HomeMy WebLinkAbout012-640-17-3308-LUP-1992-358 • Application for Land Use Permit �' �
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 require- o
ments of the Sawyer County Zoning Ordinance and the laws and regu- M
lations of the State of Wisconsin. f
PRINT - USE BLACR INK OR PENCIL
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Owner Bui der �
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Mailing Address Mailing Address
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��z�i.-t����o'� Gl,^,-. .J-��c �S 5-Cot�l� LR-��, lx�I Sd87Co
City;'State, Zip City, State, Zip
Building Land Use Zone District �e-� o �
(^'j New ( ) Filling rt
O Addition O Dredging Lot size m r�Dt
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres _L tj�}-
( ) ( ) �'
New Construction �'
Size �� ft wide ft ide ?.
, �h
%5�c ft long f long ^
Floor area ,�jD� sq ft sq ft
� �
Total htg /.�� � to peak to peak � �
Stories � Stories
No. of Bedrooms rear lot line or waterline.� , u�
'�`1"��,s.�; o
(year round) or (seasonal) �z43'oIZ ` � rt
Type of Bldg or Addition 5' � S' ��� \ a o
( ) Dwelling .� �So' si � rr
( ) Garage (1) (2) car � r.
(�) Storage Building �'
( ) Boathouse � , ,i . o
( ) Livingroom � „_ -����� �
( ) Bedroom � ,.�
( ) Kitchen-Dining I � r�� �
( ) Porch - enclosed/roofed n' � �
( ) D,Q/��)k - open 'v �
. �� 7='!-.�U.'v f. �Y v� G I N o�"
� ) � '/�� � ;� L
Type of Construction N � \ �
( ) Frame ( ) Block
�
O Log O Concrete I Fv�S�,v� i����,�%� �-Fw
( sfi" Pole O Steel ; F,�a � � cn
(��j�Metal ( ) Co� � q� , m
�.� � KU;l^��� i 1 n
Construction Cost $ /`�'�'�c" ! ~ '
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Vol. !�9{D Pg 7tC� of deed
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CS Vol �Z Pg Il-�G' 4 �-I•� - ro �
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Cer. Soil Test �� � l��r'� �
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Sanitary Permit �r � ���- - CL Road z
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I�',.i c� �;,c�c� • z
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Issued 2? �Q�U�--t.fYl�, �q�(Z. Denied ,�
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i� .�6� �':��-z<t'�cre'` _; �T�i.ar.i � - C7 DUT�1 �
Owner Zoning Adminis rat r
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SAWYER COUNTY CERTIFIED SURVEY MAP
Part o£ the SW4 of the SW4, Sec. 1�, T. 40 N., R. 6 W.
BASE OF�0.1NOS
SCALE 1��=100' TN uNE SEC• FD 2�/Z��P
� NOP 2637.94' N/4 CON.
N BB'28'04"E SEC.17
� I�� 21�0 F02V2" 131fi.79'
I.P.NWCOR _ �
SEC.17 ����^^
P b`J
� R�i�'e ote�
O—FD 3/4" I.F Sawyer Coun }'
•—FD.3/4�� I@ON ROD ty
Q—SET�4�X24�I.P. w}.1.131bs/ft w Aeceivedforremrdthe o�� a
� —� A D 19_a� � ��
0 !!!��� o'alock
' N o�and recorded jn vol.�
60 99 N90' r � on pa9e_��.z-
59(�d W 297.00. — .
.3g•pB"�5 3 R003 �� ...
N e9 C/L POAD EASFMENT A`=9�Re!
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SIIR4EYOR'S CERTIFICATE
I, LYLE L. ELLIOTT, regietered land suxveyor hereby certify that by the
direction of RANDY LEONARD, I have aurveyed and mapped the land parcel
which is repreaented by thie Certified Survey Map:
A part of the Southwest Quarter of the Southwest Quarter, Section 17, Townehip 40
North, Rang+e 6 West, Town of Hunter, County of Sawyer, State of Wisconein, and more
particularly described ae follows:
Coffiencing at the Northwest corner of said Section 17, thence N 88°28'Oty" E 1316.79
feet; thence S 0°59'3�" E 3939•60 feet; thence N 90°00'00" W 297.00 feet to an iron
pipe being the point of beginning;
thence S 90°00'00" W 60.99 feet to an iron rod;
thence S 61°51'06" W 195.69 feet to an iron pipe;
thence s ie°34'54" W �66.5� feet to an iron pipe;
thence S 89°10'48" E 210.82 feet to an iron pipe;
thence N 16°40'00" E 264•2T feet to the point of beginning, said parcel containa
1.0ly acres more or leae, and is sub�ect to ar�y eaeemente or reatrictione of record.
