HomeMy WebLinkAbout012-740-09-1402-LUP-1992-035 Application for Land Use Permit
County of Sawyer � o
The undersigned hereby makes application for a Land Use Permit and �
agrees that all work shall be done in compliance with the require- o �
ments of the Sawyer County Zoning Ordinance and the laws and regu- �
lations of the State of Wisconsin.
�a_ 7j7$Cp ConCo�' `foo� PRINT - USE BLACR INR OR PENCIL C 1
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I�ENN�S /f 1LGi/��� OwNF�2 ,!�i�iG�/'�' `'I
Owner Builder �
�2q ��x �3�7- � {
Mailing Address Mailing Address �
�1�r�Yw���� w� SYssy3
City, State, Zip City, State, Zip �
Building Land Use Zone District � � o �
( ) New ( ) Filling ��-� rt
(�G� Addition ( ) Dredging Lot size �.Gy� x [3 '-(o� � n
r j Alteration ( ) Grading
( ) Moving On ( ) Acres �
O ( > �
Z
New Construction � � ���� Z
Size (2. ft wide m7�1�'+'���y'i ft wide N
� ft long ��� ft long �
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Floor area 5 yG sq ft sq ft �`
tr' Z,
Total htg �2� to peak to peak x �
v
Stories � Stories
No. of Bedrooms rear lot line or waterline c�
0
(year round) or (seasonal) ��' �, n
Type of Bldg or Addition � � a' r
( ) Dwelling i Gl � a: °
( ) Garage (1) (2) car � � �.
( ) Storage Building � � N
( ) Boathouse � c �
( ) Livingroom j �
y'� Bedroom e.ntLq�j�uy �x1s'Tiuy
( ) Kitchen-Dining � U
( ) Porch - enclosed/roofed � 9� rn
( ) Deck�.y-� open�7 '
. � �- '� A�./ L^/11L./7�6�1U�J 7�� �� / 'J r�"
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( ) /?a-.r>,ea�m 5 A-ND �Ylo�2i_= ccos.G� � �
Si°/1��= � Q �1
Type of Construction � `(� -C �
{� Frame ( ) Block ��` � � 19 r�
( ) Log ( ) Concrete p y
O Pole O Steel � � o � cn
( ) Metal ( ) r � �D
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Construction Cost $ D 0���? j�Y �
ip
Vol ��(.o`� Pg ��3 of deed F
CS Vol Pg � ro `�
1 F--� � �
Cer. Soil Test �� - (� I }'�� o „�
m
y �3 - - -_- ----_ z 0
Sanitar Permit
C-T� �'�', � z
Issued ��� /�L,� �"1"IL Denied �
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Owner Zoning Administrat r
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� DILHR SANITARY PERMIT APPLICATION COUNTY
SAWYER • °0
In accord with ILHR 83.05, Wis. Adm. Code �
� � . STATESANITARYPERM�T# �
CST 87-209 98408 , �
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER - �'�
8'F� x 11 inches in size.
-See reverse side tor instructions for completing this apptication. pETiTioN
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR vnRinNCE ❑ YES ❑ No
PROPERTY OWNER PROPERTY LOCATION
�' (,(>�'�1�2? e � ,C/�Y< Y<, s r Ye , N, R E (or
PROPERTVOWNER'SMAILINGADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISIONNAME
�
GTV STATE � ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LAKE OR LANDMARK
/
� VfLLAGE : u
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family � OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #�. Check#2, 3 or 4, if applicable)
t. a. � New b. � Replacement c. 0 Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. � Conventional b. ❑ Alternative c. ❑ Experimental
2. a. � System- b. ❑ Holding c.� Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. See a e Bed b. ❑ See a e Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): p �/ �
�� / / Feet � Private ❑Joint ❑ Public
CAPACITY
VI. TANK in allons Total #of Manufacturer'sName Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks Tanks structed
Se ticTankorHoldin Tank � ❑ ❑
Lift Pum Tank/Si hon Chamber ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installatioP f the private sewage system shown on the attached plans.
PlumbeYs Name (PrinQ: Plumber's Sigr.,wre: (No Sta ps) MP/MPRSV�No-= Business Phone Number.
d D n� a �' � a � �..
lumber's Adtlress (Sireet, City, le,Zip Code : Name of Designer:
� PL � � -��-YJz
V II. SOIL TEST INFORMATION
Certified Soil Tester( ST) Name CST#
.v �D7Y' n.f �c��
CST,,7's ADDRESS (Street, Ciry, State, Zip ode) Phone Number
/1'�' 1 �7� � N �Pl� � c -�(oG ^ � � �
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Grountlwater ate Iss � gent Signature (No Slamps)
� Approved ❑ Owner Given Initial Surcharge Fee
AdverseDetermination $90 • �� ? rJ . O� 1� -22 -$�
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398((ormerly Plb-67� (R. 03/86) DISTRIBUTION: Oriqinal Io County, OneCopy To: Bureau of Plumbing,Owner, Plumber
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