032-540-35-5211-SAN-2024-016 ' Department of Safety c°""t`' `/� �
t & Professional S€rvices, � a �r �
. � Sanitary Permit tiumber(t be filled in b} C
� �: Industry Services Division
�.. (p S �'1 I �I �
,
Sanitary Permit Application State Transaction Number �,
_--
In accordance w•ith SPS 3R3.21(2),\�'is. Adm.Codz,submission ofthis forn�to the appropriate go��ernmental unit or
is requ'ved prior to obtaining a sanitary pemiit.\ote:Applicalion fonns for state-owned P01�'TS aza submitted to Project Address(if different than mailing addr ess)
the Department of Safet}�and Professional Sen ices.Personal information you provide may be used for secondary
pucposes in accordance with the Privac}�Law�,s. 15.0�(I xm).Stats.
I.Application Information-Please Print All Information s�(p -� �U`�� n �[�
Property(�uner�s�ame Pazcel�
�c�ti�n �- pa�-r���e ����r� U 3a-5�10-35-5-a 1
Propzrt}Ovaner's Mailing.�ddress Propert}�Location ���
(,J- 1 I 3�3 Q r r.c.s i �;r'e e K �� Ga.�_�r at
Cin.Statz Zip Codz Phone?vumber ��
P�.��l� �� �L` (�' f f J_C�`t�_C�`.3 I .__ l e, �a. S2CtiOR
IL Type of Building(check all that apPly) �t� T L�Q N R E o
�1 or 2 Family Dw'elling-Number ofBedrooms C� � Subdi��ision Name
Block"
` C7 Public,�Commercial-Describe tlse
❑Citv of
❑State Owned-Describe Use CS�I Number ❑Village of
����.J � ��� fPlTowm of C� f� I�e/�
III.Type of POWTS Permit:(Check either"New" or"ReplacemenY' and other applicable on line A. Check one box on line B.Complete line C if
a licable.
4' �New Syst�m L�' Replaczment S}stem r' Othzr'lfodiYication to Existing System{zkplain) ❑ Additional Pretreatiuznt L''nit(e�plaiu)
� olding Tank .� In-Ground .� At-Grade ❑ '.lfound u Lidividual Site Iksign ❑ Other T��e(ztplain)
(convantional)
C. �� Ranewal Beforz u Revision � Change of Plumber `' Transfzr to 1ew O�vner ���z�ious Permit Number and Date Issued
Expiration
IV.DispersaUTreahnent Area and Tank Information:
Design Flow'(gpd) Design Soil.�pplication Rate(gpd's� Dispersal rlrea Rzquirzd(s� Dispecsa)Area Proposed(s� System Ele�ation
a� � �a N � Na N�1
Capacity in Total �of �lanufacturer
�
Tank Information Gallons Gallons Units L � U '; � �: J
'� '� J N :A V:
tiea Tanks Existing Tanks y e cr � y � � �
E� �.J V� v. V� :z. �.i �.
Septic or Holding Tank � +56� S K(��� �:� /+ S` �
l.c�
Dosing Chamber � ��5� / J�'4� �(� �1�5� X
V.Responsibilit3�Statement- I,the undersigned,assume responsibility for instaDation of the POWTS shown on the attached plans.
Plumber's tiarne(Pr'vit) Plumber' ignaturz h1P%�1PRS\umber Businass Phone Number
.
Cr�,� '�aM .� -� aa �v �rs-a��-a s�l��
Piumbers Address(Street,Ciri�.Statz.Zi Code)
�v�( �f-� .���yo,�n �'� C�i�l�e�, (,cJ� s��"1l�
VI.Cou /Departrhent Use Onl��
�App o�ed ❑Disapproved $zmiit Fee Date Issuzd Issuing Agent Signature
� ❑Ownar Gi�•en Reason Yor Denial ��'6� ��1'''�� �' 1���� ' ' Lta-
Conditions of Approval,Reasons for Disapproval —�
3 ��. � '. �
_, I '
;� A °� ,_ _ a--1� ��Y �
, ti
,
� �.3�kt, �y�`� ,,� �-, f
� � � -v _ F � 0 '� ���`;
�sl N��- , 3`�� �5 � �;�,�w°��,�F_:����������t-
� _ r -� . ,>;.�,:>�.
