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HomeMy WebLinkAbout026-939-23-1311-SAN-2020-068Industry Services Division1400 E Washington AvcP.O. Box 7162Madison, WI53707-7162^( U^c9rSanitary Permit ApplicationIn accordance with SPS 3S3 .21(2), Wis. Adm. Code, submission of this form to the appropriate goventmental unitis required prior to obtaining a sanitary permit. Note: i^Iication forms for state-owned roWTS arc submitted tothe Department of Safety and Professional Services. Personal information you provide may be used for secondarypurposes in accordance with the Privacy Law, s. lS.04(n(m). Stats.L Application Information - Please Print AH laforroationCountySanitary Permit Number (to be filled in by Co.)State Transaction NumberProject Address (if different than ipaiiing address)/iTb'^G UJ IrctlProperty Owner's NameC,OParcelH3.S1 3 uProperty Owner's Mailing Address7//8 AJ oYTa-u-zaProperty LocationCovt. LotCity, StatetincILZip Coden. Type of Building (check all that apply)1 or 2 Family Dwelling-Number of Bedrooms,aD Public/Commercial - Describe UseD State Owned - Describe UsePhone NumberLot#VSu; Vj A)^ 'A Section 73•3C3 G ("«='« one)t33_N; R_i EoiWSubdivision NameBlock ItGSM Numberv/78D City ofD Village ofTown ofV-eU<^£_in. Type of Permit: (Check only one box on line A. Complete line B if applicable)A.n New System..^^Replacement SystemD Treatment/Holding Tank Replacement OnlyD Other Modification to Existing System (explain)B.D Permit RenewalBefore ExpirationD Pemiic RevisionD Change of PlumberD Permit Transfer to NewOwnerList Previous Permit Number and Date Issued■g7-on, •ifihiIV. Type of POWTS System/Component/Devlce; (Check all that apply)0 Non-Pressurized tn-Oround 0 Pressurized In-Ground D At-Oradc 0 Mound >24 in. of suitable toil D Mound< 24 in. of suitable soil^'Holding Tank D Other Dispersal Component (explain) D Pretreatment Device (explain)V. Dispersal/Treatment Area information;Eiesign Flow (gpd)Design Soil Application Rate(gpdsf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System ElevationVI. Tank lofoCapacity inGallonsNewTaaJuExisting TuksTotalGallons«ofUnitsManufacturerla31II£ O'aS«ptic or Holding TankQcoo)UJ(e<rAiXDoting ChamberVII. Responslbfllty Statement- L the andenfened, assume responslbflfly for faitailatton of the POWTS shown on the attached plans."TlenyTfii^fexcavatlng, LLCW208 CounTiber's Address (StrejpCode)Plumber's SignatureMP/MPRS NumberBusiness Phone NumberPlumfier's Address fStreStoneXake,Vni. County/Department Use OnfyD DisapprovedD Owner Given Reason for DenialPermit Fee5 ^ov.*Date IssuedIssuing Agent SignatureIX. ConditioDs ofApproval/Reasons for Disapproval01NO REFUNDS Ai=TERISSUE OF PERMITSAWYER COUNTYAttach to complete plau for the tyttem asd suomlt to the Couaty onty on paper doI leaa than 91/2x11 lach^Lajto^ ADMINISTRATI^^SBD-6398 (R. 08/14) Sawyer County Zoning & Conservation Administration10610 Main Street. Suite 49cCt-B Hayward, Wisconsin 54843'jffffffP-'' ^ FAX(7l5|A.tX..')277'j<i wv,«,s.mvcaoimlvgnv.on;/ n ^ l-:-iiinil: iiotiinii.sccfii-Mwvcreoiinivgov.orgn » Toll Frcr Courliiouic/Gcncral Inrortnation l-877-<i99-JII0■t.u.Holding Tank Approval Checklist'crShed DaleSiainpSanitary Cover SheetPlot Plan_X'^roperty LinesSite Addressy. StructureXWellLegal DescriptionParcel ID# O S. i>3 '=\ .^3 - ^ 5 I \Benchmark BM ▲y[ North ArrowX Scaley < 25' to Service RoadNearest Road Intersectiony Setbacks to: Property Line, Well, Structure. Water bodies. RoadsIII. Required PlansIndex Page with Original Signature_2S. Management Plan/Contingency PlanX Scr\'icing Contract_2^ Holding Tank Agreement formIV. Holding Tank SpecificationsX Cross-section - Manufacture. Gallons:_XTank Anchor Calculations [SPS 383.43 8) g)]X Locking device, chains/locksv Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) andState Statutes 10i.862{2)and 101.862(3)X 3" Bedding Material < 1/2 "V. Molding Tank Plans per Component POWTS Manual^ Version 2 SBD-10855-P (R.3/07) /u)Owner: Plumber: > A.Application Review Date;POWTS Reviewer:4'=t57(lLicense «Revised 4/11/2013 1 urHolding Tank PlanIndex & Cover SheetVersion 2.0,8BD-10856^ (N. 03/07; R 01/12)Pg 1 Of 4 Index & Cover SheetPg ^ei4 Plot PlanPg 3 of 4 Holding Tank SpecificationsPg 4 of 4 Management PlanAttachments:Enclosuies:POWTS Application for ReviewSoil Evaluation Report & Site Map (if applicable)Holding Tank Pumping Contract (if applicable)Holding Tank Agreement (if aoollcable)Project Name / Description^— Phone;Owner Address: ^//« /u XfProject Address: /ScFiG uj Lt^OovtLot i/4of A^-e^.l/A.SecHon.^^ T3°VNZip: /4t°t eDot WXSV'V-'. County:Township:Designer InformationM..u..~Se.Pc-v Phone; 7<r.M'W-9.Ho'Hnnslgnir* AHHwoaa? uj ^ Uulj V A—S7<><o<. i.c>feg.r Zlp:_^ Ih.F n^^H. p. ^ . f^cr Thlsspacer^ervedforepFOvalstamp.License Number.Remarks:Signature:PDate;({gnatum t8()ulrad on oath otdMnlttBd copy. CHECK BOX AS Am>USW£.□ SOIL EVALUATIONSITE MAPPROJECT NAMEPROJECTADDRESa Qj Tr'>BMBavagon: /OQ • O „BMOMolpliaK CjQ Sc^t'njr^WellByniSoKEsppBettle); ©1Scale: rs 40-■■MMV?10'ipage 2 OFmT(nOctfinartibyOmrinaiBanwonthsilipreptoBaLCHECK BOX AS APPUCABLE.0 SYSTEMPLOT PLANDEBIQNFLOW: SoO QpoAttach design flow eatculaUons (or commndal planB.Pipe Matsilal / ASTM Slandant (Tables 384.304 & 384.304)^ BanHaiySewRi;. iHO Pvc^k;aForoaIMn;.JMEQHttMLShow greund elevailon oontoum at suMable tntsivals.\-looS^ - -i.LcJ<c. - &©-o±fw"2.000 c^o^llo^ Uie-S^S i3> C:> PAGE 3 OF 4HOLDING TANK SPECIFICATIONS(No Scale)P Westtmpraof—JuncflonandAlannBoxBec&lcal must comply viMi8P8 318 and NEC 300irMln.cr2.0ftd>owAnnim»ri EfltabBahod Flood Etavadon/ (M*-)Appnjved Locking ManholedWentP^ / ^VVtonlngLaMAtiBohid>10nnDmBiddingConduitAlidghtSea!Iff* MattfPleal)Approved JotmsvkMi.Approved Pipe 3 ftentoSoBdGnundIntelrweit^ Ma)c12'or 90% of total vdume^ I If more than one tankAlarm-OnHOLDING TANKVQLUMga 3.0C301-rrr3'Approved Beddtng Material Bwweth Tardcl/.\4'Mia or 2.0 ft droveEfltabBahad Flood Elevation(trpicd)l/FMehedOnde.A.",'VtaterflghtPlugTANK MANUFACTURER:Andior tank as necessarypursuant to SPS 383.43(8)(g)Ballast Weight s [(cu.fttank.vol x 62.4 Ibs/cu.ft) -Ballast Weight=[(j£^£_cu.n. x 82.4 ibs/cu.ft) -xl.5*15= 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. Admln. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, this holtflng tank(8)^1! be considered a human health hazard if not maintained in accordance with tiiis approved management plan.Furthermore, ail inspection and medntenance activities shali be performed by a registered POWTS Malntainer inaccordance ^th SPS 383.52 (3), Wisa Admin. Code.Estimated Dally Wastewater Flow B gpdInspection Cheekltet INSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors (/.e. odors, user complaints, etc.)o mechanical malfunction (/.e., pumps, valves, switches, floats, etc.)o material fatigue (/.e., ieato, breaks, corrodon, etc.)o neglect or improper use (/.e., exceeding design capacities, prohibited activities, etc.)o elMtricai components (/.e., raring, connections, svvitchra, controls, timers, alarms, ^c.)o surface disdiage of effluent or sewage back-up into structure senredSERVICING FREQUENCYo The tank(s) shall be pumped by a certified septage senddng operator licensed under s. 281.48 Wise. Stats,when the wastewater In the tank(8) reaches a level of one foot below the Inlet Invert of the tank(8).Di^xisai of contents shall be pursuant to NR113, Wise. Admln. Code.Tank pumping reports shall be submitted to the proper local government unK In accordance with SPS 383.55 WIs.Admln. Code. R^rt any component failure or malfunction to:Name of individual or company: ^CoTT^S Phone: 73. "7*^—Local govwnment unit ^ r <>->0^ Phone:Local govemment unit address: IQfolO STT f'^Vti.br^ZIP: 'S'MAny 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. C^e.No product for chemical or physical restoration of the POWTS may be used unless approved by the department inaccordance SPS 384, Wisa Admin. Code.ContinQenev PlanIn the event that any failed component of this holding tank(s) cannot be repaired, it shali 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 CONTRACTThis contract is made between the Holding Tank Owner and the Pumper.Holding Tank Owner's Name:TruS7'~^Pumper's Namfe:Parcel Identiflcation Number:(12 Digit Legacy ID) 3 R - 'Z 3 - 3 111. 