014-941-12-1201-LUP-1992-251 Application for Land Use Permit �
County of Sawyer o
The undersigned hereby makes application for a Land Use Permit and � �
agrees that a11 work sha11 be done in compliance with the require- o
ments of the Sawyer County Zoni.ng Ordinance and the laws and regu- M
lations of the State of Wisconsin.
PRINT - USE BLACK INK OR PENCIL � �
/rl
I_UGILL.� J. ��k��.� �I c'� �l N'-�c'GK�.._��;•'�`
Owner Builder
; 4�,��� � �✓�'� (l�.'% 1
Mailing Address Mailing Address
i-l�`��1�1,�,��� � 'vl/i. �f�"��. � �
City, State, Zip City, State, Zip
Building Land Use Zone District �R-� r �
( ) New ( ) Filling �
�
� Addition ( ) Dredging Lot size (�6�' x �2_g-[� �, n
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres
��__�H�-s-�,�,�'7r�' ( ) �
New�Con tr ction ����� r
�,p I .,U
Size 'I%��' ft wide ft wide
, i _�
'"-.'' '" ft long ft long � (-"
Floor area . ��>�-' sq ft sq ft �� r
1 N c�' r
Total htg ,�'� to peak to�eak,, � r
��.
Stories � '✓ I � �ta�$ L
No. of Bedroo�� ���'''��'�
�' ' rear lot line or waterline c�
� o
(year round) or (seasonal) � C�Co�' G rt
Type of Bldg or Addition '� �' r'
� Dwelling � � rt
Garage (�-car `��,�� r,
( ) Storage Building � N
( ) Boathouse ~�
0
( ) Livingroom � �
( ) Bedroom `;,� -
( ) Kitchen-Dining t _ '
�
j}�} Porch - enclosed/�.3c1 r
�J Deck - open , I ..
�i -�,�;; ��
S=�- �r� ��, �� � i�
c > ` , . � t='
;�:�' • � r
Type of Construction �'
� Frame ( ) Block ��� ��
( ) Log {� Concrete �, -
( ) Pole ( ) Steel � r'", 3 �
( ) Metal ( ) ��,' 6 �� , � / �
Construction Cost $ - '���'
i�.-� -
Vol Pg of deed j �
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J� i
CS Vol Pg I s I ' ,ti £
�°n a
Cer. Soil Test �
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Sanitary Permit ----------CL Road ---- I
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Issued �()�{�,�(�/ ��qZ Denied !v� �
c�>�,�Jv,� �. .�� ��r� �_��� -�-�Zti �
Owner Zoning Adminis rato�
�4WN OF LENROOT
SEC. 12 TWP. 41 N. R. 9 W. .
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W'ARRANTY DEED. STATE OF �i7SCONSIN—FORM No. 9 ��
� _ . ., . M.G MILLFR CO., NILWAVCFE
NUMBER This Indenture, Madeby Frances 0, Ha�€rberg, sole o�rner
16685
grantor , ot Town o£ I,�nroOt� ��8wyer County, Wisconsin, hereby conveys and warrants to
Lucille J, i�ckley
grantee , of �it;;� of t�ayiaard,Snwyer pounty, wtsconsin, for
thesum of One ($1.00) znd other �ood and valuable consi_deration
� the following tract of land in ����7yPr County, State ot Wlsconsin:
� All of' the Northwest �-<�uarter of the idortheast �dizarter (P7rJy P.�.4) of ->��ction '1'�-.�l��e �12) 1'o��:n:��':S.p
Forty-one (4_L) Idort of i� :nge Nine �9) �+�eat, and
� Al]_ i;hat paz�t of ttie tdorth��ast �uar•t�r of the Idorthea t ��•luarter• (i�i, NE4) of S�c�ion Pw�lve �];'_)
� lo�•�nship F'ox•ty-one (Z61) I'dorth, �L•in�e I'd9.n� (9) ��est� lying '�.Je�t of th � •am�] 3#Ton ��iver, exc�� L that
� I. p�rt, hereto sold and c��nv�ynd to Jacic i';u-11en. hi_s hoir� ancl as,ign�, un_3�r ,late of June �, 1�ri.
recoi•d-:d in Volittne 90 of lleeds at ��3�e 2�%: subj^.ct to exi:;t�n� re�ery :tions of i•ecord.
i 'Pt�i� dned al3o cor.veys as ho*•einabove stat�d a�l of that ,•art � f' the i�Iorth�n�,1: .�ti���rt��!, �i' the
Idortheast '2uart;er �I�'%v ��v) of �nction �l�:�elve �17_) , lo�:n�i in F�rr,��_„Iza (',l) }'ortli� it_n�*�
' tline (�) �'�est, i.n iahich a priv�te ro�rl c, asem�nt was �rant��d to J1cl: I;tillen a_nd �ance� 1 ��d, b-✓
deeds as shown in ��o]_�zme 98 of ���eds at ���es 3>l, 35�� 353 � 3Sr�� 35� an�� "356.
