HomeMy WebLinkAbout020-639-12-2203-SAN-2020-147Industry Services Division1400 E Washington AvoP.O. Box7162Madison, Wl 53707-7162 ./ No Oo^.. )Sanitary Permit ApplicationIn accordance wiili SPS 383J1(2}. Wis. Adm. Code, submission of Ibis form lo the oppropriale govemiiiciital unitis required prior lo obuining a sanitary pctmil. Mole: Application forms for state-owned POWTS arc subinilleJ toIhe Dcparlmeiil of Safety and Professional Scrvies. Personal information you provide may be used for secondarypurposes in accordance with the Privacy Law, s. l5.0-t(lXm). Stats.I. Applic.nliori Information-Please Print All InfoniiationProperty Owner's Name4- 7'f^cyProperly Owner's Mailing Addressfo B0>( VV7CountyCo .Sanitary Permit Number (to be filled in by Co.)State Transaction NumberProject Address (ifdifferent than mailing address)5City, SlateZip CodeII. Type of liuiltling (check all thai apply)"Kl or2 Family DwellinB-NumberofUcdrooms ^D Public/Commercial - Describe Use _D Stole Owned - Describe UsePhone NumberProperly LocationGovi. Lot ^ 0^ 5"18IfJVi/ 'A. >JvJ 'A, Section / jLLol#J2(circle on^T 3 ' N: R 6 EorlWSubdivision NameBlocksGSM Numberu [□ City ofD Village ofB^Town of ^J"/ktA/A.HI. Type of Periiiil; (Check only one hoxoti line A. Coniplcte lincH if applicable)A.^Ncw SystemB.D Replacement SystemQ Permil RevisionD Change of PlumberD Permit RenewalBefore CxpirationTv. Type of I'ONVTS Syslem/Componcnt/Dcvice: (Check all thai applyD Treatment/Holding Tank Replacement OnlyD Permit Transfer lo NewOwnerD Other Modification to Existing System (explain)List Previous Permit Number and Date Issued□ Non-Pressuri/cd In-Ground □ Pressurized In-Ground D At-Gradc □ Mound>24 imofsuilablesoii □ Mound <24 in. ofsuitable soil^JS'lIoiding Tank □ Other Dispersal Component (explain) Q Pretreatment Device (explain)V, Dispcrsalfrreatment Area Infonnatioii:1)^.11 Flow (gpd)Design Soil Application Ratc(EpdsODispersal Area Required (sf)Dispctsat Area Proposed (sf)System ElevationVI, Tank InfoC»p;icjly inGallonsTolaiGallonsHotUnitsMiimifaclutcrPrefabConcreteSite Condetcurts"3uFiberGlassPlcitsaNew TanksllxisiiiiBTiuiksScpljc o^tolJing Tadc^?,(IOO^«0t1(.fternsf^VDosing Ch.imbcfVII. RcsiionsibilityStalcnicnt- I, the undtrsii;ittd. assume rtsponsihility for Instaiialion of Che I'OUT.S shown on Hie attached plant.Plumber's Name (Print)Piumbet>8lBnaitkcMI'/MW>S1<umbcr Dusin(H^cv C(Ol(=^Plumber's Address (Street, City. Slate. Zip Code)/cssPhone Number ^O.'-i t2/tAJcH i? [aM^'fTT /•* * I -III r.VIII. C'uvnfv/DepnrlnictH U.sc Only^AnTOTOrn Q Dis.vpprnvedjsW I D Owner Given Reason for Deni.iiPermit FeeWoo-Dale Issued'7-«.?>/-c.24:24-IX. Conditions of Approval/Reasons for DisapprovalNO REFUNDS AFTERISSUE OF PERMITORIGINALIssiiiiiG Agent SignatureAliacb lo couijiicic plant for the sjjitm and submit (o die Couoiy only on paper not tcs« IbaaS lli It inches in'SUl)-6398 (1(0313)c0^^\0^
Sawyer County Zoning & Conservation Administration-xv\\i. 10610 Main Street, Suite 49Hayward, Wisconsin 54843(715)634-8288VAX (715)638-3277Toll Free Caurlhous^Gen^^M^^(i^F^7-699>4110Owner;Sanitary Cover SheetHolding Tank Approval Checklist/cr Sheet Date Stamp 07 /Plot PlanProperty LinesyShe Addressy StructureTCWellParcel ID#/ ^ O3 1_-J_ JBenchmark BM A "Uf HV~/ North Arrowy Scaley < 25' to Service Road_2( Legal Description Nearest Road IntersectionSetbacks to: Property Line, Well, Structure, Water bodies, Roadsin. Required Plans_y, Index Page with Original SignatureX Management Plan/Contingency PlanX Servicing Contract^Holding Tank Agreement formTV. Holding Tank SpecificationsX Cross-section - Manufacture, Gallons:K Tank Anchor Calculations [SPS 383.43 8) g)]X Locking device, chains/locks_XAlami and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) andState Statutes 101.862(2) and 101.862(3)yC 3" Bedding Material < 1/2 "V. Holding Tank Plans per Component POWTS ManualX Version 2 SBD-10855-P (R.3/07)Plumber:6-4l<Application Review Date:POWTS Reviewer:LicenseRevised 4/11/2013
