HomeMy WebLinkAbout010-941-21-2208-SAN-2020-202Industry Services Division1400 E Wasnington AveP.O. Sox 7132Madison, WI 53707-71S2n.N, csr Qj )Sanitary Permit Applicationinaciorfl^wnh S?S 383il[2). W15 Adn. Code, submssio.i of this form to the eppropriate governmental unit15 reovired p.-iar to sbtainin| a sania.-y permit Note. AppliMiioa forms for saie-o«med POWTS a-e s^b.mitted toi,,e Departrneni of SafePr and Professional Servies Personal information yoo provide mav be used fei seoonda.-vpumoses in atatordance with the Privacy Uw.s 15 Od(iyml. Stats.CountaSanitary Pemi: .»^ber (to be filled in by Co.)\State Tiansaciion Number]■ Applialion Infonnatian - Please Print AH InformationPropecy Ovmer's NameProject Address (if different than mailing address)Property Owner's Mailing Address ■ .i —ftotrbW Di'ier LnICm-, Stale.. . I Zip Code, itiaiII. 1 ype or Building (check ail that apply)^ I or2 Ftmiiy Dwelling-NumberofBedrooms Q-Pf ^D Public/Commercial-DescribeUse,D State Owned - Describe UseIII. Type ofPtrmit: (Check only one box on line A, Complete line B if applicable)Phone Number7/5'-Sr5^-^7Ut«aCSM NumberFarce) tProperty Locationgeui-Uit^^MW ■/., U'*JSection :i\T N R ^ Ecifcleone)orWSubdivision Name□ City of.D Village of,Town of.^ New SystemD Repiace.meniSysiemD Treatment/Holding Tan!: Replacement OnlyD Other Modification to Existing System (explain)B.D Permit RevisionG ChngeofPlumbe:D Ptrmil RenewalBefore expirationType of POWTS System/ComponeBCifPevice: (Check all that applyD Permit Transfer to NewOwnerList Previous Pemit Number and Date Issued□ Non-iTessurized In-Gtourd D Pressurized In-Ground 0 At-Grade □ Mound > 24 in. ofsu.tablesoll D Mound <24 in'ofsuitable soil^ Holding Tank □ Other Dispersal Component (explain) Q Pf„reaOTettt Device (explain)^V. Dispenal/rreatment Area Informacion:Design F1ow{gpd)Design Soil Application Rate(ipdsf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System ElevationVI, Tank InfoCapacity inGallonsTotalGallons«ofUnitsManufactureiL>ll13SteelFiberGlasslPitsacNew TanLsExisting TanksSepiic cr Holding Tani.aooo9^0IW"it6tfr(Wre4-e.XDosins ChamderVII. Responsibility Statement- 1, the uodenlgned, assume responsibility for Installation of the POWTS Shown on the attached plansPlumber's Name (Print) ' pi—u.... — v, ■ ' 1 .FMP/MPRS NumberBusinPlumber's Address (Street, City, Slate, Zip Code)79j?'30/ess Phone Number715-SS1t;-/fe73g'959N tWivdcLrri!, UJ'D-./in 11^. I.. fVin^^i^^^epar^ment UseOnivP0ov« DisapprovedD Owner Given Reaso.n for DenialPermilreeDate IssuedIssuing Agen; SignatureIX. Conditions of Approval/Reasons for DisapprovalORIGINALNO REFUNDS AFTERISSUE OF PERMITAttach 10 eomnleiefliiu for tht jyjltr, and submit 10 the Couatv only on paoer sol less rtiingl/Ji 11 inches iinUe SAWi'CnZONING ADMlNlSTRATtOMSBD-6j98[R0313)Habitable Living areashall not be createdin accessory structures
Pg1of4Pg2of4Pg3of4Pg4of4Holding Tank PlanIndex & Cover SheetComponent Manual Design References:Version 2.0, SBD-10855-P (N. 03/07; R 01/12).Index & Cover SheetPlot PlanHolding Tank SpecificationsManagement PlanPAGE 1 OF 4Attachments:Enclosures:POWTS Application for ReviewSoil Evaluation Report & Site Map (if applicable)Holding Tank Pumping Contract (if applicable)Holding Tank Agreement (if applicable)Project Name / DescriptionOwner Name(s):SWi\m ^ \J n L0V\yUlA€. Phone:Owner Address: |(^/(^(gUl PtfgT UnI ^ip:Project Address: rVgrLN) UTCGtJvtrtot; I^W 1/4 of 1/4, Section.^ . T V/n-R^^ 61""! or WTownship: County:Project Parcel ID #: O\0 M •"Designer informationDesigner Name Phone:Designer Address: ^5"9 Al SfecfiC l2d. QT? uSl Zip: SE-mail: g>lr>aA*m64olajr2t^^ iJS>Us, Thi.s space resen'ed for approval stamp.License NumberRemarks:Signature:Original signature required on each submitted copy.Date:/
