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HomeMy WebLinkAbout026-939-11-5320-SAN-2020-214Sanitary Permit Ap^icationIndusoy Services Division1400 E Wadiiagton AveP.O. Box 7162Madison, W153707-7162(Nob acGordanee with SPS 383.21(2), Wit, Adm. Code, submiMtoo ofthis fbnn toifae sppropriao ptm unitit nquiisd prior to obtaimng • tamtsy pennit Note: AppUation fbnns for itete-owoed POWTS tie lubmilted tothe Depuimest of Seftty ad Prcdesrio^ Services. Pcnone! i"*--*"'you provide mey be •■«—* fin eeeondery,;eurooeet in acoofdnce wifli the Privacy Ijw. t. lS.04flVm>. Statt.L Appltattton Information - Plaaaa Print AD InformationPr^erty Owner's NamePiopeity Owner's Mailing AddreuaCity, Simsc>^ujrZip Ceden. Type of Bniidittg (check all tiiat apply)or 2 Family Dwelling-Number ofBedrooiat_^^D PublicCaatmereia! - Describe UteD State Owned - Describe UsePhone NuoberLot#Block#CSMNun^er3/7.DCLTypaofPenalt; (Cheek only one box on line A. Complete Una B if eppUcable)CotffliySanitary Permit Nomber Do be fiUed in by Co.)state Tiansaction NumberProject Address (ifdiffiowm t>i»n Tn»itmg iddteat)^ o hL,-. YParcel#Property LocatioaQovtLot -3_V4, Section 1T N:Sobdivition NameQ (ctrclerm^R_l_Eor<E)□ Ciwof.□ Vill^of_BfTownof SfkrOd-B.D New SystemD PermitRaowilBefiare Er^intioDilacsmeiit SystemD Pcsnh Revision0 Ttfatmem/Holding Ttsk Replscemem Onlyn Change of PlumberG I^nait Transfer to NewOwner0 Other Modifieition to Bv)»ring Syitttn (explato)Lift devious PerniU Number ad Dale IttuadIV. Type ofPOWTS Syatam/Compoaent/Pavice! (Check aU that aniilT□ No».Pretsuri2edIn.Otoutid □ PRatnriiedloJSrouad □ At-Giade □ Motmd>24m. ofsuitibletoii □ Moimd<a4 in. ofiuitabUsoil^Holding Tank □ Olher Dispessal Componant (oylajp) □ Pieaeatmeni Device (explain)V. IMinweal/Treatnient Araa InformariontDesip Ftow (gpd)3c?(j>Detipt Soil Appikmica Sate<gpdsf)Dispersal Area Required (sf)Dispersal Area Frepoeed (sOSystem HevmioDVL Tank InfoOpacity inNewTttknPinigiiig XqIoTotalCallotti#ofUnitsMou&cturaraa1Bk OS^tic or Hokli&f Taolt^occ)Hocx->S/CA u-/dtamtiesfVn. Raaponajbiilty Statement- I. the tadarrignsri, tmnniarcaponslblUty tor laaiallattoncf the POWTS shown oafot attached p**"*PlMPumbsr'i Name (Print) T Pltanha'a SignttmJerry Ruid Excavating, LLC ^ jQ/MPRSNtmibcrBuiioflai PhoBC NiHnbcT7/5--HtriMtf»*14ett'(S<rtti( Cii^ Stite^ Coda)Stone Lake, Wl 54876VUL CountvyPepartment Uae Only0 DisqipiuvedD Owiter Oiva Reason fiar DeniilPermit Fees <iOO.Dale IssuedT—iiiftg Aganl SiputunDC Conditlont ofApproval/Reasons for DiaapprovalNO REFUNDS. AFTERISSUE OF PERMITAStseh to —T**" plaae tar tte eyeta ud ubatt ts the Cooaly anly ee paper net lin Oea 11/2 a 111ID.SBD^398 (R. 08/14)SEP 0 9 2020 Sawyer County Zoning & Conservation Administration10610 Main Street, Suite 49Cr»'*» Hayward, Wisconsin 54843(715X,34.K2S«TAX (715)638-3277l!-matl: yfining.scciS'sawvcrcdunlvgov.orgTall Tm Courlliousc/Gcncral Informalion I-K77-499-4fl0Sanila!7 Cover SheetHolding Tank Approval Checklist/er Sheet Date Stamp 0*^ / on /Parce!rD#(D;iC.