HomeMy WebLinkAbout002-840-20-5405-LUP-1992-483 Npplication for Land Use Permit x`�
County of Sawyer O��
The undersigned hereby makes application for a Land Use Permit and agrees that � �
all work shall be done in compliance with the requirements of the Sawyer County p��
Zoning Ordinance and the laws and regulations of the State of Wisconsin. �
PRINT - USE BLACK INK OR PENCIL 1
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Owner �— Builder �-�
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Mailing Address Mailing Address
��i,iAR �is,
Cit , State, Zip City, State, Zip
r �Building Land Use Zone District � - � °
( ) New ( ) Filling N �
(✓f Addition ( ) Dredging Lot size
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres �,l��f Z-'�
( ) ( ) LJ �
New Construction �
/ �'
Size � ft wide ' wide ' wide �
�i{ / ft long ' long ' long
/ '�
Floor area b OD sq ft sq ft sq ft c�
m
r
Total hgt �_ to peak ' hgt ' hgt �' �
Z
Stories �
No. of Bedrooms ��, rear lot line or waterline o
(year round) or (seasonal) .c ����li_ .�; � �� �-���� m rt
Type of Bldg, Addition Use a o
( ) Dwe 11 ing -S�� f�TTA�/��� r• �*
'�a(�/f Garage (1) 2 ��_ N•
( ) Storage Bui ing r.
( ) Boathouse � �
( ) Livingroom �
( ) Bedroom
( ) Kitchen-Dining I
( ) Porch (enclosed) (roofed)
( ) Deck - open
( ) �
( )
Type of Construction I
(✓f Frame ( ) Block �
( ) Log ( ) Concrete � r�
( ) Po1e ( ) Steel i
( ) ( ) Pole/Metal � cn
m
_�� n
Construction Cost $ �
Vol �� Pg $S of Deed � �
CS Vol _� Pg _l� �y
ro �
Cer. Soil Test �-�U`� n
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Sanitary Permit Qpj-O8� � �' �
---------- L road --------------
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Issued �� �.p�pm�. ��'(qZ Denied �� �
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�1�( I� l V�K-�-�71-�, �
Owner Zoning Administ ator
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�ERTIFIED SURVEY ��AP �
REGISTE� DECDS SAWYER COUNTY
N u n�� a E R �-- C, _
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0' S0' 100' 200' �00' �1-00' S00'
SCaLE I"= 100'
L�GEND
a I" 1 FON PI PE I.60 L35. P�R LIN�A! cC0? 30'' LONv
� ` � 2" I RO�I PI FE 3.b5 LS�. FC R I�INEAL FOC"r ?0" LON �
Cc_RTIFICA i� OF SU�VEY
1 , EDWARD E. GOBLER ,A REGISTER�D SURVEYOR ,�'E��B1'
�ERT(FY ,THAT I HAVE IN T�� �.icf�iTH OF �EBRUARY , SUR`✓EYED
THE SOUTH �IVE NUNDRt(� 50C' FEET OF GOV�RNLfEi��T LOT FOUR,
SECT ION T�N'ENTY 20,TOWN SHI F FORTY 40 NORTH, RANGE EIG!1T
8 `NEST, LYIPIG WEST OF C. I.ri. "I�C" , IN ?I-fE T�WN OF BA55 �P,I<E,
SAWYER COUN i Y, V�/ISCONSIN.
THE EXTERIOR BOUN�A�!ES DESGRIBED AS FOLLO�`i5� CO�,�i��!-
ENCING AT THE SOUTHWEST CORNER OF GOVERI`I �'ENT LOr FOUR�
THENGE RUMNING VARIATION NORTH EIG!�TY I�IINE DEGRECS EAST,
N 89�E� ALONG TI�C SOUTt-I l INE OF GO�/ERNtvI�NT LOT FOUR 4� A
DfSTANCE OF SIX HUNDRED SIXTY h60` FCET , THENGE RUNNIiVG
VARIATiON NORTH ONE DEGREE TI-1f RTY MINUTES WEST N 1�30'W�
�. DfSTANCE OF ONE HUNDRED TWO AND F(VE THOUSANDS 102,005'
FECT, TO TI-fE POINT OF BEGINNING:
?HENCE CONTINUING SANIE VARIATION A DI�TANCC OF THREE
NUNDRED NIr:ETY EIGHT P,ND TWO HUNDRETHS 398.02" FEET; �fH�'NCE
RUNNING VARIATION SOUTH EIGf-fTY NINE DEGREES WEST 589�W� A
DISTANCE OF THREE i-IUNDRED NINETY SEVEN AND SEVEN 397 7'FT,
TO "THE SHORE LIN� Of= GRWCSTONE LAKE ,TI-tENCE RUNNlNG SGUTH
�iVESTERLY �LOfvG THE SNORE LtNE A L�ISTANCE OF FOUR HUNDF2ED
FOR'T"Y SIX 44G` FEEi; THENCE RUNNING VARIATION NOR?FI �IGHT�'
NfNE DEGREES EAST A DISTANCE OF FI`✓E HUIVDRED NINETY A�lD
THIRTCEf�I �IUNDRETHS 590.13" rEET TO 'THE POIiV I Or BEG-
INNING.
