HomeMy WebLinkAbout010-841-35-5113-LUP-1992-076 /
Application for Land Use Permit X�
County of Sawyer o
� N
The undersigned hereby makes application for a Land Use Permit ared agrees M
that all work shall be done in accordance with the requirements of. the Sawyer �
Coun�� Zoning Ordinance and the laws and regulations of the State of Wisconsin.
PRINT - USE BLACK INK OR PENCIL u
Joanne M. and �
�;
Donald R. Spainhower � Cain Construction Inc . ti
Owner Builder
Rt 4 Box 4612 ,_. Rt 5 Box _5209
mailing address mailing address �
__Hayward,WI 54843 ___,___ Ha�ward, Wi 54843 �
Buildirrg Land Use Zone District RR-1
( ) New ( ) Filling
( X) Addition ( ) Dredging Lot size 140 ' /244 ' x 654 ' /709 ' _ � �
( ) Alteration ( ) Grading ^ �
( ) Moving On ( ) Acres 2 . 94 � �
�
t ) � ) _
— — o
New Gonstruction laundry/bath °
Garage �
Size 20 ft wide 13 ft wide
_ �
24 ft iong 11 ft Iong
�
Floor area 480 sq ft 92 sq £t �
� 3
ai �_
H
Total hgt 13 to peak 12 to peak x G
t
Stories 1 1 �
— --- `�
No. of bedrooms 0 rear .lot line or waterline
(year r.nunci) or �����1� ��`---�- �O�6,c/ i o
Ty��e of bldg or adclition � ,� i
( ) Dwelling � / c�% /Gy• i � rt
�
( X) t:arage �f�� (?) car � ,�o � `-"._d, � a� o
� �
( ) Storage bui.l<3ing � / �� ._i � rr
( ) fioathouse � �
� i �
( ) I,ivin room t �'�- � , � o
K j z',_6� Xi��� — 6t� _-_ i
( ) Bedroom I � _
i 3 yy 3 �
( ) Kitchen-ditiing � �, �
� �
( ) Porch - enclosed/roofed ��3 '� 7 �
� � ` ��ov r k`� � '
De.ck - onen �' � _ ii y��h i �
( x) laundr _ba_�h___`�__�_. �i '�;" � � ,
po� , �--- ---- 7? __ _- -i
( ) ----- — - �i-�s-�+s �� �.� i
Type of construction �� ' {�`'k"y ` �� t
( x) �'rame ( ) Block � �'�� �'�� �M �
ih
( ) Log ( ) Concrete � , i� ��n � I
4 I �
( ) Pole iE %� -� 11
( ) Steel i �---�--i �
( ) Metal ( ) � ' w � � i U1 �
--- —---- i y i—� r47� —f �V i �
�
Construction cost $ ��.�T�__ ��� �y� � n
l.�aD �Q�— ty � I (
�T � I W
L.�.vol V 393 ____ Pg 493 ____ of cleed ; 8 � v,
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CS VoJ_ 11 Fg_ 258---- j i
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Sanitarp Perrciit87-086 '-"�"'-�, ? ,� -----_______ o �
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s � N ��, CORNER SEC. 35 CERT/F/ED SURVEY MAP
� 3�� � FD. 2/z' I.P. W/CAP ppRT OF GOVT. LOT I, SECTION 35, T 41 N, R 8 W, v, �o
� -� � SAWYER COUNTY WISCONSIN. � �
o m 33' ; fD �/j a N
O � p_ FD. �Q" ton � � �
m \ — a — — N 89'43'56" W. 674.17'— — _ran u • 6 J�� LL
FD. I"qON ,' p.o• � 654.17' / 68.49� O
ROD. w
�� ' �� � � �� tD
� � ;� a
W , �or i �,�/
= a �n /33,080 SO. Fr! _ � � ROUND
. Ct 01 °0 /NCLUO/NG ROAD EASE. 9' � — —
� N N - _ 33.1 � L AKE
Ey ' 632.06' " 22e.a3' SCALE : I" = 100'
� __ S80'54'54,�,N =i
69.3�� +
I q; 4, / O-\ N �
� i , - 313-08' Pj t°'2 a"�\
6�
3 °f ayy �/, �� e?� .