5��-CsT �o�o3S �� 0-7 -
Attach to complete plans for the system and submit to the County onh•on paper not less than 8 1/2 s 11 inches in size
3lr'S�
NO RE�UNDS AFTER
tSSUE OF PERMiT
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
`������11
� �R Cp 1� Hayward, Wisconsin 54843
���i' -��Ci�� (715)634-8288
�Q ���� FAX(715)638-3277
�y��� --� _ !</ www.sawvcrcountygo�.org
� o i o � E-mail:sanitaiianh�saw crcounty>ov.org
I �=��'�i � Toll Free Courthouse/Gencral Information I-877-699-4110
I �`�=vr�' %
It�L� `c�_
�i�\oN��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stainp �/ p S /��
Parcel ID# c�3 2- S'Y o - 3 �' - �� ( 1
II. Plot Plan:
�Property Lines p�Benchinark BM ♦
�C Site Address oC North Arrow
DC Structure �C Scale
�Well �<25' to Service Road
/Legal Description Dd�learest Road Intersection
D�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
d�Index Page with Original Signature
�Management Plan/Contin�ency Plan
� Servicing Contract
�( Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
�( Tank Cross-Section: Manufacturer: ,S�G�-l/J Gallons: ��6g/���
�Tank Anchor Calculations [SPS 383.43 (8) (g)]
�Locking device, chains/locks
�Alarm, electrical per SPS 383.43 (8) (e)
�3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: � re..v� Plumber: C�'
Application Review Date: d a-l o� rz�
POWTS Reviewer: ���,���1�
Name
�,1 � (�_ Rev. 4/27/2023
Gedential#
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Holding Tank Version 2.1 (May 2022-2027)
Pg 1 of 4 Index&Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map(if applicable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
OwnerName(s): �c���� � ��f,C� t�Ufei1 Phone: �f5 -`f�5 - ��3
Owner Address: (,cJ-1�30� ��u5 h CreelC �'� 111e���c� Zip: 5�1`lS 1
Project Address: SS �f-t,c� 1`1�a1'�-�� �'�
Govt.Lot:�o _ 1/4 of 1/4, Section�,T ��(} N-R S E❑or W�
Township: ��i�'�e-l- County: 5�i rJ y�,�
Project Parcel ID#: D 3 02 S��(�} 3S S c2)I
Designer Information
Designer Name: �f-'���; / n���n Phone:�IS -(0107 - I�7�
Designer Address: �O g`1-I`l �rn(JS�i1 � ��n�e-� Zip: S���1�
E-Ifl81�:�'�'1�1�1('�I��1�. �l7 I�er �O/� '7'i.J-;space recen•ed for�ppro�at�:.,- -
Lisense Number: o���l�
Remarks:
Si nature: �^�� � S� Date: l-1`6-aL�
� OnginalS(gnature required on ach submitted copy.
CHECK BOX AS APPIJCABLE. CHECK BOX AS APPLICABLE.
❑ SOIL EVALUATION o Scale: 1�� 40� � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: ��o �d� �pz DESIGN FLOW: � (.l.J GPD
Attach design flow calculations for commerciai plans.
PROdECTADDREss: .Ss�-:�t—� 1���'�' � �-i.K Pipe Material /ASTM Standard (Tables 384.301-'3 & 384.30-5)
N Sanitary Sewer � �` / �/
BAA S�rrt�bol: � BM Elevation: FT Force Main: /
I�)/1 G,.,� ] ��/-�,,��/ �^� / I• ,
BM �BSCII�IOfI: �/"1T ✓L��1 P I�I���'• O� 1"• P` �'V �(Js ��r
SIo Gradi�d % Indicate north by IMPORTANT:
� ( � j�� � Well S�rmbd ('rfapplica6le]: 0 drawing an arrow Show ground elevation contours at suitable intervals.
of Tested Ar�:
on the approprite li�e.
m�r�1 � �
SS�C��-ln�
I I
� v3� -S�(a-3S'-S�� 1 (
� (
� S 3S'�`{� �R S"v✓ �
I P�- . �,o� ��--� I
I e�,\ �
� o� �
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i (
( a� L
I I �� I
I � I
I �/' �'� � �
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
4"PJ Venl Pipe
Weelherpioof >10 ft fiom
Junclion end Alerm Box APP�d Building
A rovedLockin Menhole VentCap �Z"Min.ar2.ORabove
PP 6 Establlshed Flood Elevetion
Eleclncsl musl comply xdlh 4"Min.or 2.0 ri above
SPS 316 end NEC 300 wich Weming Label Atleche0 INP��aO Effieblished Flood Elevetion
(�YPicaq (�vPicep
Conduil
Airtight5eal _�1/ W
Finiahed Grade
18"Min.
