HomeMy WebLinkAbout002-840-17-5309-LUP-1991-035 Application for Land Use Fermit x .
County of Sawyer y �
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1'he undersigned hereby makes application for a Land Use Permit and ayrees '
tliat all work sliall be done in accordance witli the requirements of the Sawyer �,
County Zoning Ordinance and the laws and regulations oE the State of Wisconsin. (�1
PRIN'P - USE ONLY f3LACK 1NK/PIiNCIL �k� �
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SUd�1 �
1�OYr,�(D i� �' �Y( ! �I C i bc.Ut�l��._ y
Owner Builder � �
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mailing addr s mailing address �
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city, state, zip city, state, zip
�uilding Land Use Zone District �GL-�
( ) New ( ) Filling I
(� Addition O Dredging Lot size �Odl��7 X >I(p/2t;Q s �
( ) Alteration ( ) Grading ' t m �i
( ) rtoving on ( ) Acres �%x
( ) ( ) �
New Construction "D�('� �'�
Size .ry5 fl: wide �v ft wide r
H
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ft long e�'v ft long ~
Floor area ��� sq ft d 0� sq ft �
I� � � � � /� �N
Total hgt[IQC� ����+�.o peak ; �b to peak x
WI V/0 �J���_J _ _ C�'�r'1� �
Stories C��r�p�
j ,--.. d
No. oE bedrooms � ` '-=-��r.-waterline
�°.1✓'f- n � i
(year =ound) or seasonal) � _ --j�—„ �
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lype of bldg or addition �"-� � o
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( ) Dwelling � � �
( ) Garage (1) (2) car i � ry�'
( ) Storage building � i � i < rt
( ) Uoatliouse � � � �
( ) Livingroom � �� i yI�U
(.�Uedroom � '� � �
( ) Kitchen-diniug � �'�`
i,�
O Porch - enclosed/=oofed � � �N � �o'� �'�; N
(?Q Deck - open � i r, �:�' - ��r+�� \_� i,�'_± i
( 1 �'� � � ..�, ' i � � �
( ) �I Y ��� �7!{Sti�1 � ��IY/ N', jJ �I..-
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Type oE construction � � —�pr �° � � _�`� i ,�I �
(� Frame ( ) Block -� i � ,�! ( � �
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( ) Log ( ) Concrete � l �
( ) Pole ( ) Steel � �
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( ) Metal ( ) j �
i iy � N
Construction cost $ ���1`.�.C�(,� � � �
i 5� � i
Vol �q� Pg o��J� of deed j �� i --1
CSM Vol _`�_ Pg p�p O"_ --
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Cer. Soil Test 8(p - ��q- j o �/C!.54' � ��
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cy �- ----------CI, road p (>
� '� S�nitary Permit '`� r- ��,� �[£„"js Q�
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18��� l�l�� c�
Issued Denied
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� � RONALD L. �„�o ��
� PETERSON � .�^� �y \�
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I , Ronald L. Peterson, �Jisconsin Registered Land Surve��or , i,er��by certify
that in compliance �•�ith Chapter 23� : 34 of the �Jisconsin Statutes and
under the direction of Mr. Louis Duh , o�,�ner, I have surveyed , d�vided
and mapped the land herein described and that said land is located in
Govt . Lot 3 , S�ction 17, T. 40 N, R. 8 W. described as follorrs ;
Commencing at t'r,e north:�est corner of suidGovt . I�t 3 , being a "y2" steel
rod on the nortnea�terly shore of Grindstone L�ke , Thence Iv. �9°Co ' 40" E,
along the north line of said Govt . Lot j, 755 . 0� feet to the intersection
with the westerly rioht-of-way line of County Trunk High�•ray "�", Thence
S. 36° 33 ' 3C" L, alono said we� terly rioht-of-way line , 97 . 88 feet to
the actual point of begir.ning , Thence continue S. 36 ° 33 ' 3C" �, along
said westerly rigt:t-of-way line , 3�2. C7 feet , Thence S. ']1° G� ' 10" 1�J,
185 . 04 feet , Thence S . 48° 34 ' 40" �•J, 1']2 . 40 feet to the meanaer
corner on the northea: terly snore of Grindstone I..ake , T:ier�ce
Ir. 62° 16 ' 20" 'rJ, alon� the n>under line , j21 .03 feet to tne end oi =aid
meander lir.e , Tr.ence N. . 48° 34 ' 40" E, 489 . 19 feet to tne point of
beginning, znd including all the lanc between the rr:�ander lir.e and tne
waters ed�e of Grindstone Lal%e b�tween the p�rcel lines extended .