N SeE SHEE-f 2
� � -- - - - - - - - ' °00' ------. 33' 50'
70' n o\� 327.7' �O� • �
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� ' O IS 533.2$' �
�I � / 35' 498.28' . `� .
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/ --- - - - - - - - - - - - - - -590.13' S89°00'W- ---- �n!
c� o��
1.5' ACRES � '
� TH f S PARGEL NOT A PART aF TH IS p1'
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i �. P L���_ I%
2��- - - -�- - - - - -660'--- -589�00' W - - - - - - - - - - - -- 33' S0' ,
SOUTH LINE GOV"T. I_O? 4 5 2p
:er�ftsd S�uvop Ao�,,,1= _--� .. ._ . _��s
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sH � Er 2 oF �2
GERTIFI ED SU RVEY MA P
GOV' T. LOT 4 S �0 T 40 N R 8 W
THAT � I , HAVE MADE' SUGH " CERTIFIED SURVEY P�tAP " BY
THE DIREC7' ION OF "HAf� RY P, MOELLER° � OWNER OF SAIp
L{�ND.
THAT , SUGH M /4P IS A GORRECT R�PRESENTATION OF ALL
EXTERIOR BOUNDARIES OF THG LAND SURVEYED AND THE
M�4P THEREOF MADE .
THAT f HAVE FULLY GOMI�LfED VJITI-f THE PROVISIONS
OF GHAI�7ER3 23C�.34 — � 36. 15 AND 236.20 OF THE WISCON -
,i�'ATUTES AND TF{ E SUBDIV1510N RCGULATIONS THEREIN
fN SURVEYING AND MAPPING SAME.
/l, ,��_.�_. �=.1� � ���� ,��". i`f=_�__.n��- �'` I����%I
WITNESS � WIS. REG. NO. 5- 527
� i c' z i c ��Cc' .� ./��� -i c-" (lx � .
wirriEss = �
SUBSCRI BED P. ND SWORN BE �ORE ��IC 7F115 �� ,j�
DAY OF • �' t'�°�r- `�:r 1959.
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MY COMM I SS ION EX P'I RES
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SANITARY PERMIT APPLICATION �o�NTY
�DILHR In accord with ILHR 83.05,Wis.Adm Code SAWYER ' �
� STATESANITARYPERMIT# �
CST 88-104 114356 �
-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBE:R �
S'/z x 11 inches in size.
-See reverse side for instructions for completing this application. penrioN
i. APPIICANT INFORMATION-PLEASE PRINT ALL INFORMATION. �� FOR VARIANCE ❑rEs ❑No
PROPERN OWNER PROPERTV LOCATION
S'�Y< Y<,S T Q,N,R � $(or)W
P PERTY WN R'SMAILING DDRESS LOTNUMBER BLOCKNUMBER SUB�IVISIONNAME
�
CITY, TATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD,LAKE OR LANDMARK
❑VILLAGE: 1 ..�
�11�
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
Iil. PURPOSE OF APPLICATION:(Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ❑New b.l�Replacement c. ❑Replacement of d.❑Reconnection of e.❑Repair of an
System � System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
. IV. TYPE OF SYSTEM:(Check only one in#1 and only one in#2)
1. a.❑Conventional �Alternative c.0 Experimental
2. a. ❑System- b.❑ Holding c.❑ PitPrivy d.�VaultPrivy e.�Mound f.❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. See a e Bed b.�See a e Trench c.�See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4, ABSORPTION AREA 5.SYSTEM ELEVATION 6.WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): q.
a� �� o� Feet Private ❑Joint ❑Public
VI. TANK CAPACITY Site
in allons Total #of Manufac[urer's Name Prefab. Con- Steel Fibery plastic'�Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks Tanks structed
Se IicTankorHoldin Tank � CA �
LiflPum Tank/Si honChamber �06 � � � �
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber'sName(Print): Plumber'sSignature:(NoStamps) /MPRSWNo.� BusinessPhoneNumber:
V a�`Cl / 6
P m er's A dress(Stre t,City.State,Zip Co e)� SL�`3 Name of Designer -
�il �� -/'+•f' .
