002-184-06-0200-LUP-1990-189 .K
_
71pp1iciL-ion for I�and Use Fermit
' Cou►ity of Sawyer F�
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S'
1'he undersigned hereby makes application ior z Land Use Permit and agrees � �
that all work shall be done in accordance witli tlie requirements of the Sawyer °
County Zoning Ordinance and the laws aud regulations of the St�te of Wisc�nsin.
PRIN'i' - USE ONLY DL11CK 1NY./PLNCIL �
,1 Ct.U� d �. /1 r�.��r�k �f,'c�r� e_ _ l 'l c°-1 C"C�L� 6t°s2�z �
Choner Builder
��C�, ; ,�� /`� /� _._L��-- ,80�- /3 7�' .
mailing address mailing address
�✓Y f�/�,C`�� G v/1 .5 ���� . �(Ot!P_ �C�' K � lili�S J�����
city, state, zip city, state, zip
IIuilding Land Use Zone District �j�<' t
( ) New ( ) Fillinq
(� l�ddition O Dredging Lot size S �
( ) Alteration ( ) Grading n � n
( ) Moving o►i ( ) Acres , ��L�
( ) ( ) `� �
New Construction ' �
Size �_ f� wide ft wide �
�� f t long f t l�ny •
Floor area _`�-�`— sq f t sq f t
tn �
� �
'I'otal hgt � �r, to pe�k to peak %" �
�
Stories �_ �
�
No. of beclrooms -� rear lot line or waterline
(year rou��d) or (seasonal) _ �
i �•---------i ci
Type of bldy or addition � � �
( ) Dwelling � � � � ��
� i G rt
( ) Garage (1) (2) car � • � « �'
i i N.
O Storage building i i C rt
i N•
( ) IIoatl�ouse � � N
(,'�tl Livingroom j -� ��,Z,,d - ''? � �
( ) Beclroom i n ��x? y�N , �� s'�`�
(X) Kitchen-dining i r, �" _ .,. � �S
( ) Forch - enclosed/roofed r'�,, �•� ��� �hZ i �
( ) Deck - open � ' � i �'
( ) i i��,"� � �
( ) ' � � �
� �
i , � e..
Type of construction i i
(X) Frame ( ) Block � � �
i
( ) Log ( ) Concrete i � i,�
( ) Pole ( ) Steel � , � i i a-
( ) Metal ( ) i ✓ � jv
�
i i y' i� c- v'
i i �o
Construction cost $�S, ��C, � . �� i C`, �
—� � � i�
Vol � pg�y oP deed � i �
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esrt--��_�g_� �j ��V, -��� i i "' ro
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Cer. Soil '1'est ��,�; -��`=�', � � �
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�' ----------CL road ------------------- z �
Sanitary Permit �� - ��Z p
T (� 1 ' r � f / .
l �-1 t-,L�V�T h� �l�3" �j1i`�'�.� � 4
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Issued 31 1 990 Denied n
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s�-'�.-�'� � `" '�
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owner 7oninq I�dminis rat r �' '��`
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�' DIL�R SA,NlTARY RERMIT' AP�LlCA�101� COUNTY �
in accord with ILHR 83.05, Wis. Adm. Ccde SAWYER '� �
'�"'""�""`^"^^�^�� STATE SANITARY PERMIT # `
; C
CST 88 - 038 104228 ` '
—Attach complete plans (to the county copy only) for the system, on paper not less tha.n STATE PLAN I.D. NUMf3EA �
8Yz x 11 inches in size. r
—See reverse side for instructions for completing this application. PETiTioN
1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. FOR vARinNCE ❑ � Es ❑ No
PR ERTY OWNER , PROPERTY LOCATION
` '/4 '/4, S � T , N, R g E (oi W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
�� � /��rc. {7?JOi✓ I
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
r-- VILLAGE : /J
�- i , G /� b � e✓U� ✓ ��t',
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family Z- OR ❑ Public (Specify):
ill. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable)
1 . a. �New b. ❑ Replacement 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 previously 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 Cop�i.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1 . a. �onventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holdiny c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1 . a. ee 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:
(Minutes per inch): REQUIRED ;Square Feet): PROPOSED (Square Feet):
/ !� /, � � Feet �rivate ❑ Joint �� Public
CAPAGTY
VI. TANK Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks Tank:> structed
Se ticTankorHoldin Tank �.Sd �=ti-cee, ❑ ❑ ❑ ❑ ❑
Lift Pum Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plum er's Name (Print : Plumber's Signature: (No Stam MP/M�- Business Phone Number:
�
/ c �,,�/� � �' � �z ��� �v- -��
Plu ber's Address (Street, City, Stat , Zip Code): Name of Designer:
,� �j' .�d x � ?��i c_ � �
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST �
l t�C �/�� �Cr-�'i�.� �.�j/�)
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
� � � � (',c� 7� � 6 - 3
IX. COUNTY/DEPARTMENT US O LY
� Disapproved Sanitary Permit Fee Groundwater ate iss g Agent Signature (No Stamps)
I � Approved ❑ Owner Given Initial Surcharge Fee
Adverse Determination � .
X. COMMENTS/REASONS FOR DISAPPROVAL: J
I
� — — 1
SBD-6398 Iformerly Plb-671 (R 03/86i DISTRIBUTION: Original to Cour,ty, One Copy To: E3ureau of Plumbing, Owner, Plumber
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