002-940-23-5205-LUP-1992-057 Application for Land Use Permit �
County of Sawyer o�
The undersigned hereby makes application for a Land Use Permit and �
agrees that all work shall be done in compliance with the require- o �
ments. of the Sawyer County Zoning Ordinance and the laws and regu- M
lations of the State of Wisconsin. �
PRINT - USE BLACR INK OR PENCIL (KJ
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Jeffrey M. Jones �U w N�=RJ r.
Owner Builder � �
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2430 Kirk Drive Route 3 �
Mailing Address Mailing Address
Eau Claire, WI 54701 _ _ _
City, State, Zip City, State, Zip
Building Land L'se Zone District {�R�o`� r �
0
�Q New ( ) Filling � n
O Addition O Dredging Lot size Ivy� � L� �� m n
( ) Alteration ( ) Grading
O Moving On O Acres 1•s3 0
( ) ( ) �
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New Construction
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Size .2'� ft wide ft wide �
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.�'{ ft long ft long �
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Floor area �7� sq ft sq ft �
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Total htg 'g to peak to peak �
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Stories � �Z Stories
Nn, nf $oriroeP.!s N�N6 ,. �, .
--- - --- -- waterline I o
��2.�vo 5 ro.vc L�¢-fec C
( (seasonal) U; rt
Type of Bldg or Addition N�_ � �QZ 3� � � a o
( ) Dwelling �S� C ,Y
(� Garage � � car
( ) Storage Building �, N �
( ) Boathouse ~�
9s"'a o
( ) Livingroom , F„*'''N� ,� �
( ) Bedroom �3"`„ G�� u '� —' I
( ) Kitchen-Dining ;� ,�q'�'
( ) Porch - enclosed/roofed k� 3i,
( ) Deck - open �'�o' �
� ) �� `�y r
( )_ � '� �,—.��".—�'1���v.i S6� �
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Type of Construction � w
f� Frame O Block 3 m ' ��.
( ) Log ( ) Concrete 3 � +'� � �
( ) Pole ( ) Stee1 7 � � m
(� ) Meta1 ( ) : 3� f �D
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Construction Cost $ /�5��. — a �
Vol �loS pg ,�o7-a�3of deed +'r"'`T" '�"'4P �- (ni
CS Vol 7 Pg '�/3 - I— 3 ,b �
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Cer. Soil Test �9-�f{`j Jao.S�' -� �
Sanitary Permit �9- ID8 ----------CL Road -�5�--�.�F~ p
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Issued � �-�21� /�QZ Denied • '
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ff Jones Own � Zoning Administr tor
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SAWYP:R COUNTY C�RTIFI�D SURVEY FllIP NO
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' Q�T� SECTION 2] Rf9191'S
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' SURVEYOR�S CERTIFICATE
I� LYLE ELLIQTT� registered land surveyor� hereby certify that by the direction of ILIA ANDREI,
I have surveyed and mapped the land parcel which is represented by this Certified Survey Map:
That the exterior boundary of the land parcel surveyed and mapped is described as follows:
A part of Government Lots 2 and k and part of the Southwest Quarter of the Northeast Quarter,
Section 23, Township k0 North, Range 9 West, Town of Bass Lake, County of Sawyer, State of
Wisconsin and more particularly described as follows:
' Commencing at the So�thwest Corner of said Government Lot 2; thence alon� the West Line of said
Government Lot 2 N 0 33' 35" E 37h.99 feet to an iron pipep thence S 67 00� 55�+ {J 109.08
I� feet; thence N 0° 33� 35" E 632.58 feet; thence N 30° 26� 50�� W 3�2•55 feet to an iron pipe
being the point of Beginning;
( thence continuing N 30° 26� 50�� l�J 100.85 feet to an iron pipe;
ithence N 67° O1� 15" E 662.90 feet to an iron pipe on the shore of Grindstone Lake;
thence along said shore on a meander line s 35° 15' 20" E 102.31� feet to an iron pipe;
thence S 6�° O1' 15" 4J 671.55 feet to the point of Beginning; said parcel contains 1.53
acres, more or les�, including all lands betti•reen said meander line and the waters edge of
Grindstone Lake� and subject to any easement of record.
