010-941-26-3102-LUP-1990-230 . . �
Application for Land Use Ferm.it �\
County of Sawyer g
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7'he undersigned hereby makes application Por a Land Use Permit and ayrees 'i
that all work shall be done in accordance with the requirements oE the Sawyer �°
County 2oning Ordinance and the laws and regulations of the StaLe of Wisconsin. '
PRIN'P - USE ONLY 6L11CK INK/PliNCIL '_
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Owner Builder
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ma.tling address mailing address
�n�;r�+�2'0 -��z. �-�: NAYw✓i�:� �.t -�,X,;�
city, state, zip city, state, zip
Building Land Use Zone District 1c"'I
(-� ) New ( ) Filling
( ) nddition ( ) Uredging Lot size ���� �rt �
( ) ]1lteration ( ) Grading N n
O Moving on O Acres . S D p v �
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�j-Clj 2fi�jE_ fbU l�W� --
New Construction �'
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Size � fC wide ZL,-_ [t wide ,r
' �y f t long _�Z f t long �
Floor area p�D sq ft -]�p 8 sq ft
— �
Total hgt I� to peak �d� to peak x
Stories ���' i L_�-���� �
No. of bedrooms 2 rear lot line oT waterline
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jY�ar��cound�; ur (seasonalj � � -� �-' — �� I
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Type of bldg or addition � � o
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(X) Dwelling � Z� � �'
O Garage U) (2) car i � a S'
(� Storage building �, i S'i C rt
( ) 6oathouse `'��� � � r
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• ( ) Livingroom "T�� � �- i ol
O Bedroom '�_��t�i L_____----�-- i
( ) Kitchen-dining o�� � �
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( ) Forch - enclosed/roofed :�i 1C�re'�o`) �' i
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(X) Log ia��:�� O Co�icrete � jC :>f i t�
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O Pole O Steel � � N+�a' '�. i a-
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Vol �� �� � Pg of deed � � �
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Cer. Soil Test i ` i n `�
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Sanitary Fermit -73- 2 g� ----------�L road ------------------- z_
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Issued �_��� ���C� Denied ��f
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�; , owner �7,oning Adminis rato
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T� � � N � F� HAYWARC�
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State of Wisconsin and County �' L �� t,�` `
Uniform Permit Application �� i
for Private Domestic Sewage Systems
State Permit�Q ,TAN County Permi�[> � �
Number � Number ��
A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
LEGAL DESCRIPTION�� _ �^ I , ' Name One:
(Sec., Lot, Block) J lN
CITY VILLAGE
6 W�/t/ �h � ! i �' + �C TOWNSHIP
B. OWNER OF PROPERTY MAILING ADDRESS �`
Na �, �� (Street; City� Zip Code) - -- —
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� t � W � t. 1 � '1"1 l� tcF '� ( i�� +, i �'i',i i �l :
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C. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION _
MATERIALS: Prefab Concrete Poured in Place Steel Other ; No. of Tanks �
D. TYPE OF OCCUPANCY �,,� � p
One or Two Family Residence U � L�� No. of Bedrooms � c.N'�
Commercial Industrial Other No. of Persons to be Accommodated �
(specify)
E. APPLIANCES, ETC.: Food Waste Grinder YES �JO Automatic Clothes Washer YES ��VO
Dishwasher YES _L�O Other (Specify)
F. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT _
a � f .� .�
Seepage Trenches: No. Lin. Feet c��� Trench Width Depth � Number of Lines
_ _ _.. .. _ _ .
Seepage Bed: Length Width Depth Tile Size _,!�� No. Lines
Seepage Pit: Inside diameter Liquid Depth
G. Percent of slope of land ''Y1.--�'��-- % direction
H. Indicate Slope of Land & direction of slope on sketch 1. Tile Depth •
PERCOLATfON 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 Period Last Period Period One Inch
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RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED
S O I L B O 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
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RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED
(COMPLETE OTHER SIDE)
Name of Owner '�v �-- �� County Permit No.
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 (3�, Wisconsin Administrative Code, and that the data
recorded a loca of holes are correct to the best of my knowledge and belief.
NAME� �� �/' �� �� TITLE
(Type or Print)� � Q' � �
REGISTRATION — or MASTER PLUMBER LICENSE No. �
ADD R ESS
�
DATE OF TEST LL/ ���� SIGNATURE
----------------------------------G----------------------------------------------------------------------------------- ------�---�-5,..�--;-------------------------------
MASTER PLU E A G AP CATION } MP
Signature License Number: MP RSW
For: Provide sketch below of system
(employer) (Include direction and percent of slope and all applicable distances)
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Note: The application 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 Fees Paid State County
Permit Issued/Rejected (date) Inspection Yes �� 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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