HomeMy WebLinkAbout022-739-09-5410-SAN-2022-127 �.
� Industry Services Division Counry �
4822 Madison Yards Way Sawyer �
- � Madison,WI 53705
S P Sanitary Permit Number(to be filled in by Co
: P.O.Box 7302 !� �
Madison.WI 53707 �i � '-I � � � �
a
Sanitary Permit Application State Transaction N=-mber —
In accordance�vith SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit Note Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addr
the Department of Safety and Professional Services Personal information you provide may be used Yor secondary 6705N Brecke Ln. Coudera W�
purposes in accordance w�ith the Privacy Law,s 15 04(1)(m),Stats. y,
I.Application InFormation-Please Print All Information
Property Owner s Name Parcel#
Ronald Hentz 022739095410
Property O�aner�s Mailing Address Property Location
7443 Jeffery Lane �;o�t Lot a
City,State Zip Code Phone Number
Cottage Grove, M N 54828 651-261-7341 ��. �%, Section os
II.Type of Building(check all that apply) Lot# � 39 N R �� E or
�/ 1 or 2 Family Dwelling-Nmnber ofBedrooms 3
Subdivision Name
Block#
�ublic/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number Village of
�To��,of Radisson
III.Type of POVVTS Permir (Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
�� ew S stem e lacement Spstem ther Modification to Existin S stem ex lam Additional Pretreatment Unit ex lain
� Y � p � € y ( P ) ❑ ( P )
B' �Holdine Tank ❑In-Ground �At-Grade �Mound Individual Site Des�gn Other Type(explain)
(conventional)
C• ❑Renewal Before �Revision hange of Plumber �ransfer to New O��mer '��t Previous Permit Number and Date[ssued
Expiration
IV.DispersaU'I'reatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
300 NA NA NA TBD
Capacity in Total #of Manufacturer
Tank Infonnation Gallons Gallons Units � o 'o �
New Tanl:s Eaisting Tanks v � � � y p ro �
0
a v v� �, v� i.=. C7 a.
Septic or Holding Tank 3000 3��� 1 Wieser �
Dosing Chamber � � �
V.Responsibility�Statement- I,the undersigned,assume responsibili or instal ation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signat MP/MYRS Number Business Phone Number
Jason Kuettel 675751 715-798-3355
Plumber's Address(Street,City,State,Zip Code)
PO Box 66 Cable, WI 54821
VI. u ty/Department Use OnI�•
�. �r ❑Disapproved Permit Fee Date Issued lssuine Agent Signature
$ �W.a� � � �.r� ^� n 7+/' � /l/I/L"J-
❑OHmer Given Reason for Denial ` '�"" )��+-X-�� .,r,..,_,+ �,.,,,...,;.-i r�-�;r-G
Conditio�s of Approv�al/Reasons for Disapproval �l i r.„��, : ��' � �
� � '�---
� C�� �D� I�.e , _J��3 � �f ����--
�� � � . , �
���
� ;-
� ..; .
tiF>,b�; , �,��' <«;�.:;��.;
ZONING ADNiiNI�i�>,^•`:J;'�
Attach ro complete plans for the system and submit to the Counh�only on paper not less than S 1/2 x ll inches in size
sa�-639s�x.ozizz� NO REFUNDS AFTER
ISSUE OF PEAMIT
Sawyer County Zoning & Conservation Administration
```"�`, ]0610 Main Strcet, Suite 49
� I� Hayward, Wisconsin 54843
���� � �� (715)634 8288
� ���� �� FAX (715)638 3�77
� .. C �.�� ;, � x,e�;a ,� c � � , t� � ytc'
� .. _. . .. ..
� � � Toll Free Cour[house/Genera ������ _+�� ������
�� � i � I Informahon 1-877-699-4110
��.: �. , .� � `..