It is mutually a�ree�i b�� the parti�s h�ret�,their• h��it•s, mi•sonal rc7�r�;enLat.ive�s and � ;si.Rns, t.h�;i.
n� d��elling �'it� hF' ��ctcd on tLe described Troperty for � va7uc� of 1� � than 'I�aelv� �l�hou;ar.d
j � '�1'l.,UUU.OU) llol.l.a,r� ; that in orciAr to pre:��rve and rrotect thr d�.�i.ra},ili.t,,%, br riuty .nc' --;ltr^ of ; ' l
� {:he ]_rmd in �aid des�i•i.b^d pi•or�rty for t,he b�cnfi�, of a'1 t}�e o�rn�rs Lh,,,.�or �n;� r},a+, a ' 1. c n•:�<< ,nc�s
hereafter m�de shall bind t.he h�ax•s , r�i-sona7_ renres�ntata_v�s and a>si�ns �±' an,-,� .^r �, ' 1. ^" i �� r����-c�l
of l�nd and sha_L1 c��nLain the x�estricti_ons _�et torth in i,hi_:, ��]_au,�; an�] t,hat the cov�-nant°a ha1__L
bc con.,trued as runnin�* with the l��nd.
��8.£�0 �evenue st.amps at,{;rached and cancel :t�d.
t
� �
IN WITNESS NHERF,OF, the sald grantor ha S hereunto set her hand and seal ttil� 1°�th day of
J�y , A. D., is 63 . �
Signed snd Sealed Sn Presence of Fr•:nc^3 �%. l�a^�bE�r� (SF.AL
)
7'erence td. EIickey ituth A. Brot•m P'iti'�1�iCI�;S 0. Hi1G[;gf1tG
� TEi�?;iaCE R. HICSL:Y RUTH A. I3:?r7;1i'd (SEAr.)
(SEAL)
STATE OF WISCONSIN, (SEAL)
99.
S3wyef Oounty.
Personally came before me, this l�'th day ot J�y A. D., 19 E 3 .
theabovenamed Fr�nces 0. H�€-�*berg
I
ito me known to be the person who eaecuted the foregoing lnatrument and aclalowledged the eame.
IRecelved foc Recozd this �3rd day of 1'�I•cnce i1, t�ickey
Trrr�nce T?. 1+_iok�Y
f� �)i15r A. D., 19 (3, at 3 ;��� o'clock F M. I�ot;arittl
SAal Notary PubIlc, ;;.,..,,,.,r County, �Vis.
( Laui•a �, i�icj'af'f-an Reglster of Deeds. Af fix�d
i
My Commission �t�6A� i,� I ''I'R"n�t�t , A. D., 19
! Deputy.
I
�raft^d by Tei�ence P?. Ffick^Y� 31� Io:.�n �'�ve. , 11��^.r�r�1, .,i:�.cnr�:;:.n
+
� "`"� w'S`o"S'^ APPLICATION FOR SANITARY PERMIT �
� � D 1 L H R (P�B 67) SAWYER COUNTY W
-OEPRRT7T1EflTOF UNIFORM SANITARY PERPJIIT ,�`F—�
� IflOUSTqV,lqBOq 6 MUTGifI RELRTIOf15 C S j 8 6-12 8 8 6 011 �
—Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Yzx 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PR ERTY OWNER Luc' lle ACICleY MAILING ADDRESS
— Y� Z � - � N �.Y � l,3 �
OPERTY LOCATI N �C--
V I L{�EE: /
1/4� 1/4, S �� , T , N, R G�er� W TOWN OF: (�e�i r t
T NUMBER BLOCK NUMBER UBDIVISI N NAME NEA T ROAD, L STATE PLAN I.D. NUMBER
� I p � Ca.
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedro�ms: � C] Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
,�Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
�Seepaye Bed ❑ Seepage Trench � Seepage Pit ❑ Holdiny Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ 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 �(���P� �'000
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer. S'
IF THIS IS AN ALTERNATIVE SYSTEfJI CONIPLETE 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 �UATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
y � ��'� Private ❑ Joint ❑ Public
I,the undersigned, hereby assume responsibility for instaliation of ihe private sewage system shown on the attached plans.
Name of Plumber (Print�: Si ture: MPRSW No.: Phone Number:
� • v c�� , 0.:3�0 ��/.S'�6' — �S'
I ber's Address: Name of Designer:
�`. c 0 � v i,
COUNTY/DEPARTMENT USE ONLY
Sig ure of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
9 5 . �� �- 3- 8 6 '� APProved Adverse Determination
Reason or Disa oval:
Alternate course(s)of Action Availabie:
DILHR-SBD•6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plurnber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P,O. BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707 c
�ONVENTIONAL ❑ALTERNATIVE S�a�ePlanl.O.Numbcr.
