010-841-36-5136-LUP-1992-447 • tip�Izcatian for �and Lse �ermit
CoU,n�y af Sawy�� X
' �
T#�e undersig:�ed hereby makes application for a Land Use Permit and a.grees ` t
tYtat a�.I wark snall be done in ac^erdance w�.th t.he requirements of the Sawyer �
Caunty Zoni.ng Or;�inance aazd �re �aws :a�d �egi��1_ati�ns of Lhe State of Wisconsin.
�2�mt� ��r,�c,�,� �3�Z-CI,E �- }��TE�`�� �s�. ONLY 33Y,ACK INK/FENCIL �
/ '1,�
�/ L , ��
�� I�/'y`�t� .�r. %���`.� f �f��'�;1 T �[: L � o �Y
Owner Builder -
��d '� �'x ra� `�.�"' � / l'?' �/ .�'�"�K c� �,, G' ____ �`
ma9.Iing address ! mailinc� aadress �1 �`
���� ;�'-��'1,�,J�i c�� � " Y:r y'�,,,,?, �e5':��rf�`f �-�=' ���'y�f��f,,,� (
- � �
city, siate, zig city, statn, z.ip
Building Land Use Zone DiM�Y���_c�. � - �
�C) �iew ( ) �'illing —A..� � � c.�
( 3 Adc�.ition ( ) Dredgina L��t. s�.�.e 131' 27f� �c 12�' �7�-r ct �
{ ) Alteration { ; Grad�ng �n n
� ) Maving on ( ) ,'!cr�•s e!'_�8 � •��___--� �g
( ) ( ` � �.E `��
� �
hew Constructioz�. STa���.- U '�S T� t�` �
s�2� � ft ���;� �4 �t W�a� v
,�
� �t �.o�g ��.
�_� fi t lorac�
. P
Floc�r a��a ��p _ sq ft loT�-� �72C� sq ft �
----� vy _
� �;
�'otaa h�t �/ la to peak ___._� 4o peak � � '
Storz.es .___���
Na. Uf �edrooms rear �c�+� l�.ne ar_ waterline
(Ycax xaurzd) or (seasonal} � --_-----.-1
� �
Type of bldg or ac�dition � � � �
( i Dwrell.i.ng � ! �, rt
(x) GaragP (� � car 'Tt�vsfc�e�.f c e N¢'. �S
( ; Si.arage �auzlding � o G rt
c � sQ�.tnQus� ► � n �
� i o —
( } LivingrQom f
E ) ;3edrr�om � � � �
� ' j
�
( � Kitchen-:�ining f � E
( } ;PpxC}1 — GTlC�OS2���44f�C� F `
C ? l�eck - agea� � ` � �
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E
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t � � ._ i G(� � (`-� � i C0
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Type of construction � r�_ i w
° ► �
{�() �'�ame ( ) �lac:k � ; �
( ) Lag f } C�.�ncr.�te E � `� �1
( ; Pole t ) Ste�� � �
t ) t�ietal ( � � i -� �
� �
i �
Carzs�r�u.c�t.3 ox; �r��,tv $ �,��Qr�_ a"v P i �
q" 20 8 � ► t �,
VQZ -�G}� � -.__� I _ r}r c�.EL�� ` � i W
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CSM Vol __�..,�_. -9 ��,._r__--- � i �
� t r� �
Cer. Soii Test �
�,.,�y r
_�1-_`_-�j1_�.__.. .�.� _ E m
Sanita�y �ermit �-] _���.0�_ -____.___--CI, ro�c� -.-_.__�_____________ ���
T ��0��l.�tJTa �pA-� ��
x�s��a � �____.—__— l4 2 ��n�_�a �'
-- ---- . �.__���_ �.__--____.�____._. ____.�. ���<x�
__�__ -- ,.��
���'� , ,��' �;� .�,�° '�.�-�.�- ���, �-� —��.)� ,�
cw�ner Zar�i�,g Admini trat r
Saw�fcr Coias� ty '% oniu �; �1�3;n .� riisr. c•r� �r. ion J
O�
Inspection P�epoz•t �
Truman R . Spencer , �
�
Bettie A . Hogue ,
Trudy L . Tyson , & , �
Owner Francis E . Tyson %� y
-------._ _-------- --
� �C
AddrEss �� 106 Shoshoni Trail _ ` Apple Valley Minnesota' S5124 p
, — z
Name of business N/A
- ---- �
Builder Harry Moeller _ __ ' �
n
Address Route 2 Box 1074 IIa ward _ Wisconsin 54843 ~'
---�—--- ------------ �
Plumbe .r Clarence Metcalf �
---------_..__._. .__.�..__._ _ __
_ M
�`�ddress Route 6 1layward Wisconsin 54843 �
�_ _— ---._------ — -- r
Ins�ection
(� 1'?- ivate O Put> l i c ( i �'�r<��� � rt }� ( `�'9' Sctback - lake � y
V �_ol .� t :ion l ) ll�,,'r1 1 i.rrt; O `ci.hacic �• road o
� ) '�:c; h i ! c� I '�sl � �� ��et�� ack - lot line �
( ) Sanitar}� ( ) ��oning ( 1 G��r:� �c; ( ''� Average o
. '�j ; �) i' �' l_ v;' � � __, M O �-h
.��' acres Zoned R- 1 V 280 P 226 & V 341 P 208 �
�_.__»_ _ _ --.--.--______�_—._____�_� x
v� �3 i��� ,- , J � �1�- �
_� - = -� _ _- --- - �
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_,.-- _ .-� �. - `�_ .�-. ____.
