HomeMy WebLinkAbout022-638-21-2201-LUP-1994-375 - Applicati_on for Land Use Permit �
County of Sawyer o
, 7'he �ndersigned hereby makes aPplication Lor a L�nci Use Per.mit and agrees that �
a]_1 work shall be done in compl.iance wi.th the requir.ements oI the Sawyer Cot�nty o
Zoning Ordinance and tiie laws and regulati.ons of: the State oL Wisconsin. �
PRINT - USE BI,ACK INK OR PENCIL '
I�I���-. s �r� (�, �
r `^
,� � A-� �� c�I< �.e k1 ���^'�".�'--t� �
Owner Builder �
,
� � 0 7� 3 �7 �'�-- � ��-��►a--�. c�
Mai�ing A ress Mailing Address
� ��; b �G- `-' � S � �E �� z s�t�3�
City, State , Zip City, State , 7ip
r �Building Land Use Zone District -�, -� ; - � rt
� New ( ) Filling -� �
Addition O Dredging Lot size � �i
( ) Alteration ( ) Grading �
( ) Moving On ( ) Acres D
( ) ( )
New Construction
� (�,:i- �
Size � � f t ���i-�' ' wide ' wide �
ti
f t long ' long ' long '�
Floor area sq ft sq ft sq ft ��
tz�
Total hgt l3 �` �� t� ' hgt ' hgt �'
s���-
Stories � �
No . of Bedrooms ^-- ��
rear �,
(year round) or (seasonal) L� «�' � � �cx� �O� �n �+
Ty�e of Iildg , �lddition , Use �Z����� n, �;
O Dwe 1 l_i ng N F-�• r-+
( ) Garage ( 1 ) (2) car � �.
( ) Storage Building y� �'
( ) Boathouse ' � � o
( ) Livingroom ' � �
( ) Bedroom �
0
( ) Kitcheri-Dining (`� Q
( Porch (enclosed) (roofed) F
( ) Deck - open ��r N
) �1[.�v i� vY�A-►.r.vY� #��T , �► N r��
( ) ,� �
Type of Construction ✓ ���`' W �
( ) Frame ( ) I3locic m'R' 1X � �
O Log (�!� Concrete ;� Q , � r��,
( ) , Pole ( ) SLeel �o �v
( ) ( ) Pole/Metal — �„
J �D
�a n
Construction Cost $ 2�0�� N
Vol L(..�5 � Pg ��.-] of Deed � N
CS Vol g ,�
b �
Cer . Soil Test Gp0 - D�.-1 �
�
�o W
Sanitary Permit �(� -�� � '-'
---------- L road -------------- �
z
0
. z
Issued 23 Se�temhPr 1994 Denied �'
G�
�
� �
�
Owner Zoning � ministrator
J
4� �1LHR SANITARY PERIIAIT APPLICAYI�►N � �
In accord with ILHR 83.05,Wis. Adm.Code COUNTY �
����'� SAWYER �� �
CST 90-047 STATESANITARYPERMIT# O
—Attach complete plans(to the county copy only)for the system,on paper not less than 13 7 9 6 4 ,'` �
8'�x 11 inches in size. ` �
� Check if revision to previous application
—S6@ f2V6fS@ Sld@ fOC If1StfUCtIOf1S fOf COfllpl@tln9 thlS BPPIICStIOfI. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION.
PROPE OWNER PROPERTY LOCATION
/`/ ,'/a �%a, S� T��, N, R , �{or) W
PROP TY NER'S AI NG ADDRESS LOT# BLOCK�
U �9c�i�.� .
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Ii. TYPE OF BUILDING: (Check one) ❑State Owned ,VILLAGE � NEAREST ROAD
❑ Public �1 or 2 Fam. Dwellin � lf,Iav G�� /-� '�G%
g—#of bedrooms� ARCEL TAX NUMBER( )
III. BUILDING USE: (If building type is public,check all that apply) 022-638-21-2201
1 ❑ ApUCondo
2 �i Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
tV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.�New 2. �Replacement 3. ❑ Replacement of 4. � Reconnection of 5.❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 � Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1.GALLONS PEFi DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
�� a d �� �j Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total #of Prefab. Fiber- Exper.
New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel 91ass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank d � �
Lift Pum Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): � Plumber' ignature:(No Stamps) MP/A4PRS{�fRho.: Business Phone Number:
p w L� /J �/I� ( 7/j_L/ `/.�"�.���
umber's Addre (Street,City,State,Zip Code):
� ' �'� J '
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (inciudes Groundwater a e ssue Is �n Agent Signature(No Stamps)
Surcharge Fee) Q .