I have Pully complied with the provieiona of Section 236.34 of the Wisconein revised
Statutes and the eubdivision ordinance of Sawyer Covnty in euxveying and mapping eame.
L. LLIOTT�S 1300
D : Septe�pber 6, 1989
I hereby certify that thia survey ie oorrect to the
beet of tqy lrnowledge and belief.
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SAWYER COUNTY CERTIFIED SURVEY MAP N�°E �Z' ''
�,,— — m
Section 17, T.40 N., R.06 W. Pti�y�' ag a
�ag/ \90
Certified Survey Map For: g�y I,EONARD /.��
A part of the Southwest Quarter of the Southwest 6�oy`
Qvarter of Section 17, Townehip !�0 North, Range N w
06 West, Town of Hunter, County of Sawyer, State ��
of Wieconein. / $�
e
L. ELLI , land suxveyor �
WI consin Regietration S 1300 �/
I hereby certify that thie survey
is correct to the best of �y g�
lrnowledge and belief. g A
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NORTH LINE SECTION 17 ; v $
N88°2909"E 2837.94' /� LOT O
LEGEND 1316.79' � I F
^a a 157�
� FOUND I-I/4" IRON PIPE �iv ^_N / B93SF,
u- > 3.63AC.t
� FOUND 3/4� IRON ROD ;� w pa/
Z Y. M $ 2 LL (yg W
p FOUND 3/4� IRON PIPE m b � �.�Q ,p
O FOUND I/2� IRON PIPE a �+ m =/ �N
� FOUND I�� IRON PIPE O N
0 SET 3/4��x24"IP.WT. 1.13L85/FT. ZgT�pWp� $�
�i/
//5q': 3 7�o°35'W p6.8'Rec �/
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r7s.sp. 206.84' Q 'a
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Z�SF� �HIPpE�F�`�\ N SCALE : .�1"��= 100�
`J°\o /SF`' , l` `` p 100� 200
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����� �� � CI �,Z �,� ro T<—Z '��Sheet 1 of 2, Page 1 of 2
^'9�.��aWi�!! /a /
5.
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SAWYER COIINTY CERTIFIED SIIRVEY MAP
SIIRVEYOR'S CERTIE'ICATE
I, LYLE L. ELLIOTT, regiatered land aurveyor hereby oertify that by the direction of
RANDY LEONARD, I have surveyed and mapped the land parcel which ie repreeented by
this Certified Survey Map:
That the exterior bowadasies of the land pascel surveyed and mapped ie deeoribed ae
followe:
A part of the Southweat Quarter of the Southwest Quarter of Seation 17, Townehip !y0
North, Range 6 West, Torrn of Hunter, County of Sawyer, State of Wiaconein, and more
particulaxly deecribed ae followa:
Commencing at the Northv/est corner of Section 17, thenoe N 88°28'04" E 1316.']9 feeti
thence S 0°59'3�" E 3939•60 feet; thence N 90°00'00" W 297.00 feet to an iron pipe
being the point of beginning:
thence S 16°!�0'00" W 83l�.02 feet to an izron pipe;
thence S 70°52'20" W �85•39 feet to an iron pipe;
thence S ly°58'00" W 119.13 feet to an iron pipe on the shore of the Chippewa
flowage;
thence N 73°23'05" W on a meander line of eaid Flowagw 225.60 feet to an iron
pipe;
thence N 65°06'05" W on said meander line 1j1.88 feet to an iron pipe;
thence S 25°11 '00" W on said meander line 78.61 feet to an iron pipe;
thence S 42°57'15" E on eaid meander line 102.88 feet to an iron pipe;
thence s 56°4i '25" W on eaid meander line 68.55 feet to an iron pipe;
thence N 12°53'25" W on eaid meander line 105.51 feet to an ixron pipe;
thence N 7�22'15" E on eaid meander line 211.87 feet to en iron pipe;
thenoe N 38°07'03"E on eaid meander line 316.06 feet to an iron pipe;
thence S ']1025�05" E 206.84 feet to an iron pipe;
thence N 18°34'54" E 479•4i feet to an iron pipe;
thence N 61°51 '06" E 195,69 feet to an iron rod;
thence N 90�00�00" E 60.99 feet to the point of beginning, eald paroel containe
�.68 acree more or lese, including all land from eaid meander line to the watere
edge, and sub�ect to any easementa or restrictione of record.