All subject to easer:ents and reserv� tions of record .
This ir.strument cirafted by'-
Ronald L. Peterson
February ��, 1Q'�3
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A �roved thi� �_d�v of Februar 19%3 b, i �, �
Pi ., Y, �` C.- %�. /. /L. � L�.!t?�
Sa��yer County �nin`- „c�;,inis�rator
1 � 325 '7
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Feb'y.- 7� 8t�0 , ,,:__•. Fa�;e 2 of Z pages
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, : rt. Surve�rs . 2L2-23 �
CGf.�!�-. �'�' v� ,�./_ C,
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(�, ��� SANITARY PERMIT APPLICATION COUNTY -�
LI D'LHR In accord with ILHR 83.05,Wis. Adm. Code SAWYE� � loc
STATE SANITARY PERMIT� v
CST 86-104 98343 �
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER� ti
8'/� x 11 inches in size. �0
—See reverse side for instructions for completing this application.
PETITION
I. APPLICANT INFORMATION—PLEASE PRlNT ALL INFORMATION. �0�� a V_l, 3 FOR VARIANCE ❑YES ❑ No
PROPERTY OWNER PROPERTY LOCATION
c� � �� �' ) � iC � Y4 '/a, S / T O, N, R C�r) W
PROPER Y OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
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ITY,STATE ZIP CODE PHONE NUMBER CITY : N CfitB,rtAKE OR LA�N�B�P�!{4RK
'� ❑ VILLAGE : S `
L-
Ii. TYPE OF BUILDING OR USE SERVED: �—Y'1 � a S'�'QN`�
Number of Bedrooms if 1 or 2 Family � O� ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if appiicable)
1. a.�� New b�iReplacement 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. I�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):
U� Feet �Private ❑Joint ❑ Pubtic
CAPACITY
VI. TANK in allons Total #of Prefab. Site Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel 91ass P�astic I App.
Tanks Tanks structed
Se tic Tank or Holdin Tank a�b �0 t1 � y� ❑ ❑ ❑ ❑ ❑
Lift Pum Tank/Si hon Chamber (y OQ d � ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached pians.
Plumber's Name(Print): Plumber's Signature:(No Stamps) .AkP/MPRSW No.: Business Phone Number:
� n Y .� 3' � (3 ��o
Plumber's A dress(Street, ity,State,Zip Code): Name of Designer:
�
VIII. SOIL TEST INFORMATION
C tified Soil Tester(CST)Name CST#
� � '/
T's ADDRE ( treet,City, tate,Zip Code) Phone Number:
. d V S �'�
IX. COUNTY/DEPARTMENT U E ONLY
� Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stampsj
�A roved Surcharge Fee
pp ❑ Owner Given Initial
AdverseDetermination $70 . 00 $25 . 00 7-31-87
X. COMMENTS/REASONS FOR DISAPPROVAL:
I J
�_ _ __.-____ -_ -_ __-_-_. --_-_._--_ _.-
SBD-6398(formerly Pib-671(R.03/86) DI5TRIE3UTIQN: Origin�i to County.One Cepy?0 6ureau of Plumbing,Owner,Piumber
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DErARTMENT OF INDUSTRY, INSPECI"ION REPORT FOR SAFETY & BUII�DINGS
LA6QR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O: QOX 7969 BUREAU OF PLUMBING
MAUISON, WI 53707
�CONVENTIONAL ❑ ALTERNATIVE Sta�ePlanlD Number
�If assignetl�
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PEHMIT HOLDER�. AUDHESS OF PERMIT HOLDER INSP[CTION UATE�
�l0.rsha1l F � � 11 � e�t a� 1 1�ov \as Qr . L.c�d srn��-h 8 -6 -81
BENCH MARK IPermanent relerencepom�l DESCRBE IF �IFFERENT FROM PLAN REF. PT. ELEV. CST REF. PT. ELEV
. �
�m 5tc��i'�. o-F Dc�J . 00
Namr ol Plumber. MPRSW Nu Cnumy $nn;i;�ry Prrnut Nurnhcr
o � p � w e� 8� - 1 �-� �83�
SEPTIC TANK/HOLDING TANK: COmlp��0.�,1oh '�-0�11� SC, tC � V�n '�4ank
MANUFACTURER: LIOUtDCAPACI�V TANKWL"eiELEV TANKOUTLETELEV �h'ARNINGLA6EL LOCKINGCOVER
" _(� (� qQ Q PHOVIDED PROVIDED�
�V"T't' CV� I 'D �O � � • a I V •-1 � �ES �_� NO ❑YES ,�NO
BEDDING. VENT DIA.� VENT MNI HI(iH WATEH NUMBER OF ROAD. PAOPEHTv WELL BUILUING�. VENT TO FRFSN
�� ALARM FEET FROM �'"E r / � AiR i"�ET 1
❑ YES ❑NO � �� ❑YES C_� NO NEAREST S6 3O � � � �3
DOSING CHAMBER:
MANUF�CTUHER BEDUING UUUi(� CnPnCi tv NUMv M�;irtl �'un�V Si�'��r�r� t,tnNu� ��CiuNk H WANNING LABEL LOCKING COVEH
II � (� 1 PROVIDED PqOVIDED�.
