HomeMy WebLinkAbout010-941-14-4301-SAN-2022-042 ���"'� lndustry Services Division Counry
,,,��" _(y,�;
'-�� '� 4822 Madison Yards Way .SC�W -e �-
��s^tieSp �-'' Madison,WI 53705 ��('�Q Sanitary Pcrniit Numbc (to be filted in by Co.)
�i „% P.O.Box 7302 J , . �
:�,y�,�-�;:�j Madison,W153707 ��Q��'I_�
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Sanitary Permit Application Stare Transaction Nmnbcr n
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In accordance with SPS 383.31(2),Wis.Adm.Code,submissinn uf this form to the appropriate govemmental unit — X•�
is required prior to obt��ining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Pmject Address(if different than mailing address)
the Department of Satety and Pmf'essional Services.Personal information you provide may be used for secondary `' ' L�
purposes in accordance with the Privacy Law,s. I�.04(I)(m),Stats. i 5Z-���1 �"�O�j�!']Tl�� �.
[.Application Iaformation-Please Print All Information w�,�..� (tS�, -j�(��3
Property Owner's Name Parce u
o�. LLL [3en � ��.e � O l0 -Cly 1- Iy-y��01
Property Owner's Mailing Address Property[,ocation
d 561 (� r��n i �� � .
City,State Zip Code Phone Number
NQ�L �� w� 5 y�y3 l�2 y� V.J-1 I �'�+,5� '/,, Section�
II.Type of Building(check all that apply) L��� T 1 N R `"1 E or
I or 2 Fa�nily Dwelling-Number ofBedrornns r- Subdivision Name
Block H
�ublic/Commercial-Describe Use ._
❑City of
❑State Owned-Describe Use CSM Numbcr 'illage of
-' �Town of
III.Type of POWTS Permit:(Check either"Ne��•"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C it
a licable.) c
A' ew S stem e lacement S stcm thcr Modification to Existin S stem ex lain Additional Pretreatment Unit ex lain
Y � P Y, � S Y� ( P ) � � P )
B' �-lolding Tank �In-Gmund ❑At-Grade �Mound Indi�•idual Site Design Other Type(explain)
}�� (com�cntional)
C- ❑Renewal Before �Revision hange of Plumber �ransfer to New Owner �st Previous Permit Number and Date Issued
Expiration
1
iV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Sail Application Rate(gpd/s� Dispersal Area Required(sn Dicpersal Area Pmposed(s� System Ele��ation
�� — �- — _
Capacity in Total #of Manufacturer
Tank Information Gallons Galloos Units � � c '$ o
New Tanks Existing Tanks � � v 2 J � � ��.�y
o. U �n �, rii i.L C7 Ls.
Septico HoldingT k D Z�� ' W �ese�-
Dosing Chamber � Q �
V.Responsibility Statement- I,the ondersigned,assume responsibility for installallon of the POWTS shown on the attached plans.
Plumber's Name(Print) -iilarr�xr�Signaturc MP/MPRS Numbcr Business Phone Nutnber
b f.��.s��e � - ��_ . ��2_ � � �s --�a c��3-�
Plumber's Address jStreet,City,State,Zip Code)
1 y s � � 5-t- `"7�7 � 5�(��I 3
VI.Co n /Department Use Only
IF�,App e ❑Disapproccd Permit Fee Date Issued lssuing Agent Sienah�n
� ❑Owner Gi�-en Reason fi�r Denial � `���� �_�-�- �I�
Conditions of Approvat/Reasons for Disapproval _
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Attach to complete plans tor the s�atem and submit to the Counh�uah�on paper not less than B t/1�1 I inches in size
NO REFUNDS AFTER
ISSUE UF P�RMIT
Sawyer County Zoning & Conservation Administration ' �
�������� 10610 Main Street,Suite 49
� -y. �� Hayward,Wisconsin 54843
�� � ��� (715)634 82R8
� ��� FAX(715)638 3277
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� i E-mail ur:� � ... _��.ir ,. ��'�
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� Toll Free Courthouse/General Informahon 1 877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp Oy / OS/ �.�
Parcel ID# O ( O -9 � I - I �- Y,3 � �
II. Plot Plan
�Property Lines Benchmark BM ♦
� Site Address North Arrow
� Structure Scale
�Well X<25' to Service Road
'�Legal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans
lndex Page with Original Signature
Management Plan/Contingency Plan
Servicing Contract � �
Holding Tank Agreement fonn ��to� '�e,w� �'"hS� `�� '�
,�, ��-,��.,�C-�l sys��
