HomeMy WebLinkAbout026-939-11-5205-SAN-2020-226Industiy Services Division1400 E Washington AveP.O. Box 7162Madison, W153707-7162itMadison, Wl 53707-7162-v(j^6 JSanitary Permit ApplicationIn accordanco with SPS 383.21(2), Wij. Adm. Code, sabmission of tiiis form to the ^pfopriate governineotsl unitis required prior to obtsining a sanitaiy pensit Note: Application forms for stale-owned POWTS are submitted tothe Depaitmnit of Safety and Profbssional Servica. Personal mfbrmaiion you provide nay bo used for secondaryoutposes ineccordaacewitfathe PrtvacyLaw. s. 15.04(iym). Stats.L Application Information - Please Print All InfonartionProperty Owner's NameKdu'CountySanitary Pemtit Number (to be filled in by Co.)^<=^7^33State Transaction NumberProject Addresa (ifdifferent than tna^ng addnas)I:Parcel# ^0 liJS'X':>'>Prt>p>erty Owner's Mailing AddressProperty LocationCity, StateMZip Coden. Type of Building (check all that apply)^1 or 2 Family Dwelling-Number of Bedrooms,D Public/Commercial - Describe UseDstatt Owned-Deecrtoe UseHPhone Number14,3^Lot#N; Rfiid, Section //(circle on^Eo<WBlock#pel, juSubdivitiaa NameCSM Number\o\D City ofD Village of^Town ofin. Type of Permit: (Check only one box on line A. Complete line B if applicable)D New SystemD Permit RenewalBefore Expiration¥Replacement SystemD Permit RevisionD Tremment/Holding Tank Replacement OnlyD Cban^ ofPlumberD Permit Tnutsfer to NewOwnerD Other Modification to Eidating System (cs^lain)List Previous PermitNumber and Date IssuedIV. Type of POWTS Svatem/Comnonent/Device; (Check all that apply'□ NoD-Piessuiized In-Ground □ Piessuiizcd In-Ground □ Ai-Grade □ Mound >24 in. of suitable soU □ Mound < 24 in. of suitable soUHolding Tank □ Other Dispersal Component (explain) □ Pretiealment Device (e:q)lain)V. Dtspcrsal/Treatme"* information;Design Flow (gpd)HooDesign Soil Application Rate(gpdsf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System ElevationVL Tank Infoedacity inGallonsNewTBksSsdstisg TioloTotalGallons#ofUnitsManu&cturerE f■»£ OI£Septic or Koldiag TsskHda-y1a#S.3/-C.AXDesiBg CbambciVn. Reaponslblllty Statement- L the tmdersigptd. asaomt reaponalbilHy for imtallatioii of the POWTS shewn on the attached ;Jans.MP/MPRS NB"-JI^TlffltxcavaUng, LLC Ciumbmuiineas Phone Number..Copnty/Department U»c OnlyD Disapproved0 Owner Given Reason fin DenialPermit FeeDale IssuedIssuing Agent Signatureyyuj/iJcojDC Conditions of Approval/Reasons for DisapprovalORIGINALSHP \ ^ 2029Attseh t» eomplete ^saa for the systen iBdiabiatt to the CouBly only en poper net Icti than 81/3 X 11 Inchsalnilat QAtA/YrR COUNTYZOnS ADMINISTRATIONSBD-6398(R. 08/14)
Sawyer County Zoning & Conservation Administration10610 Main Street, Suite 49CqUj Hayward, Wisconsin 54843(7l5)«4.f!288fax (715)638-3277Owner:li-inail: zoning.scc^sawvcrcounlvi.'nv.firgToll Free Caurtliuusc/Gcncrnl Inrormallon I-877-699-41I0Holding Tank Approval Checklist/er Sheet Date Stamp 0*^ / 1^ / ^Sanitary Cover SheetPlot Plany! Property Linesy Site AddressX StructureXWcHX Legal DescriptionParcel ID^ ^Ak.-^3.2.-±L-^^Q.-EyC. Benchmark BM sX North ArrowX Scaley < 25' to Service Road)C Nearest Road IntersectionSetbacks to: Property Line, Well, Stmcturc, Water bodies. Roadsin. Required PlansIndex Page with Original SignatureX Management Plan/Contingency PlanX Servicing ContractZ^Holding Tank Agreement formIV. Holding Tank Specificationsy Cross-section - Manufacture, Gallons: Q-*')y Tank Anchor Calculations [SPS 383.43 8) g)]y Locking device, chains/locksy Alann and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) andStale Statutes 101.862(2) and 101.862(3)X. 3" Bedding Material < 1/2 "V. Holding Tank Plans per Component POWTS ManualVersion 2 SBD-10855-P (R.3/07)Plumber:•:s. *2v.rjlApplication Review Date:POWTS Reviewer:?/69r^\LLicense 0Revised 4/11/2013
