002-940-35-1206-LUP-1991-172 , Application for Land Use Permit ,
� County of Sawyer o .
The undersigned hereby makes application for a Land Use Permit and
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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 1
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/�lJE �. �N b CAZ S 0/V 5��.r �
Owner Builder
�47e- 2 �3t�' �o4�f1. �
Mailing Address Mailing Address
f-f/-F-Y a✓ft.e�,J�1/S ����f'3 �
City, State, Zip City, State, Zip
Building Land Use Zone District (��; : :[ :� � o �
( ) New ( ) Filling �*
l�i Addition O Dredging Lot size c� n
( ) Alteration ( ) Grading �" �
( ) Moving On ( ) Acres � -7q
( ) ( ) �
New Construction
Size �L�- ft wide ft wide Z
� ft long ft long �
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F1oor area ?jO�j sq ft sq ft f°
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Total htg �4 to peak to peak �
Stories � Stories
No. of Bedrooms rear lot line or waterline c�
(year round) or (seasonal) L.C-O LAkc =- � rt
Type of Bldg or Addition o' r
( ) Dwelling . a o
( ) Garage (1) (2) car � 7$ r• rt
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( ) Storage Building fvrl'��� �� �4�� N
( ) Boathouse � ~�
(>Q Livingroom X ISTJ h1CY �z �
( ) Bedroom ,(ii.D�,
( ) Kitchen-Dining Z¢ � ' 7
( ) Porch - enclosed/roofed �
( ) Deck - open i J�. �
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( ) ADDI'TIUN' �,
Type of Construction � '�m
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� Frame ( ) B1ock , r�.
( ) Log ( ) Concrete
( ) Pole ( ) Steel � cn
( ) Metal ( ) ,C �
Construction Cost $ 00� �
Vo1 ��<< Pg 5�y of deed �
CS Vol ` Pg , �
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Cer. Soi1 Test t�f! n
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Sanitary p �7j—I(o� - ---- CL Road ~ �
_ermit ---- - ---------------
W H-1l� S f4N PS '�o Ap o
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Issued 26 Julv 1991 Denied � ^
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�e.. J� �N I� I�—�D�'C� E
Owner Zoning Administr tor
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Plb 67
' State of Wisconsin and County
Uniform Permit Application
` for Private Domestic Sewage Systems
State Permit ._, , County Permit
Number 4`�� Number `3 ^ ��
A. LOCA�fON OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
LEGAL DESCRIPTION : Name One: •
(Sec., Lot, Block)
� a , �� �� _ 4Q — � Lb� � GTY VILLAGE
—Li�S__��_�, TOWNSHIP
B. OWNER OF PROPERTY MAILING ADDRESS
Name (Street, City, Zip Code) S S <<�
�R�� i-�. � ►�o��.so� �ic�� ��n�� ocuvE ��-. �� m, ►�N
C. SEPTIC TANK CAPACITY �S� Gallons NEIN INSTALLATION � REPLACEMENT ADDITION --.
MATERIALS: Prefab Concrete Pou;ed in Place — Steel —�Other ; No. of Tanks �
D. TYPE OF OCCUPANCY
One or iwo Family Residence ��� No. of 8edrooms a _
Commercial Industrial Other No. of Persons to be Accommodated
(specify)
E. APPLIANCES, ETC.: Food Waste Grinder ___YES —_NO Automatic Clothes Washer �YES __ NO
Dishwasher YES NO Other (Specify)
F. EFFLUENT DISPOSAL SYSTEM NEW ✓ EXTENSION ADDITION REPLACEMENT
Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines
i
Seepage Bed: Length a4' Width � � Depth �— Tile Size ¢ No. Lines _
Seepage Pit: Inside diameter Liquid Depth __
G. Percent of slope of land �_% ��� direction
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H. Indicate Slope of Land & direction of slope on sketch 1. Tile Depth lc�
PERCOLATION TEST
Indicate Soil map number And Soil Type _
Hours Water Test Time Drop in Water Level Inches Minutes
Test Depth Character of Soil Since Hole in Hole Interval Second to Next to Last To Fall
Number Inches Thickness in Inches 1st Wetted Overnight in Minutes Last Periocl Last Period Period One Inch
I a8 � v ry o ' 3
�d `� 1 N 3 � !
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�� t � 0 3 a '
RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED
S O I L B 0 R I N G S — Minimum 36" Below Proposed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
l
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RECORD DATA FROM MINIMUM OF 3 BORE HOLES !N THE ARFF� IN WHICH THE SYSTEM IS TO BE INSTALLED
(COMPLETE O�fHER SIDE)
.
Name of Owner �N� 1-� . �fUCJ�cS�N County �A���i�� Permit No. 4'� �`�
PERCOLATION TESTS
I, the undersigned, hereby certify that the Percolation Tests reported on this form were made by me or under my supervision
in accord with the procedures and method specified in Section H 62.20 (31, Wisconsin Administrative Code, and that the data
recorded and location of test holes are correct to the best of my knowledge and belief.
NAME �A� (� t. cSC�JflIJ�SO� TITLE PL-v4�'(1��.
(Type or Print)
REGISTRATION N0. --_ or MASTER PLUMBER LICENSE No. ��9a
ADDRESS ��T�_��-��\ S���tJU� �(��C'�� l�Jt
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DATE OF TEST A��='_����Z 4- SIGNATURE
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MASTER PLUMBER MAKING APPLICATION MP �� Qa.
Signature: License Number: MP RSW
For: ����sZ�-'oT- St9�A�.lscsv Pi-'P� � Provide sketch below of system �
(employer) �t��`��' (Include direction and percent of slope and all applicable distances)
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Zp' fl� ��. PLAN ���VIEW (Locate Percolation;Test& Soil Bore Holes� __. __ f � _.
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Note: The appiication cannot be considered for filing until all of the above questions are answered and the fee paid.
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Do not write in space below— FOR DEPARTMENT USE ONLY
Date of Application �-�LLST �� ��3 _ Fees Paid State �•��= County I C�. CCl
Permit Issued/RE7eeted (date) ��`����'�� �C `�� Inspection Yes Q� � " No
Issuing Agent Name ` � Valid No. Date Rec'd
DIVISION OF HEALTH,P.O. BOX 309,MADISON,WI.53701 —Revised 4-1-73 •
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