IV. Holding Tank Specifications �„� -�..'�w`� - �
Cross-section— Manufacture, Gallons: 1�1 �� o��
Tank Anchor Calculations [SPS 383.43 8) g)]
Locking device, chains/locks
�Alarm and Electrical per NEC 300, SPS 316 &383.43 (9) (e) and
State Statutes 101.862(2) and 101.862(3)
�3"Bedding Material < U2 "
V. Holding Tank Plans per Component POWTS Manual
�Version 2 SBD-10855-P (R.3/07)
Owner: � �.s+� (....�L Plumber: �� ��r�
Application Review Date: __ �y�b„� �� �
POWTS Reviewer: ����
Namc �
�9'Sb I
Liccnsc#
Revised 4/11/2013
' PAGE 1 OF (o
Holding Tank Plan
Index & Cover Sheet � �
Component Manual Design References:
Version 2.0, SBD-10855-P (N. 03/07; R 01/12),, �
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan -Z Q�� Z�
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicable)
.� Holdin Tank Pum in Contract if a licable)
� �O Holdin Tank A reement if a licable
Project Name / Description
Owner Name(s): � � l.rz�,� (-1-C,. Phone: 60Z. - 4oZ_ 63Q f
Owner Address: �0�'6l ►.1 b`�rie+� f{,�l( � {—f'4,� w�r� Zip: S `-!�� �l3
Project Address: l 5 2�S t�l �os�,�a.� � t-���,w4��
Govt. Lot: S�-�J 1/4 of S C 1/4, Section I�} , T �f 1 N-R�_E ❑or W �
Township: }-�-2•lwcer � County: S4w�-1 2�"
Project Parcel ID #: O� b -, ��{l -- l`� -- 430 �
Designer Information
Designe� Name: �o� (..� ��,v�r� Phone:—1(s - 6 l�- E7S 3 �o
Designer Address: l`iS��lq w S-� �w� 1`7 a�cv�r�Zip: S�d�f 3
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E-mail: 1��-;,,!,.i��� r��cr��t��11,,,.<,��,-r��,�:t� s�.in,�,
License Number: "2_. �-- 1p Z� Q,
Remarks:
Si nature: ,-���_ �/�� ��.-. Date: �.� Zo�,z-
9
Original signature required on each submitted copy.
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Owner: AB Land
Tax ID: 12071
Recorded Acres: 40.370 878'
Structure to be >40' from wetland �
'*' Well 585'
:,:>
Cleared Area
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■�■� Blacktop
�� . -- .� .�.a�,�.� ,,,�.� �..��.��.W��..�,�....,.,_.�,�.��,m� 1
�.� �I o,� "�
�� House 81'x#�3' �...�._...��....._.r._.....�......�.,�.._..w..��.,..�,..,_..�.,�..�..__,.�.,., � _.
+�- � 01
�.:; I �
� LP Tank �
�iin F?�nnl .1!',.
� Holding Tank/Septic
Existing g16'
�, Powerline &
Overhead Wire - '" ,,,;;:
�.._ Proposed New 100'
Line.
N
� House Setbacks �
- Septic Setbacks 312' �
—�► Driveway Setbacks �
:�,...���,�.,.�, 1216�
219 —�► } <,af30'
Hospital Rd. `
PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.0 ft above
Junction and Approved Established Flood Elevation
Alarm Box Vent Cap (typical)
I
Electrical must comply with � Approved Locking Manhole �
SPS 316 and NEC 300 4"0 Vent Pipe with Waming Label Attached i
�Conduit >10 ft from (typical) 4"Min.or 2.0 ft above
Building I Established Flood Elevation �
� (typicai)
Airtight Seal o " � I
1 =_ � ° Finished Grade
18"Min.
(tYPical) a a
I a ° 9 . ° I
1 � a.. . .. d ' ' � i
Inlet Inlet Invert I
f �Watertight
Approved Joints with —/ P��g I
Approved Pipe 3 ft onto Max. 12"or 90%of total volume
Solid Ground if more than one tank I
a I
° Alarm-On I
a
a
HOLDING TANK
VOLUME = d�d gal �
e
i
i
a a , a
a .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: W ��'S'`�-
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight = [(cu.ft.tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt]x 1.5
Ballast Weight = [( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1.5 = Ibs
PAGE 4 OF <o
Holding Tank Management Plan , .
IMPORTANT:
The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. 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 in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Estimated Daily Wastewater Flow= (�0 O gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
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 (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o surface discharge of effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats.
when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s).
Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company: {� � La�� L LC Phone: 6o Z— 4 0 Z- �39 I
Local government unit: s w r Co, �Z o v�.� Phone: 1L�� 63�(.— a��
Local government unit address: (D 6 f p ��",�S f S'}� y q (-�c�� w a r� ZIP: s`-f 8 �! 3
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Plan
In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
System Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
HOLDING TANK SERViCING CONTRACT S/�
Contract Date: � l L l Z�G�
This contract is made behveen the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
� �a rl. L� �— �c���— � P�-e—
�� �
Parcel Identification Number:
(12 Digit Legacy ID) �� �-�� � - 1 �-� � D �
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 Maintenance
Agrcement for a Holding Tank required under thc Sawyer County Private Sewage System
Ordinance for thc 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 to
permit the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-wcather access road or drive so
that the pumper can service the holding tank(s) with the pumping equipment. The owncr
further agrces to pay the pumper for charges incurred in servicing the holding tank(s)as
mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to thc Governmental Unit, Sawyer County, a report for the
servicing of the holding tank(s) as required under SPS 383.55, Wisconsin Administrative
Code and the Sawyer County Private Sewage System Ordinance. The pumper further
agrees to include the following in the report:
a. The name and address of the person responsible for servicing the holding tank;
b. Thc name of the owner of tl�c holding tank;
c. The site address of the holding tank;
d. The date the holding tank was serviced;
e. The volumes in gallons of dle 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 cffect until the owner or pumper terminates this contract. In
the event of a change in this contract, the owner agrees to file a copy of any changes to this
service contract or a copy of a new service contract with Sawyer County within ten (10)
business days from the date of change to this scrvice contract.
Owner's Name: (Print) Owner's Signature: �oniy one owner signature required)
�� La►�� L L C� ��� c�'<-�r v�-�_
Pumper's Name: (Print) Pumper's Signature: �
�Co�-�- ►�06�(��-- --� �='�,� � �� ' :,,
Pumper's Registration Number:
� �',
1� � �
Rev.03/26/13
- USE BLACK INK ONLY -
POWTS MAINTENANCE AGREEMENT
For Holding Tanks
Owner's Name(s)as shown on deed:
�� �l,� C/(.�
Parcel Identification Number:
(12 Digit Legacy ID) � � �-���- � �-��Q �
L.egal Description of Property:
-SEE ATTACHED SHEET -
We acknowledge that application is being made for the installation of a holding tank(s)on the
property described on the attached sheet.
Return To:Sawyer County Zoning and Conservation Administration
10610 Main St.Suite 49,Hayward,WI 54843
As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the owner is
responsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to all
applicable 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 by
Section 281.48 (3) (d), Stats.,to have the holding tank properly serviced and to file a copy of the service contract with the
governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service
contract, 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 to
the governmental unit in accordance with SPS 383.55,Wis.Adm. Code,for the servicing of the holding tank. In the case of
exemption under Section 281.48 (3) (d), Stats.,the owner shall submit the report to the governmental unit. The governmental
unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the
holding tank is not being properly maintained.
3. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit to prevent
or abate a human health hazard as described in Section. 254.59, Stats.,the governmental unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4)Wis. Stats., a governmental unit may assess the
owner of a private sewage system for costs related to the pumping of a septic or holding tank.The charges will be assessed
as prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the governmental unit for
inspection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate
any 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 systems
certifies that either a soil absorption system that complies with SPS 383,Wis.Adm. Code, or a municipal sewer serves the
property. In addition,this agreement may be cancelled by executing and recording said certification with reference to this
agreement 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 submit
the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will
permit the existence of the agreement to be determined by reference to the property where the holding tank is installed.
-Only one owner signature required- ACKNOWLEDGMENT
Owner's Sig State of:C 1Vi.5(��(��1`'� "
� County of:
Owner's Name (Print): Subscribed and sw rn t before me on this
�� �►� �-� �day of �L , 20 �
Dat /� By(Owner's Name):
L /�Z Notary Public Signature: __
Drafted b � Public Notary Name (Print): � �
� ✓�- � � �30 � ���
LORRIANE WHITE
Notary Public
Personal information you provide may be used for secondary purpos s[Privacy L��'�.(���9�(�A�i� Rev.03/26/13
W1250/750—MR
TANK SPECIFICATIONS � �
- � o
o a
155" DIMENSIONS: a �
WALL: 2 1/2" � o
BOTTOM: 3�� a a
COVER: 6" o
MANHOLE: 24" I.D. PRECAST CONCRETE RISER �
HEIGHT: 66" O.D. n
LENGTH: 155° O.D. �
�— — � WIDTH: 86" O.D.