Pg 1 of 4Pg2of4Pg3of4Pg 4of 4Holding Tank PlanIndex & Cover SheetComponent Manual Design References:Version2.0,SBD-10855-P(N.03/07;R01/12)...Index & Cover SheetPlot PlanHolding Tank SpecificationsManagement PlanPAGE 1 OF 4Attachments:Enclosures:POWTS Application for ReviewSoil Evaluation Report & Site Map (if applicable)Holdinq Tank Pumpinp Contract (if applicable)Holdina Tank Aareement (if applicable)Project Name I DescriptionOwner Name(8): Ivc^rcx- \AJ<^\^-erOwner Addrras: S'^^HProject AddrMs: ISovo wGovt Lot: 1/4 of .1/4, Section U.Phone:Zip:Township:Project Parcel ID #:, T_5fl_N-R_fL-E CH or WCounty:Designer Information_ , Jerry Ruld Excavating, LLCDesigner Name: —wgOO County HWY ADesigner Addr^: StoneE-mail: ^ ^-e«\jTu«r'Y l-e^f » r\j€7CLicense Number 'X'=\<S>'XRemarks:Phone: 7/5 - ^ 3-HcRZip: S"H8 "76Tliis space reserved for approval stamp.Signature: _OiigbigUbnature requiieigb)gU^nature requiiBd on each iOJbmtted copy.Date;
• IHo*-( \^«eC 'St^ '♦*\-Vl> ■<^--Jerry Ruld Excavating, LLCW208 County HWY AStoi^Lake, Wi 54876/yiP^s- p.c^(a«po 'VVoos^ hh.o6 iT-O 7»s~U^ke.V/dti Tf K<eT"s;.; r fck««^«X-5»li Ci Voj.cvo "Z. O. - /of< -'y.'ir —Z- "ico" ■^^e^l/.isj l~>t<iiir-K VJ iH'cr':SoiH fircw.e'- Aue.J[ clitOei_ fKiU/6~O70UJ Hd-
4" min. above siirroimiling grade or 2 ft. aboveestablished regional flood oievallon, unless^access port Is water and gas tightCover with warning label/ apd lock If access opening Is/ groater than B Inch dia/Cover with warning labeland lock If access opening Is^ greater than B Inch dIa.6uiloin<» L, ^watertight junction boxCucnoisD IncJimin. diaB InchmIn. diaPower sourceMaximum alarm on level setat 12" below tank Inlet iiivenor 90% of the liquid impacltyof the tank below the lankInlet InvertsuecSfiicMi. Ar fte/iU&C. 300 Auto CaMtn HaAlarm neatCross-Section of Holding Tanks maeoOtts/CmAMCHott TAMIC AS Ta tJecmArts g*«ovawev -HoUDIUG, TutJH d ACACI r 3f/oLOlMCt TAMK l>lAAluPACJUK£ltALAlttin MAAAat='AC rUAslI ^ ^ALAR An A'taoeL Mu Ml i3«anfej^ecr Oc^K Rdori.u\vnc5og: Excavating. LLCWP08 County HWY AStone Lake. Wl 54876 /MpgsOsKinaMEUr iBfltoUiOL. UutWiAfR ^ ^ ^
PAGE 4 OF 4Holding Tank Management Planimportant:The owner of this holcHng tank(s) ^11 be responsible for its petpetual operation and maintenance pursuant torequirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, this holdng tank(s)shall be considered a human health hazard if not maintained in accordance with tNs approved managonent plan.Furthermore, all inspection and m^ntenance activities shall be performed by a registered POWTS Malntainer inaccordance with SPS 383.52 (3), Wise. Admin. Code.Estimated Dally Wastewater Flow = gpdInanaetlon Checklist INSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors {I.e. odors, user complaints, etc.)o mechanical malfunction (/.e., pumps, valves, switches, floats, etc.)o material fatigue (f.e., leaks, breaks, corrosion, etc.)o neglect cr improper use {I.e., exceeding design capadties, prohibited activities, etc.)o electrical components {I.e., wiring, connections, switches, controls, timers, alarms, etc.)o surface disdiarge of effluent or sewage back-up into structure servedSERVICING FREQUENCYo The tank(s) shall be pumped by a certified septage senridng operatcr licensed under s. 281.48 Wise. Stats,when the wastewater In the tank(s) teaches a level of one foot below the Inlet Invert of the tank(s).Disposal of contents shall be pursuant to NR113, Wlsa Admin. Code.Tank pumping reports shall be submHied to the proper local government unit In accordance wHh SPS 383.55 WIs.Admin. Code. Ri^ort any oomponmt failure or malfunction to:Name of Individual or company: SccTTS Phone: 7^7^Local government urtit r Phone: "7 f ^30Local government unit address: lOlblO S7T f'^VtUaT^ZiP:Any defective part of this s^em 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 uniess approved by the de|»rtment inaccordance with SPS 384, Wise. Admin. Code.Contlngencv 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.