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�I�isc.u�7sec1 i�:� it:�i cwncr ( ) ro
T��_ :> cussed �.�ith builder ( ) � z:��
Discusseci ti� i'ci� plun�ber ( ) •� �•- ••
Piscussed with • � ~ G'� "
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ll a t e ��// -��1 �. .___ • . o0 00 ;",
Si�nature of �fficer ��,���� �
David Heath - � ZA . '
. • ��::
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. �ip;;l�ca�i:u: "o��_ Y_�r:d. Ose i'er,nit �
County of Sau;�er_ y
The undersigned h�reb� nalces applicatior�� for_� a. i:and U,e Permit and agrees
� '
that ali work snall be 3or.e in acccrdanc� with. the rEquirements of the Sawyer �,.�.�,
County Zoning Ordinance and the 1ao�s _,nd xegnlations of tne State of Gaisconsin- O
Truman R. SpenC2r, Pk<INT - IISE QNLY &LACK INK/PENCIL x
Bettie A. Hogue, w �
Trudy L. Tyson; & �
Francis E. T son* w
___Y Harry M¢e11er r�
Own.er �uilder --- �,
*106 Shoshoni Trai1 Route Z Box 2074
mai.ling add�ess ^ ma�_ling address
Apple Va11ey Minnesota 55124 Hayward Wisconsin 54843 __ I
city, stat�, z�p --- -- city, stste, zip
Buil ing Lard Ose ?oae Dis�rict R-1
(�ew ( ) Fillinq S �
O Addi�ion O nreagina Lot s�.ze __221'/137'/ x 174'/123' rt �
! ) Alteratio.i ( } Gradino ^ . m ra
( ) NIoving on ( ) ,'.cres .78
t ) ( ) -- - -- — 'v�r�x m
-- — --- �c o ro
c��th
New Construction �y�z
,ni n
�
Si,^.e 28 �� �aida _ _�, _ ft :vi.de �y�'�
40 _ tt long 12 �t long 5y y�
C�H C�'
Flaor area _1216_ sq f�t tOtd1 ____ sq ft c�9 z
�r-a
Tota2 lzgt _ 16� _ to peak _____ to peak Ix �
� 3
Stories 1 �;
--- ------ >.
� ��OUN� �. Z
No. of bedrooms Z :ear ?.�*-l�,ne-or o:at:er7.ine
-- 2z I'
(year roundj X3c��}c�A���v} -
T"y�pe oP 'bldg o� ad<:;_-�ion �S�i �� � i m <�
�r7 Dwelli.ng I �, � �.''T
( ) Garage (1.) (2; cas � Q� �d� � a�r,'
( ) Storage �aaildi.ng � � � r
{ } Baa.thous� �.5��5 � � �'
( ) Livinqrocm � —a14� 1zl! '��� i �I�w
E7 � ' I
Bedroom � �J-' �
( } Ki�tchen-d:.nina �� _,F �� � ��
( 3 Posch-- er�closed/rocf�d ���
G���P� i i
( ) Deck - ope.; .� �g i oa
( 1 L� 'PP /V ; �
( 1 ------- -- ��Ce" N � �
— --- � � i c"'
� i i �a.