I have fully complied with the provieiona of Section 236.34 of the Wieconein revieed
Statutes and the eubdivision ordinance of Sawyer County in eurveying and mapping same.
�°���rj�,o��},��ry
� ', a
.J�� Y;� S/+Y�+, L. ELLI , an e yor
,-''Y` �'�''y .
Wi oonein Regi ration 5-1300
� LYIE L ELLIOTT Date: March j0, 1988
� S-13a1
SP(TONER, WI I hereby certify that thie survay ie correect
% : to the beet of � lrnosvldege and belief.
., �.
a
,,��eOl��d SUfd6j6a°?�
==�z�.«,:t,=� -,, � 5 '7 �
�,� �� � ,J
gasYlt COuntY
A�eived(or{¢cord 1h°��� .
I—' AD19�I m oe�oat Page 2 of 2, Sheet 2 of 2
--�e�-�M.and recorded fa voL
o[(.!!M'• °n D�Ue—��
f`-���� �A� L
---�'--AoWetec
°°°'�` /,� �
DOCUMENT NO. I STATE BAR OF WISCONSIN FORTf 3-1982 TM�S SPACE pESEflVEO FOq qECOflDING D�T♦
2 � �l 1 1 % QUIT CLAIM DEED
-----------�-----I �— --- Neout�i�011lc� � .
-- ----------
i.wre� Caunlr
,,,,...RANDALL..U:_LEONARD end MAR6ERET C: LEONARD, hls �t°• �"� •'O'•a �r '?'s d•� •�
� �-�� (� �_ A D 19 � al o'docl
wlfeR_ and JEFFREY S. LEONARD, a resldent of the . ..� Mnaa�e��d�dio.oi.�
State of Illinois � —
�� � � ALLAN W� �LEONARD�end R�NE L. LEONAR�; fiusbanil °� H�°`da °���a�Q�—
quit-Claim9 to . _ .... __...' .. . . .
and wife as� survivorsiiip.marital _property . . _ _ _ _ _.. . A�
--- ----��- - -- --� -� -- - - ...._.... - - -- --...- ..... --- ....... - ---�- �
_..-�-�-�. .............. �--- -- ._.........- -....__...------ -� � -- - - -- ---�� - Pw■h
...............................�--- ._...- ---------.....-------�-�- --�- -- ---- - - �-�- --� �
. . Saw er .-�--�-� --�............. ca��c
the followmg JesenLed reul estnte In .............y......_ Y, 1fu
State ot Wiswnsin: �1II�IG�BI��A.—K6IS8y;�Aa•�: � �� �----
P.O. Box 1071
� Hayward, WI 54843
Tax Pnrcel No: ..............................
That part of the Southwest Quarter of the Southwest Quarter (SWY� SWY�)
of Section Seventeen ( 17) , Township Forty (40) North, Range Six (6)
West, described as Lot One ( i ) recorded in Volume Twelve ( 12) of
Certified Survey Maps, page 447, Survey No. 3084.
TR�SFER
S
FEE
I S f10t .... homeatead p y.
Thia ........................ Pro ert
(is) (is not)
Dated this ........_�9LIl.---- �--'-----........ .(.�f1 ay or .... October .� 1e_89..
// � � .` ��:«!l (SEAi.�-�--. . ..GC¢:.�--�LR�/...��............1..... ..... . ....