-"l3"^-l 1 P. OPlot Plan%■ Property Lines/ Site Address^ Structure>( Welly Legal Descriptiony. Benchmark BM Aj/* North Arrow^ Scale)C< 25' to Service Road_ / Nearest Road IntersectionJy Setbacks to: Property Line, Well, Slruciure, Water bodies, RoadsRequired PlansV Index Page witli Original SignatureAManagcment Plan/Contingency PlanServicing ContractHolding Tank Agreement formHolding Tank SpecificationsCross-section - Manufacture, Gallons:tC Tank Anchor Calculations [SPS 383.43 8) g)]K Locking device, chains/locks^ Alann 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 "Holding Tank Plans per Component POWTS Manual^ Version 2 SBD-10855-P (R.3/07)Owner;Application Review Date:POWTS Reviewer;Plumber:License HRevised 4/11/2013 Pg 1 of 4Pg2of4Pg3of4Pg4of4Holding 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:Enciosures:POWTS Application for ReviewSoli Evaluation Report & Site Map (If applicable)Holdlna Tank Pumping Contract (If applicable)Holding Tank Agreement (If applicable)Project Name / DescriptionPhone:Zip: o/^Owner Name(8): Dq-t/tciOwner Address: l-(c((Project Address: \kj d*-* Hu^y SGovt. Lot:^3 1/4of 1/4, Section / < . ECHor W0Township: County: y-c/""Project Parcel ID #:Designer informationD«.gn.,N.m.:^B2wSg^Designer Address: Stona LaIta, wiE-mail: ^ (-c^f »/\/^cLicense NumbenRemarks:Phone: 7/5" - ^*^3- T-HcP^ZId: ^HS 76Tiiis space reserved for approval stamp.Signature:^nature requlmi on each submitted oo;v-Date; Coc^rTi^ Oe_viAor^-^Ho^ _ \JE.?- C»fW i-oHoose ^"V^ooiC "?Sf^Ci \!ef&ic"i"2." ^CPCJC? C-cO^/Zc"^l.O n lo&i-Tr' r-- (.^ - Vo -?")^K^LkJ Pr'eCesC.%'^ /-/ofcilrJ^ IJerry Ruld Excavating, LLCW208 County HWY AStone Lake, W154876;VVf ^ S - o- G C>-ZdT 3Cs;/^V-ValCf-esT" t>r. 2.rouGr3i'.3»AAf 2^919 MSC9 C-mK H/iAA V •-jgllA Br,q EJ^csAS'-jud' rrc • r /a- * t ^ Cover wlili warning label/ a^d lock If access opening Is' groaler lhan B inch dia.mln. above surrounding grade or 2 f(. aboveablished regional flood olevalinn, unlessaccess port Is wafer and gas llghlWalerfight Junction box. Cover wUh warning label/ and lock If access opening Isgreater than 0 inch dia.3uiLOIM6i I— ^CMtnoi-D Inchmln. diaBInchmln. diaPower sourceMaximum alarm on level setat 12" below lank Inlet Invertor 90% of the liquid capacityof the tank below the tankInlet Inverteijetmie.nL As: Penuec. 200 A*dto ^atvitr\ lt»Alarm floatCross-Section of Holding Tank& i m ^g»g \3 aeooiAjtmAMOtote. TAidifc At Jee.ass.nsy Ta iJeCmArs C«<oYaijev-HoLOiutm -Tnun Copacir/ ''(OOCifAsLoiMA Tank. MMMPHtcjuxet AALnHKi Mn/ju^AcruK£li ^ ^tLnaSn Mooec Wo in aisa _J92L"femecj" Ko // lA^Sft-L) VQg&tta.H-2-A(ba.CrDMflakiEljr l^nfltouflt- UutvracR ^ /o'T^ 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 382-364, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, tNs holding tank(s)shall be considered a human health hazard If not maintained In accordance with this approved manag«nent plan.Furthermore, all inspection and ma'ntenance activities shall be performed by a registered POWTS Maintalnn' inaccordance with SPS 383.52 (3), Wise. Admin. Code.Estimated Dally Wastewater Flows gpjInspection Checklist INSPECT EVERY 3 YEARSo typeofuseo age of systemo nuisance factors (/.e. odors, user oomplsdnts, etc.)o mechanical malfunction (/.e., pumps, valves, sv^t^es, floats, efc.)o material fatigue (/.e., leaks, breaks, corro^on, efc.)o neglect or improper use (/.e., exceeding dedgn capacities, prohibited activities, efc.)o electrical components (/.e., wiring, connections, switches, controls, timers, alarms, efc.)o surface discharge of effluent or sewage track-up into structure servedSERVICING FREQUENCYo The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wise. Stats,when the waatewater In the tank(8) reaches a level of one fbot below the Inlet invert of the tank(8).Disposal of contents shall be pursuant to NR 113, Wise. Admin. Code.Tank pumping reports shall be submitted to the proper local government unit In accordance with SPS 363.55 WIs.Admin. Code. R^ort any component failure or malfunction to:Name of individual or company: ^c.oTT'S C— Phone:Local government unit rrwe^ Phone: "7f 38Local goverronent unit address: IQfelO WVocikj S7T SckTC..Any defective part of this s^m 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, WIsa Admin. C^e.No product for diemical or physical restoration of the POWTS may be used unless approved by die department inaccordance with SPS 384, V\Asc. Admin. Code.Contlnaencv 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.Svstem AbandoninantIf 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: l'~\ / |Tbls contract is made between the Holding Tank Owner and the Pumper.Holding Tank Owner's Name:Pumper's Name:•Sc-rTlTParcel Identification Number:(12 Digit Legacy ID) O Gd3 q - 1 1 -s- 3 a o2.3.1. 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 Maintenance'Agreement 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).The owner agrees to have the holding tank(s) serviced by the piimpw and guarantees topermit the pumper to have access and to enter tqjon the property for the puipose 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 punqjing equipment. The ownerfurther agrees to pay the punq)er for charges incuired in servicing the holding taiik(s) asmutually agreed iqwa by the owner and punqjer.The punqjer agrees to submit to the Govemmental 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 punqwr 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 tanV;c. The site address of the holding tanV;d. The date the holding tanV was serviced;e. The volumes in gallons of the contents punqted fiom the holding tank for each servicing;f. The disposal sites to which the contents from the holding tank wae delivered.This agreement will remam in effect until the owner or pumper terminates this contract. Infile 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 fiom the date of change to this service contract4.Owner's Name: (Print)Owner S Signature: (Only oa« owner t^ntgn rwiulnd]Punqjer's Name: (Print)Punqier's Sipiature: xPunqier's Registration Number;Rev. 03/26/13 -USE BLACK INK ONLY-POWTS MAINTENANCE AGREEMENTFor Holding TanksOwner's Name(s) as shown on deed:Parcel Identification Number:(t2 Digit Legacy ID) O ^ G? - ^ - [ \ - S -3 ^ OLegai Oescdption of Property:n SEE ATTACHED SHEET -We acknowiedge that appiioation is being made for the instaliation of a hoiding taRk(s) on theproperty described on the attached sheet.Return To: Sawyer County Zoning and Conservation Admlniitrstion10610 Main SL Suite 49. Hayward. Wl S48430 3 b 2 2Tx:4022806426331PAULA CHISSERREGISTER OP DEEDSSAWYER COUNTY. WI09/10/2020 10:39 AMRECORDING FEE 30.00PAGES: 2As an inducement to the County of Sawyer to issue a sanitaiv 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 ailapplicable 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 with thegovernmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new sen/Icecontract, with the govemmental unit within ten (10) business days from the date of change to the sen/Ice contract.2. 