HomeMy WebLinkAbout002-940-16-2407-LUP-1990-208 �Application for Land Use Permit �
County of Sawyer j
s
7'he undersigned hereby makes application for a Land Use Permit and ayrees �
tliat all work sl�all be done in accordance witli the requizements of tlie Sawyer �
County Zoning Ordinance and the laws and regulations of the State of Wisconsin. �
FRIN'P - USH ONLY lli.ACK INK/PIit7CIL �
Patricia J. Chelstrom � �
�i�� �6,Yf eIISTY'b(�!? ��6� ��- S E r�/iY 9/� �
Ownec Builder �
—� ( 8�x 6�/`I � � 6 Qnx 6sso � �
mailing address mailing address �
_����,�� � w r�s �y�y3 J-�,�yW�,�� ��'s s�v3
city, s ate, zip city, state, zip
�uilding Land Use Zone District ��1���
� New ( ) Filling �q S' �
(� nddition ( ) Dredging Lot size ��G x /`'/��a X /��rt
r, m
( ) Alteration ( ) Grading 1��J � H
O Floving on ( 1 Aczes �s/ 7 I�CY'� y �
( 1 I ) g�
New Construction � ' ��
Size �_ fl: wide ft wide ��
�1Q ft long ft long (1
Floor area vZ O sq ft sq ft -��-..
�/ tn �
Total hgt ��S to peak _ to peak x �3
St�C��s A
No. of bedrooms �. � ��S}�� xear lot line waterline
(year round) or (seasonal) L ����� � I
� � i ' ... � i ci
Type oE bldy or addition f � � �A i G <
( ) Dwelling ��� ��
l ) Gazage (1) (2) car j\� � ti S'
i p i <r
( ) Storage b�ilding � �
( ) �oathouse � i � 9� � ��
� �� _
( ) Livingcoom i \ �,��'- � �I
( ) oedroom � \ q' �� �
( ) Kitchen-diniug � " j � 3�" i
( ) Forch - enclosed/roofed � �., � � � �
( ) Deck - open � �
(�-Y �Ctleo�/✓A �Gr7 � � � ��� O �. "1
( ) �
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Type f construction � i r �0 .
( Frame O 131ock ..�. i � i (F,
( ) i,og ( ) Concrete � D �
( ) Pole ( ) Steel � � � . � ,�t-
O t4etal O i � D,� i C.
/� �L i
Construction cost $ `'�r/� � I\ �� i �
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Sanitary PermiC _�7=��a.� � O Q
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rssuea _ 10 September 1990 _ oeniea__ o �'
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owner. Zoning �dministr tor o
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Aeqisicr-s Odn_u � � s � y� � L� -
Sawy�r CouniY ��•
ecerved tot rewrd Ihe 3 U day of
�L�� A D 19]�0�� oclock
�_Pd md cecorded in vol. 3
ot�.��—on page-s�z.- .3 73
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Peqister
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�, Certi(ied 5urvey N�/r f s `�
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— EAST ��NE SEI/q_ryg,��4
NORiH-SOUTM I/— q��NE --
546-9 --- S2o03�12���-W,320.97� —
� �
I, Ronald L. Yeterson, Wisconsin Registered Land Surveyor, hereby certify
that in compliance witti Ch�pter 236:3�+ �f the Wi;consin Statutas and under
the direction of itobert Dixon, and tlichael Scribner, o�,ners, 1 have eurveyed,
divided and rnapped the land herein de:cribed, th:+t naid rnap is a correct
representation of the survey made to tlie best of my kno�aled�e and ability and
tt,at said land is located in the S}�-M,4-Nyz-S'/z-NW}'v, Section 16, T.40 fl, R.9 W. ,
� dFscribed as followsp
Commencing et the Northeast corner of the SE�r-N',J'/w, Section 16, T.bO N, R.9 W. ,
Thence S. 2° 03'12" W, along the F,ast line of said forty 32C.y'] feet, Thence
s. 88° 39'00" W, 195.81 feet to the point of be�inning, Thence continue
S• 88° 39'00" '�I, 639.96 feet, Thence N. 2° 44'SG" lJ, 159•92 feet, Thence
N• $8° 37'1�" E, 648.93 feet, Thence S. 0° 2�'42" W, 160.28 feet to the
point of beginning.