. j�F� ..2:�d .. .,�c� - --- --. �..__._... . �/� ../.......................(SEAL)
/ / (
. ..FFRE.._S,_..LEONARD._._....__.__...._.... . RANDALL_D.,._ LEONAR� _.
...... . .......... .. . ... ... .... . .. ...._ISEAL) . l�/I.�A.!f��ln� l' . � ,CJl1�l;-1- :� ........�SEAL)
• ................._._._......................................... • MARGEREI..C_..LEQNARR..._...._ _.... ... ....
AUTHENTICATION ACHNOWL�D�MENT
s���at�,.efa� Jeffrey S. Leonard, Rdflddll STATE OF WISCONSIN
D: Leonard and Margeret C: Leonard � ss.
_ ' ' ' ..""""'...........y......."'.....County.
nuthenticat ie ._.. ey ot_..0 . ' b21'_. 1989. Personull cume before me thia _....._........day ot
� ..._---.-_--., 19....-_- the above named
• -- ��- - ---- -- - �--�------------�-----•
-- ��--•---�--- --��. ............. �• -- -- -�� - --��- -�---��--�-�---�
. Mi ael A. Kelsey
...... .._... • -- --�---.. ..... ............��- ��-------�---�-�- -��- ....--�� �� �------- •-�----��---� - - --------------��--�----�- —
TITLC: MEMBER STATE B OF W SCONSIN �
----------�-'-----------'---`--.__......------------'-------------'--'-
([f not� -----.._....-'------�--'... ... ............—......._.
'--'-------....------"--`�----...._.."------�--�-'-----'-"'----
I authorized by § 706.06, Wis. St ) to me known to be lhe person ............ who executed the
foregoing instrument und ucknowledge the aume.
TMIS INSTRUMENT WAS DRAFTED BY
......""'"'_"""'"""_""...............'_""'"'_'_'""_""_'__"""......._..
........ . i.c ae ..A--KQ1.s�X..-..Att4r.nex...--.--......
.
_.. - ..... .. - - ......... -- ... -�-- -
----_-- aYkldr..,_Wt_sconsin__ 54843 rro�aTr r���ii� .-----.--.----.-- ---cou�cn Wis.
---..... � -- - �----- -..
(Signah�res mny Le authenticaled or acknowledgeJ. I3oth Tfy Commission is permnnent. lif not, stute espiration
nrc nut necessury.) dale:
.._.._.._..--�-----.....___.._----------� 19....---•)
''�L� 4 x PG � � 2
QUIT CI.AIM DI•:G❑ ti'P\'I'I; II\It IIF 1i'itil'IiNti1N N'isn�u.�,in L��cn1 ul.,�� n., �.,..
I II II
' i
�
. DOCUMENT NO. I STATE BAR OF �'VISCONSIN FORM 1-1992 �I� T��� enwci eeeenvw ron ncconomo DATA
WARRANTY DEED i
--- �� � 5a-� � --
---" . . .--- ---- -::-- :..-�- — —� Mcc'�tos�e01lfoe
I) THADDEUS W. DZIALO and Sa�"�e� Cam } '
� This Deed made between I h y �
� "'.........""".............""..............""""' Ae,:e�ved lor record {he da7 d
ELEANORE_.T_.__DZIALO his wife ____________________„__._ i • �,,
.� . . . .. . ... ...............
� - - - �-� ----� � ,�y , ���111
i �C,/ ,�d A ed
- D 1 al o'dock
_ , an reoo� ln tol�
.. .. .. . . .. _ ......' "... . .. � GrenWr. � al hoe:.:ie on e�
and _ ALLEN W LEONARD and JEFFREY S. LEONARD and _______._. �, Y •
. . . ... . . - -' --.. . --- �-
RANDAT T D LFONARD as tenants in common I - c'tCSr-c... ,�Ic.-�
.
