HomeMy WebLinkAbout014-841-07-3201-LUP-1992-071 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 r
lations of the State of Wisconsin. O
PRINT - USE BLACK INK OR PENCIL
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Owner Builder t
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Mailing Address Mailing Address
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City, State,JZip City, State, Zip
Building Land Use Zone District R R-a r �
(� New (�f) Filling �
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( ) Addition ( ) Dredging Lot size c� n
( ) Alteration (� Grading
( ) Moving On ( ) Acres ��;, ��is
( ) ( ) 11
New Construction �+� �,
Size Z.� � ft wide � ft wide �=
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� ft long �� ft long
Floor area zD/(o sq ft )/Z O sq ft �,
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Tota1 htg Z� � to peak )Z�s1 to peak � ,'
Stories � p/�,� '��. � Stories �
No. of Bedrooms 4 rear lot line or waterline u�
0
(year round) �al) �11 v, rt
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Type of Bldg or Addition -y � r'
(yO Dwelling �-� $ /� a o
(� Garage (1) (2)+car d r• rt
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( ) Storage Building � �, �
( ) Boathouse N o ,�
( ) Livingroom J � �,,
( ) Bedroom y� - -
( ) Kitchen-Dining £ �
( ) Porch - enclosed/roofed - - - - _ _ _ _ '�
( ) Deck - open � �
( ) �r�
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( ) � o '�
M J ��
Type of Construction ,
(�O Frame ( ) Block
O Log (x) Concrete T M � � r\
( ) Pole ( ) Steel �� ^, yuy � O �
( ) Metal ( ) P � �
Construction Cost $ yS,000-�- �
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Cer. Soil Test -D.`_�� � Q, � � �
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Sanitary Permit ���-���q ----------CL Raad --------------- z �
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Issued .5 V I �9 cJ Z Denied
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�eY Zoning Administr�ito
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�' DILHR SANITARY PERMIT APPLICATION __��_ `o
�_��.�� In accord with ILHR 83.05,Wis.Adm. Code courvrY i�N
Saw er `°
C ST 9 2-0 53 STATE SANITARY PERMIT#
—Attach complete plans(to the county copy only)for the system,on paper not less than 164286
8i�x 11 inches in size. ❑ Check if revision to provious,ipplication
—See reverse side for instructions for completing this application. si-ArE P�AN i.�.NUMSER
!. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. S 92 -- �o/S"l
PROPERTY OWNER PROPERTY LOCATION
Nie!'C ,E'i1/ .4 LL �►M�'/a .st�s/ '/4, S 7 T '¢�, h, R 8 (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# --�
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CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
�syw�za �� �a�3 - — -----
11. TYPE OF BUILDING: (CheCk One) ❑ State Owned VI AGE� NEAREST ROAD
�VKooT f�/�/�f� �p�
❑ Public �1 or 2 Fam. Dwelling—#of bedrooms '� ARCELTAXNUMBER( ) �—
Ilf. BUILDING USE: (If bui lding rype is public,check al l that apply) 014-8 41-0 7-3 2 01
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ 5ervice Station/Car V�!ash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) �
A) 1. L"! New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an
System System Tank Only Existing System Existing Syste�Yn
B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 Ll Mound 30 ❑ Specify Type 41 ❑ Flciding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: ��
1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FI►�Al_GRAbE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEV�TION
`�S� 37.� 37S /. Z e 30 993v Feet /�'/.S-'' F�et
CAPACITY ��
VII. TANK Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name �oncrete Con- Stee� 9�aS5 Plastio �p�
Tanks Tanks structed
Se tic Tank X bG� .2 tSi?�L�SSG7J �_��_
Lift Pum Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plars.
Plumb r's Name(Prin Plumber' ignature:(No mps) N4P/Mf'RSW No.: Busfness Phone Number:
Nd�� ��1�1s's'� 3 93 � 7�S ?98'3�s
Plumber's Addre s(Street,City,State,Zip Cod �
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IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(inciudes Groundwater ate ssue Issuing Agent Signatur (No Stamps}
�Approved ❑ Owner Given Initial Surcharge Fee) �
Adverse�etermination $17 0 . 0 0 4-16-9 2 �p✓�,
X. CONDITIONS OF APPROVAL/REASONS FOR DISAP�ROVAL:
SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to Counry,One Copy To:Safety&Buildings Division,Owner,Plumber
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Tha erea 25 betow the down edpp" �4.i��, r„d.ea �
gd�ppcorpti Syst�m must msln un0latu L,�i �nvK�
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. DEP Eh7 OF IN TRY,LABOR AND HUMAN RELA76�Piu
DIVI SAFEIY AND BUIIDtNGS
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p���' � �92- 24151
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