OI 1 /NS � 2 2 �
0 3 P5 �0 2 � • \ N 37'42'49" W
o �� o / ��p�E �'9.900 �a. L�� 50 �Ap EASE- A9 '"s� � 48.93'
a' � �n c�c �.°00'� � �j \. F \ IN���OM� R ,�.�.p ,�.0{13 d. zSc
— O � � �a \? O� �O 1 FD. 1�/�'LP. .. %
� 9 o-i � SC01 y$I'
�I N / Wi+_ / Z�p96 �Op OP v 156.0- � . Sy�� 3. 4��'9g5�i�l ��� �
��� e e�'� AA� 65• �RONALD L
� c"'q / � „ n�7�"g21� N 6A �I, P �/ PETERSON �
� I M m w �1.84. � .A �Q�.' I $-8�9
o l � a � G S'•' O-DENOTES I" IRON ROD SET - WT? 1.13 LBS/FT. ` H A Y W A R p
. ' � �-DENOTES MONUMENT FOUND-TYPE AS NOTED 1' . �� , 4,
� so.z"tP. � olp �2so• ' N 0'S9'49" E •-DENOTES I�/4"z 30" I.P. SET. WT: 1.13 LBS/FT . "Q � �
sw con. oF ' a sourn c� 323.64' ��r,ior� ' �Z 90, f S O'00' W 1 -DENOTES RECORDED MEASUREMENT. �� Su`�.O/�y
Gl I - $ 89•06•�rJ�• E, 343.64�- - � FD. I�RtON ROOS I `��"-- '�- � _ O
� r� � BEARINGS ARE REFERENCED TO THE N-S /4 �INE. -- �-
3 i � ASSUMED TO BEAR S 0'01'31" W.
3
`— co s AREA OF LOT 3 = 10940 S�. FT,
r� i o �
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o � I NOTE 1 LOT 3 /S TO BE AOOED TO AN EX/ST/NG PARC£L.
o - �oc� �
� � 1 �
` C '/, coRNER SEC. 35 RONALD L. PETERSON
� Fo. 2�,z� 5a� 5-08�3
JUNE 30, 1986
i I I
i
DOCUMENT NO. STATL�' BAR OF WISCONSIN FORM 1-1982 ,�'� T��� ��wea euuveo �oe xeconoiHa D�TA
2 � � � � 9 WARRANTY DEED i' •
i,
I __ _ _ . _ =_ = _ _ _ _ ll ���.c�n� l .
�� THOMAS W DUFFY and Sewyo� Cou,ry ) �
I TI'11S Deed� made between .._._' _'.. .. .. . .... .. . " .... rha3 I�r recerd Ihe �a�� deT d
RICHARD A. WARDER - - II �/,d�_ A C 1�Z c:L o'd.�ok
--------'------- ---------------------------...-'--'--_..--�----------------'--'---.....--'---'----'- �M �nd �aa:rdwo la vcl._�GJ�
------- Grantor, I� ol Hc,c..:r� on ib9a �y
DONALD R. SPAINHOWER and JOANNE�M. �SPAINHOW�R � �f_�h � �`
and.--�- �--....._... .---�--�-�-------•------...._..................��----'---'--'---'--............... ; pl� �
husband and wife as joint tenants being nonresidents,l �
of Wisconsin
........ . - - -. ... ..... ... - ......... .....-- ---- 4
...---........-�----'--......._-_......_-..'-'-.."----"-----"-........-"-'.........-'----., Grantee, !I Q+od�
� WILROSSCLIl, '1�hnL thu enid Gruulo��, for n vnh�nLlc cnnr�idcrntiun.._'__ 'I�i
Iof one dollar and other valuable coneideration �, _ _
'i . . . .. Sa er � acronra ro
conveys to Grantee the following described real est¢te in ....- .�`.'Y..... ......... I�
. County, Stete of Wisconein: I�
�� '----_ ����-�-- - -_ —
Part of Government Lot One/(1) , Section Thirty-five
� (35) , Township Forty-one (41) North, Range Eight (8)
Tax Parcel No: """"_""""""_._"""""
West, described as Lot One (1) , recorded in Volume
Eleven (11) of Certified Survey Maps, page 258-259, Survey No. 2435.
��:
I� Together with the right of ingress and egress across Lot 2 as shown on
i;i Certified Survey Map recorded in Volume 11 of Certified Survey Maps, page 258-259.
�I i
�I This deed is given in fulfillment of the land contract between the parties
i, recorded September 9, 1986 in Volume 393 of Records, page 493-494, Documen[
II201721 in the Office of the Register of Deeds for Sawyer County, Wisconsin.
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���=��.;��JF��
c�
5, _�
F�►_
Thie is not___.___. homestead property.