..-�-�---_._...._....--.-.._.._--�'-..............................................................'---•-" XW��:
'------'-'--'--------'------�---'--'-'--'....................'-'--""-�----•'----.....---"----'-----• -- -
.............._...._---....._.- -�- ..... - ----��-- ---��- -�--...-�----�-�-��----....� Grantee, G+Dri
Wltri8552t11, That the said Grantor, for a valuable coneideration...... '�,,�,
of one dollar and other valuable consideration -- - -- --
. ... -_._._........._... ...__... - -- ._..... ......... . .. .. .... .. .. . _
Sa.. _er PETUPN TO
�i conveys to Grantee the following described real estate in ............�'Y.................. /�
��� County, State of Wisconein: (J�� � �
Ii
That part of the Southwest Quarter of the Southwest Taz Parcel No_ _______________________
...--------
�Quarter (SWZSW�) , Section Seventeen (17) , Township
Forty (40) North, Range Six (6) West, described as Lot One (1)
as recorded in Volume Nine (9) of Certified Survey Maps, pages 93-94,
Survey No. 1870.
This deed is given in fulfillment of a land contract dated August 26, 1982
and recorded September 1, 1982 in Volume 342 of Records, pages 468-470.
Subject to any conditions or restrictions set forth in the aforesaid land
contract.
$�D aER
FEE
This is not._.__..__ homestead property.
...............
(is) (is not)
Toficther with ell and singulnr the hereditamente and appurtenances thereunto belonging;
p„� ._. grantors
- -..........................----�-'--......................---...........--............_._------.............-.....--'--
wnrrnnts that the title ie good, indefensible in iee simple and free nnd clear of encumbrances except
all easements, exceptions and reservations of record.
nnd will warrant and detend the same.
Datedthis ..............------'-'-----��--'------.-.. day of ---......._---..._.....-- -------._...........--'-`-------., 19...--�--•
------...__.....----------....----�-------------------._(SEAL) �---L�� GC/C�;I�J.---�SEAL)
._---------'-----'----l��--��-----
. � THADDEUS W. DZIALO
- - �- ---- - ... � - -�---�-•-- - -...-- --�- - - -- -- - - -
.................-----......_..................-�----�---...........(SEAL) x .�„(,Gy.:Id�F2�C:Q1. ..... ... ..L� �SEAL)
...
� - � `` ---..��..�....
' .................. -- -.._....... - -�--�-�- ---- ......_ . ELEANORE T. DZIALO
P.UTHENTICATION ACKNOWLED6MENT �
ISignature(s) --------------------------------------•-•---•----•---•...__. STATE OF WISCONSIN
I •---••---••----�----•-----------•----�-•----•---------•�---------••--- SawYer as.
---...---•
i Y
...'-'-_"-"--'-"--"""""'-"'.Cou n t
authenticated this ----._..day of-----•----.-----•---------� 19---•-- Y�-
Personullv came before me tLhis/'._. _ ._. _..__day of
----------'----------'--'--------------------•-'--'-'--------------------------- -------"-�'f-���--- "---- --� 19_U..G the above oamed
Thadd�us W. Dzialo and Eleanore T.
- -�-------- ------•----------------------------------------------- --------
"...--� --- ---- - Dzialo
TITLE: M�MBER STATE BAR OF WISCON.SfN":;:5:��- - -�------�------------�---------•----�-----------�------------------------
I (If not� --'-'--"--" --�---- - 1'�.V...':_'•.�...� i,.""•"'---"""-""--""--"-•""-""'-_"•'-"-""•_""""""""'
authorized b "�-""'...-"---_ �.1 � �'f�•
Y § 70G.06. Wis. Stnts.)=C� (�v�j-""-'-.--'---"---.."---'---'-----"---"--"'---
"._""._ ...___.'.'_
� �, <to�ne kno�vn to be the person ...__._..___ ��ho executed the
i{:i T HOh1„�. �`. fo�� 'ng ins snmfiR� nd a no
THIS INSTRUMENT WqS DRAFTED BY f DUF�� �� �
� � ..F .
---Thomas_.W._Duffy.----------�----•--...._�.N,,,_ ---�-�--��-- s-- -- ----- ---------�----- ._-- -�---- ... - --- --
- Hayward.t..WI.-- ��I��9fF NS��=�- --�- - --��- ------ --�- - -- --- �� -- - - --- - ---- --
-�-------------•----- - �
- ---� -- --- 1 OF. Sawyer
�fj" 1Vr$C `�NotarY PaLlic ---:----- ------------'---'---. ountc, �Sis.
