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024-741-19-5602-LUP-1994-025
Application for Land Use Permit County of Sawyer �� � H 0 The undersigned hereby makes application [or a Land Use Permit and a�rees tl�at � - all_ work shall be done in compliance with the requirements of the Sawyer County o � Zoning Ordinance and the laws and regulations of the State of. Wisconsin. � PRINT - USE BLACK INK OR PENCIL � P t- �.S ; � ; o� /�C r,'s �,' � � � e, ; c� e l 4 w K e ►--- L.� �.� ; ' rf � �<� : -,, � � Owner Builder . /o :3 � 'f �evo � s� ,� �� ��1� ?�zio � ', �, . ,; , - �., Mailing Address Mailing Address �7 l o v h-..� �L Je K �+�+� `3-} i�31 � r c , (� _� City, Stat , Zip City, State , Zip � Building Land Use Zone District �(Z-� o � ( ) New ( ) Filling � � � Addition ( ) Dredging Lot size v '� (�'j Alteration ( ) Grading � ( ) Moving On ( ) Acres ,�' 7'. � (�1 ,� ( ) ( ) - New Cons truc t ion t�� c � � � Size � ft wide ' wide ' wide T � y� ft long ' long ' long � .�' Floor area �1,{,;� sq ft sq ft sq ft � m Total hgt 3 �� fa�e ' hgt ' hgt x' �, � I Stories — ,s �"'c��,:t�di'� � '�� T No . of Bedrooms r- rear lo_t ._l.ine_ or waterline � ._.. . (year round or (seasonal) -- - - � � Type of Bldg , Addition, Use � r ( ) Dwe l l ing � d o� � � �= �5 �' � a a o �• rr ( ) Garage ( 1 ) (2) car — �' J ~• ( ) Storage Building E--- �y —� `�Y� �. Q� ( ) Boathouse � � ( I � i(�° � ( ) Livingroom ( ) Bedroom ��►-c(� � ( j Kitchen-Dining � �._. - - - - L Porch (enclosed) (roofed) s --� � j�Q Deck - open '��, � r�r ( ) � . _ n� `� � Type of Construction ; T� �'" � pQ Frame O Block i ' — ���'t �`•u� N l ( ) Log ( ) Concrete i , � �' ��/'��'��' � ¢-��� .� `�- $�, � F�� ( ) Pole ( ) Steel � ,� ( ) ( ) Pole/Metal � C � • � � n Construction Cost $ /�on � <• �.� � � J ,� � r"„/ te�- , �' � L17 Vol '�D I pg ��� of Deed �'o � c � � �--�. c� 7�Ys�'� CS Vo1 - Pg - � � �c � �- . � � H u� . � � �.++� W Cer . Soil Test �' `�'� -�a� K ��-� � � Sanitary Permit _ - ��� __________ � ~ � L road -------------- z �i'-` �" ..,, { �:: T_ .a,. � � �` /y � ��y, t . � O � 1 > u��I. �.. ��.._,�1_.2_,�, ,_Q_ Issued 30 March 1994 Denied � � � Q� � � � - � ^_-�^� Zoning Administ ato Ca� � �'a�e� � " u.. - � i � i�.l j I o � - � � \ ' � ,c „ � z �: � L ""• �' ; X �� Ll.� � � r � � I / � �` ; i � i �% i :�: / / j � , ` �--. ; ' � � ; i ' � / � � '; �., ; G I ,� ' ;t— I d ` ' i . i a �= � 's -- � 1 � i � — tr ' 1 T�' ` = ��' I , � � � ,; . . � ": � g � �3 � V� ' � �� �— ,`' —i i � � = � '� = 4 J � � a�+ � '� � � � � t � � J ��� � � q 7 i c— ='C�1 � � I 1 ( �{ I �O � `� , ��``� ^ � � — � ` �,,+,', �,. --�-- 1 C�' � � � � f � ' ,-. � i � � - � - - r, i y � � �--� s_ —, ,' /^� �l , .�J j� y I ` � 0 J 1 � :� , I � � � �� { U � �` I v �' �!•} ' cs� � , � � � I �; ` ���� � � ��, r .x � � . � , �� —� , ' - - - - - y � � � � I �: Q 2 ,� 1�� � � � r � E I i i �\ � � � � � � — i I �— • .,� I �EPARTMENT OF � APPLICpT10N �' SAFETY & BUII 71NGS INDUSTRY, FOR SANITARY � DIVISiON LABOR AND PERMIT P.O. BOX 7�69� HUMAN RELATIONS (PLB 67) MADISON,WI 53701�, . W � Attach plans for the system on paper not less than 8Yz x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal '� and vertical elevation reference points must be shown. All appropriate separating 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 must be included. Property Owner: Mailing Address: � � � r� � ' ! `1 � �`�S. � �' roperty Locatior�: , or Township: Co nty: �� �aS � iT NiR (or) W �A��(� �t�umbeJ: Blk No:: Subdivision Na e: Nearest Road, Lake or Landmark: State Plan I.D.Number: `T L, � /�� // � ,)����N� %�� (If assigned) iC/ 67 D� TYPE OF BUILDING Number of ❑ Public* ❑ Variance' ❑ Other (specify)* Bedr�s: 1 or 2 Family "State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (St�ecif ) SEPTIC TANK CAPACITY `' O HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: � � EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): P OPOSED (Square feet): ❑ NBW �Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit ' / -; ❑ Alternative (specify) ❑ Seepage Trench EJ Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): c� Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signatur , MP[�APBSl4F-f�fo-- Phone Number: .C.