HomeMy WebLinkAbout002-939-01-5311-LUP-1992-368 E�pplication for Land Use Permit �
. � County of Sawyer o
r �
� The undersigned hereby makes application for a Land Use Permit and � �
agrees that all wor',c sha11 be done in compliance with the require- o
ments of the Sawyer County Zoning Ordinance and the laws and regu- � 1
lations of the State of Wisconsin.
PRINT - USE BLACK INK OR PENCIL
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Owner Builder
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i�tS4- 5r.i�e.t�����fv C'..7 St��tc � (.� ��35'� �,,4iveStaRp Q� �
Mailing Address�- Mailing Address
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!l�eW `�R�•;l�r�� ,�'1 N S5 i I �: �J��r�. �� S�b"i�
City, State, Zip City, State, Zip
Building L�:nd Use Zone District �Q-Z r �
(�) New ( ) Filling � � �
O Addition O Dredging Lot size a�: r .X � �74' 1� I`}C � n .
( ) Alteration ( ) Grading � �" �
O Moving On O Acres ,"1�'�j �}
( ) ( ) � `'�
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New Construction �x �
Size � ft wide ft wide �' �
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��_�•, ft long ft long
Floor area ��f .�l�/'" sq ft sq ft �
� �.
Total htg jC% � �G��to peak to peak � o
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-4�
Stories ( Stories
No. of Bedrooms ' j-'�}� �""vk�� �}�f"� �-�-�5
or waterline c�
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(year round) or (seasonal) "?3�� G rt
Type of B1dg or Addition ,af � a o
( ) Dwellin 3'�
( ) Garage gl) (2) car � :� �, rt
O Storage Building Y v� L11
(�� Boathouse ��. '�tl o�
( ) Livingroom �"� � �
( ) Bedroom .7�� "J� �.
( ) Kitchen-Dining o£
( ) Porch - enclosed/roofed •
( ) Deck - open ���,��iwl
{ ). .�-�RN�C � w
( ) � � r.
` C�G �
Type of Construction h
(� Frame ( ) Block � ��
� t: ��
( ) Log ( ) Concrete ,',
( ) Pole ( ) Steel � v�
( ) Metal ( ) _ � �
Construction Cost $ �� L��r�% ,� —
Vol :t'G� pg ���%'ti('` of deed
CS Vol Pg _ ro '�
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Cer. Soil Test �''� �' - '��.r�i� � f,,
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Sanitary Permit ` � - CL Road --------------- ri
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Issued �_�}��Qr' �qg2 Denied �,; �!
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�iv k�-l�-�D�U u-, E
Oconer Zoning Adminis rato
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SCALE: I INCH=�00 FEET FOR ASSESSMENT USE ONLY N(
DRAWN BY: DATE : 6 8 84 INTENDED TO SHOW CONCLUSI�.
C_�LON (:1 INDIGATES GOVT. LOT EVlDENCE OF OWNERSHIP OR
iDEPARTMENT OF �`�� APPLICATION �; SAFETY&BUIIDINGS
`irvousrRv, FOR SANITARY DfVISIOiJ �
LABOR AND PERMIT P.O.BOX 7969 �
HUMAN RELATIONS - (PLB 67) MADISON,WI 53/07 F-
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Attach plans for the system on paper not less than 8%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 specifie[I 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 I�y a Master
Plumber, the date, signature and license number must be shown.A legible reproduction of the soil test report or the owner's cof�Y must be
included
Property Ownec Mailing Address:
�'AR!�!. r F�OI��'R/CX !al Si07T /1S� SE���1�1�17��T N�W BR/GN7UN,MN• S�i'.:�
Property Location: Ciry,Village or Township: County:
r�1�'/��T�Y<S / iT3�I NiR q E(or�� �iJt55 �fy/�E SAW}��/�
Lot Number. elk No.: Subdivislon Name: Nearest Road,Lake or Landmark: State Plan I.D.Nu nbec
� � (lf assignedl��.�S��J
TYPE OF BUILDING
Number o�
�❑ ublic" ❑ Variance` ❑ Other�specify)" sedroons:
or 2 Family "State Approval Required. �
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY I
HOLDWG TANK CAPACITY Q � � Y �
LIFT PUMP TANK/SIPHON CHAMBER '
MANUFACTURER:
EFFLUENT DISPOSAL SVSTEM .�f ./R .
