HomeMy WebLinkAbout032-540-31-5701-LUP-1994-500 Application for Land Use 1'ermi_L
County of Sawyer � �
The undersigned hereUy makes application for a Land Use Permit and agree�hat F1
� all work shall be done in compliance wihh the requirements of the Sawyer County
Zoning Ordinance and the laws and regulations of the State of Wisconsin. rfi
�- " � •' (�'-�' PRINT - USE BLACK INK OR PENCIL �
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Owner��Cr�t';�C-,ryC,l� � (�?�,:�, Buil er
Ma'i�ing A�dress Mailing Address
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L�r� c�r �`�8�� ��
City, State, 2ip City State, 'Lip
r �Building Land Use Zone District �-� o
{,)q New ( ) Filling � m
( ) Addition ( ) Dredging Lot size `� �'
( ) Alteration ( ) Grading �
O Moving On O Acres yi �1 c�� /g-�
( ) ( ) .
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New Construction ���.
LEAt.�'-i--�lc�� �CL C
Siz��e� ft wide �D 1 ' wide � wide
�� / ft long _��' long �_ ' long �
Floor area �� sq ft _���� sq ft sq ft ,
m
Total hgt /y� to peak � y ' hgt � ' hgt �'
Stories � I
No. of Bedrooms Tl�f} . a�
—� rea�r-"}.o^t.��:n7e� or ,wat�r�l'r�e � e
(year round) or (seasonal) �` '`�'�x�
� rt
u��•nT�- G
Type of Bldg, Addition, Use �� ����'�'� ���,�J � �` �'��r a o
O Dwelling ._,'_ f . 4S e' rt
(� Garage (1) � car �y �•
( ) Storage Bui ding ,-,�! -(�I �� � J
( ) Boathouse �� '- .t �
( ) Livingroom � �.--�-
( ) Bedroom �`�" 1 ��M� �o��
( ) Kitchen-Dining � 7b �� o .r-�� -�
C�l Porch (enclosed) (roofed) yv, ��;
� Deck - open =�'"� !
( ) a� • . �. - �. r
( ) � � �r � ' � ,.
�� � i ..78 �
Type of Construction � � 3(; �,
bj[) Frame ( ) Block � ` � µE��� `
( ) Log ( ) Concrete � � �-�(,A�A� ��/ ' r�
( ) Pole ( ) Stee1 � � a�' ���6� ��� -''
( ) ( ) Poi�e/��iet� - - �
�..�s�QQd• - �i�����I�� t ! n
Construction Cost $ '' i�_�,j.«�
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Vol �/.S] Pg �/� of Deed i�- u,
CS Vol _�/�/�¢ Pg -r' ; � ro �
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Sanitary Permit �-1'� CL ro ~ t�
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Issued 09 November 1994 D niedZ3�DU S-r :t-�c; "
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SEC,31 TWp 40N. R.5W.
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4� DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNn
— � SAWYER _ o,
�. CST 89- 159 STATESANITARYPERMIT# �o
—Attach complete plans (to the counry copy only) for the system, on paper not less than 124066 r-�
S�fz x 11 I�Ch@S in SIZ@. ❑ Check if revislon to Drevious application "
�ee reverse side for instructions for com letin this a lication. �
P 9 PP STATEPLANI.D. NUMBER
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. �� �T
PROPERTY OWNER PROPERTY LOCATION
, ' , Ya, S �/ T y0, N, R S' E (or) W
PROPER OWNEF'SMAILINGADDRESS LOT# BLOCK}�
� a�
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
G' /�.V )- �!� � Q � � C (c'_
II. TYPE OF BUILDING: Check one GITY � NEAREST ROAD
( � ❑ State Owned ❑ VILLAGE /,' �u � r ' � ,^
w
❑ Public ❑ 1 or 2 Fam. Dwellin�#of bedrooms 3 PARCELTAX NUMBER(S)
III. BUILDING USE: (If 4uilding rype is public, check all that apply)
032- 540-31-5701
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Fac�lity
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
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 Permitwas 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 PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM EIEV. 7. F�NAL GRADE
REOUIRED (sq. ft.) PROPOSED (sq. tt.) (Gals/day/sq. ft.) (Min./inch) g EIEVATION
t� �C (e � j �O� � � /.J �Feet Feet
CAPACITY
VII. TANK Site
in allons Total #ot � Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel ylass Plastic APP
Tanks Tanks structed
Se ticTankorHoldin Tank trbD � �' .
Litt Pum Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instal lation of the onsite sewage system shown on the attached plans.