Sawyer County Zoning & Conseiwation Administration10610 Main Street, Suite 49*'oV»> Hayward, Wisconsin 54843(Tisiew-sstis/ l^AX (715)538-3277Sanitary Cover SheetI'nll Free Coiirtliauic/Gcncral Informalion 1-877-599-4110Holding Tank Approval Checklist/cr Sheet Date Stamp 0*1 / oi / gLoO-OParcel iDtiII. Plot PlanProperty Lines / Benchmark BM A_/ Site Address North Arrow/" Structure Z-Seate-y Well 25' to Service Road_/ Legal Description y Nearest Road IntersectionSetbacks to: Property LineTwell, Structure, Water bodies, RoadsIII. Required PlansX,Index Page with Original SignatureJ2L. Management Plan/Contingency PlanServicing ContractHolding Tank Agreement formIV. Holding Tank Specificationsy Cross-section - Manufacture, Gallons:y. Tank Anchor Calculations [SPS 383.43 8) g)]y Locking device, chains/locksy Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) andState Statutes 101.862(2) and 101.862(3)^ 3" Bedding Material < 1/2 "V. Holding Tank Plans per Component POWTS ManualVersion 2 SBD-10855-P (R,3/07)Owner:Application Review Date:POWTS Reviewer:Plumber:0*^1 6 I /Q\SZ\License 0Revised 4/11/2013
DATE.BYDRAWING NOSHEET OF.JOB NO..TITLEn\\^5
PAGE 3 OF 4HOLDING TANK SPECIFICATIONS(No Scale)Electrical must comply withSPS 316 and NEC 300vi/ \\yQ Weatherproof—Junction andAlarm Box12' MIn. or 2.0 ft aboveApproved Established Flood Elevation(typical)- Conduit4"IS Vent Pipe>10 ft fromBuildingVent CapI18'Min. 1(typical)InletAirtight SealApproved Joints tvlthApproved Pipe 3 ft ontoSolid GroundkApproved Locking fwlanholewilli Warning Label Attached(typical)4" Min. or 2.0 ft aboveEstablished Flood Elevationj. / (typical)Finished Grade1-T-Inlet InvertT J—WatertightPlugMax. 12" or 90% of total volumeIf more than one tankAlarm-OnHOLDING TANKVOLUME = O^OeO gal3* Approved Bedding Material Beneath TankTANK MANUFACTURER:WIESER CONCRETEAnchor tank as necessarypursuant to SPS 383.43(8)(g)Ballast Weight = [(cu.ft.tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt) x 1.5Ballast Weight = {(,cu.ft. X 62.4 Ibs/cu.ft) -lbs] X 1.5 =lbs
PAGE 4 OF 4Holding Tank Management PlanIMPORTANT:The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance pursuant torequirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2). Wise. 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 inspection and maintenance activities shall be performed by a registered POWTS Maintalner inaccordance with SPS 383.52 (3), Wise. Admin. Code.20Estimated Daily Wastewater Flow = gpdInspection Checklist INSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors {i.e. odors, user complaints, etc.)o mechanical malfunction {i.e., pumps, valves, s\Antches, floats, efc.)o material fatigue {i.e., leaks, breaks, corrosion, etc.)o neglect or improper use {i.e., exceeding design capacities, prohibited activities, etc.)o electrical components {i.e., wiring, connections, switches, controls, timers, alarms, efc.)o surface discharge of effluent or sewage back-up into structure servedSERVICING FREQUENCYThe tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wsc. 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 MR 113, Wise. 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 comoanvr^ij^^^lA Phone: "7/ G-'SS-R'/hT^Local government unit:Local government unit address:Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wise. Admin.Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wise. Admin. Code.No product for chemical or physical restoration of the POWTS may be used unless approved by the department inaccordance with SPS 384, Wise. Admin. Code.ContinQencv PlanIn the event that any failed component of this holding tank{s) cannot be repaired, it shall be replaced pursuant to aplan submitted to the appropriate agecy for review and approval.System AbandonmentIf use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wise. Admin. Code.