- - -
(is) (ia not)
Together with all and eingular the hereditamente and appurtenances thereunto belm�g�ing;
pn�_...,_grant_ors
'--'---- - � - ��- - - - - --'--'-- . ...... ....... . .. . ._ _.._......_........................
warrants that the title ia good, indefeasible in fee simple end free and clear of encumbrances except
all easements, exceptions and reservations of record.
I and will warrant and defend the same.
� Dated this -`------"-'...9th----......-----�---'- day of ------.....------...June-------------�---.....---'----., 19.87._.
II ..._.....-"-`---_'--....._-�--......_'-.--.-"-."--....--(SEAL) . ...... . ...._ -'---..._. .�-..... ..� (SEAL)
THO S . UF Y
+ �.................�,,...�.,...,.........,.,....................... • ............,�... ..... ......... r
r ......... . ......
..........._._....._............................-....(SEAL) ---....._�../L .� � / ,: �,
�I �., ,-� -��-_.�Z��Z..y�:_�...._lJ'E�L)
• ...- -�- ...- --� -... - - - .... ��-- ---- -� . RICHARD A. WARDER
- .._...__...._......_..........................._.... -
�
� AUTHENTICATION ACSNOWLED(}MENT
�I Signature(s) _'...............'---------'---.--'-'...-•--'-•--------•- STATE OF WISCO:ISIN
II Sawyer � as.
-----------------•--------•---------•--
"""•'__.__.__'_"""'_"'.____.Co unty.
euthenticated thia '_"'..day of"'-"'-"'-""•""""" lg"""
Personally came before me this _..�th. d�p of
I •-"-"""'.-"""'-"-...'--"'-"--.'--."--"""-`"- "".-- '-"'--'.-June--�--..."--------� 19.87-" the abo e named
I � ,; ;,.,y;•.;��., � _..._Thomas__W,_ Duffy._and_.Richard__a,: c4;ar,.iar
- -..... .. . , u•?„ �
. .. .. . . . -- --� ' rN
I' TITLE: MEMBER STATE BAR OF W�I f�T LCj� � ---' "" -- -�-- - .._ _....
r.�.�
i
(If not� .. . .. � ,� ._— ....
. _
i authorized b ' ' - - -" � ��� � - HLEEN N. �et�'
Y § 706.08� Wis. Stat .. 'j--------------�------------"'---------- - - - . . ..
` MILLER �`a' me known to be the person 5.......___ n�ho executed the
I� ?' f �Pgoing 'nstrument and acknowledge the same.
THIS INSTRUMENT Wq5 DRAFTED BY S��t�i ��
i Thomas W. Duffy d'*,�: . ,,;:�.-���
. -- --. -�------- - - -----------------------------�- ---,vy��
, ''•;;,. r� :',..._,•Nr. _..._._.___...
il Hayward. WI. �w`1s1C�v.�' •..._.Ka_th.l.ge-p--j�,_Mi17.eF.--.............._.._
I ..._..........."'_....._.' C .._._R....
'."..""""'_"."" Notn:•1' Pnblic .__...Sa �I' ..
I ' ""._'.
(Siqnaturce muy be nuthenticeted or acknow]edged. Both � ��� - -�""
Inre not necessnry.)
TIp Commiaeion ie permnnent. (If not, etnteUexpinrtion
j' - dntc• .. October 1 ���
� .............--'--
/Y, �/�) .'-_------7.._....-.-� n l
•Nemce o( ncreom el¢ning in nny enpocity ah i�R{i.���f� ��ed� their�nn�cs. '
.�
_ •��.��� -_ -.�., � `i'14TF IInI '1F 1PIifUA'S1S'
I! �',
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DOCUMENT NO. STATE BAR OP' WISCONSIN FOAM I1-1982 � rHu sv��. acsc�v�o row ntconoina o.0 .
LAND CONTRACT
� �� � � Individual �nd Corporoln
II (TO RF. USF.D FOR ALL TRANFACTIONS R'HF.RC O�'F.RI
� f26,000 IS }1NANCM:U AND IN OTIII!It NON-CONSWIER !
