010-941-32-4405-LUP-1990-262 Application for Land Use Fermit �
County of Sawyer ,�
V
7'he undersigned hereby makes application for a Land Use Permit and agrees � 1
that all work shall be done in accordance with the requirements of the Sawyer °
, County Zoning Ordinance and the laws and regulations of the State oE Wisconsin.
PRSN'P - USG ONLY DLACK INK/PICJCIL �
osella R. and h
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Owner Builder � �
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dress mailing address
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city,tstate, zip city, state, zip
Building Land Use Zone District �}�� R-1
( ) New ( ) Filling �-
(� Addition ( ) Uredging Lot size 2 �i �.{�� ,� '�����'S�-� �rt �
O Alteration O Grading r�� � N n
O Moving on O 7+cres x�Q�4x�x]�/ 2.00
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New Construction ' � -�
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Size �6 fL wide Pt wide
ZZ� ft long ft long ��
Floor area 352 sq ft sq ft �
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Total hgt � � to peak to peak Y' "-
Stories _�
No. of bedrooms rear lot line or water7.ine
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(Y ea�--rotinc3 I-"or-1 s easarta3} i i
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Type of bldg or addition ^� � �
( ) Dwelling � i � � i � ''
(�) Garage (1) (2) car S � ' � � �'•�
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( ) Storage building � . i , '
O Boathouse S � ..'. � i v�i
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( ) Livingroom ,; ; ; � j 7
( ) Bedroom � �
( ) Kitchemdining ' j i i
( ) Porch - enclosed/roofed �j � i � ;
( ) Deck - open ��� � � �
, 333 � � � ��
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Type of construction j . ' �.i � ,i,
(� Frame ( ) Block , i �5 � I
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( ) Log ( ) Concrete i �
( ) Pole ( ) Steel � - ZQ � ""
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( ) Metal ( ) '� I y�18r ��G ib�`8 � --�i
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Construction cost $��'�'� I i p y Ra-a �9 � i �� �
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cer. soil Test /�' �i IJ� �✓� � —�oo--� �-- j i m �
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Sanitary Permit �q- c��- ,
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Issued 24 October 1990 �enied _ I
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/1 tl��t� �C• �IJ.��C. �I �- t V�.�— � ` C�I
Robert A. Mil er owner zoning ndminis rator
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SGAL � /" _ /oo FEET
- � BRA55 CAP /7oN, / N PLACE
DESCRiP7iVE � �„ x 30 " IRoN F'/PE PLACED
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TowN 2G7. 43' 200. 00� 30� ROAD
N. 88' sS' W, ' 497,43'
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P � B 6 7 f �� y State and County State Permit # _
�y `�!� r Permit Application County Permit #
;,� ' for Private Domestic Sewage Systems County SawXer •
" DENOTES STATE APPROVAL REQUIRED CST 9 - 215
Date Approval Received from State if Required State Plan I .D. #
A. OWNER OF PROPERTY Theresa A . � Alphoase D . Mailiny Address:
� H min
. • � X Xxx r .� � v 2C°�� 5 4 g �� 3
B. LOCATION • ' YQ . r�Ya , Sec �on �,L , T � N , R � E -(6r) W Lot # City
Subdivision Name, nearest road, lake or landmark Blk # Village
Townshfg% . ,-�;,r l
�'�--
C. TYPE OF OCCUPANCY : *Commercial * Industrial 'Other (specify) * Variance
Single family � Duplex No. of Bedrooms � No. of Persons .i
�� SEPTIC TANK CAPACITY C Totai gallons No. of tanks %
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel �Vr Fiberglass Other (specify )
New Installation Replacement
Lift Pump Tank or Siphon Chamber � Total gallons Prefab concrete Poured-in-Place Other (Specify)
-- ----- - -------- ------- _ — - - - --- - - --
E, EFFLU NT DISPOSAL SYSTEM : Percolation Rate •� Total Absorb Area sq. ft.
New Replacement Alternate (S ecify)
Seepage Trench : No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches_
M1
Seepage Bed :�Length � Width�s�� Depth� '�_Tile depth (top)��No. of Lines�.�
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land � �) �' Distance from critical slope
WATER SUPPLY: Private� Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I , the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I hiave sized the effluent disposal system from the EH - 115 prepared
by the Certified Soil Tester, /
NAME s L C f E� f�/ C.S.T. # ,S f — �b �� and other information
obtained from (owner/bui�der� .
Plumber 's Signature � .r �� Mp��y�# 5 7 /O Phone #��j'�� ,l�`{-.,;�
Plumber's P.ddress � -�'�
PLAN VIEW: Provide sketch below of system ( include direction of slope and all distances in accord v,rith H62.20. Weli loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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� Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY
ate of Application 10 - 09 - 79 Fees Paid: State 15 . 00County 15 . 00 Date 09 OCtOber 197g
�rmit Issued/R��� (date) 10 - 09 - 79 Issuing Agent Name Elaine Nehrlin�
spection Yes�it.LNo State Valid# Date Rec'd
county (white copy) 3. owner (green copy) DIVISION QF HEALTH, P.O. BOX 309, MADISON, WI 537C11
state (pink copy) q , olumber (canary coovl
Department of Zoning and Sanitation
Satiyer Cov.nty �
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Inspection Report y
Otaner Theresa A. and Alphonse D. I-]elmin a
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lddress Route 6 Hayward, WI 54843 "
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T?ame of bus�_ness c
Builder �
Address �'
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Plumber Robert Vitcenda p'
Addreas Exeland, WI 54835
Inspect9_or.
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(�() Private ( ) Public Property 1( Sanitary-instal �* �
Dwellin� �etback -- lake �
Violation X Mobi_le Hm Setback road °,
Gara�e Setback-lot li_ne
( ) Sanitary ( ) Zoning privy
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Discussed with owner yes no �
Discussed with Bui.lder yes no
Di_scussed with plumber yes no
D-iscussed with yes no I �
Date __�____Q�T 79
�gnature �f Officer �,�y�� ,�� ,y ��7 `
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