HOLDING TANK SERVICING CONTRACTContract Date: ^ / ^6 /This contract is made between the Holding Tank Owner and the Pumper.Holding Tank Owner's Name:Pumper's Name:LoiA^"fin-£,Parcel Identification Number:(12 Digit Legacy ID) 1 - 2- / - 2- 2— O ^1. The owner agrees to file a copy of this contract with the governmental unit. Sawyer County,which has accepted and reeorded with the Office of the Register of Deeds, the MaintenanceAgreement for a Holding Tank required under the Sawyer County Private Sewage SystemOrdinance for the issuance of a Sanitary Permit for the installation of a holding tank(s).2. The owmer agrees to have the holding tank(s) serviced by the pumper and guarantees topermit the pumper to have access and to enter upon the property for the purpose of servicingthe holding tank(s). The owner agrees to maintain the all-weather access road or drive sothat the pumper ean service the holding tank(s) with the pumping equipment. The ownerfurther agrees to pay the pumper for charges incurred in servicing the holding tank(s) asmutually agreed upon by the owner and pumper.3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for theservicing of the holding tank(s) as required under SPS 383.55, Wisconsin AdministrativeCode and the Sawyer County Private Sewage System Ordinance. The pumper furtheragrees 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 serviced;e. The volumes in gallons of the contents pumped from the holding tank for each servicing;f. The disposal sites to which the contents from the holding tank were delivered.4. This agreement will remain in effect until the owner or pumper terminates this contract. Inthe event of a change in this contract, the owner agrees to file a copy of any changes to thisservice contract or a copy of a new service contract with Sawyer County within ten (10)business days from the date of change to this service contract.Owner's Name: (Print)Owner's Signature: (Only one owner signature i^uired)A-Pumper's Name: (Print)hf'PuiT|^'y^nature: y XPumper'Registration Number: ■«-/Rev. 03/26/13ZONlNQ ADMI
- USE BLACK INK ONLY •POWTS MAINTENANCE AGREEMENTFor Holding TanksOwner's Name(s) as shown on deed:Longtine TrustParcel Identification Number:(12 OiQil Legacy ID)Legal Description of Property:• SEE ATTACHED SHEET -We acknowledge that application is being made for the installation of a hoiding tank(s) on theproperty described on the attached sheet.Return To: Sawyer County Zoning and Conservation Administration10810 Main SL Suite 49, Hayward, Wl 548438 0 3 4 8 6Txf^022585426126PAULA CHISSERREGISTER OF DEEDSSAWYER COUNTY, WI09/01/2020 12:54 PMRECORDING FEE 30.00PAGES: 2As an inducement to the County of Sawyer to issue a sanitary permit for a hoiding tank on the above-described property, the owner isresponsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to allapplicable requirements of SPS 383, Wis. Adm. Code relating to holding tank management, including the following:1. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, except as provided bySection 281.48 (3) (d). Stats., to have the holding tank properly serviced and to file a copy of the service contract vnth thegovemmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new servicecontract, with the govemmental unit within ten (10) business da^ from the date of change to the service contract.2.3.4.5.The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit pumping reports tothe govemmental unit in accordance with SPS 383.55, Wis. Adm. Code, for the servicing of the holding tank. In the case ofexemption under Section 281.48 (3) (d), Stats., the owner shall submit the report to the govemmental unit. The govemmentalunit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate theholding tank is not being property maintained.If the owner fails to have the holding tank properly serviced in response to orders issued by the govemmental unit to preventor abate a human health hazard as described in Section. 254.59, Stats., the governmental unit may enter upon the propertyand service, or cause the tank to be serviced. Pursuant to Section 145.20(4) Wis. Stats., a governmental unit may assess theowner of a private sewage system for costs related to the pumping of a septic or holding tank. The charges will be assessedas prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the governmental unit forinspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abateany human health hazard caused by the holding tank.This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systpmscertifies that either a soil absorption system that complies with SPS 383, Wis. Adm. Code, or a municipal sewer serves theproperty. In addition, this agreement may be cancelled by executing and recording said certification with reference to thisagreement in such manner which will permit the existence of the certification to be determined by reference to the property.This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submitthe agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which willpermit the existence of the agreement to be determined by reference to the property where the holding tank is installed.Owner'js Signature:• Only one owner signature raguircd -Ownprjs Name (Print): . y /tlTUStSfeDate:2 Zo 2.0Drafted by:ACKNOWLEDGMENTSlate of: y>5Co>r&c^nCounty of:Subscribed and sworn to before me on thisid sworn to before rr_dayBy (Owner's Name):lame):sT,20Personal information you provide may be used for secondary purposes [Privacy Law, § 15.04II) (lb'Notary Public S|^i|«Ma^(|Rev. 03/26/13
010-941-21-2208, ^10 Oil 21 220r. Parcel 1:Lot One (1) of Certified Survey Map No. 8193 as recorded in Volume 34 of Surveys on Page 309, asDocument No. 405795, located in and being part of the Northwest Quarter of the Northwest Quarter(NW1/4-NW1/4) and part of the Northeast Quarter of the Northwest Quarter (NE1/4-NW1/4) of SectionTwenty-one (21), Township Forty-one (41) North, Range Nine (9) West, Town of Hayward, SawyerCounty, Wisconsin.
