HomeMy WebLinkAbout026-939-16-5418-LUP-1994-075 Application for Land Use Permit i � �
County of Sawyer o
The undersi.gned hereby makes application For a Land Use Permit and agrees that p �
alJ work shall be done in compliance wilh the requi.rements of the Sawyer County o
Zoning Ordinance and the laws and regulations of the State of Wisconsin. �
PRINT - USE BLACK INK OR PENCIL �n 1
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ner Builder
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Mai ing Address Mailin Address
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�ity, State,��ip Cit� Zip
Bu ding Land Use Zone District ���'-Z r o
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�New ( ) Filling N �
( ) Addition ( ) Dredging Lot size
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres � , �y �
( ) ( )
New Construction
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Size 2� ft wide ' wide ' wide
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.2�� ft long ' long ' long
Floor area �CP� sq ft sq ft sq ft '�
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Total hgt _�� to peak ' hgt ' hgt x'
Stories �_ �
No. of Bedrooms �e or waterline o
(year round) or (seasonal) J •�� �-u�� �' rt
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Type of Bldg, Addition, Use 2 a o
( ) Dwelling � �• "
Q!J Garage (1) (2 car . � :y, > N•
( ) Storage Building � �iv y _ �5l"¢ � o•�
( ) Boathouse 20 ` yy,E`�' �--3`1
( ) �
Livingroom I`y�
( ) Bedroom � �,
( j Kitchen-Dining ��'s��v.�
( ) Porch (enclosed) (roofed) � v�-��`
( ) Deck - open � , Zo`
( ) i`" ���57 AU-_S'TEK � �'
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Ty of Construction ������� I� ����� �
�Frame ( ) E�lock �
( ) Log ( ) Concrete � �
( ) Pole ( ) Steel �
( ) ( ) Pole/Metal $ �
3 � `°
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Construction Cost $�� �� � �
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Sanitary Permit `"<: � ; ';`^� __________ �L road z
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Issued 04 May 1994 Denied
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'Loning dministrator
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Sawyer Count;� Zoning AdministraLion �
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Inspection Report £
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Owner Adele V.� Gerald W McDouga� �i�
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Address 1603 Devney Drive Altoona Wisconsin 54720 �
Agent/Purchaser �
Address �
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Blder/Plber/CST — a
Address £
Inspection ( ) Dwelling ( ) Setback - lake
( ) Mbie Hm (� Setback - road
( � Private ( ) Public ( ) Commercial ( ) Setback - 1ot lire
( ) Garage ( � Soils Verif �
Violation � ; Addition ( ST �+w� z�/�o * o
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( ) Zoning ( ) Sanitation �
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Discussed with o�-✓H4r' Sa+d �4k� �—�~ �-�_ �, �
Date (,-Z- 13 Time /��45' - l z;4.�
� iISS`I S4�1C. . F'
Signature of Inspector b�l�" �
.'�QEPARTMENT OF APPLICATION �
� SAFETY& BUI L DINGS
irv�usrRv, FOR SANRARY DNJISION
LABOR AND PERMIT P.O. BOX.J9E9�
HUMAN RELATIONS . (PLB 67) MADISON,WI 53)U7 '�
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Attach plans for the system on paper not less than 8%z x 17 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points mus[ be shown. All appropriate separeting distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown:�An index page or each page must be signed,sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy rnust be
included.
Property Owner: Mailing Address: �
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r pert Location: City,Village or To ship� � Count . �
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S` Ya, l�'/<S / iT� NiR (or) W � �
Lot Number. Blk No.: Subdivision Name: Neares Roa , Lake or Landmark: State Plan I.D. Numbr�c
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�/ . G1 (If assigned)
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TYPE OF BUILDWG -
❑ Public* ❑ Variance'" ❑ Other s ecif N�mberof
� p Y�x Bedrooms:
.�1 7 or 2 Family "State Approval Required. �
� TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITV
HOLDING TANK CAPACITV
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: �
EFF W ENT DISPOSAL SYSTEM � �
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): � New ❑ Replacement ❑ Experimental �Seepage Bed ❑ Seepage Pit
��� � ,L��� ❑ Altemative �specifY) � ❑ Seepage Trench
/
Water Supply: pwner's Name as Listed on Soil Test Repott �1f other than present owner�: �
,,� Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plum6ec Sign re: < MP/MPR3W�pp.; phone Number.
,C l��i�/� 1�,�iy�V/S' � .. �jr�fs�a� iS���2�t'S�/
Plumber's Addre s: Nam of Desi er: �
COUNTY/DEPARTMENT USE ONLY CST 81- ll0
Signa u e f Issuinq AgenL Fee: Date: � qppROVED Sanitary Permit Number.
