HomeMy WebLinkAbout026-121-00-1005-SAN-2020-225Industry Services Division1400 E Washington AveP.O. Box 7162Madison, WI53707-7162No C5T7162Sanitary Permit A^lications.la with SPS 383,21(2), Wis. Ato. Code, suhmissioo ofthis fonn to the appropriate governmental unitIS reqturedpnor to obtammg a samtaty perauL Note; Application fonna for state<iwnc<l POWTS are submitted tothe Department of Safety and Piofcssiotial Servicee. Petaoaal mfotmation you provide may be used for secondarv.purposes maccordaneewitbthePrivacvLaw, i. IS.CWtym)^ st«t. •owuu«y^L ACountyScV ''/-i.'t"Sanitary Penait Number (to be filled in by Co.)State Tratisactioa NumberI-f1pplication Informadoo - Please Print All InformatinnProperty Owner's NameProject Addreas fif diffBrem rtme mniUng «.t.t,Tsi) fKParcel ttRtjperty Owner's Mailing Address/c>o^s7 c7City, StateZip Coden. Type ofBuilding (checlcali that apply)or 2 Fatnily Dwelling-Number of Bedrooms 2>D Public/Commercial - Describe UseD State Owned - Describe UsePhone NumberPropaty LocatiooPrV.Oovt. Lot vjj14.Vs Section X |(circle one)L^/,^ ,c.jur(T3fi_Ni R.f;}v EorfcSubdivision NameBlock#CSM Number□ city of0 Village ofKXown of ^g-vrOfl.nL Type of Permit: (Check only one bo» on line A. Complete line B if appileable)B.D New System0 Petmit RenewalBefore Expiration0'Rep!;acement SystemD Permit RevisionD Treatmnit/Holding Tank Replacement OnlyD Change ofPlumberIV■ Type ofPOWTS Syrtem/Comnoncnt/Devicei (Check all that apptv□D Permit Transfer to NewOwnerD Other Modification to Emating System (explain)List Previous Permit Number and Date Issued Non.Pm.surirodb.Oround □ Ptesntrimd In-Ground □ Al^ □ Mound>24 m. ofmitihle soU □ Mound <24 «. of ntilri,le«.il§^HoldingTank □ Other Disperad Component (explain) □ Prttieatmenl Device (««laia1V. Diiperaal/Treatment Area InformertnwDesign Flow (gid)Design Soil Applicaiioa Rate(gpdsf)Dispersal Area Required (si)Dispeiaal ASrea Proposed (sf)ystem ElevatioaSepac or Holding TaskDoaing Chamberedacity inGallonsNew TbIs'•/oooTotalGallonsVCCOi»ofUnits3.Mftiu&ctunr& 1Vn. Responsibility Statement- I. the nnderalgntd. assume responiibUlty for InstaUation of the POWTS shown on the attachedPlumber s Name (Print) PiumWa <>on.r>mi rrscrscrrrt—: 14-number's SignatureMP/MPRS NumberB8S3Ph. OJerry Ruid Excavating, LLCSusinees Phone Numbertone Lake, WI 54876Ctmnty/Department Use Onlvi^SIVD Dis^provedD Owner Given Resson for DenialPermit FeeSu^rx da•YOD.'K. Conditioiu of Approval/Reasons forSlaapprovalDtt0 ImnrfftIssuing Agent SignetuteORIGINALAttach to complete pUn for the lystco sad tubmll to the Ceaaty only oa pepernot ket thanl l/2xUlDch<ZONING AD'SBD-6308{R. 08/14)
Sawyer County Zoning & Conservation Administration10610 Main Street, Suite 49Hayward, Wisconsin 54843(715)634-8288■iifffft i (715)638-3277m Toll Free Courlhouse/Gcncral Information 1-877-<99-4n0Sanitary Cover SheetHolding Tank Approval Checklist/er Sheet Date Stamp CPT / / V / ^AOII. Plot PlanProperty Line.sZ Site AddressX Structure)C WellX Legal DescriptionParcel ]DU <o A (a -\ S, \ .C>0-^ o O 5"Benchmark BM ▲X North Arrown<25' to Service Roady Nearest Road IntersectionX Setbacks to: Properly Line, Well, Structure, Water bodies, RoadsIII. Required PlansX Index Page with Original SignatureX Management Plan/Contingency PlanServicing ContractX Holding Tank Agreement formIV. Holding Tank Specifications_jC Cross-section - Manufacture, Gallons:X Tank Anchor Calculations [SPS 383.43 &) g^]X Locking device, chains/locksZ^Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) andState Statutes 101.862(2) and 101.862(3)Z 3" Bedding Material < 1/2 "V. Holding Tank Plans per Component POWTS ManualVersion 2 SBD-10S55-P (R.3/07)/nprr Pliimhfir- l^uT^Plumber:Owner:Application Review Date:POWTS Reviewer:License tlRevised 4/11/2013