Real Estate sawyer County Propeity ListingToday's Date: 9/1/2020Property Status: CurrentCreated On: 12/14/2017 8:36:40 AMDescriptionUpdated: 12/14/2017OwnershipUpdated: 7/9/2020Tax ID:PIN:Legacy PIN:Map ID:4300257-010-2-41-09-21-2 02-000-000080010941212208Municipality:(010) TOWN OF HAYWARDSTR:S21T41N R09WDescription:PRT NWNW 8i PRT NENW LOT 1 CSM34/309 #8193Recorded Acres:5.740Calculated Acres:0.000Lottery Claims:1First Dollar:YesZoning:(R-1) Residential OneESN:444^ Tax DistrictsUpdated: 12/14/20171State of Wisconsin57Sawyer County010Town of Hayward572478Hayward Community School District001700Technical CollegeRecorded DocumentsUpdated: 7/9/2020CORRECnON INSTRUMENTDate Recorded: 6/4/2020424170CONVEYANCE RECORDED NOT USEDDate Recorded: 5/19/2020423900CORRECnON DEEDDate Recorded: 12/14/2017410225QUITCLAIM DEEDDate Recorded: 11/22/2017409933CONVEYANCE RECORDED NOT USEDDate Recorded: 11/13/2017409754CERTIFIED SURVEY MAPDate Recorded: 3/15/2017405795COVENANTSDate Recorded: 2/17/2017405447WARRANTY DEEDDate Recorded: 8/1/2006340561JUDGMENTDate Recorded: 3/12/2001289573WARRANTY DEEDDate Recorded: 1/15/1996252323WARRANTY DEEDDate Recorded: 6/13/1986200417LONGTINE TRUSTHAYWARD WIBiiilna Address:LONGTINE TRUST16166W DEER LNHAYWARD WI54843Maillna Address:LONGTINE TRUST16166W DEER LNHAYWARD WI 54843^ Site Address * indicates Private Road16166W DEER LNHAYWARD 54843^ Property AssessmentUpdated: 6/28/20182020 Assesnnent DetailCodeAcresLandImp.Gl-RESIDENTIAL5.74049,500159,5002-Year Comparison20192020ChangeLand:49,50049,5000.0%Improved:159,500159,5000.0%Total:209,000209,0000.0%Property HistoryParent PropertiesTax ID57-010-2-41-09-21-2 02-000-00007043001HISTORY 63 Expand All History White=Current Parcels Pink=Retired Parcels63 Tax ID: 12362 Pin: 57-010-2-41-09-21-2 02-000-000010 Leo. Pin: 010941212201 Mao ID: .6.163 Tax ID: 12355 Pin: 57-010-2-41-09-21-2 01-000-000290 Leg. Pin: 010941212129 Mao ID: .5.2963 Tax ID: 12340 Pin: 57-010-2-41-09-21-2 01-000-000140 Leo. Pin: 010941212114 Mao ID: .5.1463 Tax ID: 43001 Pin: 57-010-2-41-09^ 1-2 02-000-000070 Leo. Pin: 01094121220743002 This Parcel ^ Parente ^FchUdren
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