002-940-25-5317-LUP-1989-067 �
. Application for Land Use Permit
County of Sawyer � �
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T'he undersigned hereby makes application for a Land Use Permit and agrees o ,
that all work shall be done in accordance with the requirements of the Sawyer �'
i:ounty Zoning Ordinance and the laws and regulations of the State of Wisconsin. � O
PRINT - USE BLACK INK OR PENCIL
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Owner Builder' �
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mailing address mailing address
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Building Land Use Zone District �1� ;� "
( ) New r �
( ) Filling
(?�j Addition ( ) Dredging Lot size o �
( ) Alteration ( ) Grading / � �
( ) Moving On ( ) Acres �7. 7S `� �
( ) ( ) -
New Construction
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Size �J-.L�" ft wide ft wide
�"f' ft long ft long
Floor area s,� sq ft sq ft
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Total hgt � a.. to peak to peak x �-�
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Stories _�_ 'I
No. of bedrooms rear lot line or waterline
- ,SLb
(year round) or (seasonal) i i -
1'ype of bldg or addition i �� i o
{ ) Dwellinp. � � Z i G ,�,
O Garage tl) (2) car i ' i a C• n'
( ) Storage buil;ling i ,o i � ,°y ,T
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( ) Boathouse ' �
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( ) Livingroom i i f ,. � r' !1;
I � �L � 7
( ) Bedroom v� � - i �
( ) Kitchen-dining �� � �e� � � .�
(3� Porch - enclosed/roofed � i ' � J .
( ) Deck - open i L �-$c�:'c:; t.'� i
c � ; �,_; �v i = � r�
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Type of construction ��. '�-F �
(�Q Frame ( ) Block i , ,,�{� �
( ) Log ( ) Concrete � � i
( ) Pole ( ) Steel � � � �
( ) Meta1 ( ) _ _ � i � �
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Construction cost $ ��.V�)t7 � � ._.. . ; � � n
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Vol �.��_ Pg �Q of deed � �
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Sanitary Permit 1 -��j____ o
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T ssu�d�1�_� ��0� Denied � �
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���� owner %oninc; Adm n3strator
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L � � � State and County State Permit #
� � Permit Application County Permit # __9 - O 11
for Private Domestic Sewage Systems County ___ SaW�'2T '
"DFNOTES STATE APPROVAL RLQUIREO CST H - 311
�ate Approval Received from State if Required State Plan I.D. # _ ___
A. OWNER OF PROPEFiTY Mailing Address: ROUte 2 BOX 11�
� • �� �� �x ��' ����������,���t'� Hayward , WI 54843
�'—Mo e 1 1 .r--- .r z. ����''x' _.�--
3. LOCATION: Y4 Ya , Section �c.'�—T /�L� N, R f'' � (or► W Lot# __.
—..— __ City ---��5 � �>
Subdivision Name, nearest road, lake or landmark Blk# Village ___ _
___ --- ___ . _ _--
Township _
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,- - - -- -- �,� - -_ ---- r----- ----- - _ , _ __ _ _ �. ------
. TYPE OF OCCUPANCY: Commercial Industrial __ Other (specity) __ Variance
Single family _� __ Duplex_ __ No. of Bedrooms__�' __ _ No. of Persons __� __
'. TYPE OF APPLIANCES: Dishwasher YES —� NO Food Waste Grinder YES�NO # of Bathrooms�
Automatic Washer �YES __NO Other (specifyl _ _ _
c. SEPTIC TANK CAPACITY _�otai gallons No of tanks _ �
"Holding tank capacity Totzl gallons No. of tanks
New Installation _�— Addition _ Replacement _ Prefab Concrete _
`Poured in Plar.e Steel Other (specify)
. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1 ► L�2)�) , ;�/�Totai Absorb Area _L��_sp. ft.
New Addition Replacement `Fill System T
-- - - ---- -- --- ---
Seepage Trench: No. Lin . Feet Width Depth Tile Depth __ _ No. of Trenches
Seepage Bed: Length _,�[ � � Width __?_ pepth _�'___ Tile Depth f� ''_ _ No. of Lines __ .�/_
Seepage Pit: Inside diarneter ' Liquid Depth _ ___ Tile Size �
-- --- -�----
Percent slope of tand, /• L.�� _ Distance from critical s�ope � � .: s ,Q
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Jisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
y ihe Certif�ed �Soil Tes�er,
dAME `�` '�,Gfi��' ��z'ti _C.S.T. # � ,�J_�1'��' � and other information
btained from C�;y —� (owner/builder►.
lumber 's Signature _�-C"� - � . Phone #Z/f Z���..�,3�
�—. TMP/MPRSW# _1��x��
iumber's Address " � �t -�e�/� L �
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PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well►.
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Not Write in Space Below - FOR DEPARTMENT USE ONL �
of Appl ication 4 _ 2 6 - �9 _Fees Paid: State 10 . 0 0 County _ 15 . 0 0 _ Date ? 6 Ap r i 1 19 7 9 __
nit Issued/���i (datel _ 4 - 26 - 79 __Issuing Agent Name Elaisa__ NI . Nehrli_n�_
Action Yes No Valid# ___ Date Rec'd _
�ounty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
�t2te (pink copy) 4. plumber (canary copy) Revised Date 6/1/76