Pg1of4Pg 2of4Pg 3of4Pg4of4Holding Tank PlanIndex & Cover SheetComponent Manual De^n Refemnces: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)Holdinq Tank Pumpinq Contract (if applicable)Holdina Tank Aareement (if applicable)Project Name / DescriptionOwnerName(8): l(Phone:Zip: / 2 ^Owner Address: /OPS' 1 ^Project Address: AJGovt Lot: 1/4 of .1/4, Section I . N-R*^Township:County: v-■□or wEerProject Parcel ID #: o 3. c> 13. t oc> I c:>oS^Designer informationDasiffner Address: StnriA I aIta, WW gaa7^ Zlp:_2JlE_l^W - j * m wmm wE-mail: ^ c~-er\frur^ i-c~{License Number: 'X'^KS^'XRemarks:Tliis space reseived for approval stamp.Signature:/ (j^Inal dgnature reInal dgnature required on each aubmHted copy.Date:3-l!r^
Jerry Ruld Excavating,W208 County HWY AStone Lake, Wl 54876/■~7/s"—ed^rti L^i(re.O OhZ<^MC.I-\(por^£i <=^<=V.cl\ <x/vjk SiT^ «=j 7^l-c^Ke, -V)ws'o.o '^„c^ — r^ —1- SCJCJCO t-JceSc'.rHc^ic^t^c \ c.^tCLc,^ (c,Uf iy 7 f1 <^77VJc»C'*i' t)C->V"'Y
. Cover with warning label/ apd lock If access opening Is/ groalor than B Inch ilia.4** min. above siirroiiniling grade or 2 ft aboveablished regional flood elevalion. unlessaccess port is water and gas tightWatertight Junction box?UILOIN& SisV/Rt L, ^0 inchmin. dia0 inchmin. diaPower sourceAlarm floatCover with warning label/ and lock if access opening Is^ greater than 0 inch dia.Ctfutoe-VentCross-Section of i loldine Tank& i»» sMaximum alarm on level setat 12" below tank Intel invertor 90% of the liquid capacityof the tank below tiie tankinlet invertELecTfOCML. AfhJSC. 300 AAtta Cotsnkn lb* 3 OeODlhitmAloeuoce. TAKIIC At j6e.ASSLA^ Ta g«<OVax>CV *Hot-oiucm TnHk: tlnfMctrV HOOC,UdLbtHb TAUK. CkJ'AUtfUsn MAMJfi^ACnJtOEaALAR An ManeL MuMiOianjfia.1'feo^ecj' e.-/ /fLut-itse^—Jony Ruid Cxcavating, LLCW2Q8 County HWY AStone Lake, Wl 54876CcjKtft>ijeur i*OAi«jum_ kJtj.nacR '2.>o r^—
PAGE 4 OF 4Holding Tank Management PlanIMPORTANT;The ovwier of this holding tank{8) shall be respon^ble for its papetual operation and maintenance pursuant torequlrwnents of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise Admin. Code, this holding tank(8)shall be considered a human health hazard If not msdntained in accordance with this approved management plan.Furtiiennore, all Inspeison and maintenance activities shall be perfoimed by a registered POWTS Maintainer Inaccordance ^th SPS 383.52 (3), Wlsa Admin. Code.Estimated Dally Wastewatar Flow = gpdInspection Checkltet INSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors (/.e. odors, user complaints, eto.)o mechanical mdfuncHon (/.e., pumps, valves, switches, floats, eto.)o material fatigue {he., leaks, breaks, corro^on, eto.)o neglect or improper use {he., exceeding design capacities, prohibited activities, eto.)o elTOtricai components {he., ^ring, connections, sy^tches, controls, timers, alarms, etc.)o surface discharge of effluent or sewage back-up into structure senredSERVICING FREQUENCYo The tank(s) shall be pumped by a certified septage senricing operator licensed under s. 281.48 Wise. Stats,when the wastewatar in the tank(s) reaches a level of one foot below the Inlet invert of the tank(8).Disposal of ccmtents shall be pursuant to NR113, Wise. Admin. Code.Tank pumping reports shall be submitted to the proper local government unit In accordance with SPS 383.55 Wls.Admin. Code. Report any componmt failure or malfunction to:Name of Individual or company: ^CoTT^S C- Phone: —72.7*^—Loccti govanmentunit Phone:Local govanment urdtaddress: lOfelO STT ^^ctS/tUaT'^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.ContlnQencv PlanIn the event that any feiled 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 l>e alsandoned In accordance with SPS 383.33, Wise. Admin. Code.
