HomeMy WebLinkAbout002-940-09-2102-LUP-1991-083 Application for Land Use Fermit h
Cou�ity of Sawyer ,a +
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1'he widersigned hereby makes application for a Land Use Permit and ayrees � t
tliat all work sliall be done in accordance witli the requirements of Clie Sawyer °
County 2oning Ordinance and the laws and regulations of the State of Wi�consin.
PRIN'P - USE ONLY UWCK 1NK/FtiNCIL
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Owner Builder F'
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mailing address mailing add=ess
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city,�state, zip E city, state, zip
Duilding Land Use Zone District �� � 1
(� New ( ) Filling
(Y) ndditlon ( ) Dredging Lot size �3Q� k�3Q� 1c�`6�� Sn �
( ) l+lteration ( ) Grading ur n
( ) Moving on ( ) Acres (p_2f pUT oF »-6L/}c �
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New Construction .�j�g-/Zq�� �2F_r�v f{udsE .QErry»� ��� j�, �
Size � EC wide � 'r ft wide }
oi-�{ ft long �_ ft long �
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Floor area S7� , sq ft o2�Z sq ft �•
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Total hgt i�- to peak '-� to peak x��
Stories I ( :
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No. of bedcooms � rear lot line or waterline
(year Lound) or (seasonal) i �
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Type of bldg or addition � � �N �
( ) Dwelling � , � �
A ; ; rys
(� Garage (1) ",� caz �\
O Storage building � � � i C n
( ) Ooatliouse � <`�� �; � �^
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( ) Livingroom � �\��, � � �
( ) Bedroom � -� � 3��
( ) Kitchen-dining j � t
( ) Porch - enclosed/roofed � i i� �
O Deck - open i 9' i � �
(K) GiPFFaJ �Ld dsF_ �d/�'� �j � aN—� '^I�
( 1 j ` �SY �ay; i ` c R'
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Typ/e of construction � ,����s� . Gwt►yEt� � Q�
(V' Frame ( ) Block i � �„s�, �g; � I �
( ) Log ( ) Concrete i �vt \� ��
O Pole O Steel j 4 '�' T i . IC °"
( ) Metal ( ) j � i N
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Construction cost S �Fp-p� .c9� j r �� n
444 2i3 � � `'3--;
Vol �/3 S Pg a.7 of deed ; 4�4i '�, i �
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CSM vol �-- Pg j � 'd
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Cer. Soil Test �'y-08� _ � 8 D` v� ��
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Sanitazy Permit �`J-/Y6 ��� �� �� , I'>
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Issued Denied � I
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owner. Zoning Administ ator
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� DILHR SANITARY PERMI7' APPLICAT'iON _
In accord with ILHR 83.05, Wis. Adm. Code couNry a
— ' SAWTER `�
CST 78-088 STATESANITARYPERMIT# '—
—Attach complete ptans(to the counry copy only)for the system,cn paper not less than 124037 �
8'h x 11 inches in size. °
Check if revision to previou=appiicatlon
—$BB fOVBfS@ Sid2 f0!' if15SfUCSiOnS fOI COfT1PIESIf1J IhIS HPPIIC3Si0(i. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION—PLEASE FRINT ALL INFORMATION. �
PROPERTY OWNER PROPERN LOCATION
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PROPERNOWNER'S MAILWG ADDRESS LOT�/ BLOCK#
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I ,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
, _ 3 0 /- a 7 - /
II. TYPE OF BUILDING: (Check one) f,ITY NEA EST ROAD
State Owned ❑ VILLAGE : ` � �
r� Lc
❑ Public 1 or 2 Fam. Dwelling—#of bedroomsc.L_ RCELTAX NUMBER(S)
III. BUILpINGUSE: (Ifbuildingtypeispublic,checkallthatapply) 002-940-09-2102
1 ❑ ApUCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify —
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicableJ
A) 1. New 2. ❑ Replacement 3. ❑ Fleplacement of 4. � Reconnection of 5.❑ Repair of an
ystem System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
1�Seepage8ed 21 ❑ Mound 30 ❑ SpecifyType 41 ❑ HoldingTank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
t.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
n REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
lI Feet Feet
CAPACITY
VII. TANK Site
in allons Total #of . Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel 91ass Plastic APP
Tanks Tanks structed
Se ticTankorHoldin Tank
LittPum Tank/Si honChamber
VIII. RESPONSIBILITYSTATEMENT
I,the undersigned,assume responsibiliry for installation of the onsite sewage system shown on the attached plans. .
Plum6er's Name(Prinl): Plumber's Signature:(No Stamps) MPRSW No.: Business Phone Number:
C_.ZX> ._cQ�
I mber's Address(Stree,Giry,S[ate,Zip Code:
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1 . COUNTY/DEPARTMENT USE ONL
❑ Disapproved Sanitary Permil Fee (incWees Groundwe�ar a e ssue Iss � g Agent Signature(No Stamps)
Surcherge Fee)
❑X Approved ❑ ownerGiven�nitial $11$ . �0 9-13-89
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Salety&Buildings Division,Owner,Plumber .
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