�� '�."``��
Holding Tank Approval Checklist
1. Sanitary Cover Sheet Date Stamp �� / � � / ��
Parcel 1D# � � �-� 3 `� - O �- S y ( �
II. Plot Plan
�Property Lines / Benchmark BM ♦
�Site Address � North Arrow
� Structure � Scale
Well � < 25' to Service Road
� Legal Description � Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans
� Index Page with Original Signature
� Management Plan/Contingency Plan
� Servicing Contract
�Holding Tank Agreement form
IV. Holding Tank Specifications
X Cross-section — Manufacture, Gallons: �.v�es,s� 3,��
� 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 < 1/2 "
V. Holding Tank Plans per Component POWTS Manual
� Version� SBD-] 0855-P (R3/07) „ ,
�� �
Owner: �P�,;� Plumber: �
Application Review Date: 06 (� fo (�'-.�
�
POWTS Reviewer: ��,, �..�,,D�-�
Namc
6� � ��
Liccnsc#
Revised 4/11/2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manua/Design References:
Version 2�,SBD-10855-P(N.03/07;R 01/12),_,
Pg 1 of 4 2 ` Index&Cover Sheet
Pg 2 of 4 Plot Plan
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)
Holdin Tank A reement if a licable
Project Name I Description
HENTZ- Holding Tank
Owner Name(s): Ronald Hentz pho�e: 651 261 7341
Owner Address: �443 Jeffrey Lane S. Cottage Grove, MN Z�P; 55016
Project Address: 6705N Brecke Ln. Couderay,WI 54828
Govt.Lot: 4 1/4 of 1/4,Section 09 ,T 39 N-R�� E❑or W❑✓
Township: Radisson County: Sawyer
Project Parcel ID#: 022739095410
Designer Information
Designer Name: �ason Kuettel Phone: �15 _798 _3355
Designer Address: PO Box 66 Cable,WI ZiP: 54821
E-mail: tim@andryras.com
License Number: 675751
Remarks:
Signature: Date: ! zz u L�
Origin si nature required on each submitled copy.
CHECK 90X AS APPLICABLE. CHECK BOX AS APPLICPBLE.
❑ SOIL EVALUATION o sca�e: 4°Q ao' so 80 � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: , oesicN F�ow�. ��� cPo
(10tlgriG) �p
��LN�Z t-/0�D w� '�7'-�N IL Attach design flow calculations for commercial plans.
PROJECTADDRESS�. C'��C S N i�RI�GKL L N � Pipe Matenal/ASTM Standard(Tables 38430-3 8 384.30-5)
\ N Sani�arySewery S�°* '�" (�"Y-
BM Symbol�. � BM Eleva�io¢ 7Q! ) FT Force Main�. /
BM Descnplion'. / 3�
Slo eGredieM % i�a�ca�e�onnoy IMPORTANT:
ot Tested Area�.� � f« 'Neil Symboi(ilapplicabie): � araw�nq a�a�v.r Show ground eleva[ion contours at suilable inlervals.
on�ne approprite line.
OI.,N`� � ,ZeirA-c:D t�NT�
F1.�2c3S . (a�vSr d�cKt LN �y..DCR-r}'t, wa=
IL�v� .• �'�zr- �v, ��� �l S" o i T'39�v ,�07 N . I
i j�X �� � OZ,2739oSsY� � I
7oU� u� �zA-��SSvN. SsaW Y� Cr7.
I
I _ _ , _ . I
I _ — � I
I _ ' : I
I I
�
J
I ,' `� _ I
I3�,,t���n.��, ���c�'r � I
I , nh �R� ' "- I
I �V -�� "���'r � _ I
IF+.7VM1L 4 S��t4� . . _. i
F�'—
� I I , ��: �j jPoSc17
._ ___ ,_ _ __ ___ .
i \ ,3 3c� ° �
\ o I
I � N,�'S'c'� 3oc� t� I
I � tt'T- I
IS��� .�.L I
I �,Nc ��E�L cJ picNfa-i-7 . . . . � I
I I ;_ I
I �2— ' � 675 751 ' I
I �/�/Z„2Z I
I I
PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherpmof 12" Min. or 2.0 ft above
Junction and Approved Established Flood Elevation
Alarm Box Vent Cap (tyPlcal)
ElecMcal must comply with 1 Approved Locking Manhole
SPS 316 and NEC 300 4"0 Ven[Pipe � wi[h Warning Label Attached
�—Conduit >10ftfmm (typical) 4" Min. or2.Oftabove
Building I Es[ablished Flood Elevation
` I ' � ([ypical)
- �AirtighlSeal "
1 __ ^ Finished Grade
18" Min.
(rypical)
1 a 8 .
Inlet Inletlnvert
/ —Watertight
Approved Join[s with J Plug
Approved Pipe 3 ft on�o � Max. 12"or 90% of[otal volume
Solid Gmund � ii more ihan one[ank
a
Alarm-On
HOLDING TANK
VOLUME = 3000 gal
. a . . . . .. . . d .
3"Approved Bedding Ma[erial Beneath Tank
TANK MANUFACTURER: WIESER
Anchor tank as necessary
pursuantto SPS 383.43(8)(g)
Ballast Weight = ((cu.ft.tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt] x t.5
Ballast Weight = [( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1.5 = Ibs
PAGE40F4
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 353.52 (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= 300 9pd
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 surtace 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: AIICIf�/ RBSITIUSS@fl H� SOIIS phone: �15-798-3355
Local government unit: SBWy@C CO. Z011lflg Phone: 715-634-8288
Local government unit address: 10610 Malll St. #49 Z�P 54843
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.
Continpencv 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.