ACT TRAN$AQTI�N$1___"..."--'I
___'_ _"_' '
II RnCJ4i��OHfoe 1 �
THOMAS W. DUFFY and �r�� CMmh f �
COritTaCt by and betwean ......""""'......""""""'-""-""""....."-"" p. :ci�,.+! tor rarni lho � c4.� d
iucunii� n. wnitueit . .. 7— �C
"'_"___""""_""""_'_"""""""'_•""' ""'_""""""""'....""_""•"""""""""' ' �:�-/.. ._. ADliy�� _ al n�oi��
__"""........'__"'_.'"..""".' "'_"_"""'_"'_"_.__"""""""""""""_..... ���Vendor"� ' ��!/ _p
DONALU lt SPAINIIOWER and JOANNE Pl. -(r � �' '"'� '�'�""'�"� �" ��"�'�-r�'/�"-
whethcr ono or more) nnd_'--"---."-"'e'--""""'--""""'-'-"""""""_"---"""' o� It..��.�,t.. - 7
.� `
. SI'AINIIQWI?R,..)7q:5�7�n(�..:7Ad..W�.f_0...tS._,}.Q1,RC"'C.@.AARC.S...1IlS�..AS...... Y � •{,n �..:•� _x __.�_!,_�
- . i'ii'u._ ..�'. ��1-�--
.nonresidents_ uf,;�Ji,�conS�.n...... ("Purchaser", whether one or more). ���*
Vendnr eclle �ind n1P'ccs to convay to Purchnscr, upon tlio pronpt nnd full Pcr- . ..
formance of tliis contr¢et by Yurdiaser, the following property, together with the� ' , ��
rents, profite, f�xtures zmd otlier.appurtenai�t interests (ull cnlled tho"Property"), �' ----- -�� -��- �
. _.__.- -:z. -- - -
..Sa er.....___ �,.� �.. County, State of Wisconsin: qEr„R� ,o '
in_"'--- ""' ' c,'y Y1+ . ,. ..."_-"' , �
� „ .. j �— � f�l.r :�`
Part of Government Lot One% (1) , Section Thirty-five t
(35) , Township Forty-one (41) North, Range Eight
�8) West, described as Lot One (1) , recorded in Tax Parccl No. ..................................
Volume Eleven (11) of Certified Survey Maps, page 258-259,
Survey No. 2435.
Together with the right of ingress and egress across Lot 2 as shown on Certified
Survey Map recorded in Volume 11 of Certified Survey Maps on page 258-259.
This ._is__not homeatead property.
(is) (is not) '..
Purchuser agrees to purchase the Property end to pay to VendornY.as-. tP�_hy...VendnL.............
the sum of $.27_�000..00--.---'--------_---------------__.. in the iollowing manner: (a) $._..�000._00..._......_..._...... .._'-
at the execution of this Contract; and (b) the balance of $.�:9�.OQQ,_QQ____________._,._, �ogether �vith interest from date
hereof on the Ualance outstanding from time to time at the rate of_...tep__(107�_,_,.____.____ per cent per annum
until paid in full, as follows: said principal and interest shall be payable in monthly
installments of not less than $250.00, including interest, with said payments �
to commence thirty days from the date herein, provided the entire outstanding i
balance shall be paid in full on or before three years from [he date herein.
r�
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I'NJ1�3r}.��C1�KIXN.MIS)c0{aQwlu'tCcMXJ7tS�h�7(UAI�;t]cMx[L1Cx1(IICNMIfJt�Si[NKH]iiiWU'vY�UCfl}t7SXKdCXXXXtiYtititi:�\.l"7:tIN1cJ�C �.
.xxxxxxxxx xxxxxxxxxxK�xxxxxpcltocm�xCmekgx�teajx
L'ollowing uny defnult in pay�uent, intemst shnll nccrue nt the rate of .._LQ.._.°o per unnum on the entire umount �
in default (whicL shtdl include, without limitntion, delinquent interest and, upon accelerution or maturitp, the entire II.
principal balvnce).