Contract Date:HOLDING TANK SERVICING CONTRACT/ xs '2-^ ^This contract is made between the Holding Tank Owner and the Pumper.Holding Tank Owner's Name;Pumper's Name;Parcel IdcDtlllcafion Number: ri(12 Digit Legacy ID) / 1 - 2^ O S"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-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 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-wea&er 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) asmutuaUy 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 Sew^e System Ordinance. The pumper fartheragrees 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 hoi ding tank for each servicing;f. The disposal sites to which the contents from the holding fnnk 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, tire 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 c^te of change to this service contract.Owner's Name; (Print)Owner's Signature; (Only one owner (ijfnatarereqniTeiQPumper's Name: (Print)Pumper's Signature;Pumper's Registration Number;9 1 (o^0Rev. 03^26/13
-USE BLACK INK ONLY-POWTS MAINTENANCE AGREEMENTFor Holding TanksOwner's Name(s) as shown on deed:\(ml £,\Mca\WParcel Identification Number;(12 DiQil Legacy ID)Legal Description of Property:- SEE ATTACHED SHEET nWe 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, Kayward, Wl 548438 0 3 5 7 9Tx:4023185426676PAULA CHISSERREGISTER OF DEEDSSAWYER COUNTY, WI09/23/2020 12:39 PMRECORDING FEE 30.00PAGES: 2As an Inducement to ttie County of Sawyer to issue a sanitary permit for a holding tank on the above-descritjed 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). Slats., to have the holding tank properly serviced and to file a copy of the service 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 properly to investigate the condition of the holding tank when pumping reports may indicate theholding tank is not being properly maintained.3. If Itie owner fails to have the holding tank properly serviced in response to orders issued by the governmental 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.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 property where the holding tank Is installed.Owner's Signature;- Only one owner signature required nOwner's Name (Print);'6\va\M(xVkv-Date:Drafted by:ACKNOWLEDGMENTState of: VA i LiM£'?dT/^County of:Subscribed and sworn to before me on this/6 '^-b day of 5gP , 20 ZOBy (Owner's Name):Notary Public Signature:Public Notary Name (Print): J -My commission expires on:S4RAH J KASTAN; ••5 igtl: Notary PublicPersonal Information you provide may be used for secondary purposes [Privacy Law. § i: Cornmis^"'^- n ' Jan 31, 20258v. 03/26/13
Parcel 1 of CSM 1-lOl^Map No. 88, a part of Government Lot2 of Section 11, Township 39 North, Range 9 West (in theTownship of Sand lake) EXCEPT roadway conveyed in Records200 126. 000009
Real Estate Sawyer County PropertyListingToday's Date: 9/14/2020Property Status: CurrentCreated On: 2/6/2007 7:55:47 AMDescriptionUpdated: 5/8/2020Tax ID:2817957-026-2-39-09-11-5 05-002-PIN:OQOQSOLegacy PIN:026939115205Map ID:••2.5Municipality:(026) TOWN OF SAND LAKESTR:Sll T39N R09WDescription:PRTG0\/T L0T2 PRT PCL 1 CSM1/101 #88Recorded Acres:3.370Lottery Claims:0First Dollar:YesWaterbody:Lac Courte OreiliesZoning:(RRl) Residential/Recreational OneE5N:423^ Tax DistrictsUpdated: 2/6/20071State of Wisconsin57Sawyer County026Town of Sand Lake572478Hay ward Community School District001700Technical College® OwnershipUpdated: 5/15/2020Recorded DocumentsEB QUIT CLAIM DEEDDate Recorded: 5/13/2020□ MAP OF SURVEYDate Recorded: 2/17/2020ea WARRANTY DEEDDate Recorded: 7/1/2011eS CERTIFIED SURVEY MAPDate Recorded: 1/4/1965KARA E WALTERBillino Address:KARA E WALTER5024 BRUCE AVEEDINA MN 55424EDINA MNMaiiino Address:KARA E WALTER5024 BRUCE AVEEDINA MN 55424Site Address * indicates Private Road15070W OAK RDProperty AssessmentSTONE LAKE 54876Updated: 9/28/20172020 Assessment DetailCode Acres Land Imp.Gl-RESIDENTIAL 3.300 392,600 122,3002-Year Comparison 2019 2020 ChangeLand: 392,600 392,600 0.0%Improved: 122>300 122,300 0.0%Total: 514,900 514,900 0.0%4238081399-50373247000009Property HistoryUpdated: 8/9/2011http://las.sav;yercoijnlycjov.org/AccG!;!i/master.asp9/14/20, 6;03 AMPage 1 of 1
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