Svstem Abandonment
If use of this tank(s)is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
�-+o��ll�;�c: TA1VK SERttfCING CONTttAC-r
Contract Datc: b / z�! Z�2 Z ����
This contract is made bet���een thc� Holdiug Tanl; O�vncr und the Pumper.
I-[oldin� Tank O�vi�er's Namc: 1'umper's Namc: �
Norihwest Sanitary, Inc.
�2UN�L.�i �—}CN7-,z,� PO BOX 155
Radisson, WI 5486�
Pareel Identific�tion Number:
( l2 Digit Lcgacy ID) � �2 - � 3 `) - O �7 - S �-) 1 p
1 . The ���mcr a�rcc� to file 1 copy of' this contract wrth thc guvern�Ticntal uiiit, Sawycr Cc�unty,
which has ��cccpted and recordcd with th� Olficc of d�c Elcg�atci• of Dccfls, !hc vtai�?tci�<ncc
flgrcement fi�r a !-lolding 1'ank rcc�uircd under thc S�i���ytr C'ounty Priv��te Searagc Systcm
Ordinancc lor thc i�.�uancc c>f a Sai�itary Ptrmit kor the instalfation of a holding tank(sj.
2. The owncr a�recs to have dic holdin; tank{y} s�rviced by the piunper antl guar�ntees to
permit thc pu�Yiper t� have ncccss and to enter upon thc property fur thc purposc of scrvicin�
tlie holdin� t�t►il<(s). 'nc� owncr agrees ro m�►int<tin thc aEl-wclther access road c,r dc-ivc so
th�t the pumPcr can scrvicc thc hulding tank(s} with lhc pumping �quipmcn�. Th� o��-ncr
tLrther as�rees to pay thc pumper for a chargcs incurrcd in servicing Ihc holdin�, rank(s) as
mutuc�lly agrccd upon by the o�+�ncr and piuuper.
3. Thc pumper agr�es t� submit ro thc Govci7�ment�l Unit, S���vycr Counry, a report for thc
scrviciilg uf thc holdi�ig tank(s) as rcquired undcr SPS 383.SS, 4Viscori�{❑ qdil�inistrativc
Codc and thc Sawyer County Privaic Scwagc Systcm Ordinancc. Thc pumper furthcr
.�grees to includc rh� following in thc repo��t
a. Thc name and addi•ess of thc persun responsib)c Ior servicing ihc hol�ing ta»k;
b. "1'he namc� of thc o�vncr of thc halding tank;
c. The site address o(�the I}olding te�nk;
d. The date th� holdiz�g tank wa, scrviccd;
C. Thc vUlumCs in �alloris of thc contcnts �iun��ed Fi•on, ihc holdin� tank lor cach scrvicin�:
t: "i'he disposal sitcs to 4vhich thc contents fi-om the holcting tank �4-cre d�;livercd.
�. This agrccmcnt �vill remai�� in cff��r ii��til (�7: i?'S`:ii :�f �'suiilf��,� (i;i'li�lfl;l�l'S 1111S COIilf:lCi. (li
t„c c��ci�t oi a chan`;: in this contr�ict, thc owncr ,��•4cs to tilc a copy of 1ny rhangcs t�� this
scrvicu contract or a copy of��i ncw scrvice contract �vith S�w•ycr Cowitv ���i�hin tcn ( 10)
busiucss days from tht datc of changz to this scrvice contract.
�wncr's Namc: (1'rint) n�Vti�l''� �i[�TC1�7[UCC: (Onh onc o�rncr si;;naturc rcquircA) �
�e N A t_� i-��ry i -�z. �
�� , ,
G/
Pumper's h'�mc: (Print) Pumper's Signaturc: -
Ronald L Vieceli, owner Northwest Sanitary,lnc ` �y i
_. -�'l:--t�{..c.� L , �� C�'�'
Pumrer's Re�istration Numbcr: __-- �--,
#T_389
R���. U3I��;113
6/24/22,1 47 PM Real Property Listing Page
R2dl EStdte Sawyer County Property Listing vropertystatus: current
Today's Date:6/24/2022 Created On:2/6/2007 7:55:39 AM
�.:�•�:°'Description Updated:10/11/2021 ��Ownership Updated:10/11/2021
TaxID: 23120 � �� RONALD M NENTZ � ��� COTTAGEGROVE
PIN: 57-0224-39-07-09-5 OS-004-000100 MN
Legacy PIN: 022739095410
Map ID: :4.10 Billing Address: Mailing Address:
Municipality: (022)TOWN OF R4DISSON RONALD M HENTZ RONALD M HENT2
STR: 509 T39N R07W 7443 JEFFREY LANE S 7443 JEFFREY LANE 5
COTTAGE GROVE MN 55016 COTTAGE GROVE MN 55016
Description: PRT GOVT LOT 4
Recorded Acres: 3.080
Calculated Acres: 3.D47 '�Fl Site Address *indicates Private Road
Lottery Claims: 0 6705N BRECKE W � � COUDERAY 54828
First Dollar. No
Waterbody: Blueberry Lake „I.�property Assessment Updated:4/27/2021
Zoning� (Fl)Forestry One 2022 Assessment Detail ����
(RRl)Residential/Recreational One Code Acres Land Imp.