PERCOLATION RATE ABSORPTION AREA
(Minures per inchl: PROPOSED ISquare feetl: ❑ New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit
❑ Altemative(specify) ❑ Seepage Trench
Water Supply: Owner's Name astisted on Soil Test Report(lf other than present owner�: �
❑ Private ❑ Joint ❑ Public
I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans.
. Name of Plumber:. igna re: MP/MPRSW No.: Phone Numbec
G'Ui3r�s i�1�Tc',9�.r i�/qy ��r���3y-�.�y3
Plumber's Address: Name of Designer. .
C��l r�� � Gdt1 R1� //i5G 5 8�/3 C�UR T/5 /I�TC r7�%
COUNTY/DEPARTMENT USE ONLY CST 80-160
� Sign f Issui Ag Fee: Date: [�qppROVED Sanitary Permit Number:
�6�.�� 11-�-8Z ❑DISAPPROVED 311�4
Reason for Dls ovaL .
Altemate coursels)of Action qvailable: .
�
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 will.void the sanitary permit. .
DISTRIBUTION:White-County,Canary-Bureau of Plumbing,Pink-Owner,Goldenrod-Plumber �
DI LHR-SBDE398(R.07/81) �
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVtSION�.
P.O. BOX 7969 BUREAU OF F LUMBING
MADISON,WI 53707 -
❑CONVENTIONAL ❑ALTERNATIVE s�a«�ia„io.N�mne�
(If assigneA�
�Holding Tank ❑ In-Ground Pressure ❑Mound r
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER�. INSPECTION DATE.
t , f �4� �
BENCH MARK IPermaneni re�crence pointl DESCRIBE IF DIFFEf7ENT FROM PLAN�. REF.PT.ELEV.: C57 REF.PL E�_EV.
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Name ol Plumber-. MP/MPRSW No.. Coun�y. Sanitary Permit Number:
LF SA(,UY� 3 1
SB?�F6-�fek'K/HOLOING TANK:
MANUFACTUREFi: LIDUID CAPAGTY: TANK WLET ELEV_ TANK OUT�ET ELEV. WP.RNING LABEL LOCKING CQJ/�R/
�A�/� PROVIDED�. PROVIDED:�Yn LOC�
/��1� � Q�O ❑YES �NO �ES ❑NO
BEDDING�. VENT�IA.�. VENT MAT�.. a ARMn7EH � NUMBER OF�::�. ��ROAD: � L OPERTV / WELL: eUILDING�. VEfiTTO FRESH
❑YES ❑NO � G�}�''� FEET FROM 1/� �U� �� � � � °'���� •
YES ❑NO NEAREST l� a c
DOSING CHAMBER:
MANUF�CTUREH BE[)DING'. LIOUIDC��ACITv PUMNMODEL �'UM1�P,SIP4iONMANUfAC7l1HEH WARNINGLABEL LOCKINGCO`/ER
PROVIDED� PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMPANDCONTROLSOPERATIONAL NUMBER OF �'HGPERTV WELL BUILDING VEP,TTOFRESH
(DIFFERENCE BETWEEN FEET FROM ���E Aia iN�ET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moistureat the depth of plowing �Fhc;rh o��^n=_Te�v r,�Areaini_ar�o c.�aHKirvc
FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONALSYSTEM:
INIDTH LENGTH NO.OF pISTR.PIPE SPACING COVER INSIUE DIl� =PITS L QUID
BED/TRENCH TaErvc�Es �,+arEHin�: P�T o_PTH
DIMENSIONS
GRAVFL.^.E�'T�� 4ILLDEPTH DiSTf; PIPF DISTR PIPE DISTR.PIPE MATERIAL NO o�srA. NUMBER OF PROPERTV WELL BUILDING� VEPTTOFRESH
�E�nl'J PIPFS AE3UVE COVER ELE\' INLEi ELE�/.END °'PEs �.�EET FROM LINE� AIR INLET.
