008-146-00-0700-LUP-1990-104 Application for Land Use Fecmit .T
County of Sawyer y O
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1'he undersigned hereby makes application for a Land Use Permit aud ayrees �
tliat all work sliall be done in accordance witli the requirements oE tlie Sawyer H, �
County Zoning Ordinance and the Laws and regulationa of the State of Wi�consin.
PRIN'P - USE ONLY ULACK 1NK/CEt1CIL l``
J hn H, ,�ine�}art—Fx Sandra �: 1m
Jy��t /-� /Y%�nc`iu� � Rhinehart
;�avi��•a /'� �/l'Ll �n Gian/ (lW✓1 e 1'� O
Owner Builder �
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�_j G Z /_ �.c�w� �T� �
mailing address mailing address
/
�L1 U �'�u t hc_ In,�.= 5����' �
city, state, zip city, state, zip
Building Land Use Zone District RR-1
( ) New ( ) Filling
�) Addition ( ) oredging Lot size 155'/166' x 200' S �
O niteration O Grading 47 m n
( ) Moving on ( ) Acres
( ) ( ) ' x
C H
New Construction ' �� �
Size / ,2 fC wide ft wide �
� �
_L� ft long ft long �.y
S �"
Floor area 2� 6 . sq ft sq ft �
trf3� z
Total ligt f L to peak to peak x� x
Stories � �
�3;rc�i �nkz
No. of bedrooms�i�� ��axe--or wate�line
year rou�u3j or (seasonal) � `y 6 , �
� i c,
Type of bldg or addition � � ._� � �
`-J '-�,elling i , n} i �'
( ) Garage (1) (2) car � i a S'
( ) Storage building � ' + i �G, r
( ) �oathouse � ' � N
i..
( ) Livingcoom � "�-- . i � �
(� eedroom-R�cp�c. �.�usTi N�j i. � FVp i'� �!,'�'�i1 � i_
( ) Kitclien-dining i t N ����' � t-, i
S�^f i
O Porch - enclosed/roofed ��j�' e I�,t�y �e�. z�' � i � i
O Deck - open i \`�� u 0 ow 6� i Ir. i
� I� {`\�� �� l� ff C~ � � N I
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� � / � S `1 \ � �� 1 �fl 1
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Type of construction � j � i
� Frame ( ) Block � � �
( ) Log ( ) Concrete j � �I�
( ) Pole ( ) Steel � � � � � "'
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( ) Metal ( ) � �U �
i i � �
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Construction cost $ �T�9�� j � � °
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vol 257 pg 473 of deed ' I '
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Plat Envelope 87 i ; o �
CSM Vol Fg j � i OD N �q
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Cer. Soil 7'est 75-154 _ i �i��;✓i /'L 0�t�X/ ' �� a
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---`------C road -------------------o z
Sanitary Permit 89-033 L o° �
- {-N��sia�. La�v.�. o � 7
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Issued �q i.qa�� 1990 Uenied �"�
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� DILHR SANITARY PERMIT APPLICATION
����� In accord with ILHR 83.05, Wis. Adm. Code CouN�r��� e � � �
� �
CST 75 - 154 `O
STATE SANITARY ERMIT# �
Attach complete plans (to the county copy only) for the system, on paper not less than 114 5 43 � �
w
s�i4 x 11 inches in size. ❑ Check if revision to previous application W
.S@@ �@V@CSe SIdB fOf If1StfUCtIOf1S fOf COfTIPI@11f19 thlS 3ppIICSt10�. STATE PLAN I.D. NUMBER
, APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
'ROPE�Y O NER � PROPERTY LOCATION
� '/a '/<, S �9 T7j7N, R E (or
'ROPERTY OW H'S AILI(JG ADDRESS LOT# BLOCK #
/i Lf1/U
;�, STAT � ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
�1�u. � � l.l�� . 5 ��o ' i.� ���-� .� o li� r � ;'r��? .� i9�� /t�i�N ro�i.�" .�
CITY � NEAREST ROAD , ' < •
I. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE � � ZoUJ/��'LoY. L'1 J� iU�` �7 rL � ��
❑ Public �1 or 2 Fam. Dwelling—# of bedrooms � P,a CELTAX NUMB (s)
11. BUILDING USE: (If building type is public, check all that apply) D ���� .�� (� .� '�� �
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. � New 2. ❑ Replacement 3. ❑ Replacement of 4. � Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
3) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 � Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
/I. ABSORPTION SYSTEM INFORMATION:
I. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
RE ED (sq. ft.) PRlO/POSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) � ELEVATION
3 � � � ']`p�� + /� �3�� Feet �V Feet
CAPACITY
/II. TANK Site
in allons Total #of Manufacturer'sName Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New xistin Gallons Tanks oncrete glass App.
Tanks Tanks structed
te tic Tank or Holdin Tank � �d !.(` Y11L�.
.ift Pum Tank/Si hon Chamber
llll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibiliry for installation of the onsite sewage system shown on the attached plans.
'lu er's Name (Print): Plumb s ignature: (No Stamps) MP/MPRSW No.: Business Phone Number:
�/� D � ��si � ' '� � �✓! �� 1�� �'S���- .��� ;�
'lumbe 's Addr�,ss (Street, Ci S te, Zjp Code):
r
f� �( � f � � � �
X. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Inciudes Groundwater a e ssue Issu' Agent Signature (No Stamps)
�Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination $115 . 0 0 5 - 2 4 - 8 9
(. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
3D-6398 (formerly PIb�7) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
ti
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&HUMAN RELATIONS DIVISIUN
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES 8 APPLICATION
MADISON,WI 53707
State Plan I.D.Number�
�CONVENTIONAL ❑ ALTERATIVE (Ifassigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
� � 33a8 � . �.o.wn S�4 . �av CLa�re CU1 S- �-S -8�
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.P7.ELEV.: CST REF.PT.ELEV.:
D�.--�C.� o-� �w . j6 0 �
Name of Plumber: MP/k4PH9Y0'17o.: County� Sanitary Permit Number:
� . Zes� er l � S�►Y�� 8�-�33 ll�s
SEPTIC TANK/HOLDING TANK:
MANUFACTURE.R`: LI�UID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
1 �V�—j'�v� v OO I Cj • I S G C) •S PROVIDED: PROVIDED:
ES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: � PROPERTY WELL: BUILDING: VENT TO FRESH
�� ALARM: FEET FROM L/ LINE: � � I AIR INLET:
❑YES ❑NO C-S-- ❑YES ❑NO NEAREST—► T S >SO '67 g
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PFOVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑YES ❑NO NEAREST—�
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (if soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: � LENGTH: � NO OF DISTR.PIPE S;ACING: COVER INSIDE DIA.: #PITS: LIOUID
� TRENCHES: MATERIAL: P�T DEPTH:
DIMENSIONS 3S � ,+
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRE:iH
BELOW PIPES: ABOVE COVER: EL V.INLET: ELEV.END: PIPES: FEET FROM LINE: J � �/ I AIR INLET:i
n `� �c�.� CIc1.H � C p� NEAREST—� 3O � SO � 1'b > �'O
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fiil material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑YES �NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH� LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTF.PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE' HOLE SPACING: DRI�LEO CORRECTLY: COVER MATERIAL: VERTICAL LIFT COFRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO � ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDINC.:
COMMENTS: FEETFROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST�
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�1� �b��S � f�-� PI an
�r�s-�o_�\eC� �s c�ra w n
Sketch System on Retain in county file for audit.
Reverse Side. RE: ri . ,
SBD-6710(R.06/88)
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