Q Approved ❑ Owner Given�nitia� $115 . 0 0 5-14-9 0
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
-._ _._ ,_ _
SBD-&398(formerly�' '`(R.11/88) DISTF �al to C:;.. ���To:Safety&Buildings Divisi:. . - Plumber
DEPARTMENTOF INDUSTRY, � INSPECTION REPORT FOR SAFETY�,
LABOR 8 HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES 8 APPL CA.
P.O.BOX 7969
_PnADISON,WI 53707
State Plan I.D.Number:
�CONVENTIONAL ❑ ALTERATIVE (Ilassigned) �
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER� ADDRESS OF PERMIT HOLDER� INSPECTION DATE:
Rt��t R.�r�o�.� R.��sso� w z s-��.-qb
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN� REF.PT.ELEV': CST REF.PT.ELEV.:
�O M !-l0�(l.E !�t� I 0 O
Name of Plumber: MP/MP}t�+h�No.: County: Sanitary Permit Number:
�'c�ccryD 5 �0 SR-�U Y� �b -0 4d
SEPTiC TANK/HOLDING TANK:
MANUFACTURER�. LIOUID�CAPaC!TY�. TANK INLET ELEV.: TANK OUTLET ELEV.� WARNWG LABEL LOCKING COVER
� • 1 ` � qQ p PROVIDED: PROVIDED:
1 1�`.. 1 d -lC� ��S IS•3� YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.� VENT MATL: HIGH WATER I NUMBER OF ROAD: PROPERTY WELL� BUILDINCy VENT TO FRESH
�� ALARM�. � LWE: � � I A!R INLET
I � FEET FROM
❑YES ❑NO! C,1._. ❑YES ❑NO ' NEAREST—� �O � IOO � S
DOSING CHAMBER:
�4ANUFACTURER� BEODING LIOUID CAPACI7Y� PUMP MODEL� PUMP/SIPHON MANUFACTUFER: WARNING LABEL LOCKItiG COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL� BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑YES ❑NO NEAREST—�
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soii can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS' LIQUID
8ED/TRENCH � � TRENCHES: � MATERIAL: P�T DEPTH:
DIMENSIONS j� �� �— 6
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL� NO.DISTR. NUMBER OF PROPERTY WELL: � BUILDING: VENT TO FRESH
BELOW PI�,5: ABOVE CO��R: E V NLET: ELEV. ND: ►t PIPES: FEET FROM LINE' ( Q � AIR INLETI: 1
o�j ��•IS q� P y C NEAREST—� � SQ �j � o�b
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
�YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER I TEXTURE: PERMANENT MARKERS: 08SERVATION WEILS;
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOI� SODDED: SEEDED: MULCHED.
CENTER: EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH W�DTH: �ENGTH� NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TFENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: I OBSERVATION WELIS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: i FEET FROM LINE:
❑YES ❑NO i ❑YES ❑NO NEAREST—♦
j�� P l�� r��.s P��' P c.�►�
`�.t�L S'rPrl.(.E p �S D R��J ts
Sketch System on Retain in county file for audit.
Reverse Side. i TURE Ti7LE c
�
SBD-6710(R.06/88) ,
.��`. �: GEPARTMENT OF AGRICUL TURE � � �
� SOIL CONSEAVATION SERVICE ORAWIN6 /V0. WI-001 REV. 8/90
CONS TiqUC TION PL,4N �
PRACTICE���C��T� L � r4 �`� V�) ��i C S'�oC���` �>r,� ij �`l2�
OWNER � �� MO 1-J�� R�'�� �': �A
ADOf�ESS v J 1 � V� 1,`
COUNTY LANDOh'NEl� PHONE NO. �`� s ` 2-� � �
TOf✓NSHIP EZ /1'� 1 S `�?
SECTION Z � TOI+'NSHIP � g � RANGE � �/
FIELD OFFICE E-A�ySI`^ '?� �l TELEPHONE NO. �1 S - .S 3 2 �� S 2 '7 Z
--- - - - _ -- --
__- �_ �-- � � - � �--
, i ,i �- �; _ L� � O ..
��-' _ ' � �`�� �-� ' t-�w Y 2�
_ ; � , a ��
, , } - . lZ M I
-� ,�- � _ � � �
� /?96 �� . �199 � ,
i. , _ loGra� I Pit `,,,_,�
r�/� .,.- ✓lLG � ,,,�
i � � _ _ �
)� n I _. J�-�-.-� -
� ' ,_ - _-_.,,, ,
, uil i; , ..`�� � ' i
. _ / ��7'
I' � , L` .-�- _.-
� �/.. ���� : '�'[ � _ e Y
� --�-�/ _�-� p -
. i .� � � .��+, - . .
