010-118-00-1900-LUP-1992-053 /
Application for Land Use Permit X �
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. 1
PRINT - USE BLACK INK OR PENCIL
(�ORDON F. S1l�E'II2 Casimer W. Flardenaa. Jr. �
Owner Builder
5333 Minnehaha Blvd. Rt. 7, Box 7780 �
Mailing Address Mailing Address
Fdina, NN 55424 Havward, WI 54843
City, State, Zip City, State, Zip
Building Land Use Zone District B � o �
( ) New ( ) Filling n
(g) Addition O Dredging Lot size ; •,' - m n
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres ,%--� �
( ) ( ) � �
New Construction o �
DDC'[C �
Size ft wide ft wide
'?/� ft long ft long ,�
Floor area :; ° sq ft sq ft
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Total htg — to peak to peak �
Stories Stories
���liiri L/'���=
No. of Bedrooms �_�flr--�a--=-n� or waterline c�
0
(year round) or (seasonal) N rt
Type of B1dg or Addition a o
( ) Dwelling C rr
( ) Garage (1) (2) car N,
( ) Storage Building �
( ) Boathouse � ~�
0
( ) Livingroom �
( ) Bedroom
( ) Kitchen-Dining _ _ ,
( ) Porch - enclosed/roofed ��=
(X) Deck - open -
f ) � 36 � � �w
( ) Fi
Type of Construction E�p�pl ��. �
(X) Frame O Block � r�.
( ) Log ( ) Concrete
( ) Pole ( ) Steel � � �
( ) Meta1 ( ) _ �
Construction Cost $ �30�," ! a, �
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SCALE: 1 INCH=4OO FEET FOR ASSESSMENT USE ONLY N�
DRAWN BY:RVH DATE:7-2�-87 INTENDED TO SHOW CONCI.USI
SAWYER COUNTY ZONING ADMINISTRATION � �
,1
INSP�CTION REPORT o
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Owner Pearl E . HultQren ro
m
Address 10801 Wyzata Blvd II300 Minnetonka , MN 55343 n
— r
Name of Business �
Builder G
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Addre s s �°O
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Plumber ' �
Address
Inspection O Property iXl Setback - lake
( ) Dwelling ( ) Setback - road
(�) Private O Public O Mobile Hm O Setback - lot line r, r3
Violation ( ) Garage ( ) o 0
(x) Addition ( ) -- �a
( ) Sanitary ( ) Zoning `�
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Volume 416 paQe 447 74 acres �,
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Discussed with owner ( ) o °� �
Discussed with builder ( ) � �
Discuseed with -J� �.�; s � ;,, , w�� � oR„ jw
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Signature oi cf�icer ��{�� ��
;
� DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis. Adm. Code SAWYER
� � STATESANITARYPERMITq
CST 88-144 114410 . �
—Attach complete plans (to the county copy only)for the system, on paper not less than STATEPLAN I.D.NUMBER �
8Yz x 11 inches in size. 588-20236
—See reverse side for instructions for completing this application. PETinoN
i. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Foa vnRinNee ❑res ❑ No
PROPERTY OWNER PROPERTY LOCATION
c�L��E7ZY L uGTC-,2E�✓ '/a '/a, S .zG T /, N, R � �o W
PROPERTY OWNEF'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAM
7��eo l+/, /SD�' ' �S�" /9 ��,o — �d e.wz /��2�
CITY,STATE ZIP^.ODE PHONE NUMBER ❑ CITV : NEAREST ROAD,LAKE OR LANDMARK
rio/' 4Ce /Yln • SS37Z 7/.S b3¢3io7 o vi��ncE: Z u/=r�/ o%�n K-
II. TYPE OF BUILDING OR USE SERVED: �
Number of Bedrooms if 1 or 2 Family ��d OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in#�� Check#2,3 or 4, if applicable)
1. a. � New b.�eplacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2 � A Sanitary Permit was previousty issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. ❑Conventional b.�Alternative c. 0 Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. L'J Mound f. � IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. � See a e Bed b. ❑ See a e Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minu[es pe�inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
�30 ?SO ZSD �U�•O(< FeeS [&private ❑Joint ❑ Public
CAPACITY
VI. TANK Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistingGallons Tanks Manufac[urer'sName Concrete Con- Steel 91ass Plastic APP
Tanks Tanks sVucted
Se tic Tank or Holdin Tank � S�� �.S rn USJ�r1 ❑ ❑ �
Lift Pum Tank/Si hon Chamber � �j00 ' �' � � � � �
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print�: Plumber' ignature:(No S ps) MP/MPRSW No.: Business Phone Number
�va�e� �SMUSJE7 3 93 8� 7iS 7�P''.33SS"
Plumber's Address(Street,City,S�ate,Zip Code): N e of Designer
�. o . /�o� 4 4 e.a-B��.- k1i s5'�
VIII. SOIL TEST INFORMATION
Ce ifiedSoilTester(CST)Name CSTq
..�Tr�//s �s�s�is ���
C5T's ADDRESS(Street,City,State.Zip Code) s��Z Phone Number
/2l• / l3o�C /� �-/�G� l�z l 7/S 798=�7a¢
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermitFee Groundwa�er ate Issun entSignature(NoS�amps)
�Approved ❑ Owner Given Initial Surcharge Fee
AdverseDetermination $145 . �� $25 . �� 8-19-88
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerty Plb-67)(R.03/86) DISTRIBUTION: Originai to Coun�y,One Copy To:Bureau of Plumbing,Owner,Plumber
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