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 tha case ofexemption under Section 281.46 (3) (d), Slats., 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 properly maintained.3. If the owner falls 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 govemmental unit may enter upon the propertyand service, orcause the tank to be serviced. Pursuant to Section 145.20(4) Wis. Stats., a govemmental 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 prescribe by Section 66.0703. stats. The owner agrees to pay all charges and cost incurred by the govemmental 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 govemmental unit responsible for the regulation of private sewage systemscerlllies 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 owiar. 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.- Only one owner slgnatafOqulred -Owngtis-^gnalure: ^.kUUMM 1Owner's Name (Print):1lUli -kDrafted by: ' -OF>.. ACKNOWLEDGMENTState of: V /NDscribed and sw;day ofiro before me on thisOaeAT'Bjj{(©wner's Name):Public Signature_,20_^hcommission expires on:—1-Personal information you provida maybe used for secondary purposes [Privacy Law, § 15.04 (I) (m))Rev. 03/26/13 County of Sawyer, State of WisconsinParcel No. 026-939-11-5320That part of Government Lot Three (3), Section Eleven (11), Township Thirty-nine (39) North,Range Nine (9) West, described as Parcel "B" as recorded in Volume Three (3) of Certified **Survey Maps, page 245-246, Survey No. 589, EXCEPT, described as follows: Commencing atthe '/i corner between Section Eleven (11) and Section Twelve (12), Township Thirty-nine (39)North, Range Nine (9) West; thence N03®09'W, along the East line of the Section 292.70 feet toa point on the North right of way line of C.T.H."E"; thence N89°58.5'W, along the North rightof way line of said C.T.H. "E", 216.54 feet to an iron pipe; thence N03°49'W, 270.20 feetto an iron pipe; thence N80°10.5'W, 64.40 feet to the point of beginning; thence from the pointof beginning N80°10.5'W, 85 feet; thence S04°36.5'E, 56 feet to the water's edge of theChannel; thence along the water's edge of the Channel to a point which lies S09*'49.5'W, 48 feetfrom the point of beginning; thence N09®49.5'E, 48 feet to the point of beginning.** document # 149331 MAP or SURVEYPART OF PARCEL B OF GSM NO. 589. LOCATED IN GOVERNMENT LOT J OF SECTION 11.T. 39 N.. R. 9 W.. IN THE TOWN OF SAND LAKE. SAWYER COUNTY. WISCONSINsmrrx's emrniti jAxn A /Am mvESSKTML vwo IV rne siatc or msasHsn mwf cmrr.Mrov 7TC QUA or AMD I MK SU/HCiW At€ MAPPED rAPT OF PftRCQ. 