„ � , �
^ � ' ;
, � " ..� ..-.��- �----�%�; ` `` ---- - ___ .- ---
,- -
--- - _ e--�- - - ;- - -- � — _O -
_ _- -- --- :
_ i
, ;�,�� -��. > r ��� � � ; , ;
} � , � o � ` `J ;
���_� �
�., ,
' • - =: �:� ;,; �-, :�.�:'�� �.��.. _
'��� � `�� __� � — r _` ,z� � — . -- -
. - a, ''�. - ,✓ • � I� o /L'�" ~ _
.. .. �1""'t �Z5� �v � �-� . _ -. .1 � �L�� .
}�+ ;�_ :�J�-.� -�_����, � i =_ y ", 'Z"s a'�
� - — `�� ✓^ ____ 1 ��1' , �,", ,/ �
, ` �,�-`i�"` �_' _ `�`'_ —�j� \/ � ( '� � _ ���
'Z�oL r t `�`
� % � l2 i ..
\'
__ _ � � _� - ,• � "��� ;�
. . . �•- � � _ /Q/ ` � _ � f �_ ` / _ . . -
� I ` �
i �'�. — -�- `�p..
' \'i _ �" — p {� �� � -_
L DC,4 TIOIu M,4P �
NOTICE TD LANOOWNERS AND CONTRACTORS REGARDING UTILITIES
NO REPf,E'SENTATION IS MADE BY THE USOA SOIL CONSERVATION SERVICE QR THE �Q�i,)YE R COUNTY
LAM7 AAO MATEH CONSEHVATION DEPAlaT,NENT AS TD THE EXISTENCE OR NQNEXISTFNCE OF LV1d7EHGR0UhD KAZAR7S.
PHIOH TO Th�' START OF CQNSTAUCTION THE OMNFRS C1F UTILITIES MUST BE NOTIFED Of Th�E PEAQ7ING
CONSTHUCTION. YOU h'IL L BE L IABL E FOR DANAGES RESUL TING FRQN CQNSTAUCTION ACTI VI TIES.
CONSTRUCTION ORAh'INGS AND SPECIFICA TIONS ACCEPTANCE
I/h'E HA VE f�EVIEWEO AND DO ACCEPT THE A TTACHED PLANS. I/WE AGREE
TO HA VE THIS Pf�OJECT CONSTF�7UCTE0 IN ACCORDANCE 1✓I TH THESE PLANS
ANO SPECIFI l`ONS AND�-�' NOTIFY ALL AFFECTEO UTILITY COMPANIES.
SIG/VF'D.' �� � OA TE.'
OESIGNED BY.' �c.,4 OATE.' � - 9 Z
CHECKED BY.� � -�� C� ,,- -�, ,� . ,� DA TE.' �- ��n-�'-,�
APPfI0VE0 BY.' � OA TE.'_ �-3 C�-�3 2-
APPf�OVED BY.' DA TE.'
SHEET I OF g
�
--
SUBJECT: Request for additional information
Sawyer County Zoning Administration
P.O. Box 668
Hayward, Wisconsin 54843-0668
715/634-8288
To enable this office to process your application for a Land Use Permit
, the following information is required:
(� Complete legal property description
( �Mailing address of property owner
(� Name and mailing address of builder, if other than owner
( ) Volume and page number of recorded deed or legal document showing
proof of ownership
( ) Volume and page number of recorded Certified Survey
( �" List the size of -�� �`�'1.A-�l,v�� �►�
( ) Size of property in footage
(� Type of structure: dwelling, garage, storage building, etc
( ) Type of addition: livingroom, bedroom, utility room, kitchen,
porch, deck, etc
(� Type of construction
( �� List estimated cost of construction
(�"� The rectangle on the right of the application represents yo r rop-
e ty. Sketch in the location of the �k�-��N� ��CJ � �E�S�,
_ ty�� � 1'� , giving all distances to lot lines , roads ,
� shoreline and other buildings on the premises .
( -�'"�Sketch in the location of the existing septic system, giving all
distances to the dwelling, proposed addition, and accessory buildings
(��Attach the required fee of � (p(�.00
You may make check payable to Sawyer County Zoning
( ) Retaining your check/cash to cover the fee
( ��Signature required on bottom left line of application, use only
black ink
( ) Certified Soil Test required
( ) Sanitary Permit required •
( ) Existing septic system affidavit required
(��Please print, use only black ink or pencil. Applications complet:ed
in blue ink will be returned.
( ) What year was the existing septic system installed
( ) If the septic ia���alled after 1968; who owned the property
at that time
( ) If the new dwelling will have a loft or second story, list the
size of the loft or 2nd story in the spaces provided
( �' Return the original application; photocopies or facsimilies are
not accegted
� )
( )
, � ,
� SEC .21 TWP 38N . R .6 W
,1 . 2 .1. 3
6.1 .5.1 .21 .I .I
O O O
.7.2 .7. I
.8. I .3.1 4.1