/ � BELOW INLET: 53" O.D. � >�
/ 4" CAST-A-SEAL LIQUID LEVEL: 48" � �o
4" CAST-A-SEAL ��GHT: 14,860 LBS. SEPTIC
m24"� � � INLET AND OUTLET: W �
� O 4" CAST-A-SEAL BOOT OR EQUAL � � �
aO T� � � GASKET, CAST-A-SEAI B00T OR EQUAL � � �
\ INLET AND OUTLET BAFFLE AND FILTER: m � �
FILTER OR WISCONSIN, SEE DETAIL /�10 3 �
\ BAFFLE / (OTHER STATES SEE CHART� � Q �
LIQUID CAPACITY: 27.66 GA�/IN (SEPTIC) � o �
16.12 GAL/IN (PUMP) � a
LOADING DESIGN: 8' 0" UNSATURATED SOIL W�
TOP VIEW � �
R�Sers LoG �S �� � MN TANKS: C o �
� l c�„� S pc„- �o �e WILL HAVE ONE VENT OVER OUTLET � � �t
� AND WILL HAVE TWO VENTS IN COVER OVER INLET z °�
A lctrw�s� �le�� v'�c.q. �' � o I
1 �e.r D �� ¢
cn o 4" VENT TANK CAN BE USED AS: � N
Q �, SEPTIC/SEPTIC, SEPTIC/PUMP � r7
� OR SEPTIC/SIPHON W � �
� COVER: MIX DESIGN #8 (NO FIBER) � _ �
TANK: MIX DESIGN #10 (STRUCTURAL FIBER) W�
CUSTOMIZED TANKS: `O
INLET - _ _ _ _ OUTLET FOR CUSTOM TANKS CONTACT WIESER CONCRETE � �
3
N N N
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u� 2�" a � � � a "' � � N
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JOB INFORMATION : ; � o
N ~ c . `
PUMP PAD CUSTOMER: /�}�j �,.i� LLL � w S "�J
~' t/) w
]OB NAME: �
SIDE VIEW DATE NEEDED: �
311 PGd��v�,oJ APPROVED BY: SHEET�
APPROVAL DATE: 1 OF �
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS �
1 � �
4/6/22, 10:53 AM Real Property Listing Page
R2a) EStat2 Sawyer County Property �isting Property5tatus: Current
Today's Date: 4/6/2022 Created On: 2/6/2007 7�55:21 AI�
__i
�'Description Updated: 7/9/2015 � Ownership Updated: 1/6/2022
Tax ID: 12071 AB LAND LLC HAYWARD WI
PIN: 57-010-2-41-09-14-4 03-000-000010
Legacy PIN: 010941144301 Billing Address: Mailing Address:
Map ID: .15.1 AB LAND LLC AB LAND LLC
Municipality: (010)TOWN OF HAYWARD 10561N O'BRIEN HILL RD 10561N O'BRIEN HILL RD
STR: 514 T41N R09W HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT SWSE
Recorded Acres: 40.370 � Site Address * indicates Private Road
Calculated Acres: 36.158 N/A
Lottery Claims: 0
First Dollar: No i-� Property Assessment Updated: 11/9/2015
Zoning: (R-1) Residential One 2022 Assessment Detail
ESN: 444 Code Acres Land Imp.
G5-UNDEVELOPED 17.370 4,400 0
� Tax Districts Updated: 2/6/2007 G6-PRODUCTIVE FOREST 23.000 39,100 0
1 State of Wisconsin
57 Sawyer County 2-Year Comparison 2021 2022 Change
O10 Town of Hayward Land: 43,500 43,500 0.0%
572478 Hayward Community School District Improved: 0 0 0.0%
001700 Technical College Total: 43,500 43,500 0.0%
+� Recorded Documents Updated: 1/6/2022
WARRANTY DEED ��Property History
__ __ ____
Date Recorded: 12/10/2021 436422 N/A
QUIT CLAIM DEED
Date Recorded: 1/14/2015 393980
PERSONAL REPRESENTATIVES DEED
Date Recorded: 12/30/2014 393774
WARRANTY DEED
Date Recorded: 3/7/1995 246791 549/221
https://tas.sawyercountygov.org/system/frames.asp?uname=Eric+Wellauer ���
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