Pg 1 of 4Pg 2 of 4Pg 3 of 4Pg 4 of 4Attachments:PAGE 1 OF 4Holding 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 PlanEnclosures:POWTS Application for ReviewSoil Evaluation Report & Site Map (if applicable)Holding Tank Pumping Contract (if applicable)Holding Tank Agreement (if applicableProject Name I DescriptionOwner Name(s):Owner Address; p.^Phone: W-LU- %ILProject Address:Govt. Lot: 2Township:Project Parcel ID #:Zip:Iq^17 fO SJfyV4{l€ TQAiU ^A/U^ 1/4 of A/UJi/4, Section |2 , T,3_N-R_4_E CHor W0 "Y/ 6 County:Designer Name:Designer Address:E-mail:License Number: _Remarks:Designer InformationPhone: 7^5^ ^3/7/I Z.I.' ti- I'l v(sl k>r iippiovdJ .sliiinp.!3ngif>al s\gnatyr^required on each Submitted copy.Date:7/2//2<
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PAGE 3 OF 4HOLDING TANK SPECIFICATIONS(No Scale)Electrical must comply withSPS 316 and NEC 300\l/ \l/18'Mln. I(tyjrical)O Weatherpreof—Junction andAlarm Box-Conduit4"0 Vent Pipe>10 ft fromBuildingInlet12" MIn. or 2.0 ft atx>veApproved EstabSshed Flood ElevalionVent Cap /1 / Approved Locking Manholewith Warning Lattel Attached(typical) 4'MIn. or 2.0 ft aboveEstablished Flood Elevation(typical)ni/.bt ()-Airtight SealApproved Joints withApproved Pipe 3 ft ontoSolid GroundInlet InvertV— Max. 12" or 90% of total volumeIf more than one tankAlarrrvOnHOLDING TAIVOLUMETAm= 0 0gal3' Approved Bedding Material Beneath TankTANK MANUFACTURER:nI/Finished Grade'WatertightPli«Anchor tank as necessarypursuant to SPS 383.43(8)(g)Ballast Weight = [(cu.ft.tank.vo! 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 Maintainer Inaccordance vwth SPS 383.52 (3), Wise. Admin. Code.Estimated Daily Wastewater Flow = gpdinspection Checklist iNSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors {I.e. odors, user complaints, efc.)o mechanical malfunction {i.e., pumps, valves, switches, 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 {l.e., wiring, connections, svwtches, controls, timers, alarms, etc.)o surface discharge of effluent or sewage back-up into structure sen/edSERViCiNG FREQUENCYo The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wise. Stats,when the wastewater in the tank(s) reaches a ievei of one foot beiow the iniet invert of the tankfs).Disposal of contents shall be pursuant to NR 113, Wise. Admin. Code.Tank pumping reports shaii be submitted to the proper iocai government unit in accordance with SPS 383.55 Wis.Admin. Code. Report any component feilure or malfunction to:Name of Individual or company: _ Phone. 1 hLocal government unit:. o Phone;Local government unit address: ZIP;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.Continaencv 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, Wfisc. Admin. Code.
HOLDING TANK SERVICING CONTRACTI Contract Date: 7This contract is made bct>vccn the Holding Tank Owner and (he Pumper.Holding Tank Owner's Name:Pumper's Name:Northwest Sanitary, Inc.PO BOX 155Radlsson,WI 54867Parcel Identification Number:'(12 Digit Legacy ID) 00- 3 . JZJI o 31.3.4,The owner agrees to file a copy of this contract with the governmental unit, Sawyer County,which has accepted and recorded with the Office of the Register of Deeds, the MaintenanceAgreement for a Ifolding Tank required under the Sawyer County Private Sewage SystemOrdinance for the issuance of a Sanitary Permit for the installation of a holding tank(s).The owner agrees to have tlic 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 can service the holding tank(s) with the pumping equipment The ownerfurther agrees to pay the pumper for a charges incurred in servicing the holding tank(s) as,mutually agreed upon by the owner and pumper.The pumper agrees to submit to the Govenunental 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 firom the holding tank were delivered.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 fhjm the date of change to this service contractOwner's Name: (Print)Owner's Signature: (Only one owner signature required)Pumper's Name: (Print)Ronald L V/ieceli, owner Northwest Sanitary,IncPumper's Signature:Pumper's Registration Number:#2389Rev. 03/26/13