(ryPlcei) . : P�''
d.. '
Inlet Inlelinvert Wetertight
ApP�'ed Jointa with P��
Approvad Pipe 3 ft onta Mex.17'or 90%of lotel volume
Solid Gmund it more lhen one tenk
(�`1Pi�l) Alertn-0n 8,
Compartmenl 1 Vol=�'S6�S gel Compertment 2 Vol= 1,Sb�gal
�• TOTALHOLDINGTANK
VOLUME= 3 l, (v gal .
3"Apprwed BeCding Matenel Beneeth Tenk
TANKMANUFACTURER: �i��1k� r GC' �'LS�
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight=[(cu.fttank.vol x 62.4 Ibs/cu.ft)-Ibs.tank.wt]x 1.5
Ballast Weight=[( � � �5 cu.ft.x 62.4 16s/cu.ft)- � �� Ibs]x 1.5= 6,53 7 Ibs
PAGE40F4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s) shall be responsible for its perpetual operation and mairrtenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s)
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspeciion and maintenance activities shall be peAormed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Estimated Daily Wastewater Flow = aw gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o electncal components (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o surtace discharge of effluent or sewage back-up into structure served
SERVICING FREDUENCY
o The tank(s)shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats.
when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s).
Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company: IJ�n I �`�l'�5��� d- �'1S ��C- _ Phone: �1S - ��� ����� _
Local government unit: �IC'/� 1,0u-� �fi��c`�_ Phone: ��S- � 3��^ ���_
Local govemment unit address: �D��(; �1c�,n 5Z` - S`-�'�{ ����� ��k���ZIP: S�1���
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1}, Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall compiy with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continaencv Plan
In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuani to a
plan submitted to the appropriate agecy tor review and approval.
Svstem A andonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
HOLDING TANK SERVICING CONTRACT
Contract Date: / - / ��
This contract is made betwcen the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
Northwest Sanitary, Inc.
PO BOX 155
�U�(\ � � S� � �' �� � f'_ � Radisson, WI 54867
Parcel ldenti�cation Number:
(12 Digit Legacy ID) � 3 0� - � � � - 3 � - � c� � �
L The owner agrees to file a copy of this contract witl� the govermnental unit, Sawyer County,
w:�ich has aceeptea and recordeci wi�h t:�e Jfficc of thc Rcg;stc;r oi �cc�s, the [+:fain�n�nce �� - - —� --�� —
Agreement for a Holding Tank required under the Sawyer County Private Sewage System
Ordinance for the issuance of a Sanitary Permit for the installation of a holding tank(s).
2. The owner agrees to have the holding tank(s) serviced by the puinper and guarantees to
permit the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access road or drive so
that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper for a charges incurred in servicing the holding tank(s) as
mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
servicing of the holding tank(s) as required under SPS 383.55, Wisconsin Administrative
Codc and the Sawycr County Privatc Scwagc Systcm Ordinancc. Thc pumper furthcr
agrees to include the following in the report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The site address of the holding tank;
d. The date the holding tank was serviccd;
e. Thc volumcs in gallons of the contents pumpcd from the holding tank for cach servicing;
f. The disposal sites to which the contents from the holding tank were delivered.
-�r. Tltic ;�asr_�r;�rt �h,y�) rwi118tI? 221 ��iC:� '.iII�i� t:i:; 3W:1�.'' v: Yu�it..n.; �Ctil":1"1'.aiCS `litiS CUTl:iu"�. ii:
the event of a change in this contract, the owner agrees to file a copy of any changes to this
service contract or a copy of a new service eontract with Sawyer County within ten (]0)
business days from thc date of change to this service contract.
�Wri01''S N8C17�: �PT'Lrit� �Wri�P'S S1�Tri1h1P8: (Only one owner signature required)
�C.���'1 t'1�1" 4�G^?�`tr I��' �C� �"�`l ..
C��-�.�'� - ���.