VIII. SOILTE 71NFOR ATION '
Certified Soil Tester(CST)Name CST# �
Y .��3�3 I
CS 's ADDRES (Sireet,Ciry,S�ate,Zip Cod ) Phone Number
1 5� -
IX. COUNTY/DEPARTMENT USE NLY
❑Disapproved SanitaryPermitFee Groundwater ate Iss ingAgentSignature(NoStamps)
�Approved ❑Owner Given Initial $14 5.0 0 Surcharge Fee
AdverseDetermination $25.�� 6-29-88
X. COMMENTS/REASONS fOR DISAPPROVAL:
SBD-6398(�ormerty PIbE7)(R.03/86) DISTRIBUTION:Original to Counry,One Copy To:Bureau of Plumbing,Owner,Plumber
.
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ONSI EWAGE SYSTEM -- �
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)EPARtMENT OF IND S RY, U16f�R AND HUMAN RELA�,I�NS ''�� ', ,. '�
5'�
DiVISiON • SAFETY AND QUIL@INGS �. � ' < � � � c �',��
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BI.ILDING
LABOR&HUMAN RELATIONS D VISlON
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATIbN
MADISON,WI 53707
State Plan I.D.Number:
❑ CONVENTIONAL ❑ ALTERATIVE (�fa88d� aOt�
❑ Holding Tank ❑ in-Ground Pressure Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER�. INSPECTION DATE�. ���
�' �5 v R� • a- �ox a3�(s ��Y� 7-1 - a8 �- 7-��88
� BENCH MARK(Permanent reference point)DESCRBE IF D'�.FFERENT FROM PLAN: REF.PT.ELE�.: CST REF.PT.ELE\.:
�� l K ��1f l-E rt�E E ��0
Name of Plumber: .CdP1MPRSW No.� County� Sanitary Permit Number.
S 35"a SAwYErZ 88-o8Y 11�3s�6
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACIiY� TANK INLET FLEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVtiR
'` c� l/ GlI PROVIDED�. PROVIDED:
t'tV CV'�,'� I a-�D I �I�S t T• 3 ❑YES ❑NO ❑YES ❑NO
� BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESFL
l L�� �t �+ ALARM: FEET FROM . LINE: � � AIR INLET. �
❑YES ❑NO '1 �"1' ❑YES ❑NO NEAREST� � �3 � aS
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY� PUMP MODEL PUMP/SIPHON MANUFACTURER� WARNING LABEL LOCKING COVE R
❑YES ❑NO � WEO — G�V�-�S PROVIDED: PROVIDED:
8 IJ. ❑YES ❑NO ❑YES C NO
GALLONS PER CYCLE: PunnP nNo CONTRo�s oPEanrioNn�_ NUMBER OF PROPERTY WELL BUILDING: VENT TO F9ESH
(DIFFERENCE BETWEEN (�\ ❑YES NO NEARES�--� LINE: AIR INLET:
PUMP ON AND OFF d""'
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (Ii soil can be rolled into a wire,construction shall cease until �'�
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BEDITRENCH WIDTH: �ENGTH� NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
TRENCHES�. MATERIAL P�T DEPTH�
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV.INLET�. ELEV.END� PIPES� FEET FROM LWE AIR INLET:
NEAREST-�
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 TRENCHiBED DEPTHS OF TOPSOII.�. SUUUF.D- SEEDED' LCHED:
CENTER: � � EDGES: r ' . ' �
• _[_l YES ❑NO YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: t LENGTH: � NO.OF LATERA�SPACING. GRAVEi DEPTH BELOW PIPE RLL DEPTH ABOVE COVER:
DIMENSIONS
,O SO TRENCHES� �! ��/
MANIFOLD � PUMP� � MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEVATION AND ELEV.: •O ELE�.�� DIA.�. �p ELEV: PIPES�. DIA.:
DISTRIBUTION '� 8' �_
HOLE SIZE: , HOLE SPACING� DRILLED CORRECTLV�. TCOVER MATERIAL� VERTICAL UFT CORFESPONDS TO
INFORMATION � t�(� APPROVED PLANS
3O, YES ❑NO 1- C-\" ' �\ ❑YES ❑NO
COMMENTS: PERMANENT MARKERS�. Of3SERVATION WEl.1_S: NUMBER OF PROPERTY WELL: BUILDPJG:
FEET FROM uNE: t
❑YES ❑NO YES ❑NO NEAREST�� � ��
Sketch System on Retain in county file for audit.
Reverse Side. ruRE: rir�E
SBD-6710(R.06/88) _ `v�J+-JJ..!\ • t } �
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