���h'/1/ ;��iYit// �5 � , �y�.� �` /� ��5'�'i��2-�'�l Plumber's Addr ss� '— Nam f Desig r: � -_� `' - .�� COUNTY/DEPARTMENT USE ONLY CST 82- 137 Sign r of Issuing Ag Fee: Date: � APPROVED Sanitary Permit Number: 60 . 00 8-11- 82 � DISAPPROVED 29483 Reason for Disa oval: Alternate course(s)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 wi►I void the sanitary permit. DISTRIBU710N: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DI LHR-SBD-6398 (R.07/81) J�PARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILOINGS LABO'R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION ' P.O.BOX 7969 BUREAU OF PLUMBING Mf�DISON,W� 53707 • I�CONVENTIONAL ❑ALTERNATIVE S�a�ePlanl.D.Numbec 11�assignedl ❑Holding Tank ❑ In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: WSPECTION DA7E�. Do�vrNy ��DU�v6 REN 1�A4wnrz�o W!, �� �uC ��— BENCN MARK IPermanent reference oomtl DESCRIBE IF DIFFERENT FROM PLAN REF.PT.EIEV.: CST HEF.PT.ELEV. g.M, sE co2��� o� o�. �-� p �� r-��.No� T�� lao Nami•�I Plumher�. MP/MPRSW No. Cou���y Sanitary Permit Number�. �.. CJ�.N k�� ' S !�--w v c� �9 y 83 SEPTIC TANK/HOLDING TANK: MANUFACTURER�. LIQUID CAPACITY�. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING L.^.BEL LOCKING COVER -7— J PROVIOEO�. PROVIDED�. 1 �C- l O DO �IYES ❑NO ❑YES ❑NO BEDDING�. VENT OIA.. VENT MATI.. HIGH WATER NUMBER OF � ROAD: PROPERTV WELL�. BUILDING: �VFNT TO FRESH ALARM�. FEET FROM . UNE: N�F�NLET-. ❑YES ❑NO ❑YES ❑NO NEAREST �/� y�v 7SU �� DOSING CHAMBER: MANUFnCTUFEH BEDUING UOUID CnPl�CI7V PUMV MUDEL PUMP�SIP�iON MANUFnCTUNEH WARNING LABEL LOCKING COVER PROVIDED�. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTHOLS OPLRATIONAL NUMBER OF �'�����EHTY WFLL BUILOWG VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM ��"E niR iN�ET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOI L ABSORPTION SYSTEM.Check the soil moisture at the de th of lowin �ervcrr, oinnnFreH nnnreain�arvo MnaKiNc or excavation. (If soil can be rolled into a wire,construction shall cease unt9 FORCE the soil is dry enough to continue.) MAIN CONVENTIONALSYSTEM: LVIUIH LtN(�TIf N()(Jf 1)ISIIi PIVE S�'AIINI; (:(7Vtfi INSII)L l)I!� nPIiS LI�UID BED/TRENCH � � �� rHErvcNes � � n,nr in�: P�T oEPrH DIMENSIONS �YR.9j,l� Gft�vEL DE✓TH FILL DEPTH UISTN PIPF DISTR PIPE DISTR.PIPF MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL�. BUILDING� VENT TO FRESH BELOwPIPES ' ABOVECOVER ELEV INLEi ELE�i.ENO n 71PE5 FEETFROM LINE�. � �^ AIRINLET�. ( �lo .Y6 rvL' � NEAREST--► 7.20 ��� ✓V 6� 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. ❑YES ❑NO SOIL COVER. TEXTURE PERMANENT MARKERS. 065EHVA7ION WELLS ❑YES ❑NO ❑YES ❑NO UEP7H OVER TFENC�I�BED DEVTH OVFft TRENCHrBEU UEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: bYIDTH LENGTH. NO.OF LATERAL SPACING�. GRAVEL DEPTfi BELOW PIPF FILL DEPTH ABOVE COVEH BED/TRENCH TRENCHES DIMENSIONS MnNIFOLO PUMP MANIFnLD DISTR PIPE MANIFOLD MATEHIAL Nn UISTH DISTR PIPE DISTI�IdU11nN PIVE MA7EHIA�&MAFKING ELEV.. ELEV DIA. ELEV. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE ��OLE SPACING DRI�LED COHHEC7LV COVER MATEHIAL VERTIC�L UI�CORRESPONDS TO APPqOVED PLF1N5 ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENTMARKERS� OBSERVATIONWELLS�. NUMBEROF�""� PROPERTV WELL: BUILDING�. FEET FROM ��"E ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNA E TITI.E_ � DILHR SBD 6710 (R.01/82) �" / �"�Yf✓ / �!.�-��,L� /r 7/7 . i a � � � P•�ti Q � �� � e �gti� D�' -3s'�•� I ,.3'c,i. I _ i vc� TM� j _ 5'e�r. � vv� s,f�o � ig I 35: v�r f 1 � I f I . , �...,._x.......,. �. .�.�.__ __ �� � `}` -- --- .._.._._ ,�*� v , . � ���' • ' . • _ . ����� v.� • - � ��� � � . � �� `� ' � � :.. .. � e i' � . • 4,_ �i ����• � . . '�i i ,�,t -n . �-� ' � � � ' t , �` �' , .�`' R1 � �t� • -�'�� � � _ i� . �_ � =--� 1�. �t'* 1;� ` �` �; _ ,, L,-�' . ;:� � \ � � , � � . � � � r� `� . '%`� I�\ '� �� 1` � �.�. 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