Pumper's Name: (Print) Pumper's Signature:
Ronald L Vieceli, owner Northwest Sanitary,inc /%1����C, � ��.Lt'G�
�
Pumper's Registration Number:
#2389
Rev. 03/26/l 3
POWTS MAINTENANCE AGREEMENT I I i�; I I I� � III II��)
I
I� Illlii�I IIII�I I
FOR HOLDING TANKS �, ,T,,`V.l,q����
� a
��r�_� r
Document Number pocument Title ;�.:��.i,G,�i J'��y
�����d
PAULA CFiISSER
F2ES�ISTER OF ❑EEDS
SAiRiYER ��1lA[TY, WI
G2/05/20�4 t�2:33 PM
RE�C7R[�ING FEE 30.00
�A���: 4
Recording Area
Name and Return Address
SAWYER CO ZONING
10610 MAIN ST
HAYWARD, WI 54843
03� -S�o -3�-��.1 l
Parcel Identification Number(PIN)
THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE.
This information must be completed by submitter: document title name&return address,and PIN(if required). Other information such as
the granting clause, legal description,etc.,may be placed on this first page of the document or may be placed on additional pages of the
document.
WRDA Rev. 12/22/2010
-USE BLACK INK ONLY-
POWTS MAINTENANCE AGREEMENT
For Holding Tanks ;,�,,�;
I OwMr s Nam@(s�es Shown on dee0 _
5c��n I� � �u�r;�e 1� �orE/\ , >�:i:^: �i. ��.1T•.
Par�el itl¢ntihcation Number�. �.
I rt�Di4itLegacYlD1 _v�.�-�1Q-3 s_-�a11 �
I Logal Dascnptbn ot Property: �I
-SEE ATTACHED SHEET- I
We aacnowledge that epplication is baing made�w the�instana5on oT a hWtling tank(s�ai the I
pfoperty tlesCrib@tl on ihe attaCnetl sneet.
� —_ — ---
Retum To:Sawyc�Counry Zoning and Conservation AdminisVafion ',Recording Mea-Leave Blank per s.59.I3�2m)
10610 Main St.,Suite�9,Hayward.WI St8�3 '�
As en vMucement to the County of Sawyer to issue a sandary pertnit for a holding tank on Ne above-descnbed property,the ovmer is
responsibla for tha oparation and mainlenance of the holdmg tank,locking davice,alarm and access,and agraes to conform to all
appiipble requirements of SPS 383.Wis.Adm.Code relatirg to holding tank managemeM,inGuding the folbwing:
t The owner agrees to contraG with a person who is iicensed under Ch.NR 113,W is.Adm.Code,exceQt as provided by
Section 281.48(3)(d),Stats.,to have the holding tank propedy serviced and to file a copy of the service contract wrth the
govammental unli. The owner turther agrees to file a copy ot any changes to the service contract,or a copy of a new service
contract.with the govemmentel unit wiMin ten(10)businass days from the date of change to the sernce wntract.
2. The owner agrees to conGact vnth a person licensed under Ch.NR 113.W is.Adm,Code,who shall submit pumping reports to
tha govemmentai und in accordance with SPS 383.55.Wis.Adm.Code.(or the servicing of the holding tenk. In the casa of
exemption under Section 281 48(3)(d).Stats..tha owner shall submR ihe report to the govemmentat uniL The govemmental
unit may e�ter upon the property to inves6gate the condition of the holding tank when pumping reports may indiwte the
holdiny tank is rwt being properry maintamed.
3. If Ne owner fails to hava the holding tank properry serviced m response to orders issuad by Me govemmental unit to prevent
or abate a human heatth hazard as described in Section.254.59.Stats.,the govemmental unit may enter upon the property
aod service,or cause tha tank to be serviced- Pursuant to Sectlon 14520(4)Wis.Stats.,a governmental�nit may assess the
owner of a pnvete sewage system for costs related ro the pumping of a septic or holdirg pnk.The charges will be assessed
es prescnbed by Section 66.0703,stats. Tha ovmer agrees to pay all charges and cost incuned by the govemme�tal unR for
inspection,pumping,haulmg,or otherwise serncirg and maintainiog the hoMmg tank in such a manner as to prevent or abate
any human health hazard caused by the hrolding tank.