�E7� . �� 6- 1�- g2 ❑ DISAPPROVED Z36�1
Reason for Disappr I:
Altemate coursels)of Action Available: � �
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD$396 (R.07/81)
�EF�R�nnENT oF iNousTRv, INSPECTION REPORT FOR SAFETY & BUILOINGS
�.A(30R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
?.fl. F�OX 7969 BUREAU OF PLUMBING
MA[�SON, WI 53707
•
G�CONVENTIONAL ❑ ALTERNATIVE SretePlanl.D.NumOeu
Uf assignedl
, ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
tJAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: �NSPECTION OATE:
� --a � �o r �Tr Gvl .�47 � 7 SN 8�
BENCH MARK IPermanent re�erence oo�nt) DESCRIBE IF DIfFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.�
f.�a7' a � � r� �nr6 � /= .f> cu, � 04
�Namr ol Plumber�. - MPMRPRBMNo.: Counry�. Samtary Permrt Numbec
� � Av� �D�v��s ���1 � �f /�cu �� �3 6 9'
:iEPTIC TANK
MANUFACTURER. LI�UIDCAPACITV: TANKWLETELEV_�. TANKOUTLETELEV. WARNINGIABEL LOCKINGCOVEfi
h PROVIDED: PROVIDED:
�MC POS�N G�d �YES ❑NO ❑YES ❑NO
BEODING: VENT DIA.�. VENT MATL.�. HIGH WATER NUMBER QF . ROAD�. PROPERTV WELL BUILDING VENT TO FRESH
ALARM FEET FROM � � �a �INE AIR WL.ET�.
' C� YES ❑NO ❑YES ❑NO NEAREST �O �,� r 6 �G
DOSING CHAMBER:
MANUFnCTURER BEDOING�. LIOUIOCAPACITY PUMPMODEL PUMP/SIPNONMANUFACTURER�. WARNINGLABEL LOCKINGCOVER
PFOVIDED-. PROVIDED:
❑YES ❑ NO ❑YES ❑NO ❑YES ❑ NO
;ALLONS PER CYCLE: PunncnNocorvrao�soPeanTioNn� NUMBER OF PROPERTV WELL BUILDING IVENTTOFRESH
?IFFERENCE BETWEEN FEET FROM ��"E Aia w�er
'MP ON AND OFF) ❑YES ❑ NO NEAREST
!L ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing �eticr„ ��:.��,eTera �.inreain� allo nnnaKwc
�. xcavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
� soil is dry enough to continue.) '
.;CNVENTIONAL SYSTEM:
�r � WIDTN- LENGTH NO. OF DISTP. PIPE SPACING COVEH INSIDE DIA =PITS IIQUID
BED/TR'EidCH q� �. TRENCHES � MATERIAL' P'T DEPTH
D�MENSIONS C� � � S C �O T!/
t;f��,-�-.VEL DFPI�I FILL DEPTH UiSTH PIPf DISTF7 PIPE DISTR. PIPE MATERIAL: NO. DISTR NUMBER OF PHOPERTV WELL�. BUILOI�G VENTTO FRESH
�BFL�)'."� PIViS, �� AdOVECOVER ELEVINLFiELEV. END PIPES FEETFROM LINE � � �� � �� / AIRWLET�
/
V NEAREST—s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
CYES �NO
SOIL COVER T�XTURE PERMANENT AIARKERS OBSEHVATION WELlS
❑YES ❑NO ❑YES ❑NO
UFPTH OVE�7 TfiENCH BED DEPT�i OVER THENCN,BED D[PTH OF TOPSOIL SODDED SEEDED MULCHEO
Cf.f�7ER EDGES
I ❑YES ❑ NO ❑YES ❑NO ❑YES ❑NO
°S;ESSURIZED DISTRIBUTION SYSTEM:
i WInTH LENGTH NO. OF LATERAL SPAGNG�. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
! BED/TAENCH raeNci�Es
DIMENSIONS
i �� . AIAMFOLD PUM11P Ml�MFOLD DISTR PIPE MANIFOLD MATERIAL NO. DISTR. UISTR. PIPE DISTRIBUTION PIPE MATERIA� 8, R1ARKING
ELEV.: ELEV. DIA. FLEV. P�PES DIA.:
� ELEVATION AND
r�ISTRIBUTION
' INFORMATION ��nLE SIZE HOLE SPACING DHILLEO CORRECTLV COVER MATERIAL VERTICAL UFT CORRESPOND$ TO APPROVED
PLANS
❑YES L� NO ❑ YES ❑NO
,�..OMMENTS: PERMANENT MARKERS�. OBSERVATION WELLS�. NUMBER OF PHOPERTV WELI�. BUILDING�.
FEET FROM LINE:
, ❑YES ❑ NO ❑YES ❑ NO NEAREST '
�ecch Syscem on Retain in county fife for audit.
everse Side.
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