C'}VZ'TCV ❑YES ❑NO ��b �DU �S S EP� 311 � = ES C�NO YES 'JNO
GALLONSPERCYCLE: aunnanrvocorvTHo�so��rr�;�novni NUMBEROF �'�+��re�+iv ,.r,i ou��o�v ; vervtroF��4s��
fDIFFERENCE BETWEEN FEET FROM `��,f �iA ����Er
PUMP ON AND OFF) ❑YES O NEAREST—�
-�-----
SOIL ABSORPTION SYSTEM. Check the Soil moistureai thedepth Of plow�ng � � ^���� r� u�n�,r ii�+ '.�nt� r,�;;; :�.v�, n�n��K�r,r,
or excavation, (lf soil can be rolled into a wire, construction shall cease unul FORCE
the soil is dry enough to continue.) MA�N
CONVENTIONAL SYSTEM:
BED/TRENCH w�o�� � �ENc,t�+ � rvo o� uisr�+ vivt s��ncir,�. �:uvF�+ iNsiuE i>in — =7�i �s ucuio
tia[Nc��es / � n,nrEii�n�� PIT oE��rt�
DIMENSIONS I � 5 a, C,j 5-�r 0.�,J
GRAVEL UEPTH FILI DEPTH U15111 PIPf UISTH PIPE DISTF PIPF MATENIA� NO Ui���i NUMBER OF PNOPEHTV WELL BUILDWG VENT TO FHFSFi
f3f Lnw �'IPFS �� ABOVE COVEH FI f v INI I I EL! V E.NU � �� � � FEET FROM LWE � 1 � AIR 1 :LET �
�j �� �03. 85 I03. 'T81_ PV C __�_o� NEAREST---► c�6 �,�' SD 7 .SD
MOUND SYSTEM: a� "��CL'.U`R0.111
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW EL�VA-
meets the criteria for medium sand. TIONS MEASURED.
aYEs ❑ No
SOILCOVER TExTukE ��Er+ninrvtNinani+ntus �u+sE<<vnnnrvw�� �i.s
UYES L� NO �� YES ❑NO
DEPTNOVEHTNENCIIBED UEPTHOVFHTHFNC�� HFIi I)CPiHUf TUI'S��IL ti��I�I�fU �fEUFU ��ULCHED
CENTER EOGES
❑YES ❑ NO ❑ YES ❑NO ❑YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGiH NO-OF LFTEHALSPACWG !VNAVELUfPlHHELUIVPIVI� fILLDePTHAHOVECOVEH
BED/TRENCH raeNCHes
DIMEIVSIONS
� MANIFOLD PUMP M17�1NIFpLD DISTR. PIGE Ml�Nlf OLD MATF HIl�L NO UISTH UISTH PIPE UIS(HIBU I ION PIPt MATENIAL & A1AFi1(W(]
EIEV. Et.EV DiA ELEV. PiPES D�A
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE $IZE F�OLE SPl�(:W(� L`���LLED COHHE(:1L� CUVEH M1iATEHIAL VEHTICAL LIF T COHHESPOND$ TO APPHOVEU
a�nn�g
❑YES ❑NO ❑ YES ❑NO
COMMENTS: PERMANENTMARKERS�. OBSEHVATION WELl.S NUMBER OF PROPERTY WELL. BU�LDING.
FEET FROM ��"E
I ❑ YES ❑ NO ❑YES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side. �
IG URE TITLE �
DILHR SBD 6710 (R. 01/82) ' ,
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