HomeMy WebLinkAbout014-942-34-4121-LUP-1992-050 r �
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 requi.re- o
ments of the Sawyer County Zoning Ordinance and the laws and regu- �'
lations of the State of Wisconsin. r f
PRINT - USE BLACK INK OR PENGIL �t,
2
E VJ �.,
�/�"h�/h�Gf % .�ois,v a���SE D�GuNs`� :,
Owner Builder �
�.�. �a� ���
Mailing Address Mailing Address �
f�i�^iw��,o , l�l_, S��YY3
City, State, Zip City, State, Zip — O
Building Land Use Zone District I:r`��,� o �
(X) New ( ) Filling rt
( ) Addition ( ) Dredging Lot size _ � n
( ) Alteration ( ) Grading `� �,
( ) Moving On ( ) Acres . j 1 _ �
( ) ( ) ,.,
New Construction����� �or1T'/1D.✓_L£ � `
r �
Size ol� ft wide // y ft wide z
3� � ft long .�1 j / ft long W
n�
F1oor area 7L� � sq ft ��y�6��� sq ft F
, �
Total htg �y� to peak �� to peak �
Stories � � Stories
No. of Bedrooms rear lot line or waterline �, u�
(year round) or (seasonal) � �o� �� ' N rt
Type of Bldg or Addition /�l�' ^�� � � v' r
r
O Dwellin � L��`'E �,/��f �° a o
(X) Garage g1) � car ��r ����-' C rt
O Storage Bui ing loo' 6���0 r m
(�G) Boathouse /�� o
( ) Livingroom S � �
( ) Bedroom �,S�fE,,�(�3` � � ,
( ) Kitchen-Dining 5� �
( ) Porch - enclosed/roofed '� �'- (i�
( ) Deck - open � � ,y
W '
� )_ � ,e ��
( ) �d t z�, _
Ex�'sriMC i;: •' tn
f c ;_w'I In
Type of ConstYuction !� s �
OC) Frame ( ) Block ,Cor � � __ i
( ) Log ( ) Concrete '� `�
4. �,
( ) Pole ( ) Steel `:_ �
( ) Metal ( ) � ���, �
dinanc- �v'�,•� o
Construction Cost $grr/h..��-L��'°.- ,t
�/ G� �
Vo1 �F j 5 Pg ��/ of deed ���y � ,�v' I
CS Vol � Pg /�/-/FL 7�/G L�S ti E'�A y
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Cer. Soil Test �j�--_.Y'�:'- /ea� I 30' J �
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Sanitary Permit �� . , --C�`��aF,��`i��tb`a�`�--- f '_' C'
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Issued (�y fE.,��� ���,Z Denied �5�k� v«w j � �
_ � ��i1
`� �,►� I�.. .�1, � n� �, �
Owner Zoning Administ ato
c�v�� �� ur L��t�r�r� r
S�C. 34 T. 42 N. R. 9 W .
' PART of NE - SE
� '� .ia.is
IVELSON 4l
1
LAKE
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REF. � AERIAI. PHOTO C4 1970
U.S.G.S HAYWARD QUAO 1971 SCALE : I INGH = 400 fT.
SAWYER CO. DEED REGORDS
KM 5- 10-7T
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S45-61
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6�I°IC°'�d Sme°ep N�,_l�(�_�,
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� DILHR sANITARY PERMIT APPLICATION �o�"TY
In accord with ILHR 83.05,Wis. Adm. Code SAWYER �
� v STATESANITARYPERMT# ,i
CST 87-222 104176 ' �
-Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER o
8Yz x 11 inches in size.
-See reverse side for instructions for completing this application. aenTioN
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fort vnainNCE ❑YES ❑ No
PROPERTYOWNER PROPERTYLOCATION
,CL/Nd/� D�/OLE� .�KF'/a �''/a, S T ¢Z, N, R `� (o W
PfiOPERTYOWNER'SMAILINGADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISIONNAME
/?r. 3. 3Ex 3z�9
CITY,STATE ZIP CODE PHONE NUMBER GTY : NEAREST ROAD,LAKE OR LANDMARK
/-{ny�,yn,eO �i S�l843 VILLAGE : ���R��7- �E.�o�,
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): i}f.4�
111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable)
1. a. ❑ New b. L"J 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 8ed 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(Sq�u/are Feet): �j
<./O �i/,$� ��`-%" �Gz• 7 Feet u Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks Tanks structed
Se ticTankorHoldin Tank ✓ �� hSi`-jU3S� � � �
LittPum Tank/Si honChamber �C� p1 � � � �
VII. RESPONSIBILITY S7ATEMENT
i,the undersigned,assume responsibitity for installation of the privat ewage system shown on the attached plans.
