HomeMy WebLinkAbout010-839-01-5302-LUP-1991-154 Application for Land Use Permit
County of Sawyer o
The undersigned hereby makes application for a Land Use Permit and � X
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- � V 1
lations of the State of Wisconsin. y
PRINT - USE BLACK INK OR PENCIL ��
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Owner Builder
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Mailing Address Mailing Address
e.ioo o��.. r r�-� d�S/�S �S/A y w.r.�./ .....� .�y6'H3
City, State, Zip City, State, Zip
Building Land Use Zone District ��- � o �
( ) New ( ) Filling rt
(1� Addition ( ) Dredging Lot size m n
( ) Alteration ( ) Grading
( ) Moving On ( ) Acres �� �
( ) ( ) n
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New Construction �
n
Size �S ft wide ft wide
/C ft long ft long �
Floor area yuo sq ft sq ft ��'
oa
Total htg/y �G'� to peak to peak � n
Stories / Stories
No. of Bedrooms � rear lot l�ne or waterline c�
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(year round) or (seasonal) I �, rt
Type of Bldg or Addition ? � � r'
( ) Dwelling I \ a o
i C• rt
( ) Garage (1) (2) car � \� N.
( ) Storage Building , �,�►� � I � �+
( ) Boathouse �\ �3 0
( ) Livingroom /~' � � -
(x) Bedroom
( ) Kitchen-Dining �\��aA
( ) Porch - enclosed/roofed �' S ��
( ) Deck - open /�1�� ��
( ) ` ` � !C, r�
( ) _; �— _-� '�
Type of Construction � �' � ��
(x) Frame ( ) Block
( ) Log ( ) Concrete r�
( ) Po1e ( ) Steel �� �� � �,� � ��, �
( ) Meta1 ( ) C �' �` ��� n
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Construction Cost $ ,,28aao i �-�
Vol y14 pg � of deed � I
CS Vol — pg — 'pk:� . _�'�'� C��
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Cer. Soil Test -pc�t�: � ' n
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Sanitary Permit � -0 , ----------CL Road`"-'==�-' � °k`-'�`;,'_' �
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Issued 23 Julv 1991 �'
Denied
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Owner l��c��.�.���C/O.e,7A�`- ` �
Zoning Administrator
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C� DILHR SANITARY PERMIT APPLICATION F
In accord with IL'NR 83.05,Wis.Adm. Code CouNTv , �
_.�,�,,,,,_„r..o. Sawryer c
CST 91-062 STATESANITARYPERMIT#
-Attach complete plans(to the county copy only)for the system,on paper not less than 151102
8'f�x 11 inches in size. ❑ Check it revision to previous application
-See reverse side for instructions for compieting this application. srnre P�AN i.o.NunneErt
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. , ,i
PROPERTYOWNER PRO ERNLOCATION
L� �L" G�''/a "/a� S T�y � N, R E (o W
PRO ERTYO/WNER'S INGADDRESS LOT# BLOCK#
Ej � Q /✓LC/ JL7 ' (i
,STATE ZIP COUE PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER
i o ; u/' S/'�S
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE A �p�,��,�'�_� �J�
❑ Public 1 or 2 Fam. Dwelling-#of bedrooms� ARCELTAX NUMBE ( )
IIi. BUILDINGUSE: (Ifbuildingtypeispublic,checkallthatapply) 010-839-01-5302
1 ❑ ApVCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Faciliry
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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 applicable)
A) 1. ❑ New 2. �Replacement 3. � Replacement of 4. ❑ Reconnection of 5.❑ Repair of an
System 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
11 [�Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ SeepageTrench 22 ❑ In-Ground 42 ❑ PitPrivy
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. FINAL GRADE
REQUIRED(sq.ft.) PROPOSED(sq.k.) (Gals/daylsq.ft.) (�M/in�./inch) G�/7 n ELEVATION
����� �O r 3Q v"��� / /� / Feet Feet
CAPACITY
VII. TANK Site
in allons Total #of Prefab. Fiber- Exper.
INFOflMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel 91ass Plastic APP
Tanks Tanks structed
Se tic Tank or Holdin Tank �Id /f�Ci
Lifl Pum Tank/Si hon Chamber � !O /
VIII. RESPONSIBILITYSTATEMENT �/iN�{;
I,the undersigned,assume responsibiliry for installation of the onsite sewage system shown on the attached plans.
PIu i s Name(PrinQ: Plumb ' Signature:(No Stamps) MP/MPR6WNVS Business Phone Number.