Plumber's Nama(Prin[): Plumb r'S Signalme: (No St ps) MP/�1 P9SW-No.: Business Phone Number
f
S e.+/ y] � �
Iumbar's Address( treet, Ci ,State,Zip Coda):
'�. "r i� � �
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermitFee (IncludeaGroundweter ae ssue Iss ' g gentSignature(NoStamps)
X�1 $115 , p�urcharpeFee) 10/ 4/ 39
Approved ❑ Owner Given Inilial
Adverse D terminetion
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly PIb�7) (R. 17/88) DISTRIBUTION: Orlginal to County.One Copy To:Salery 8 Buildings Divislon, Owner, PlumDer
', DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SArETY 8 BUILDING
LABOR & HUMAN RELATIONS DI�fSION �
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES 8 APPLICATION
MA6iSON, WI 53707 State P�an I.D. N:, nber.
� CONVENTIONAL ❑ ALTERATIVE O�assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NA�.�E OF PER!�11T HOLDER�. �ADDRESS OF PERMIT HOLDER�. INSPECTION DATE:
.�
� �� ' , . ° r / � � ,r/ � , -s- � �� - � � - fi
BE�tiCH MARK ! ermanent relerence point) DESCRIBE IF DIFFERENT FROM PIAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
i
Name of Plumbec , MPlMPRSW No.: County Sanitary Permit Number. �
�/ l4 �� C V" � �/�L-t% �%'�j O ' � -�
SEPTIC TANK/HOLDING TANK:
A^:aNUFACTURER-. LIQUID CAPACITY�. TANK INLET ELEV.� TANK OUTLET ELEV.: WARNING LABEL LOCKWG COVER
� c PROVIDED: PROVIDED:
p — /�}7 ta C, ` G��(�(1 (c�. �� YES ❑ NO ❑ YES ❑ NO
BE�DING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM�. LWE� AIR WLET:
FEET FROM � � ; _
! YES ❑ NO ❑ YES ❑ NO NEAREST—� S� �I'' � S
DOSING CHAMBER:
I "A,:.•<L�F�CTURER�. BEDDING�. LIQUID CAPACITY� PUMP MODEL� PUMP/SIPHON MANUFACTUAER�. WARNING LABEL LOCKWG COVER
PROVIDED� PROVIDED:
I{-- ��YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLI ONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL: BUILDWG� VENT TO FRESN
� (DIFrERENCE BETWEEN FEET FROM �iNE AiR �NLE7
PUMP ON AND OFF ❑ YES ❑ NO NEAREST —�
SOIL ABSORP710N SYS7EM. Check the soil moisture at the depth of plowing pORCE LENGTH: DIAA1ETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soii is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH W�DTH� LENGTH: NO. OF DISTR. PIPE SPACING�. COVEF INSIDE DIA.�. # PITS: � LIQUID
I � ,� TfiENCHES�. ; MATEP AL� P�T DEPTH: �
DIMENSIONS �Q �7 ; ', ���p �_� I
' �P,AVEL DEPTH FI��DEPTN DISTR. PIPE DISTft. PIPE DISTR. PIPE MATERIAL NO. DISTR. NUMBER OF I PROPERTY WELLt BUILDWG. VENT TO FRESH I
� BELOW PIPES: ABOVE COVER-. ELEV. WLET. ELEV. END�. PIPES�. FEET FROM ! LWE AIR WLETt I
r : � � : G/. C . `13 � 3 NEAREST _► ' � S i 5�, � �Z�- � I;. �
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 TEXTURE: PERMANENT MARKERS� OBSERVATION WELLS:
❑ YES ❑ NO " ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED�. SEEDED: MULCHED:
CENTER�. EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BEDITRENCH WIDTH LENGTH: NO. OF LATERAL SPACING i GRAVEL DEPTH BEIOW PIPE: FILI DEPTH ABOVE COVERt
TRENCHES�. i
DIMENSIONS �
i
MANIFOLD PUMP MANIFOLD ' DISTR. PIPE MANIFOLD Ml�TERIAL� NO. DISTR. D�STR. PIPE DISTRIBUTION PIPE MATERIAL& MARKING�. I
ELEV.�. ELEV.� ' � DIA.� ELEV.�. PIPES. CIA.� �
ELEVATION AND I
DISTRIBUTION � I
HOLE SIZE HOLE SPACING: DPoU�ED CORPECTLY�. Cr'VEA MATERIAL VERTICAL LIFT CORRESPONDS TO
INFORMATION I APPROVED PLANS
' ❑ YES CI NO ❑ YES i_; N0 '
PERMANENT MARKERS: OBSERVl�TION WE�LS� NUMBER OF PROPERTY WELL- BU�LDING: 'I
COMMENTS: FEET FROM uNE I�
❑ YES ❑ NO ; � YES (� NO � NEAREST—�► '
�
�
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.y�S .��r C�'��'Lc'-' l, � j .�<Ls �%'-1 C �c �'1 �i i 1� -e
Sketch System on Retain in county file for audit.
Reverse Side. si�NAT / TiT�E:
SBD-6710 (R. 06/88) C� �(/f. !� fL-��i{._
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oocuMEr�r No. WARRANTY DEED ! THIS SPACE RESERVED FOR RECOHDING DATA .