I YAMIItDGXBbXHMtB➢KCN7C1I9P]I�d1yxXNMMtS7Ci�C¢'m{NTf7�7lKXilW6YG1TtXP(]i7C7[dOfT�fltiMYlY.vi3Ui&"2fUtCtltdcp; ,2U"t:�`fiPN(�}iC(�?:h�'Cft}:
�aaadc necau:�txavix�ca��af xtcaacesxwcn�hc�c5iecr,aacCm�acmca�;acnxRnuaArrAHawx x�bxo:rloco:R�A kwecrAmS.�ccn.�imad.Jh��:attix::
1tw[dxatngxixsN.��pEs�cp�5�ma�ksc&�t 8hcaocsbdit�nkmxsca:baa�dnscx idxaltc�cwxwrixxsceisxct�r,�6tixa�'v.ro�a�uxrp:z;nxxA xAx
1ffi1SA.�;t�Ss1L1i.�ti�1+7Lb�KMxffiXtla4x851CU74yG31x9uc8@9ADACi7Gi@cALZOcg2[7WSffi�OYx1GM0�cAixXUUXkllNSCXS��'C�U,(K'.Inafti3CD: �
�IS�06A H�X�f.@Ck7TS7G:C$4VR4(EC�4]T 7f�FA
Payments shall be applied first to interest on the unpaid bulance at the rate specified and then to principal. .4ny�
umount may be prepaid without premium or fee upon principu] at any Lime nfter._C1RS1I1 ...._.._..._,
Yyit�Fxiflxsod➢exviM�ueSmymxLn7caiM�5lcinaipxC[wifiamaL�cprotpMsckmxUC[�ti[mifoxXx P> I9YX:Cti�(�
iIn the event of any prepa}-ment, this contract sha11 not be treated ns in defnult H�ith respect to payment ;o long
us the unpaid balance of principnl, and interest (aud in such case aceruing in[erest from month to month shall be tre:.t�d
ias unpaid principal) is less than the amount that said indebtedness would have been had the monthly pa}-ments been
made as first specified aLove; provided that mont6ly pa}�nents ahall be cou[inucJ in the e��ent of credit of any ptoceeds
of insur¢nce or condemnation, the condemned premises 6eing theteafter excluded herefrom.
Purchaser states that Purchaser is satisfied with the title as shown by the tiUe evidence submitted to Purchaser '
for examination except: Purchaser is aware of an outstanding mortgage given by the i
Vendors herein to the Peoples National Bank to which the Vendors shall hold
the Purchaser harmless [herefrom.
I
Purrhnser nrrees to pny tho cost of future tide evidence. If ' �
be retnineJ Ly Vendor until the full purchase price is pnid. tttle evidence is in the form of nn nbstrnct, it shnll
PurcLaser ehnll beentitlal to tuAe possession of the Property on.... clos_ing._ '
I •Croea Out One . """". . .. ......... ..� ....... .
1 .'
! _, _, --_ _-,< _--—�`„`�_�_c;- +��_[� � e� ==---
- -�u r_....,n�.rT--���ai�in��,i n„a s'r,��rr u��+ �
�P li'Itil'UM1eIN
..�•�m in I.r¢nl fllent r„ .
,
� DILHR SANITARY PERMIT APPLICATION COUNTY �
�
In accord with ILHR 83.05, Wis. Adm. Code SAWYER .
��•-^�^�� STATE SANITARY PERMIT# �
CST 86- 122 86164 0
—Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER �
8'/2 x 11 inches in size.
—See reverse side for instructions for completing this application.
PETITION
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. , � � FOR VARIANCE ❑ YES ❑ No
P RTY OWNER PR P TY LOCATION
� o�,,f� �'/a '/a, S �S T �/( , N, R E (o W
PROPERTY OWNER'S MA�I -ING AD�4 RESS LOT NUM ER BLOCK NUMBER SUBDIVISION NAME
�07 a•y�% h`G�G �!1 � � ��✓�-✓�
CITY, STATE ` � ZIP CODE PHONE NUMBER VIL AGE : NEAR ST ROAD, LAKE OR LANDMARK
.S5' / .- �✓
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family � OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) �
1. a. �New b. ❑ 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 b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy 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): REQUI ED (Square Feet): PROPOSED (Square Feet):
� "� !v � � �v Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel 9�ass Plastic APp
Tank Tanks structed
Se tic Tank or Holdin Tank V�� { �./ � � �
Lift Pum Tank/Si hon Chamber � � � � �
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamp MP/ o.: Business Phone Number:
v ' '� �, � /� �� °� i�� �3�:�s �
Plumber's Address (Street, City, St e, Zip Cod . Name of Designer:
��—
VIII. SOIL TEST I FORMATION
Certified S il Tester (CST) Name CST #
� �"� �-7'
CST' ADDRESS (Street, City State, Zip Code Phone Number:
� �� ` �
IX. COUNTY/DE ARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Is g Agent Signature (No Stamps)
� Approved ❑ Owner Given Initial Surcharge Fee
AdverseDetermination $ 70 . 00 y25 . 00 6- 23- 87
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
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��!L�1R SANITqRY pERM�
—Attach.�,,..._.... ��accord wn�,„.._ r APpI 1I+.�•— '.
DEPARTMENT OF INDUSTRV, � INSPECTION REPORT FOR SAFETV&Bi
LABOR&HUMAN RELATIONS � PRIVATE SEWAGE SYSTEM$ ��
P.O.BOX 7969 BUREAU OF PLUh..j
MAD ISON,W I 53707 /
�CONVENTIONA�G/�jlupp ❑ALTERNATNE s �eP�a����m�,=•.
ui°����9��eio.