6 OF CSU NO. 666. OCUZD « DASMAVT uLOT 0 or SEcnoN It, r. 39 fi. P. 8 w. N i>i£ nm or sand iaxe. surfui couurr. wscohsh trmr Ttas wp 6 A mc fiSPffssEfmnoM or sajo sun€K TTHAT SA6> mvcr AND kPfi COMPLY nm CHtPTDT A^ 7 OF THE mSCOkSH ADmCTWTkC CCOC AMD jMr $AC mvcr* AMD Aftc Denser m nc sesr or to- AMifunsf Ate aocr IoreillES^PROPcm oacvjioN - as su^bocDFAPT OF PAPCa 8 or CSV NO. 669. LOCATED H OOVtMUENT lOT 3 OF SECVON tt. T. 30 N.. P. 9 W.. H THE lOmt OF SW LANE.SAtw coiMrr. hqccmsk cescttiea as /dudh^70 LOCATE THE fWT OF gEOOMNO. COVUKT AT A 3^i/4' AUM9FM CAPftD ttMJUEJfTAX n€ FAST t/4 CDPABt OF SADSeCTtOh H AM OM H ll'S'Jf' W. $12.49 fTET. 70 A f SON PiK ON £4?RAr OF LOT 3 <F CSi NO. It7i, tMGH tSrt€ tt'cawicntXE mu SAAD POfff OF BEBmnc ffrUETES AM MAOSrOft SAJO fASTEMjr C#C M TTJFSS' W. 149 73 FTU TO A I' fi» PIPE; T>€>Ct M Q^tTAO' W. 15314 flH 70 A i' B90N PftyCAMOT COADtJi 9HKM S S 0nF40' E. 12 rm. L€P£ 09 ITSS, fTfOIA Tte CMANffr fOGH mAftP Uf£ (Otm) OF LAC CWflTataiES; ffCMX l&WS SAC EASTUtr l*e AM ON A l£ANO£/f IMF NSAP SAJO CH6L. N TTSS'SS' E >60JS FEET TO A 7' PON/VE MEVm COPfCt ON THT Uf£ OF AWCft A OF GSU NO. 229. mOi B S Oiunr E }5 fm. Wf£ OR LESS. FROMU/D Ofm: nocr l£A'<9tG sad MEANOOI lib am cm sad ICST 19£. s 0rt7'41' c 2I7.0S HIT TO THE POPfT OF BEGtfPRNOMD TmiL CQVniSS 26.900 SOtPfiC fTP. NOfif OR USS. AA9CU fS 06$ AOTS. MORE OR LESS. ACIUVC THAT LVD LfPSOETWCa THE NEAAOEJi UHE AND THE OHWl OF UC COUFTT QREJUIB AM THE OlENDON OF THE LDT UNES TO SNO (MLSW ANKEl B SLBJECr 70 EASEMENTS, RESTTOCtDMS. RESOMnONS AM fOGHTS CF RAY OF RECORD OR USE. F AAff.nr OfDotiRY HCH mrtR at (cmj of lac cam am tm ra« snom amARpROxmit AM srm wwa am non isaiAivr pwoss mlkAvr uAc mot nc omwr mH mtER iiB or a lc7 or a Htmieu snsw e siDjar to obftojc mmir wtMOjrwTSzs mcisenauMD LMsramaEK ssatrt t cr nravrcsABmrm•'IPm OF PARCEL BCSU NO. 569!6900 SO. FT.iO.es AC.i* t ^^■sSaS,' -• -SGRLC: ONE 9KA4 -0 40mAirvlTsmBsamKCFlaATWAm^eSNOR NB ICVDCtB TO TK D6Iuc CFjtc a I/AC stcwN rt,mastm a orsfos' rlECEHO# TWD IftD} ROtfiPC IMESS NOTW•() Kca/sa itsaCLIENT: DAVID ROLLINSjee mt taa/iotsane r • «*ID. 5-21* K Xrtm warn tafUTzzt ovth/tons R/mmp/ucttAaiosHX.wcaaetRiiioaSURVEmO OF HAYWABD, INCtox/m Dunr KMHOWfiO, m S4S43fat ?IS/6S*'9442FAJb ?HAt34-64*4MTKMOMSlAnWLCDW Real Estate Sawyer County PropertyListingToday's Date; 9/5/2020Property Status: CurrentCreated On: 2/6/2007 7:55:47 AM^ DescriptionUpdated: 10/30/2017® OwnershipUpdated: 10/30/2017Tax ID:28204DAVID H & PEGGY Q ROLUNSHUDSON WI57-02fc2-39-09rll-5 05-003-PZN:000200Biliina Address:Maiiino Address:Legacy PIN:02$93911S320DAVID H & PEGGY QDAVID H & PEGGY QMap ID::3.20ROLLINSROLLINSMunicipality:(026) TOWN OF SAND LAKE2343 HILLCREST DR2343 HILLCREST DRSIR:Sll T39N R09WHUDSON WI 54016HUDSON WI 54016Description:PRTGOVTLOT3 PRTPCLBCSM3/245 #589r Site Address * indicates Private RoadRecorded Acres:0.64014906W COUNTY HWY ESTONE LAKE 54876Lottery Claims:0First Dollar:Yes^ Property AssessmentUpdated: 9/28/2017Waterbody:Lac Courte OrelllesZoning:(RRl) Residential/Recreational One2020 Assessment DetaiiESN:423CodeAcresLandImp.Gl-RESIDENTIAL0.640316,40070,500Tax DistrictsUpdated: 2/6/20072-Year Comparison20192020Change1State of WisconsinLand:316,400316,4000.0%57Sawyer CountyImproved:70,50070,5000.0%026Town of Sand LakeTotal:386,900386,9000.0%572478Hayward Community School District001700Technical CollegeRecorded DocumentsUpdated: 4/23/2012Q WARRANTY DEEDDate Recorded: 3/26/2012Property HistoryN/A377823htlp://tas.sawyercounlyqov.org/Access/(naslor.asp9/5/20, 7:18 AMPage 1 of 1 Q2603i1?5^ IV"(1 ^t5U6C89?0