Plumber's Name(Print): Plumber'/s�i naWre:(No S s) MP/MPRSW No.: Business Phone Number:
�niozy /�casr-�us�iEn,� G 393� 7/,S 79�'3 3SS—
Plumber's Atldress(SireeL Ciry,State,Zip Code � Name of Designer:
Kr� �, G�+x ��, �.�gc�� /� s9�y/ 7�-K
VIII. SOIL TEST INFORMA7ION
Certitied TSoil Tester(C5T)Nam� � / CST#
.1/c`N1✓/S /)L�.S�-jC/SS"��/ �J��i
C5T's ADDRESS(Street,City,State,Zip Code) � Phone Number
�r- / �x /�, C�+sc�� G.fi S9�Z / 7 is' 79s - 3"���
IX. COUNTV/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermitFee Groundwa�er Date Is g gentSignature(NoStamps)
0 Approved ❑ Owner Given Initial Surcharge Fee
AdverseDetermination �9� . �� $2.`'j . QQ lj-(-$]
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
CC� l�va� Z� u,� � � y , -
/s T. 3 ,Box 3.2 / 9 �
/�� 1��v .a x �� 1�C1 r
$'48-�3 sc_�� .� / "�q.p '
•r� �/R P /oo ' � Tr� .
SW j SW, �..35� .4,2, �� la-o`R44� .eLRfY1I
.L�`�.CS[�T TN � So,Z'�L BOiC �eV�
EtEI✓� � � / _ .� /OS.L
S'awvt� �.� I�,f� 5 QZ- - /oG. !
� l a 3 _ _-- io . �
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SYS r�rn ��✓- -�OZ• �
Q �pnvx �Ml� �c�v_.
g�,s
Li,�T t � 9 �
_„_� st PP� �
/�— P�Z oP �N�
R�5/,4�'?'►�''�, �
/000 �.a� • �'}' � . WEU- �
SE7o T/C 7N.0• ��,
(�Y �
� �
800�e►i
L�FT �
; _
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t �
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1 � ch,ol7o�vd.c Z ~ �� �1oir�/ �P 1
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ANDRY RA�,'�� JSSEN & SCN.,, I�;�...
Plg. - Htg - Concrete S�plic Tar�ks
Cable, Wis. 54��1
Seliers # 211768 - Ph. 715-798-3355
Master Plumber # 3938
�
�
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BU�LDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
�CONVENTIONAL ❑ALTERNATIVE s�a�eaia„i.o.N�m�e :
(li ass�9ned� �
❑Holding Tank ❑ In-Ground Pressure ❑Mound
NAME OF PEFiMIT HOLDEFi�. ADDRES$OF PEFiM1T HOLDER� INSPECTION DATE-
�L o o . 3 �ox ��- Y I J- 7 -8
l3ENCH MAF;K IFe���manNnt r�fererce poin�)DESCRI E IF DIFFEHENT FHOM PLAN REF.PT.ELEV. CST HEf� P".ELE V.