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STATE BAR OF WISCONSIN FOR11i 2—1962 j �
21 � 7 '7Q � I
�_-_ --_----- __---- -- -- - Hev�rAar'u rJttfcx, 1 ' _
---- - -- _--- �
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S.M.,•rr Connty
i f�ec;elv :<1 {<�t c<i�or,l tt,e _ � da� OI
Juanita__M.._Vieth�--a._widow.....---- ------- -- -- - ------ --__ . -- iI �_ �� � �� �����ec �_ o���
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conveys and warrants to _.Tim�thy_.J._._Koback and Judith L. _____. ; Reqiete�
• ••---- -- -�--- -. .
KQ�ack,...hi.s. wife .as surviv�rship_ mar�t�l. pr.on�r�y ._.. �
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the following described real estate in .----.._..__SaW.Y.er------ - � . ` - - --- -
---�-----�----Count _ - -------- �
State of Wisconsin: �
Tax Parcel No: ------•--------------------•- I
�The West 300 feet of Government Lot Seven (7) , Section Ti�irty-one (31 ) , �
Township Forty (40) North, Range Five (5) West, excepting tf�at part
described as follows : Beginning at a point on the West line of said Gov. �I
Lot 7, 662 feet North of the Southwest corner thereof; thence running ��
variation N 84°00' E, 68 feet to tl�e point of beginning; thence continuing �i
same variation 150 feet; thence running variation N 6°00'W, 10 feet to an �!
iron stake; thence continuing same variation 182 feet to an iron stake; jl
thence continuing same variation 8 feet to the shore line of Barker Lake; ��
thence in a westerly direction along said shore Iine 157 feet; thence
running variation S6°00' E, 15 feet to an iron stake; thence continuing same
variation 136.30 feet to an iron stake; thence continuing same variation 10
feet to the place of beginning.
,
.
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This ____.1.5__[1Q�_____..__. homestead property.
(is) (is not)
Exception to warranties:
Dated this --� --.2E.------- � -- ----�------------... day of - �----.Jul_y - __._ - . __ .._ , 19. 89..
.
--- - - ----�-- - -- - -._- -------------- -- -.�s�:aL> ��.��� - - ��-���..._ _�s�,�i.>
, Juanita M. Vieth
----•----•------------(SEAL) - - - - - - _ _ - -�---- _......(SEAL)
�, �
---�--------------------•---------�-----•------�--�-•--------�- - ---. .. ..__ . _--- ---
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) --•--•------------------•--•----------------•-------------- STATE OP WISCONSIN
ss.
---------•--•-•----------------------------------------------------------------- J neau
Count--------�---------------------- Y• 6
� _ .da of i
authenticated this _._____.day of___________________________ 19.___._ Pe sqnully carue Uefore me this �- . y
---- --- -- - �
--------------uly----- - ----- -----., �s89--- th� aLove named
---------------------------•---------------------------------------------------- Juanita M. Vieth
.
------------------------•----------------------------------------------------- -------------------------------------------------- -------------------
TITT�E: MEMBEft STATE BAR OF WISCONSIN '
--------------------------------------------------�:i •--•--- - ---
,,.�:,,. ,. � :�„--
(If not, -------•------------•--- .�' '�,,
------------------------------------ --- ----- — ------ ------- — -- - -- ---,���-�-�- ;;;,:::N�s,--�
authorized by § 706.OG, Wis. StatsJ to me knotvn to be tl�e pet•son ___S_<_�_�,43�]Su�execu�'e��i�tg%;
foregoi instriament and acl.nowl.d�,�',�IIE ,l:�illt;.� '• 4: �,
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THIS INSTRUMENT WAS DRAFTED BY '
..� �. V� �.
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Curt_iss__N..._Lein_,_,LE_IN.LAW__OFFICES,_P._0. - � � : F= : � 1 d - ' �: � .
* RQl]PY�t L. IIart -= '• � � � +. :'
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E3ox_ 76.1_,__Hayward_,__4JI__54843 715/634-4273 Not�,,.,, p„Llic _-,� G� ���. � �� ��� • '"co��Qt�.,�' .�s. �
- - - -- ------�-- --- --- ------- �
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(Signatures may be authenticated or acknowledbed. I3oth n��' Con�n�ission is l�ern��inent.(If not,''stat'e'expi ��i��i
y/ :., �3
are not necessary.) date: ---/L v2.�.._ ---- . 19.�,.-.)
_-- - - -- -
_____.__ ��� �
�: ►�- �
•Namea ot Dersons eiQnin{� ia any cupncity should Le IYP�d ur I�1'intcJ I� M� �ai��tu`. �� ��
I
weititnta'l`�' nr.F.1 S'CA'CL; llAR nF WISCI)PJSL'J �1'i:�:���uzin I.,��n.l Itl:�i�l. I'�� I����