That I have fu11y complied c•rith the provisions of Chapter z3�-34 of the Wisconsin revised
Statutes in surveying and mapping same.
°LSCONS''�.. —
��Q1 Iiv o�� L �LLIOTT, land urveyor
� : Wisconsin Re�istration S-1300
�,.��� ":Date: June 30, 19�
lIUOTT
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� DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05,Wis. Adm.Code couNn
— � SAWYER �
�� �� CST 89-097 STATESANITARYPERMIT� �
—Attach complete plans(to the county copy only)for the system,on paper not less than 123999 0
8�/z% 11 inches in size. Pa1^t Of r+0 V�t. ZOt Check if revision to previous application �
—508 fBVBfS@ SIdO fOf iflStfUCtIOf15 fOf COfTlpletlfl9 thlS HPPIICBtlOf1. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Ste ve Friendshuh %a '/a, S 2 T , N, R (or) W
PROPERTV OWNER'S MAILING ADDRESS LOT# BLOCK}�
P.O. Byc 432 Sava e MN. 8 0
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
$8V 8 �. $
II. TYPE OF BUILDING: (Check one CITY � NEAREST ROAD
> State Owned VILLAGE Ba3$ Ialce Gross
❑ Public 01 or2Fam. Dwelling—#of bedrooms� PARCELTAXNUMBER(S)
Iil. BUILDINGUSE: (Ifbuildingtypeispublic,checkallthatapply) 002-940-23-5205
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medic,al Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify _
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. � New 2. ❑ Replacement 3. � Replacement of 4. � Reconnection of 5.� Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑X Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE
RE�UIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/daylsq.ft.) (Min./inch) � ELEVATION
Feet Feet
CAPACITY
VII. TANK in allons Total #of Prefab. Site Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel 9�ass Plastic APP
Tanks Tanks structed
Se ticTankorHoldin Tank T.M.C.
�inPum Tank�Si honChamber X 0 1 T.M.C.
VIII. RESPONSIBILITYSTATEMENT
I,the undersigned,assume responsibility tor installation of the onsite sewage system shown on the attached plans.
Piumber's Name(Print): Plumbe ' Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
Clarence }Ietcalf �--
-�,�, rt.P.i4 8 15-b3r+ 595-
Plumber's Address(Street,Ciry,State,Zip Code): .�
Ha ard Wia. 484
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermitFee (InciudesGroundwacer ate ssue Is AgentSignature(NoStamps)
�Appfoved Surcherge Fae)
❑ OwnerGiven Initial
AdverseDetermination �11$ . 0� 9-22-89
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly PIb�7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Satery&8uildings Division,Owner,Plumber
DEPARTMENT OF INDUSTFY, INSPECTION REPORT FOR SAFETV 8 BUILD�NG
LABOH&HUMAN RELATIONS DIVISION
P.O.RC1X 79fi9 ON-SITE SEWAGE SYSTEMS OFFICE OF DNISION CODES 8 APPLICATION
MADISON,WI 53707 � / State Plan I.D.r�umDeo
� CONVENTIONAL/p�I///P' ❑ ALTERATIVE �1f855i9���
❑ Holding Tank ❑�n-Ground Pressure ❑ Mound
NAMEOFPERMITHOLDER: ADDRESSOFPERMITHOL�ER: INSPECTIONDATE'
!L�GCQ �J-Nr�C N!/ U ' � �..�J o� /3 1�1 �11�• .J 78 S_ a-C/ �
BENGhI MARK(Permanent relerence poinl) ESCRIBE IF IFFERENT ROM PLAN�. REF.PL ELEV.: GST REE PT.ELEV.:
NamoolPlumbcr: MP/MPRSWNoc Counly: SanilaryPermitNumbec
r ,n L / 9 �i4 w �eit P9— /Ofs
SEPTIC TANK/HOIDING TANK:
MA4UFAGTURER' LIOUIDCAPACITY: TANKWLETELEV.: TANKOUTLETELEV.: WARNINGIABEL LOCKINGCOVER
/ C PROVIDED'. PROVIDED:
/-Il��el� SO /9' `� �]YES ❑NO ❑YES ❑NO
BEpDING: VENTDIAc VENTMATL.' HIGHWATER NUMBEROF ROAO: PROPERTV WELL'. BUILDING'. VENTTOFPESH
ALARM' FEETFROM LWB � � AIFINLET:
�YES ❑NO ❑YES ❑NO NEAREST—►
5 i1'� 7as ��
DOSING CHAMBER:
MANU ACTURER'. BEDDING'. LIQUIOGAPACRY'. PUMPMODEC PUMP/SIPHONMANUFACTURER: WARNINGLABEL LOGKINGGOVEF
PROVIOED: PROVIDED:
Y -/�ry µ YES ❑NO S�' .�I YES O NO YES ❑NO
GALLONSPERCYCLE: PUMPANDCONTROLSOPERATIONAL: NUMBEFOP PROPEFTY WELL BUILOING: VENTTOFRESM
(DIFFERENCEBETWEEN � FEE7FROM uNe � � � aiRw�ET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST� S � 7 S
SOIL ABSORPTION SYS7EM. Check the soil moisWre at the depth of plowing FORCE �ENGTH: DIAMETER: MATERIAL AND MARKING:
or escavation. (If soil can be rolled in�o a wire,construction shall cease unlil MAIN �
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH W�DTH-. LENGTH�. NOOF OISTR.PIPESPAGMG COVER INSIOEDIA.: �PRS'. LIOUID
( TRENCHES: MATERIAL � P�T DEPTH:
DIMENSIONS /S 3� � - /o � ,Qr, �
GRAVEL DEPTH FlLL DEPTH DISTR.PIPE �ISTR.PIPE DISTF.PIPE MATERIAL 0. ISTR. NUMBER OF PR�PERTV WELL BWL�ING: VENT TO FRESH
BELOwPI„5�. A�OVEGOVER�. ��V.�NLET; EI��ND'. n� ��� PIPES' NE RESOT�+� LWE:s/ Sa� 7Zr� AIR7�. ,
/' 3
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑YES '�NO meets the criteria for medium sand. ELEVATIONS MEASURED.
$OILCOVER TEXTURE PERMANENTMARKERS: OBSEFVATIONWELLS;
❑YES ❑NO ❑YES ❑NO
�EPTHOVERTqENCH/AED DEPTHOVERTRENCHIBE� DEPTHSOFTOPSOII'. SODOEO: SEE�ED: MULCHED:
CENT[R�. EDGES:
O YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED D�STRIBUTION SYSTEM:
BED/TRENCH K'IDTH'. LENGTH�. NO.OF LATERALSPACMG. GRAVELDEPTHBELOWPIPE FlLLDEPTHABOVEGOVER:
TFENCHES'.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOID MATERIAL' NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING:
EIEVATION AND ELEV.: ELEV.� DIA.: ELEV.� � PIPES' DIA.�
DISTRIBUTION HOLESIZE'. HOLESPACING- DRILLEDCORREGTLY: GOVEFMATERIAL'. VERTIGALLIFTCORRESPONpSTO
INFORMATION APPROVE�PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKEFS�. OBSERVATION WELLS' NUMBER OF PROPERTV WELL: BUILDING:
FEETFROM LINE:
❑YES ❑NO - ❑YES ❑NO NEARES7--►
Sketch Sys�em on
Re�ain in county file for audit.
Reverse Side. sicNnruq � n/ Tir�E:
SBD-6710(R.O6/88) �L.C.�/' �
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