TyPe of constructi.on � �
i i �
(1�P'rame ( ) Block f � �
1 � ~
O Log i ? Concrei�� � t � r
( ; Pole ! ) S'�ecl � S�� � �P°'
i �
( ) Meta1. ( i r � u,
� i �N
ConstrLction ca�t S 55,000.00 i i W�
_ t
280 226 ; ;
Vo1 341 Ya 208 of dee3 � �w N
—�-�---- --- 3 51 i � �._ rn v,
csK vo1389 _ r�q 71 � i w
3 9 3 31 ; �?llo� ; � '�
cer. soil 'rest 87=009 ` �� ' ��, �
- - — ------------��� -
_ . '_}. L1���3Ca ..,._ __________ z��F
Sanitary Perr.iit s7-006 _ �(�c(������ ' o �.F..,
w �
Issue3 18 February 1987 ne:ii.ed o�
,,y ----_ —__ ` __—_—. ... W 00
"� Greater than avera e setback conducted 11 Feb 1987 - DH ,
— - ------ - ���
�x�O�S-1�1 �- 1 V -�)t'.� `J~
�w
Harry M ller, Contractor�� T zoning admi i—�str t� ..
,
� w�sconsin APPLICATION FOR SANITARY PERMIT �
�� D 1 L H R SAWYER COUNTY �
(PLB 67) o
� oeaaaTmenTOF UNIFORM SANITARY pERMIT #p
� IflOUSTRV,LRBOFI 6 MUTGifI RElF7T10115 ('C' T O '7_ O O (1 8 6 0 8 4 �
l.J 1 O / 7
—Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PR��Y �NER � a �ILIN; ADD,R�SS ` / � � • o � �
7�l C 3
PROPERTY LO ATION —E+�-�'-- �
CG�1/4.r/uI1/4, S 3 � , TU(, IV. R � �a�) W roy1w oF! l ��t� 2�
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROA AKE OR LAND ARK STATE PLAN I.D. NUMBER
��� �Q 0. � �6 C I
TYPE�ILDING OR USE SERVED
r 1 or 2 Family Number of Bedro�ms: � [� Pul,lic (Specify):
THIS PEfjJVIIT IS FOR A:
C►d' NewSystem ❑ Tank Replacement � Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System � Reconnection ❑ Petition for Modification
IF THIS I,S A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
�}Seepaye Bed ❑ Seepage Trench � Seepage Pit ❑ Holdiny Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy 0 Pit Privy
� Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank CapacitY ��
Lift Pump Tank/Siphon Chamber
Holding Tank capacitY
Manufacturer. �.r
IF THIS IS AN ALTERNATIVE SYSTEfJI C01IIPLETE THIS BLOCK: ❑ Mound � In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minut per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
( n � � Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for i all 'tion of the private age system shown on the attached plans.
Na e of Plumber (Print): S' n . MP/MPRSW�Io.: Phone Number
�l/'�-�O? � -�._ Q //1'1 !L '�Q .-r�f r% l� �Gf ( �� � � —
PI er's ddress: �J ; Name of Designer:
,_ d � l � - u/'�Zt--� C / s�f�'�C3 __-�
COU /DEPARTMENT USE ONLY
Sign u of Issuing Agen • Fee: Date:
❑ Disapproved
❑ Owner Given Initial
� 9 S . Q Q 2 - 1 8 - 8 '] � Approve� Adverse Determination
ason for Disapp val:
\
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUIL�INGS
LABOR & HUMAN RELATIONS pRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
�GONVENTIONAL ❑ALTERNATIVE S�a�ePlanl.D.Numben
(II ass�igned)
❑Holding Tank ❑ In-Ground Pressure ❑Mound
NAME OF PERMIT HOLDER: E� 0.I AOORESS OF PERMIT HOLDEH�. 1�� INSPECTION DATE�.
T �oN S�oS++��v� T2R � A�PP�e V u� s-ao -g�
BENCH MARK(Permanem reference poinil DESCRIBE IF DIFFERENT FROM PLAN�. REF.VT.ELEV.�. CST REF.PT.ELEV.
� . �
�OF SI��N.� 10�
Name ol Plumber: MP/IOtr{I"OP'1P� C�u���� San�ta�y Permii N�mber:
��a�c-N,c�, M� �a�F ��fq8 S�Y � 8�-oob
SEPTIC TANK/HOLDING TANK:
MANUFACTURER�. LIOUIDCAPACIT� iANKWLETELEV. TANKOUTLETELEV WAHNINGLABEL LOCKINGCOVER
PROVIDED. PROVIDED�.