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 Cotinty Private Sewage SystemOrdinance for the issuance of a Sanitary Permit for the installation of a hoiding 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 taiik(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 pumper.3. The pumper 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 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 lank;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 Sig^ture: (Onlyooeowaeriigiuture required)Pumper's Name: (Print)Pumper's Signature:Pumper's Registration Number:Rev. 03/26/13 ■USE BLACK tNKONLY-POWTS MAINTENANCE AGREEMENTFor Holding TanksOwner's Namefs) as shown on deed; I?< f —V —p ry- /It- 0 vjf ij;—jf ./»fnf Y^ • -*—fctl —Kt-eWri g. oV5t.-\ atij. jMof/CTc o\5^»^ Aw-<,c«^€. CWWr«.sParcel Identtfication Number: f ^ oc^'^'c. t<c\c*»q>On eT I /V5 )<12Di8SL908cylO) ^ ^33.-^3. / 3 ; /Legal Description o< Property;• SEE ATTACHED SHEET •We acknowledge thai application is being made for the Instailallon of a holding tank(s) on theproperty descnbed on the attached sheet.8 0 3 0 8 9 5Tx:4019808423804PAULA CHISSERREGISTER OF DEEDSSAWYER COUNTY, WI05/13/2020 10:19 AMRECORDING FEE 30.00PAGES: 2Return To: Smowr County Zoning and Conservation AdmlnlstraUon10610 Main St Suite 49, Hayward, WI 54843T P-P»V. IPP owner ieapplicable m,pire™„B of SPS 363. Wis. Mm. Cod. relabn'g ,o holding iSnefamern.ln'SR1.2.3.4.5.rprriLSrsSis? arr""" "■ "aSJSiirStt:; ariTbSiS sT«xZs^® tK"''® and assignees of the owner The owner shall submit• Only one owner signature reaulred -Owner's Signature;,Owne(5rDrafted by;£^f^tc.ACKNOWLEDGMENTState of: iCounty of: C_rjr\V'Subscribed and sworn to before me on thisi clay of MCaJ 202O_By (Owner's Name): '\L C'i\9<jr\Notary Public Signaturer^\Sl>oi IrlcPublic Notary NameMy commission expires on;y'OFFICIAL »EAL"!ISELDA BAUTISTA ,ry PuWtc. StatB ofTfltftSr®'^'misston Expires Aug. 02,2022 That part of the Southwest Quarter of the Northeast Quarter ofSection Twenty-three (23), Township Thirty-nine (39) North, RangeNine (9) West, Town of Sand Lake, Sawyer County, Wisconsindescribed as Lot Four (4), recorded in Volume Seven (7) of CertifiedSur\'ey Maps on Page 78, Survey No. 1368. ^ j 7 3.5-^ / Real Estate Sawyer County PropertyListingToday's Date: 5/5/2020Property Status: CurrentCreated On: 2/6/2007 7:55:48 AMDescriptionTax ID:Legacy PIN:Map ID;Municipality:STR:Description;Recorded Acres;Lottery Claims;First Dollar;Waterbody:Zoning:ESN:Tax Districts572478001700Updated: 6/19/20152890757-026-2-39-09-23-1 03-000-000110.3.11(026) TOWN OF SAND LAKES23 T39N R09WPRTSWNE LOT 4 CSM 7/78 #13680,7500YesWhitefish Lake(RRl) Residential/Recreational One423Updated; 2/6/2007State of WisconsinSawyer CountyTown of Sand LakeHayward Community School DistrictTechnical College• OwnershipRICHARD E 8i MARY 30 OLSON REVTRUSTUpdated: 5/17/2016CHICAGO ILRICHARD E 8i MARY JOOLSON REV TRUST7118 N OTTAWACHICAGO IL 60631Maiiina Address:RICHARD E & MARY JOOLSON REV TRUST7118 N OTTAWACHICAGO IL 60531Site Address * Indicates Private Road15096W TRILLIUM LN •3 Property Assessment2020 Assessment DetailCodeGl-RESIDENTIAL2-Year ComparisonLand:Improved:Total:STONE LAKE 54876Updated: 9/28/2017Acres0.750Land197,300197,300 197,30090,400 90,400287,700 287,700Imp.90,400Change0.0%^ Recorded DocumentsO WARRANTY DEEDDate Recorded: 3/2/2016O WARRANTY DEEDDate Recorded: 6/8/1992Updated: 9/23/2014Property History400049. 487/78http://ias.sAwyRrcoiiniygov.org/AccesiS/master.asp5/5/20, 1Z;22 PMPage 1 of 1