Subject to all existing easements and reservations.
This instrument drafted by-
Ronald L. Yeterson
June 30, 1978
Apf�roved thas �_�day of Juna, 19�8 by 1�/�j,�{ y�/ ���Q`�
Sawyer County Zoning Administrator
i � � �
�CON
�y1S Sf� .
--�. �,
�
AONALD L.
� PETERSON ��
s-eos
�utrw�qo
� �• � �age 2 of 2 pages
��� SUR`1F'�-O�'i
- _%
.373
TOWN OF BASS LAKE
SEC. 16 TWP 40 N. R. 9 W.
6.3 O
A 5.1 5.7 I.I
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5.8 I.3
6. 1 2. 1
6.4 .5.2 WILLIAM RD. 12
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� �ILHR SANITARY PFRM17 APPLICATION COUNTY sAta�ER �
In accord with ILHR 83.05, Wis. Adm. Code i
� ' STATE SANITARY PERMIT#, ; 0
CST 87- 032 86109 `''
—Attach com lete lans to the count co onl for the s stem, on a er not less than ~
p p ( y Py Y� Y P P STATE PLAN I.D. NUMBE:R
Bh x 11 inches in size.
—See reverse side for instructions for completing this application. pE7iTioN
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. Foa vnaiANCE �YES ❑ No
�P OPERTY OWNER Ran y L . Ke ey PROPERTY LOCATION
O�j Y� � ��'/a Nl�/'/a, S T , N, R C�{4r) W
PROPERTYOWNER'SMAILINGADDRESS LOTNUMnBER BLOCKNUMBER SUBDIVISIONNAME
� o�
CITY,STATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LAKE OR LANDMARK
E7 VILLAGE ; �' SS Ke SO-
II. TYPE OF BUI DING OR USE SERVED:
Number of Bedrooms ir.Lor 2 Family v� OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check #2, 3 or 4, if applicable)
1. a.�New b. � 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#� and only one in#2)
t. a.�Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound (. � IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 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 EIEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): /�
U �y .� Feet �Private ❑Joint Q Public
CAPACITY
VI. 7ANK � Site �
in allons Total #of Prefab. Fiber- Exper.
� .,� INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel 9�ass Plastic APP
� � Tanks Tanks structed �
Se ticTankorHoldin Tank C
Lift Pum Tank/Si hon Chamber ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. � .
Plumber's Name(Print)� Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number.
J �`�CI'� c3c� � ��v —c�� �
lumber/Address (Street,City,Slate,Zip Code): Name of Designer:
� b r
VIII. SOILTESTINFORMATION
C rtified Soil Tester(CST) Name CST q
0 c� � rP c�o'�S�
CST's ADDR SS(Sireet, City, State, Zip Code) Phone Number:
S'G�.� � s �6 � v
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SanitaryPermitFee Grountlwater ate Iss � AgentSignature (NoStamps)
X❑ ApDroved ❑ Owner Given Initial G Surcharge Fee
AdverseDetermination �" �� • �� ZrJ . �� �F-27-8�
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Pib-67) (R. 03/86) DISTRI8U710N: Origina! fo Counry,One Copy To: Bureau of Plumbing, Owner, Plumber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
,�CONVENTIONAL ❑ ALTERNATIVE StarePlanl.O. Numbec
(11 a:signedl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDEF: ADDFE55 OP 7ERM1T HOLDER- INSPECTION DA7E�.
O . 3 O C� -II '�,
BENCH MARK IPermanem relerence poin�l OESC I IF DIFFERENT FROM PLAN�. •. � REF. P7. EIEV.'. ' C5T R F. PT. ELEV
t O QS ��OD
Name ol Plumber�, MPRSW No. Cnunry Samlary Pe�mii Numben
o `J S 33 �o�w r 8 6(
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIOUIDCAPACITV TANKINLETELEV. TANKOUTLETELEV N�ARNINGLABEL LOCKINGCOVER
�`p / P�FOwVIDED PROVIDED�.