NEAREST-�
MOUNDSYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mountt systems to make certain that it ON REVERSE SIDE.SHOW ELE�/A-
meets the criteria for medium sand. TIONS MEASURED.
aYEs ❑No
SOIL COVER. TEXTUHE PERMANENTMARKERS. , O[3SEfiVATION WELLS .
❑YES ❑NO ❑YES ❑N�
DEPTH OVERTRENCH eED DEPTH OVER TRENCH.BED UEVTH OFTOPSOIL SODDED SEEDED rdULCHED�
CENTER . EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH�ELOW PIPP FILL OEPTH ABOVE COVER
BED/TRENCH raeNa+Es
DIMENSfONS
� � �11ANIFOLD PUh1P MANIFOLD DISTR PIPE MANIFOLD MATERIAL�. NO DISTR. DISTR.PIPE DISTF2IBUTION 71PE MATERIAL&MARKING
�� � �� ELEv.�. ELEV. DIA. ELEV. PIPES- DIA.�.
ELEVATION AND
DISTRIBUTION
INFORMATION �r �{OL[SIZE HOLE SPACING DRILLED COHHECTLv COVER MATERIAL VERTICAL LIFT CORRESPONDS TO AP�'ROVED
PLANS
❑YES ❑NO ❑YES ❑h0
COMMENTS: � PERMANENT MARKERS: OBSEFVATION WELLS: NUMBER OF�� �"PROPERTV WELL BI,ILDING-
FEET FROM ��"E
❑YES ❑NO ❑YES ❑NO NEAREST
� �rR��T1UE Lv�� (.i1�2�T�v�N To Qc��2Trg M�re�[.� ��,�Aus� /�lo ur�9knPzN�x
�a r� �� w�5 �-F��K�zo '�o �� ��+�o�� Gc�v��, siT� t,v� �soi ���vr���,
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATIJ$E TITLE �
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DILHR SBD 6710 (R.O1/82)
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IGRANTEE � S ADDRESS : STATE BAR OF WISCONSIN — FORM 1
DOCUMENT NO
WARRANTY DBBD
1954 Serendi�ty Ct � THIS SPACE RESERVED FOR RECC�RDING 0���
�. � 4 � "� 1 New Brighton , Minn . �,
— Heq1ile�'/ OHlo� � � � �
� T�11S Deed mude between CARL__H.._..ROLE I K .__�_�..as�ul Ser7er C`,o�mt7 �
.. _ ..['�..� . r
' ITl3ri---•---•-------•-----•'------------•------------•-------•-------•••------------•-••---••-----•---•--••-- A lor eeeord the � � � d �
-- -� -- A D 19$0 et � o'c3oci
' ....-�----------------••----•-----••-�-----•------�--...---------••-----•-------•••----•--•--•-••-•--•-•----•--- and recotded ia �oL� � u I
� - -•-••-•--•---......-•------•--------------------------------•------------•-----•--•-•-•-------------Grantor — ;
1nd......RODERICK__W ._..STOTT�.._aI1_CZ_.C_��Q�._�T_.__.5.7.'QT'�'5.�.______.. ot Records on peqe a U �o i
; I husband and wife as �oint tenants________________________________ �• �� �
I ---------- --------- --••-•--- -----•--•----- � �
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i Grantee,
-------••-•-- --•---...-•---•--------•••--...----••--••-----•----•-•-•----•-------•---..._..--••-••--
Witnesseth, That the said Grantor, for a valuable consideration______ �
$ 1 . 00 and other good and valuable__considerations
Iconveys to Grantee the following described real estnte in .__.SaWY.er .............. RETURN To i
� County, State of Wisconsin: � �
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� Tax Key No. --•---_...--•--••-•-•-••.-•-._....-•--
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' That part of Government Lot Three ( 3 ) , Section One ( 1 ) , Township
I � Thirty-nine ( 39 ) North , Range Nine ( 9 ) West , more particularly
� i described as follows : Lot Four ( 4 ) as recorded in Volume Three �
� ( 3 ) of Certified Survey Maps on page 220 and that part of Lot I
� � Three ( 3 ) , adjoining on the West , lying Northwest of Lot 4 and i
�', I East of a Northerly prolongation of the line separating Lot 3 ,
� � and Lot 4 . �
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This _... iS nOt __ homestead property.