❑Holding Tank I Ground Pressure ❑Mound .
nME oc veaMir Ha�oFn�. nooAEss oc vEaMi*Ho�oer+�. ir�svFcrioN onrE�.
�a O 7S /�!/o� ' d /�leiu �-iy-8 7
eErveHMnaKive,m,�e��eie,e�aoo���ioEscaieEiroirvEaEr�rraoav�aH /JJN•5�9/� F.vr.e�ev.�. cs,Ner.vr.E�Ev.�
mro�P��.� , , �w�„ _ �.,��� � �,�.,..����oF'6
SEPTICTANK/HOLDING ANK:
rvuca.cruaEa�. �ioc�vncirr. NKiv�EiE«v. nKoui�ErE�Ev. E� �ocKir�ccovea
. cAovioeo�.
� ��; � �p� L �I��ves ❑No ❑ves ❑rvo
eooirvc- ver�.mn.. rv*�.,�u E�+ NUMBEROF eono PAOPe ry e� ui�owa Ipi`NLOTaesN
FEET FROM W�Zy' i
eOVES ❑NO A`I(Q`tiYES L�NO NEAFEST—� �ES� tl7'S
DOSING CHAMBER:
rvUFqCiUaEN BEOUING� ]�il��nin�i�♦ Minni�i�ii r.��5ii���inninNi��nc.ii���L�� nBE� LOCKINGCOVEF
PROviDED�.
❑YES ❑NO P❑YES ❑NO ❑YES ❑NO
GALLONSPERCVCLE: maarvomrvn+oisoveWnnon.,� NUMBEROF 1° �� �i���n �roFa
(DIFFERENCE BETWEEN FEET PROM�. v. a w�r
PUMP ON AND OFF) ❑VES LNO NEAREST�L�
SOILABSORPT�ONSVSTEM.Checkthesollmolswreatthedepthofplowln9 .FORCE ������� "'"�-O nr��n.�noMnNK�n�.
or excavation. (lf soil can be rolied into a wire,c nstruction shall cease uni�il .
the soil�is dry enough to continue.) MAIN
CONVENTIONALSVSTEM:
BED/TRENCH� orN men� s sir��i• . . . nvn� ,_ iu�uin = ,u rio
DIMENSIONS : ��/!� � ���/� � _ �-� ��s� �����W p1T
'PAV L T� FILL�EGTN S�v DiSTR PE MnTEHia� ��I)i �� � �Tv L� BUIL�ING VENTTOFRESN
�owPv neovecoveN e ev� � ev v rr� NUMBEROF. .,, HE
oEs�� - � FEET FROM . i ���E'�
,QUQ. EL/� P E �p P�c' NEAREST—s 5` rvEso 7�' �Ls—�
MOUNDSYSTEM:
Mound site plowed perpendicular m slope Check the textu�e of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound sYstems to make certain that it ON REVERSESIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑VES ❑NO
SOILCOVERrxruae ��n��.v�N�n�n�«nvs s���v.,notiNE��s
L-IVES ❑NO ❑VES ❑NO
eEN,eov Nruem�.��neo oe�r�so�r�+u�tvu��u.0 �����n n,�a��� — uinu irnn _o
L�VES. ❑NO ❑VES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SVSTEM:
� BED/TRENCH.� orH uan� oemcHes '�nni_v��.w� —�in�n��ui.�,wrT•i ��uein�nxovecovo+
��DIMENSIONS ��.
�o o�� oisra.viae mnNioinmaie+n — H oisniviPe oisn�a�noNvvFm.��Hnian+naK�n
���epe�F� ev n ev cs oin. . . �
'.ELEVATiONAND
�DISTRIBUTION��'.��o�esize iew�ci�v� iuruco����eun veHMnrernn� vevr iurrcoaHesPomosroaP=novEo
�INFORMATION--�� �
�� �� � ❑VES ❑NO p 5 ❑YES ❑�O
COMMENTS: AMarvFHrMnr+KEns. oes�r+va.iorvwE��s NUMBEROF PNorEAry we���. i�uiNc�
FEET FROM "E
L��ES ❑NO L�VES C_�NO NEAREST
Skeech System o� Retain in county file for audit.
Reverse Side.
DILHRSBD67101R.01/62) �"n.ur�(�-����i� � �J , (`GQL �
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