A. This agreement will remain in ettect only until the govemmental unit responsible for the regulation of pnvate sewage systems
certifias that either a soil absoipfion system that complies with SPS 383,Wis.Adm.Code.or a municipal sewer serves the
property.In additron,this agreement may ba cancelled by exacuting and recording said cartification with reterence to this
agreement m such manner which vnll permit the existance of Me certification to be determined by reference to tha p�operty.
5. This agroement shall ba binding upon the ownar,the heirs of the owner.and assigneas of the ovmer.Tha owner shall submit
tha agreemant to the register of deeds,and the agreement shall be recorded by the register ot deeds in a manner which will
permit tha existence of the agraement to be tletertnined by reference to tha property whare the holdirg tank is installed.
-oo ooeownersiynature uircd- ACKNOWLEDGEMENT
'�Ow er' i ature: � � .. State of: (.�� �
� CountVof�. _�\nl�
���,Ow-p!ehls N1a�me(Pnnt):/ K,/ ! Subscribed and swom to before me on this
:' /"G�'//r �./�� [ Lo�`� . 1� da of .20�
;Date: 2 —�—ZL[ 89(owner) D
T
' Notary Public Signature
�Drafted by:// � ' Notary Public Name; d
/ L _ Q�� �
i �`��, -��—� My commission expires on �cZ�( Q��
Personai mfamafion you provitle may ba used for secondary purposes[Pnvacy Law.§15.06(1)(m1j Rev.092923
KRISTINA A MOREHEAD
NOTARY PUBLIC
STAT� OF W�SCONSIN
StamP �� �tamp add�r
to to
�apture ima9e "apt�re �ma�
Stamp added .
to
cap�ure image
,I
�ot Five (5) of Certified Survey Map No. 673 as recorded in Volume 4 of Surveys on Page 23, as Document No.
152318, located in and being part of Government Lot Two (2) of Section Thirty-�ve (35), Township Forty (40)
North, Range Five (5) West, Town of Winter, Sawyer County, Wisconsin.
1!11/34.7:57 A�4 .'�'oaus-�'isconsiu 4ccess cev.I3.LL08
Redl EStdt2 Sawyer County Property Listing aroPerrysr�eu5:c�Re�r
Today's Date:1/11/2024 Created On:2/6/2007 7:56:01 AM
�'Description Updatzd:12/19/2013 '�Ownership Updated:3/9/Z020
.._ __... .._.. .._._ .._.. . _._._ _._.. __..._. ._._ . ._._. ....._. __._... .
Tax ID: 36580 )ONN A&PATRICE L KOREN MEDFORD WI
PIN: 57-032-2-40-OS-35-5 OS-002-000110
Legacy PIN: 032540355211 @illing,� Mailina Address:
Ma�ID: :2.11 70HN A&PATRICE L KOREN 70XN A�PATRICE L KOREN
Municipality: (032)TOWN OF WINTER W11303 BRUSH CREEK RD W11303 BRUSH CREEK RD
STR: 535 T40N ROSN MEDWRD WI 54451 MEDFORD WI 54451
Description: PRT GOVT LOT 2 LOT 5 CSM 4/23#673
Recorded ACres: 1.770 t�Site Address *indica[es Private Road
...._. . ....._ .._._. ..___.. .___ ........
Lottery Claims: D 5569W MARTIN RD WINTER 54596
First Dollar: Yes
Zoning: (RRS)Residential/Recreational One �
ESN: qz8 —�Property.Assessment _ . . Updated:10/10/2016
2023 Assessment Detail
��Tax Districts Updated:2/6/2007 Code Acres Land Imp.
_._._ -._.._ .__. ..___ ..._.._ Gl-RESIDENiTAL 1.770 6,000 600
1 State of wisconsin
57 Sawyer County Z_year Comparison 2022 2023 Change
032 Town of Winter �and: 6,000 6,000 0.0%
576615 Winter School Distri[t Improved: 600 600 0.0%
001700 Technical College 7oW1: 6,600 6,600 0.0%
.�-Recorded Documents Updated:3/9/2020
0�WARRANTY DEED..._.._ ....__ ... ..-. -...-..... �Property History
Date Recorded:3/6/2020 ¢�¢¢Q N�A.. ....... ..".. ....-.. .... ........
0 ABRIDGMENT OF JUDGMENT
Date Recorded:10/24/2013 387920
O WARRANTY DEED
Date Recorded:7/14/1997 261866
�CERTIFIED SURVEY MAP
Date Recorded:8/IZ/1975 152318