Real Estate sawyer County Property ListingToday's Date: 7/23/2020Property Status: CurrentCreated On: 2/6/2007 7:55:36 AMDescriptionUpdated: 4/2/2020aOwnershipUpdated: 8/7/2019Tax ID:21156STUART & TRACY PRESTONHOMOSASSAPIN:57-020-2-39-06-12-2 02-000-000030SPRINGS FLLegacy PIN:020639122203Map ID:.6.3Biiiina Address:Maiiino Address:Municipality:(020) TOWN OF OJIBWASTUART & TRACY PRESTONSTUART & TRACY PRESTONSTR:512 T39N R05WPO BOX 447HOMOSASSA SPRINGS FL 34447PO BOX 447HOMOSASSA SPRINGS FL 34447Description:PRT NWNW LOT 2 C5M 21/111 #5981Recorded Acres:4.970Site Address * Indicates Private RoadCalculated Acres:5.007Lottery Claims:06877N NATURE TRL »WINTER 54896First Dollar:NoWaterbody:Chlppewa RiverLJ Property AssessmentUpdated: 8/20/2013Zoning:(RR2) Residential/Recreational Two2020 Assessment DetailESN:CodeAcresLand Imp.^ Tax DistrictsGl-RESIDENTIAL4.97037,800 0Updated: 2/6/20071State of Wisconsin2-Year Comparison20192020 Change57Sawyer CountyLand:37,80037,800 0.0%020Town of OjibwaImproved:00 0.0%576615Winter School DistrictTotal:37,80037,800 0.0%001700Technical CollegeRecorded DocumentsWARRANTY DEEDUpdated: 4/2/2020418901WARRANTY DEEDDate Recorded: 10/14/1999280095 688/127COVENANTSDate Recorded: 9/28/1999279718CERTIFIED SURVEY MAPDate Recorded: 8/11/1999278523' Property HistoryN/A
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-USE BLACK INK ONLY-POWTS MAINTENANCE AGREEMENTFor Holding TanksOwners Name(s) as shown on deed:TrtccyParcel Identification Number(12 Digit Legacy ID) dAg_.£5±.±x.^xo%Legal Descrfption of Property:- SEE ATTACHED SHEET-We acknowledge that application is being made for the Installation of a holding tank(s) on theproperty descn'bed on the attached sheeLReturn To: Sawyer County Zoning and Conservation Administration10610 Main SL Suite 49, Hayward, W1548438 0 3 3 2 8Tx:4021490425213PAULA CHISSERREGISTER OF DEEDSSAWYER COUNTY, WI07/23/2020 10:42 AMRECORDING FEE 30.00PAGES: 2As an Inducement to the County of Sawyer to issue a sanitary permit for a holding 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. NR113, Wis. Adm. Code, except as provided bySection 281.48 (3) (d). Stats., to have the holding tank property serviced and to file a copy of the service contract v4th the .governmental unit. The owner further agrees to (lie a copy of any changes to the serwce contract, or a copy of a new servicecontract, with the governmental unit within ten (10) business days from the date of change to the service contract2. The owner agrees to contract with a persi^n licensed under Ch. NR 113, Wis. Adm. Code, who shall submit pumping reports tothe govemmentai 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 govemmentai unit The govemmentaiunit 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.3. If the owner fails to tiave the hdding tank property serviced in response to orders issued by the govemmentai unit to preventor abate a human health Irazard as descnbed in Section. 254.59, Stats., the governmental unit may enter upon the propertyand sendee, or cause the tank to be serviced. Pursuant to Section 145^20(4) Wis. Stats., a govemmentai unit rnay assess theowner of a pnrate sewage system for costs related to the pumping of a septic or holding tank. The charges will be assessedas prescnbed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the govemmentai unit forInspection, pumping, hauling, or otherorise senricing and maintaining the holding tank in such a manner as to prevent or abateany human health hazard caused by the holding lank.effect only until the govemmentai unit responsible for the regulation of private sewage systemscertifiOT that eifaer a toiI absorption system that <»mplies 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 properly.hiding upon the ovmer, the heirs of the owner, and ^gnees of the owner. The owner shall submit?. f?u ®'" agreement shall be reax^a'&TOtegj^ of deeds In a manner which willpermit the existence of the agreement to be determined by referen^^Wfj^^liiie^^^ holding tank is installed.""n \Only one owner signature required. ^ A/^i^'mouwOwner's SiOHature:^ / vO'^^'^OSKNOvkEDGMENTIOwner's Name (Print): _Date:Drafted by:tatQ oF Uoyj^dcA^A|ourHyofb^^;^|^lo^bf^nbed and swotDw.^efore me on this,20 20By PrrsfagNotary Public Signature: (<JA.(L\h0Ia HiPublic Notary Name (Print): ^fvr>rl'My commission expires on: "hPersonal infotmaUon you provide may be used for secondary purposes privacy Law. § 15.04 (1) (m)]Rev. 03/26/13
Preston Legal DescriptionLot .as recorded In Volume 21 of Certified Survey Maps, page 111-112, Survey No. 5981as Document No. 278523, Sawyer County, Wisconsin, being a part of the Northwest Quarter of theNorthwest Quarter (NW J4 NW X), Section 12, Township 39 North, Range 6 West
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