1 I�.I �C , � �b � �p . 3 I �{� • �8 �IYES ❑NO ❑YES ❑NO
BEDDING: VENT OIA . VENT MnTI HIGH WATEH NUMBER OF ROAD� PROPERTV WEL BUILDI�y G�. VENT TO FRESH
�� ALAHM FEET FROM LINE � �0 ���qIR INLET:
❑ YES ❑NO � C � ❑YES C� NO NEAREST o1-0� la1e.I� �jE�'
DOSING CHAMBER:
MANUFACTURER BEDUING LIOUIII CAPAC17v VUMV M�IUEI. PUMP SIVH(1N M�NU� l�ClUHEH WqqNING LABEL LOCKING COVER
. PROVIDEO PFOVIDED'.
❑YES ❑ NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PunnrnrvocorvTNo�soaeaAriorvr+� NUMBER OF PliOPFNTV WFLL BUILDWG VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM `�"E AiR iN�Er
PUMP ON AND OFF) ❑YES ❑NO NEAREST—�
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing � f �,�,i�� n�nn,F rE�+ �.,ar� Fi�n� 4NU MAHK W(,
or excavation. (lf soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to contin�e.)
MAIN
CONVENTIONAL SYSTEM:
IVIDTH LENGTH NO O� UISiH PI�'C tiV�1:INt, COVEH INSII)L UTA =PIiS UOUIO
BED/TRENCN ` T�aervcriES � a�nrEwin� P�T DEPTN
DIMENSIONS / � 3� � ���
GHAVEL DEVTH FILL DEPTH UIS1H PiPf UISTH PIPE DISTF. PIPE MATEHIAL NO OiSIH NUMBER OF PHOPERTV WE�� BUILD`NG� VENT TO FRESH
BELOWPIPESI� ABOVECOVEH EIFV INLf I ELEV ENU PiNES FEETFROM LINE I n Of�`y AIRINLET:
oZg" ' q �.q8� �I�.�_�[ � NEAREST--► I a- �� �' �'oo►�+
MOUND SYSTEM:
Mound site plowed perpendicular to slope �heck 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 ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOILCOVER TExruRe �t��n�nrv� rvrn�ni+Kii�s oi4sEi+varir�Nwt ��s
❑YES ❑NO ❑YES ❑NO
DEPT1-IOVER iHENCH dED DE7THOVFN THEN(:�� HFU UlVillOV /i)PSfuL S��UUfI) JFEUFII MULCHEU
CEN7EH EDGES
❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTII NO. OF L�+TF��AL SPACWG GViAVEL UEPTN HELUW PIVI� FILL DEPTN ABpVE COVEH
BED/TRENCH raervcNes
DIMENSIONS
MANIFOLO PUMP MANI�OLD DISTR. PIPE MAMFOLD MATEHIAL N(1 UISTN Ut51H. PIPE UISTHIBUTION PIPE MATEHIAL & MAf7KING
ELEV. ELEV. DIA ELEV. FIPES DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLESIZE HOLESPnCING L'�iILLEUC�)NNFC1Lv COVEHMl1TEHIAL pLnnSC�LUPTCOHRESPONOSTOAPPROVED
❑YES ❑NO ❑ YES ❑NO
COMMENTS: PEfiMANENT MARKER$�. OBSEFVATION WELLS� NUMBER OF PRO�ERTV WELL: BUILDING:
FEET FROM �INE.
❑YES ❑NO ❑YES ❑ NO NEAREST
. I
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Sketch System on Retain in county file for audit.
Reverse Side. riT�E
SI NA RE � }
DILHR SBD 6710 (R. O1/82) `
no we.11 v�et
no mo�ile �1om� �et
b0.semen"�, Gr�p_ CSonC.
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