HomeMy WebLinkAbout024-641-13-2418-LUP-1994-099 Ap�l.ication for Land Use Permit 4%�� r
County of Sawyer o
The under�i�ned hereby makes application Eor. a Land Use Permit and agrees th��t �
all work shall be done in compliance with the r.equirements of the Sawyer County o
Zoning Orciinance and the laws and regulations of the State of Wisconsin. �
PRINT - USE BLACK INK OR PENCIL �_� A
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Mai ing Address Mailing Address
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�City, State , Zip City, State , Zip
Building Land Use � Zone District �� - i �- � / ° �
( ) New ( ) Filling .�. �o
O Addition O Dredging Lot size .�:..c�' k, 29�� � �
( ) Alteration (X) Grading r-
(}� Moving On ( ) Acres �, ,r,� �;:' C
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�Construction �/i
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Size a G �; ft wide ' wide ' wide
� ,� '� r f t long ' long ' long
Floor area � sq ft sq ft sq ft m
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Total hgt /� � to peak ' hgt ' hgt �' �
Stories � b
No . of Bedrooms �,-���.�.�_.Q� �,,�aterline � o
(year round) or (seasonal) � � s����`�� ����"' w�'� ���-k C ����.,� � �
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Type of Bldg , Addition , Use '� a o
( ) Dwe 11 in ~' r*
(�q Garage (1 �(2) car � �-
( ) Storage Building �, r.
( ) Boathouse °
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( ) Livingroom
( ) Bedroom p ,�• �
( j Kitchen-Dining C � �� .c �"
( ) Porch (enclosed) (roofed) —` --� Zo � �
( ) Deck - open � �x, �
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( ) �r � '° �V
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Type of Construction N ---- -------��, 9p� �
(� Frame O Block ' �- so'-- ' t
( ) Log ( ) Concrete o � 3� '��� �' r��
( ) Pole ( ) Steel -� 1 ��
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( ) ( ) Pole/Metal �,.,r� � v� a�, �� �
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Constructzon Cost $'��Q�� �, - --
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Cer . Soil Test ` -��3 _ �. � � $.
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Sanitary Permit -� b ___ �L road -------------- z
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3�Gf Af�l�p y: 5'G Ab.t'�G��N• O•C lJ��
Issued 13 May 1994 Denied -- �, �
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6� Zoning Administr tor
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SANITARY PERMIT APPLICATION ��.._,�
� DILHR ���Nn �
��.�� in accord with ILHR 83.05,Wis.Adm. Code , 't I a
CST 92-093 Saw er io
STATE SANITARY PERMIT# I
—Attach complete plans(to the county copy only)for the system,on paper not less than 164327
8'f�x 11 inches in size. ❑ Check if revision to previous application
�ee reverse side for instructions for completing this application. srArE P�AN i.o.NUMseR
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
.fi/(,/C� � � L�C- S S� %a fl�[�'/a, S � T Yl � N, R E�) �
ROPERTYOWNER'SMAILINGADDRESS LOT# /�C(�G BLOCK#
(� !�
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
W S `�
II. PE OF BUILDING: Check one CITY � NEAREST ROAD
� > ❑State Owned ❑ VILLAGE� v� % � ��� p�
• Ci /�
❑ PUbIIC �1 Of 2 F3fi1. DW@Illfl9—�Of b@dfOOfT1S,��. PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public,check all that apply) 0 2 4-6 41-13-2 4 0 6
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining
4 ❑ Church/School S ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify _
IV. 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 previous�y 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 PER 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
�� 7 D� 7o�p , � �$ 0�+�!13 Feet Feet
CAPACITY
VII. TANK Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New istin Gailons Tanks oncrete structed glass App.
Tanks Tanks
Se tic Tank or Holdin Tank poc /Ud�J l> ^C t�r
Lift Pum Tank/Si hon Chamber `^Gb cU� t� `�
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's Signature:(No Stamps) MP/MPR�9WYao� Business Phone Number:
C i� �� � �.�D 5��Z /s S6S S%�/
P u ber's Address(Street,City,State,Zip Co ):
� � � 33 S O>v�c �/� / S� �f 7�
IX. COUNTY/DEPARTMENT USE ONLY
� Disapproved Sanitary Permit Fee (Indudes Groundwater a e ssue Iss ing Agen Signature(N Stamps)
Surcharge Fee)
�Approved ❑ Owner Given Initial $115 . �� 6-O 1-9 2
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly PIb�7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber
... _ . � �� � � �' ,y. PRIV�►TE SEWAGE SYSTEM co��cy:
Labor and Human Relations INSPECTION REPORT 5
Safety and Buildings Division �w �C�
(ATTACHTOPERMIT) SanitaryPermi No.:
GENERAL INFORMATION �6c�3z`-�
F'ermit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.:
c►+ -�- Lvca.s !� d L�..Ke
CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Tax No.:
i oo' -1-e le �►a,.�e �u K�-E. 13 dc a 24 -6�f! -(3 - Z YD(o
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic E{U G v CT �-oYl<-- 1 00 t� Benchmark �oo�
Dosing �� ` DNL SOO
Aeration Bldg.Sewer
Holding St/Ht Inlet ,�p
TANK SETBACK INFORMATION St/Ht Outlet $a, y5
ANKTO P/L WELL BLDG. ventto ROAD Dt Inlet �j
Air Intake ap•��
S tic ��j' >ZS� �5-' ZS' NA Dt Bott q p, 2 �
� ing 7�' 7ZS �S� Z$' NA Header/Man. c�`, �"]
Aer,:tion NA Dist. Pipe
Hold+'ng Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer z o� �(".� ,r.. Demand �i,�,� qb.b�
Model Number GPM
TDH Lift Lriction �eadm TDH Ft
Forcemain Length jp' Dia. Z'� Dist.ToWell �S �
SOIL ABSORPTION SYSTEM
� BE�/TRENCH Width Length . No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth
� DIMEN IONS �S YO -- DIMENSIONS
SETBACK
SYSTEMTO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type O , � CHAMBER Model Number:
System: �-�c� �S� 65 �S >�bQ� OR UNIT
DISTR46UTION SYSTEM
Header!Manifold DistribuUon Pipe(s) x Hole Size x HOIe Spacing Vent To Air Intake
�ength Dia _ length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan rPvision required? ❑ Yes '�No
Use other side for additional information. 8 � ,�,��� w, �� $ 1 3 $
SBD-6710(R 05i91) Date Inspector'sSignature Cert No.
l�BD-6398(formerly Plb�7)(R.11l88) DISTRIBUTION: Original to Counry,vne�opy �v.�n�a�r u��••���•..y--•-•-- .
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� ADDITIONAL COMMENTS AND SKETCH •
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' SANITARY PERMIT NUMBER: 3 Z7 9 Z- ' 0 7 O _
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