�M� �I SO �lg. -( c'1$. �o� .�YES ONo ❑YES ❑rvo
BEDDING: VENTDIA.: VENTMnTI i�iGHWA7EH NUMBEROF �'�� ROAD�. PGiOPERTv � WELL BUILOING: VENT70PRESH
�� �� ALAHM FEET�.FROM . LINE � n� / AIR IN�ET'.
❑YES ❑NO � ❑YES ��NO NEAREST �S well yet q
DOSING CHAMBER:
MANUFACTURER BEDUING. LI()llll)('n!',1C:Itv VIIM�'M��17F1 �'1�h1�'SI�'��()NMnNtlln(:II�IvtVl wnf�NINC;LnNEL LOCKINGCOVER
r�NUv1OLU P�70VIDED.
❑YES ❑NO C_�YES L_INO ❑YES []NO
GALLONS PER CYCLE: GUMVANUCONTHOLSOPENnTIUN.IL NUMBER OF �'�{���'FHIv WELL dUILDING VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM `�"E 41R INLET
PUMP ON AND OFF) ❑YES L�NO NEAREST—�►
SOIL ABSORPT�ON SYSTEM.Check the soil moisture at the depth of plowing �f N�,r�{ u�nn�F rE�+ n�nTF H�n� nNo n�ar+Kwr;
or excavation. (If soil can be rolled into a wire,construction shall cease unUl FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
�vioTN �ENc,rF+ No ar oisrw viv[ svncw�, cnvtt� �Nsiut i>�n -vlrs �iouio
BED/TRENCH I�� �S� rcvFrvc�+Es �t a+nrc+pn� l'� P�T oEPTH
DIMENSIONS tQT
GRAVEL DEVTVI FILL DE7TH UIS7H PU'f UiSTN PIPF. DISTR.PIPF MA7ERtAL NO n��i�+ �NUMBER OF PHOVEF7r WELL BUILDING- VENT TO FRESH
BELCJW PIPES�� Ad()VE CO�'Ef7 EI F V INLI ! ElE V E.NU + NIVE ti LINELL � n� Q� AIR INLET. �
�V•�o IV•�� c�� _��UC � NEAREST�—s T� weh ye� aV � 3S
MOUND SYSTEM:
Mound site piowed perpendicular to slope �heck the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for meciium sand. TIONS MEASURED.
❑YES ❑NO
SOILCOVER rexruae ��iiin�nrvitiin�,v�hii�s uus��+vnnnHwEu-s
L_�YES ❑NO CJYES ❑NO
DEPTH OVER TRENCH 8E� DEPT/{()VFH TfiEN<:�1 f{Ffl �)!VI11/)F i()1'S�11L tif�l�l)f I) JFFf)F 1) MULCHED
CENTER EDGES
L_�YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTRON SYSTEM:
w�DrH LENG7H No.OF Lnitrtn�SvnC�N(�� (lHnvf�. I�fP7HNF�rlwv��'! F�LLDEPT1�nHC1vECOVEN
BED/TRENCH raervcNes
DIMENSIONS
� : MANIFOLO PUMP MANI�()ll) DISTF.PIPE MANIfpL[l MATFIiIAL Nn ()ISTH UISTfi.PIPE fll$TIiIHl11i()N PIPE MATEHIAL&M11ARKING
�� � ���� ELEV. ELEV DIA ELEV. PIPES DIA�.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HpLE SP:ICIN(, L`��ILLEU(�)fifiE(:ILV <:()VEH MA7EHIAL VER71Cl�L LIF7�pRRESPOND$TO APPRpVED
a�nn�s
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKEHS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL�. BUILDING:
FEET FROM ��"E
❑YES ❑NO ❑YES ❑NO _ NEAREST� _
Sketch System on Retain in county file for audit.
Reverse Side.
SI(i A HE TITLE �
DILHR SBD 6710 (R.01/82) Q ��"�`�' ` � •
. s
� � g � ��ev • l��
��t�NC�s �Y�N , e..�a� °
Govc- L-� t 3�6. � (.g
GoYt' �t. 3 a-s- �I-g
�� `_
�� `_�O�E L�hID
---_ R+� , ---_
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C,�,�2,ok' � �
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F-35i
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8
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56
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