II (Signatures may be authenticated or acknowled�,J�H.\�jpp���� hf�� Comm�saion..�s perm¢nent (if not, state eceirsiir�
are not necessnry.)
t + � .. THOMAS W DUFP`(
,'�"OL� � 6 �'G 3 �� ��� .. �9___ ...�
_ NOTARY FU ..0
•Nemrn of nersane eiRning in any �npncity ehould be tyved or SAWYER COUNTY
ndnted below Iheir ,�e�em�es. My Commission Is Pem�anent
' � )
DOCUMENT NO. STATE BAR OF WISCONSIN FORTI 3-1982 nas sr�ce neseevco rox necoxome o�re
� �� � � � qUIT CLAIM DEED
i...,.�...y ... . .- . . . .. .�,,. . _ _ . .. __......M1.....wu.wui...uwar.� , .�... .,.., .. H�YIM��'�Otllo�
.. . ��wyat Counly } �
ALLAN W LEONARD and RENE L. LEONARD his wife and_____ aeCe1 eyd ��< <e���a my9 � da7 0�
- --" -._. . .. .-'. . .............t.... ..... �U2ai A D 150� .
JE�FREY S. LEONARD, a resident of the State__�f . Q °� °°�OCt
---:...._ - - -- -� - � -- - - � - - -� --�-- - -
i 1 1 1 f101 S M nnd cococded in vol�.�y/
...... ........._._.."..-.'.__.."........'....._..........."......_._.._.'_.........__....__.._.'.'
• RANDALL D. LEONARD and MARGERET C. LEONAR� ���dco d on pn a ��e.—
qcit- la� s to --------- ........._'---:_._...------._..._......-"'- -"- - - -
fiusband and wife , survivorship marital property _ �
Peqldu
._...... .......�---- --�----�--- --�----.._..-----....----._.... -------..........._............. �
tha following deseri6ed real estate in ..SdWy21'..___.......................... �Qunty, �i
$tate of Wisconain: ncronn ro . '.. I
�����t i' i-I4e�f �n,�
_ ==I ,
� Tax Parcel No: ...................'----.--'
✓fhat part of the Southwest Quarter of the Southwest Quarter (SW9� SW'h)
of Section Seventeen ( 17) , Township Forty (40) North, Range Six (6)
West, described as Lot One ( 1 ) in Volume Twelve ( 12) of Certifed
Survey Maps, pages 126-127, Survey No. 2912. LESS That part of the
Southwest Quarter of the Southwest Quarter (SW'/, SW'l�) of Section
Seventeen ( 17) , Township Forty (40) North, Range Six (6) West , described
as Lot One ( 1 ) in Volume Twelve ( 12) of Certified Survey Maps, page
447, Survey No. 3084.
_ h"E�
, . S_.
� ,..,, �=rtQY
��
This ...._.�.5 �Ot homeateed property.
(is) (ie not)
Lated this 19Ch...._._---__-- dey of ...October
... -- . ._.. . _.. . .___......._...... _ .._........, �s...as.
.'�,��. Tu�: .._��4\...��o�-ci'.`.�(SEAI.) ..�-Gea:!:4:.G...�.��\:�_�_.�...'�EAI.)
JEFFREN' S. LEONARD . ALLAN W. LEONARD
........_.__....................... ........................ _....._............._.._. ._- -- - ..._....._...,-.
� J � /
.. ......................—�------.........-------............(SEAI.) .... .. Qtrtz......_f�.:....�.:���Yi�.......(SEAW
� ........- �- ..._...__..._.... — �- - ................. • _.RENE .1....LEONARD..._..._......_...............
AUTHENTICATION ACKNOWL�D6MENT
Signature(s) �effreY_.S...LEOfldl'd AI �d� W_ STATE OF WISCONSIN
---"------ - �
I_eonard and Rene L. Leonard 88.
.....""--"—'--•-' '-.-"'-"'-"'-'-'-""'-""'-'...._..""'_"---"-'-• County.