HOLDING TANK SERVICING CONTRACTContract Date:-( / e-iThis contract is made between the Holding Tank Owner and the Pumper.Holding Tank Owner's Name:LtJtt ( -ei-Pumper's Name:c;-Parcel Identiflcatioii Number:(12DieitLee:acvID) C> 0^- 1 ^ o - 1 o c>1. 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 ofDeeds, 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 owner 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 can 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 ptimper.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 tnnW;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 s^mtnn required)Pumper's NaraertPrint)Pumper's RegistratioQ Number:Rev. 03/26/13
-USE BLACK INK ONLY-POWTS MAINTENANCE AGREEMENTFor Holding TanksOwner's Name(s) as shown on dood: ,Parcel Identlficat'on Number:(12 Digil Legacy 10)^ ^ ^ ^ o . j_ _oLegal Description of Property:. SEE ATTACHED SHEET -We acknowledge that application is being made for the installation of a holding tank(s) on theproperty described on the attached sheet.Return To: Sawyer County Zoning and Conservation Administration10610 Main St. Suite 49. Hayward, Wl 548438 0 3 5 7 4 $Tx:4023164426652PAULA CHISSERREGISTER OF DEEDSSAWYER COUNTY. WI09/23/2020 09:33 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. 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 sen/ice contract with thegovernmental 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 governmental unit within ten (10) business days from the date of change to the service contract.2. The owner agrees to contract with a person licensed under Ch. NR 113, Wis, Adm, Code, who shall submit pumping reports tothe governmental 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 governmental unit. The governmentalunit may enter upon the property to investigate the cmdition of the holding tank when pumping reports may indicate theholding tank is not being properly maintained,3. If the owner fails to have the holding tank properly sen/iced in response to orders issued by the governmental unit to preventor abate a human health hazard as described in Section, 254,59, Slats., 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 governmenlat unit forinspection, pumping, hauling, or othenvise servicing and maintaining the holding lank in such a manner as to prevent or abateany human health hazard caused by the holding tank,4. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systemscertifies 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.5. 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 properly where the holding tank is installed.n Only one owner signature required • ^ ACKNOWLEDGMENTOwner'Owner's Name (Print);ftDate:Drafted by:yB/// M<~c(C"'r/itniMof: ^^ '^SCO\r\<\rN• ^i^ly of:•Sutscribed and sworn To before me on thisjwprn_day of'iV-• .^^(Owner's Name)20 ^^/.Rr.O 4l®.<^otary Public Signature:Public Notary Name (Print):My commission expires on:Personal information you provide may be used for seoondary purposes [Privacy Law, § 15,04 (I) (m)]Rev, 03/26/13
That part of the Subdivision of Government Lot Six (6), Section Twenty-one (21),Township Thirty-nine (39) North, Range Nine (9) West (Also known as a part ofLot Ten (10) of Franklin Park Subdivision), more particularly described as LotOne (1) as recorded in Volume Thirty (30) of Certified Survey Maps, page 114-115, Survey No. 7545.Subject to and together with a non-exclusive easement for ingress and egress asshown on Certified Survey Map referred to herein.
Real Estate Sawyer County PropertyListingToday's Date: 9/10/2020Property Status: CurrentCreated On: 8/22/2008 9:13:46 AMDescriptionTax ID:Legacy PIN:Map ID:Municipality:STR:Description:Recorded Acres:Lottery Claims:First Dollar:Waterbody:Zoning:ESN:Tax Districts02657247800170040068Q01005Updated: 10/27/200915-138-OwnershipWILLIAM G & PEGGY R MC DOWELLUpdated: 1/12/2010WOODBURY MN-5.10.5(026) TOWN OF SAND LAKES21 T39N R09WSUBD GOVT LOT 6 (21-39-9) PRTLOT 10 LOT 1 CSM 30/114 #75450.880Sand Lake(RRl) Residential/Recreational One423Updated: 8/22/2008State of WisconsinSawyer CountyTown of Sand LakeHayward Community School DistrictTechnical CollegeRecorded Documents□ WARRANTY DEEDDate Recorded: H/30/2009□ AFFIDAVITDate Recorded: 10/15/2009Updated: 1/12/2010WILLIAM G & PEGGY R MC WILLIAM G & PEGGY R MCDOWELL DOWELL10057 RALEIGH CT 10057 RALEIGH CTWOODBURY MN 55129 WOODBURY MN 55129Site Address * indicates Private Road6099N ELSIE RDLJ Property Assessment2020 Assessment DetailCodeGl-RESIDENTIAL2-Year ComparisonLand:Improved:Total:Property HistoryParent Properties57-026-2-39-09-21-5 157-026-2-39-09-21-5 1001003STONE LAKE 54876Updated: 9/28/2017Acres Land Imp.0.880 219,500 115,9002019 2020 Change219,500 219,500 0.0%115,900 115,900 0.0%335,400 335,400 0.0%Tax ID2678426786HISTORY O Expand All HistorWhite=Current Parcels Pink=Retired ParcelsB Tax ID; 2678<40068This Parcel?-09-21-S 15-1^ Parents)1 Leo. Pin' ChildrenlOOlOOl Mao ID;http://tas.sawyercQuntyQOv.orgyAccess/maGter.3sp9/10/20, 3:03 PMPage 1 of 1
026939165113%0259391533I0'?r:y,"* •026121001004:. .ROW< ii^tej026121001005;.026939225601HYDROCC612^iXi1O02.^^/;026I2I000900026939225608« ..... <30.-02613I000700