(II assigneA)
❑Hoiding Tank ❑ In-Ground Pressure ❑Mound
NAME OP PERMIT HOLDER�. ADDRESSOF PERMIT HOLDER�. � INSPECTION DATE�.
�--uei IIe �ckl�e . 3 u�a� cl- 3 -�'v
BENCH MARK IPermanent relere�ce po�nt)DES BE IF DIFFEREN7 FROM PLAN REF.PT.ELEV.: CST HEF.PL ELE V.
�a o� �Unc�.o�. ior� SE �rh�.r dw• IoD �
Name of Plumt>e�. /MPHSW N�i (:�����+�v Sa��iiary Permii Numhe�
o n 5 ' re� l 3 sso S0.� er 8�6--13 �601
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOUID CAPACITV TANK INLET ELEV TANK OUTLET ELEV. WARNING LABEL �OCKING COVER
PROVIDED. PqOVIDED'.
�OD 'e.k• ❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.�. VEN7 MaTI �hnGH WATEH NUMBER OF ROAD�. PROPERTV WELL�. BUILUING. �VENT TO PRESH
A�nN�1 FEET FROM ��"E AiR iN�ET
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER: QY� ^f��e.` C�S� � _�U.Y��-- OC�'�e.C E�
MANUFACTUFER BE�DING� LI<]UI(J(:APA(;I(V �'l1MV'M/)I)EI �'l1MP,51f'1111NMl�Nl/l�(;IIIIiEVi WARNINGLABEL LOCKINGCOVER
1 PROVIDED-. PROVIDED:
- �D� ❑YES ❑NO ��� E O 3�I �OV�CL S ES ❑NO YES ❑NO
GALLONS PER CYCLE: PUMP AN(J CONTR()L$OPERATIONAt NUMBER.OF �'H()PFHTV WELI BUILDIN(i VENT TO FHESH
(DIFFERENCE BETWEEN FEET FROM `�Nt aiR iN�ET i
PUMP ON AND OFF) � _ Y�S ❑NO _ NEAREST--� ��� � 3� � 3�
SOIL ABSORPTION SYSTEM.Chec the soil moisture at the depth of plowing FORCE ����,r�� � u�nn�r rE�+ ^.�nrf H�n�. nn,o o,�a�+Kw�,
or excavation. (If soil can be rolled into a wire,construction shall cease until � ^ �. �D
the soil is dry enough to continue.) MAIN �3 a. �V ` S C
CONVENTIONAL SYSTEM:
IVIDTH LENC�T11 1 N() nF I)ISil1 PIVE tiV'nt:IN�� C:nVfl� INSII)EI)�A �PITS LI�UID
BED/TRENCH , � rr:Frvc��ts ! �ti�^'E"�^�� � �PIT oePrr+�
DIMENSIONS �� 5 3 W
GHAVELDEVTH FILLUEPTH UISll1 PII'I UISIH vIPF DISTF PIPF MATEHIA� NO Di51H NUMBER OF �. v"oPe�+ry WELL BUILDING VENTTOFFiESH
BELOW PIPES `1 ABOVE COVER E I k V INt f I tLE V f.NU f� �'IPf ti � �. UNE / ( � AIR WIET.
( �� ��, �,tj, _�!UC a NEARESTO--► 4�O �O ?60�
MOUND SYSTEM:
Mound site plowed 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 medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TExruRe ��t rin�nvt Ni aanr<Kt ws onser�vnnnry wEu_s
C_�YES ❑iV0 ❑YES ❑NO
VEPT11 nVER iRENC/1 HED DEPT11(7V!H Tf�EN(:11 flF IJ I)(I�i11(7{ i(){'S(�IL tifil)I)f 1� JFEUCI> MULCHED
CENTEH ED(iE5
I_IYES C�NO ❑YES L_�NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
wion� i i Ni��ui No or�— i ni�i�ni_tirni:inii,- ��,iinvi�i��Gi i�iil"iii i uiv�i��i�i-- —�i��o�r�rr�n�iuv� c�ivi��
BED/TRENCH rHFNc�Es
DIMENSIONS
MANIFOLD PUMP Ml�NIGn�I) DISTR PIPE MANIF(�Lf)MATEHIIIL Nfl [)ISTN UISTH PIPE UISTV�IBUi1nNPIVEMATEHIAL&MAHKING
FLEV. ELEV. pIA ELEV PIPES DIA
ELEVATION AND
DISTRIBUTI�N
INFORMATION������'��. HOLESIZE HpLE57l�CINC; Lf:ILLEU(;()11Ht(;ll.v (;()VEF7MATEHIAL VERTIC/1LLIFTCnRHESPONOS70APPRUVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSEHVATION WELLS NUMBER OF PROPERTV WE�L�. BUILDING.
FEETFROM ��NE
❑YES ❑NO C�YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI,N l H TITLE
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