooms: � [] PuLlic (Specify):
THIS PERMIT IS FOR A:
❑ New SYstem � Tank Replacement ❑ Repzir
�Replacement Soil Absorption System ❑ Revision ❑ Privy
,_; Altemate System L: Reconnection ❑ Petltion for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
�Seepaye Bed ❑ Seepage Trench U Seepa�e Pit —� Holdiny Tank
� System-IrnFill ❑ IrnGround Pressure ❑ Vault Privy LJ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issuea
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Cundi;iuns.
Total #of Prefab. Site Steel Fiberglass ?IasGc
Gallons Tanks Concrere Consvucted
Septic Tank Capacity
Lif� Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacmrer. t+� �
IF THIS IS AN ALTERNATIVE SYSTEf�1 C01/IPLETE THIS BLOCK: ❑ Mound �I In-Ground Pressure
Total #of Prefah. Sire Sreel Fiberglass Plastic
Gallons Tanks Concrete Consvucted -
Septic Tank Capacity
Lif[Pump/Siphon Chamber
Manufacturec
PERCOLATION RATE ABSORPTIOfV AREA ABSORPTION AFEA 1�IqTER SUPP�Y: �
(Minutes per inch�: REQUIRED ISquare Feet�: PROPOSED (Square Feet):
� � � "� � � � y�Private -� Joint ❑ Public
�
� I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
—�
,fQarPZ of Plumber I nntl:� 1 e: \ 1 _��, MP/M1dPRSiN No.: Phone Number:
1 �
"-,��i�.� 14�1-���I?� "� ��_�\_�L��_� .� 1''1 Z. (7/S IG� �`/'i�C� /�c
P ber's Address: s Name of Desi9ner
���lo ��L V_�F}I�Tj �ll L) ���`� �
COUNTY/DEPARTMENT USE ONLY
Sign e of Issuing Agent Fee', Date: ❑ Disapproved
,p 9$ . �� 1�- 3- $4 ,� q ❑ Owner Given Initial
PP�a�e� Adverse Determination
Reason for Disa rova '
Altemare course(s) of Action Available:
DILHR-SBD�6396 (R.5B2) DISTRIBUTION: Original m CountY. �ne Copy Tq [,_.uu of Pluint�ing, Owner, Pluinbar
.•
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
�ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
� CONVENTIONAL ❑ ALTERNATIVE StatePlanl.D. Numb•�
(I�assignetl)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HO�DER: ADDRESS OF PEFMIT HOLDER� INSP`cCTlO"J DATE�.
� o..Y N o.�b �M o� c� n� Rk. l� �� w c��- d w", ��-� � 3 / o - � - 8 �
BENCH MARK IPermanent relerence pmnil DESC IF DIPFEHENT FROM PLAN�. REf. PT. ELEV.�. CST HLF. �'T. ELf:V
Name ol PWrnber�. MP/MPHSW No. Counry. $annary Permit Number�.
� ub �e.rT �, c�-8 a. � �- e. 5 � `�a 5 0�, w e, �- 8`� - I � 7
SEPTIC TANK/HOLDiNG TANK:
MANUFACTURER�. LI�UID CAPACITV. TANK INLET ELEV.. TANK OUTLET ELEV . �NARNING LABEL LOCKIN3 COVER
\ ` �� � ��� � � G , / � � � ^ ,1 Q, / p PROVIDED�. PROVID'_D�.
'v l� � , V / (D , 0 B�,YES ❑NO ❑YES ❑ NO
BEDDING�. VENT DIA.�. VENT MATL. HIGH WATER NUMBER OF ROAO�. PRGPERT� WELL�. BUILDING VENT TO FRESH
� � ALARM FEET FROM LWE IAIR INLET
❑YES ❑NO � � • �• ❑YES ❑NO NEAREST �� — � aS � S I -
DOSING CHAMBER:
MANUFACTURER BEDDING�. LI�UIC CAPACITV PUMP MOUEI. PUMP;SIPHGN MANUFACTUREH WqRNING LABEL LOCKIN�3 COVER
PROVIDED�. PROVID�D.
❑YES ❑ NO ❑ YES ❑NO ❑YES ❑ NO
GALLONS PER CYCLE: PumP nrvo coNTao�s oPeaanorvn� NVMBER OF PkOPeHTv WELL BUILDING I VENT TO FFESH
(DIFFERENCE BETWEEN FEET FROM ��"E AiR iN�ET
PUMP ON AND OFF) ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing �ervcrti uianneret+ tiinTeHin� nr,o nnnHKwc
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to contin�e.) MAIN
CONVENTIONAL SYSTEM: -
WIDTH LENGTH NO OF UISTR PIPE SPAGNG COVER WSIUL UTA =PIiS LIQUID
BED/TRENCH TRENCHE$ / // lv1ATER AL: PIT _ DEPTH
DIMENSIONS � oZ 5 a --' CI� �-�C�C�,4�
GRAVEI DEPTH FILL DEPTH UISTH PIPF DISTR. PIPE DISTR. PIPE MATERIAL�. NO DISTR. NU"JfBER OF PHOPEP.TV VJELL�. BUILDING. VENT TO FRESH
BELOW PIP�$` A60VE CO/V�� ELpEV INLET ELEV. END o ? PIPES FEET� FROM LI^�E � �� ��� AIR INLET.
CD J 7' 7 (D . 9�p, � ' • �• C , �OJ� � NEAREST—� 1 v
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PR�VI�E A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT �b1AHKEHS. OBSEHVATION WELLS
❑YES ❑ NO ❑YES ��NO
DEPTH OVER TRENCH;BED UEPTH OVFH TRENCH;BE[J UEPTH OFTOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑ YES ❑ NO ❑ YE;� ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTN NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW�IPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
� MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD fAATERIAL NO DISTR DISTR. VIPE DI<TRIBUTION PIPE MATEFIAL 8 P,IARKING
ELEV. ELEV.� DIA. ELEV. �'I?ES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLV COVER MATERIA� VERTICAL LIFT CORFESPONDS 10 4PNqUVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENThtAFKEHS: OOSERVATIONW.LLS. NUMBEF. �F PROPERTY WELL: BUILDING�.
FEET FROM LINE:
❑YES ❑ NO ❑YES ❑ NO NEAREST
Skecch Syscem on Retain in county file f%;� <:udit.
Reverse Side.
SIGNATUHE. TITLE�. �
DILHR SBD 6710 (R. O1/82)
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