""'-'--'--""--------"---------
authe i " hi .�y of.... ................. 19...... Personally came before me thia .._.............day ot
9t 0 o er 89
� - ..........................�---��-�----.., 1�J.---�-- tLe nbova named
...... .........................
. ichael A. Ke .............�- -- -�--�------- � - - ---..-_.---�-�-�- •---•---------
... � --�........ ......� - --- ----------..... ...--��-�----�-�- -� -� -- - - -...-�---�-�-- -- - ----� - -- -----------• �--�-�---- '
TI I.E: MEhfBER STA BAR OF WI ,ONSiN �
...---_.._-`-----�---"---...---'-------.......-------"------'-'�------
(If not, .--'------�----"'--�.........................'----... �
-----�---��------................-------------.........---"----�----
authorized by § 70G.06, Wis. Stets.) to me known to be lhe person ......._... who executed the
foregoing instrument und ucknowledge the eame.
THIS 'INSTRt1MENT WAS ORAFTED BY
Michael A. Kel se Attorne .___................ ....__.._....._..... � � - -- --- �-�-- ....
� - �--�� -- ... - � - -- - -y ---.... - - -Y . ............ �
.
-... � ----- -- ......... - -� ---�--- ----
_....ayward.,..Wiscons_in 54843 Notury PuLlic _.-.---_.............__..._.------._CountY, Wis.
-- - - - -�- - --- --
(S�gnutures may be authenticnted or ncknowledged. 13oth Tty Conunission is perm�nenL�If not, state expiration
nrr no[ necessary.)
- = ==va��: � � �� � ���: __ _- _ _ _ - .. . �9 _.. .,
SANITARY PERMIT APPLICATION �o�"TY
� DILHR SAWYER a
� In accord with ILHR 83.05, Wis. Adm. Code
� STATE SANITARY PERAIIT�/ �
CST 88-208 114464 �
-Attach complete plans(to the counry copy only)for the system, on paper not less than srnre a�nN i.o.NUMe=rt �
8Yz x 11 inches in size.
-See reverse side for instructions for completing this application. aeTirioN
i. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR vnainNce ❑ves ❑ No
PROP TYOWN R PROPERTYLOCATION
(�J Ya��Ya, S / T y0, N, R �� E (or)�
PROPERTYOWNER'SMAILINGADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISIONNAME
�� ��c Y�od���g
CITY,STATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD LAKE OR LANDMARK
O VILLAGE : U " Q _�/ i
II. TYPE OF BUILDING OR USE SERVED: /
Number of Bedrooms if 1 or 2 Family /�O � OR ❑ Public (Specify): d .
III. PURPOSE OF APPLICATION: (Check onry one in#7. 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 SystE�m
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 oniy 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. ABSOR�yPTION SYSTEM INFORMATION: (Check one)
1. a.1�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): o
� 0 � � D � / �i-� Feet � Private ❑Joint ❑ Public
CAPACITY
VI. TANK in allons Total #of Pretab. Site Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel 91ass Plastic APP
Tanks Tanks siructed
Se IicTankorHoldin Tank ❑ ❑ � ❑
LiftPum Tank/Si honChamber ❑ ❑ ❑ � �
VII. RESPONSIBILITYSTATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumb fs Signature:(No S[ ps) MP(GEP.&SW-P1e.T Business Phone Number
�uo d C�r .� �Z � yl� � � --ary
Plumber's Address(Street,Ci ,State,Zip Code�: Name ot Desi ner
� �
VIII. SOIL ES INFORMATION
CertifiedSoilTeste/rfCST Na e CSTq C � p'
�O.r� d � �
CST's ADDR SS(Street,City,Slate,Z� Code) Phone Number:
-� 7— �1 � � i r j cS�'�i •� � -�8, r
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Is Agent Signature(No Stamps)
�Approved ❑ Owner Given Initial Surcharge Fee
AdverseDetermina�ion �9� . �� �25 . 0� 1�-2�-88
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(tormerly Plb-67)(R.03/86) DIS7RIBUTION: Oriqinai to County,One Copy To:Bureau oi Plumbing,Owner.Plumber
:
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