� (is) (is not)
I Together �vith all and singular the hereditamente and appurtenances thereunto belonging;
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� � And....C�RL---H_•...F20LEWZCK.►_.....--�----..
' _ . ..--�- - ------ • -•------------- ---��------•--�--......_........---.....
� ' wnrrnnts thxt the titlo is good, indefensible in fee aimple and free nnd clear ot encumbrances except
I ;
i Subject to a11. easements , exceptions and reservations of record .
I ttnd will wnri•ant and defend the snme.
I �� / 4/� �
Datedthis -----...---�� i^�C. .--•--------------- day of __....___..----••- - ---..,----• -•--•-----•---•--•-•--------...---� 19_PSI_. I
i , I-•----••-------•--•---------•---•---•-••---•••--•------------•--..._ (SEAL) �--��R---^--'•"-• -• ---•------•----•-•- ---•---- (SEAL)
.
_....---�--------�------------------------------------------------ '
CARL H . ROLEWICK I
------------------�--------�----------------�--------------•------
-------------•••••----......•••••-•-•••••••.....•-•••--•••..._.....__ (SEAL) -••---••-•-•-••••••••••--•••......_.._._....---•-•-•....._...._._.._ (SEAL)
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.................................••-••-•••••••--•••••-•-.......... +
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AUTHENTICATION ACKNOWLFsD (3M $ NT '
Signntures nuthenticated this .................. day of STATE OF i�Ifl6N9�l3�"N I
-•--••-••----., 1 9._...--- /L i.I
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� �--�-�-----�'o.OK__..-----�----�--co���cy. �
- - ..-----••------•------� -------- Personally came before me, this _..���_day of j
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----- - - �-------t_.���Q_ the above named -----••--•----....-- --
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TITLT : MEMBER STATE BAR OF WISCONSIN C L . ROLEWICK , _ an adult_ man i
--- ----------•-------•-
(If not� ---��-----•---- ---- - --•----•---- -•--•---------•-----•--•----- •-•----------------•-----•-----••-- �
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authorized by § ?06.06, Wis. Stats.) ..�..,,,,� �
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� I TH19'i INSTRUMENT WqS DRAFTED BV � ,� �
i I to me known to bet't . r�_r,. _�'__ who ezecuted the
� Norman L . Yackel fore n �nstr 'i ��fl ����,�j e�p�'the same.
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Attorne� at---Law k .... ... .........� ._. ... ., ,
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' (Si�natures may be authenticated or acknowledged. Both Notary Public __:,� p��C7��G�. _ �„�: .__._.County, Wis.1 � � ,
I •' y
' are not necessary.) My Commi�n� ��,�a����.���f not, state expiration
: date: _.._..��! -`-----,j'--` �N»��n��" -� ...� 19. C � . .�
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� •Nnmca of peraone eiQning in eny capacity ahould be typed or pr(nted below thelr el
��� 3 2 0 EG -
WARRANTY DEED STATi� BAR OF WISCONSIN
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