�
Ptt� l.E' O N. P V O
N�•n�ol Plu�nl�er. A1PN�iiGiN-0I C��i�+ty Sanitary Permrt N�mber:
S e n � (3� FI Cc.� "l^ o
SEPTIC TANK/HOLDING TANK:
� MFNUFACTUHER �IQUIDCAPACITV TANK INLtT ELEV TANK OUTLEi ELEV W�+HNING LA�EL LOCKINGCOVEF
VHOVIDED PROVIDEJ�
V� �OOD �� •7S l� 'S� ES ❑NO ��YES ❑NO
BEDDING. VF�YT UTA. VENT n.1,1�1 !IIf;�1lV.1TFfi NUMBER OF AOAD PqOPERTY WELL� BUI�UIN� VENT TO FRESH
I) a�,•"n' FEET FROM uNe / � I ��� ain irv�er �
❑YES JNO � � ❑YES ❑NO NEAREST O � 7 a
DOSING CHAMBER:
�,1;.n�Lii-„�:ltJUEVt BEDlJING LI(llJll)c:nf'�1C:II� �'�1�191'M�il)Fl �'IiA�PS�E'��r)NMnNll:ni:itlftE�i WAFMING�ABEL LOCKINGCOVER
7ROVIUED PROVIDE7
❑YES ❑NO 8� ❑YES L�JNO ❑YES ❑NO
GALLONS PER CYCLE: auti+P nn;u r_oNrr+o�s oPEannoNn� NUMBER OF �'H��c�r�+ry wF�� eui�owc, �eNT ro FResr+
(DIFFERENCE BETWEEN FEET FROM `�"E 'iR iN�ET
PUMP ON AND OFF) ��YES O NEAREST—�
SOI�ABSORPTIONSYSTEM.Checkthesoilmoistureatthedepthofplowing �!N��r�� u�nn�ErEr� "�nrEu�.,� nn,n��a�+�ia:�,
or excavation. (If soil can be rolled into a wire,construction shall cease until F�RCE � � � ,�
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
bVID1H / LEN(;T1� � Nt� �71 I)iyifi VIVI SV'�(.INt, C.�)VE�+. I'v;�ll)E I�i%� =ViiS LIQU�D
BED/TRENCH 2c r�vEa����ts f �����+i^� PIT uevrH
�IMENSIONS r8 �.7J
I�i�:.vc; o�:�r•� ri��uE�r�+ u�sn� „i��t uisu+ vivF oisra aiae MarENia� No n��i�+ N MBER OF vreovEF�ry �ve�� oui�oi�v� iervr ro caesr+
t3t��nv��i��i s �� ne>r>vi_covEia E i t�� i�ui i i E�E v f�,u �>i��t s FEET FROM urvE � 1 � aia irv�er �
' � IO .�S IO _�_ PYC, � NEAREST--► � IOO � '�� T IO C
MOUND SYSTEM:
�Mound site p!owed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thro�vn upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
I:�vEs Clrvo
$OIL COVER rt ziuuE � i i�rnnvi ni ��ini+nt r�s o�tsci+vntiury wt i�;
_ ��YES ❑NO ❑YES ❑NO
UE�PIIi(7VFFtTHE�J�:1+ lif17 UENI�1()Vff+THE�V(:11HF11 I�[I'ir�t)f ii)1"�(�IL ti�ll)11f11 �FfU(I) MULCHFD
C!Nl EH EDC�ES �
�YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDT�1 LF�J(ii�f NO.OF LAiffiAL SP�CINIi (��HAVEL I)FPiV1 HE l()W VIf'I FILL DEPTH Af30VE C()VEH
BED/TRENCH raErvcFaEs
DIMENSIONS
MANIfpLIJ �Pl1MP Ml1NI�f1L1) DISTH PIPE MANIf()LI)MAiF11111L N(1 I)ISiH j)I$T1i P�f'F I)ISTIiIHI�II(7Nf'INEM17ATF.NIAL&A7�HKIN(i
Fl_EV EIFV f)In ELEV �'IPES UTA
ELEVATION AND
DISTRIBUTION
INFORMATION "OLEs�rr r+��iesr�nc�rvc, i��;���F_ucnr+r�rciiv covt-Hninr[wini veHTicn�uFrcoaneSaoNosronPvapveo
v�nn�s
UYES ❑NO ❑YES C�NO
COMMENTS: PERMANENT MARKEHS p8$ERVATION WE�LS NUMBER OF PHOPERTV WEI�L. BUILDING'.
FEET FROM ""E
UYES LJNO _ ❑YES L�NO __ NEAREST— __
5 E� �w r�l�Et2s � �.o-r {� ( �N
..�N.sr����.� A�s D�w �l
Sketch System on Retain in county file for audit.
Reverse Side.
si� n rte ni�e
DILHft SBD 6710 (R.O1!82) f �