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HomeMy WebLinkAbout014-842-21-1113-PVY-2024-002 _ � < SAWYER COUNTY ZONIIYG&CONSERVATION ADMINISTRATION � 10610 Main Street,Suite 49 � Hayward,Wisconsin 54843-0676 S (715)634-8288 � www.sawvcrcou ntveov.ore NON-PLUMBING SANITARY PERMIT APPLICATION G In accordance with Chapter DSPS 391,Wis.Adm.Code and � Sawyer County Private Sewage System Ordinance APPLICATIONINFORMATION—TYPEORPRINT PAGE:lof3 Pro yOwner e i Propcnyls IlXscriplion � ' i< E�� � ��1��. S �� ,T�N.R 8 W Ptquny Owncr's Moifng Addres- I.o1 Numbcr Block Numbcr � /C [� -I'f� _' Ci� Stote Zi Calc Phonc Numbcr Su 'vision Namc m CSM Numbcr , ,: �/l/ �'I 4�1�. �a-. . 11v� TYPE OF BUILDING:(Check onc) State Owned Ci�y Newcsl Road �� ✓I ❑Public �Ior2FamilyDwelling—No.ofbedroams�=� ❑�'��0s° G �� f�.Towno(, enrJc f FiRNumbcr#�_3� C?� —/1GIN PUBLIC BUILDINGlLAND USE:[ezpiein mc uscipur�c�mm�s Percel Tez Number.(12 digit legacy number) pcm�i�,(i.c.,cemp�ewnd,frnival,rccrcetioNemeneinmem evem e�a11 �1Y-£�-��-�L-LL13 TYPE OF PERMIT: ,T_Y�E OF NOIY-PLUMBING DEVICE/SYSTEM/I'OILETNNIT: �Priry-Pit Toilet(CSTk a -x� �Nan-Plumbing(Privy,Toilet,Restroom,EtcJ ❑Privy-Vuult Toilet(200 gal, mia capacity required) (Vault size:�allons or cubic yards ❑Other. Vault Privy Type:❑Concrere�Steel❑Polyethylene❑Other ❑Composting Toilet System ❑Incinerating Toilet Device ❑Portnble Restroom Unit ❑Other RESPONSIBILITY STATEMENT: I,the undersibmed assume rcsponsibility for the installetion of�he non-plumbins sanitary rystem for which ihis pertnit is issued. 1 fwthtt agrce that any dwclling in conjunclion wilh lhis permit�cill not be providcd with indoor plumbing and/or ua�er hookup. 1 will ux Ihc non-plumbing syslem indicated as a menns of waste disposal,and I wi11 carry a•amr to ond from ihe struc�urc. I undersiand that beforc indoor plumbing and wa�er hook ups nrc insmllcd,thc proper S�o�e und County Pcrmits will bc applicd(or. I funher undersiand that any dcviotions from ihc above will constitutc a violntion of Smryer Cuun�y Ordinonces and would subject mc lo ihe penahies of Ihe Ordinane�s. By siyning this applicalion,I am elso Srenting pemtission lo thc zaning dcparlment personnel io rnter my property et any reasonable lime for ihc purposc of inspeclion to assure compiience with thc zoning ond senitalion lews rclativc to thc issuance of�his permit. Oxnje�'s Nomc:(�q 1 / OWner's$ignalure: ,�,/c a',�'/ -o rn c�� ` , 7, OFFICE USE ONLY• ��',2 ❑Disapprovcd Pcrmil Fcc: CST No. Da�c Issued Issuing Agcm Signelu�c �A provcd y �U�nerGivcn lniiiel SI50.00 ��—� �I 3� I�y Yt1�(.c�.Q�^e�y:_ Advcrsc fktcrtnination COMMENTS: "Expires 2 yean from date of issue •NO REFUNDS AFTER ISSUE OF PERMIT SHORELINE PROPER7'Y:�YES❑NO If"Yes,"Name of the body of water: COND IONS O APPROVAWREASONS FOR DISAPPROVAL: ������^ '� ..�v+r��. �,� GS� 2y—�dY� . '. S,. Rev.04/29/16 �13�J-�-- NO REFl1NDS AFT'Ep � � ' � _ `' , � LaSI�._ ISSUEOFPERMIT _.._ 1 a�a ;-va;•.;,:�. .. . .. -- - ' I�i c�'1 � .+�i""� NON-PLUMBING SANITARY PERMIT APPLICATION PAGE:2 of 3 Privy Plot Plan ��_ a��� �1.�- �lR� Please include t6c following information with distances on thc above plot plan: ❑ NoRh Arrow ❑ Nearest Road ❑ Site Address ❑ Structures o Well ❑ Property Lines ❑ Lake, River and/or Stream o Wetlands Minimum Setback Requirements: • 10' from any slab constructed accessory building • 25' from any habitable building • 45' from any property line • 50' from any water supply well • 75' from the ordinary high water mark of navigable waters • 130' from the centerline of state highways or 66' from right-of-way line, whichever is greater Rev.04/29/16 � � ' � - /_ "l.l . C_J S �G -�� • "Vw ` � : � � y i ' G . ♦ � � � . 3 � � / � --� � � �, � � / � L � � . •.. � � � ' . . . ' .- .... ' . ' . ��� . 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