D � L� :" . ��L � /D
lumber's A s treet, ity,State,Zip ode�: �
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IX. COUNTY/DEPA TMENT USE NLY
� Disapproved Sanitary Permit Fee pncivaes Groundwacer ete ssue Issu' g Agent Signature o Stamps)
Surcharge Fee)
�Approved ❑ OwnerGivenlni[ial $115 . �� 6-3-91 �
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plbfi7)(R. 11/88) DISTRIBUTION: Original to Counry,One Copy To:Safery 8 Buildings Division,Owner,Plumber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILaINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
�CONVENTIONAL ❑ ALTERNATIVE StarePlanl.O. Numbec
(If assi9ned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAML OF PERMIT HOLDER�. ADORESS OF GERMIT HOLDER: SS (ZS INSPECTION DATE�
�1 �lLe �a .� �1 8 (a P•o� �r w o�c� w4 W c�ucl 6.��r i-1�.7 6 - ( 4 - Q �
BENCH MARK IPermane relerence poinll DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. EIEV..
Name ol PWmbec MP/MPRSW No.�. County'. Samtary Permrt Numbec
�ob4� �' V ���- c.�•� �c� S1lO Sczw .tr �S//OZ �l � - Ubb'
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIOUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.�. WARNING LABEL LOCKING COVER
'/ PROVIDED�. PqOVIDED�.
S Y�c�...J — Lo�L , � ODQ 9 -T� S 97 , 7 ❑YES ❑NO ❑YES ❑NO
BEDDWG: VENT DIA.�. VENT MATL. HIGH WATER NUMBER OF A�AD: PROPERTV WELL: BUILDING- VENT TO FRESH
ALARM�. / LWE: AIR INLET�.
u�1 C FEET FROM � 3S ? �0� > St�� ��5� > ZS �
C�YES ❑NO T I �YES ❑ NO NEAREST
DOSING CHAMBER:
MANUFAC7URER BEDDING�. LIQUID CnPACITv PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
SI� PROVIDED PROVIDED
�YES ❑ NO 6O0 �'ES ❑NO �"S'ES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA� NUMBER OF �H(IPERTV WELL� BUILOING VENT TO FFESH
(DIFFERENCE BETWEEN FEET FROM ��"E � � � AIR WLE;
PUMP ON AND OFF) L�YES ❑ NO NEAREST > �0 > Sa ?ZS > �
SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing �eNc;r�, u�nti,ereN ��areaia� nrvo nnnaKwc
or excavation. (if soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.)
MAIN
CONVENTIONAL SYSTEM:
WIDTH� LENGTH NO. OF DISTR PIPE SPAGNG COVER INSIUE DIA i2PITS LI�UID
BED/TRENCH � 1� TRENCHES � M11ATEf i-au P�T DEPTH
DIMENS{JNS � a 3b — � S-Ru-�.� '
GRAVFL DEPTH FILL DEP7H UISTH PI�F D�STR PIPE DISTR. PIPE MATERIAL. N0. DISTR. NUMBER OF PROPERTV WELL BUILDING�. VENTTO FRESH
BELOVJ PIPES C ( ABOVE COV'R ELEV iNLET ELEV. END PIPES FEET FROM LINE�. / / AIR INIET/
8 � �P1.$� 4 $•3 P� L 3a3�f 3 NEAREST—► >' S ?SU ZS' ? 2S
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upsiope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑ YES ❑NO
SOIL COVER TE%TURE PERMANENT MARKERS O[iSERVATION WE�L$
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TaENCH BED pEPTH OVFHTHENCH,BED DEPTH OFTOPSUIL SODDED � SEEDED MULCHED
CENTF.R EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATE(iAL $PACING. GRAVEL OEPTH BELOW PIPF FILL DEPTH ABOVE COVEH
BED/TRENCH raeNCHEs
DIMENSIONS
MANIFOLD PUMP MAMFOLD DISTR. PIPE MANIFOLD MATERIAL�. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATEHIAL & MnRKING
ELEV.. ELEV. DIA. ELEV. PIPES DIA.:
ELEVATION AND
DISTRIBU7"ION
INFORMATION HOLE SIZE �{OLE SPACING DHILLED COHRECT�.V COVER MATERIAL pLqNS(`nL UFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑ YES ❑NO
COMMENTS: PERMANENTMARKERS�. OBSERVATIONWELLS�. NUMBEROF PROPERTV WELL�. BUILDING:
FEET FROM ��"E
❑YES ❑NO ❑YES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side. sic;Nnruae " nr�e
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