ESN:
Gl-RESIDENTIAL 3.080 111,600 0
��-'Tax Districts . Updated:2/6/2007 Z-year Comparison 2021 2022 Change
1 State of Wisconsin Land: 111,600 111,600 0.0%
57 Sawyer County Improved: 0 0 0.0%
022 Town of Radisson Total: 111,600 111,600 0.0%
576615 Winter School District
001700 Technical College
i_�Property History
_� RecordedDocuments Updated:8/20/2021 N�q����� ������ � ������ � �� ������� � � ������ ��������
WARRANTY DEED �
Date Remrded:12/18/2020 428770
SHORELAND RESTORATION/PRESERVATION AGREEMENT
Date Remrded:8/19/20Z1 434077
MAP OF SURVEY
Date Recorded:12/22/2020 9397-25
QUIT CLAIM DEED
Date Recorded:7/27/1979 170663
https://tas.sawyercou ntygov.org/syslem/frames.asp7uname=Enc+Wellauer 1/1
� �� • � � . �.' . . . ._ .
�_ ���,, -:., � y, '� � �. - ,
-.0 • - ���� � �_
..-� r ��. _ `�, �
�. ��'�, C x � ➢ ' , - � - � . -
i
;'c = .
., /�n; ,.. 1
:.�J'� � x -}� .� . �.�'- `F .' . .�� .. . ..
�.�'frr f'. �Y j��f :�,� i s '' --s _ . . ' .
t rs,�g �-�� � �1 ,.�; . . . .. , .
> ;k , ';'.'A'�yLf .a = Ti ��•` � - "
.�'�. . „ . ... _ .
s -�r�.. - t ' r "r y� • . .
Sj���x�"`�`a14 �s� ��` .�.�" � "
� .� �'� � ' ` . .
:�i �?���..�. ;k � - � . . .
� " K �
.� ;'
���� Z � , �.. ;
�v t �- t� t�,�. ti b � �` 2,, 'b�, �3 Y "'-.•'�' y� ' ...„
r
� � +f�� �4 t�, ti;uf� � y `"�' ��,�
�' .��� 4^- $� � i
. ..M '�i�
�ny W,$.; - ,• « .. :_'.�, ,
, � �.
'.t.'� � -�'t .r- � .�'; ''e
� j � f
yr�, s a n ,��t
� y� ��s � �f � � � � � � j ��x� '
'X U."' e� . �� u9: �� ✓�'i:. . �+ rt�rY � ' �.
3� � �q^q
...sY' i", ✓� .� � r�j '3� , n !",�i ���'�^ :j�.. � .<4,. ���.-,
F �� �i �➢: �/� �. . � !I tj2�. .7C.
y�'t , � t�,. .: J . �o� si L' iEf
y�E�?�y, z �:�£6Li�.�� " X."' � • ��'•,y.� � ' . y��r f.'� + S�-� . a � .
1 £` � xF," ♦ X.1.�� '4 � y
I' i � k � '� ,J ., `� �'.�. ; . '�J
' � �� �,
R � T 't�F w
I �l��/ i� '�{' 1'� y .;q..
�y� U � t �'e,j[j'3�M� `ia. �+1�• f I � � '+3� r
'� �, ,F .—.;�i+4` �.,� ,-•'j t . .?`�'a ' .�'
r , 's � ,' , . �„ . ��,.> , '�
�. a a - . S€� f r a' .,,n:�, .
� �` - ��°x�.� �1�yy� i + � ��, �z ' .5-y��
b •. �. '" '� .�. wf "` `'i � x �:' �. .^y.' S�'
( �'.._ .' �, � d
0 1 Y � ] Y r W - � � G � ��. "�
� P
, � � _ � . • :! ; t � +.'
`S .�`t ^�3� /� :,., K ++:: +�e!�� S .� t 7 _ - '�C.°5..3,yJ.'`�t
.�. -:� s.. .�y� . .� w W r�' r.�2-.:• � �� : �r �.��...
/ f Y.;Y�*. M .A' ��'lw_f( � l Y+ '� A A. {.7. .
.
e� sa . �' _r'w. � f -, � � � �:
� �. � .�.� , � �� �� .�.'�' ' � �i.v�
y . � �
Y♦ �r. t ; � .i.. ,N: • �}. � . � ff� .., ��'r y� .
q� S _ "k '` � � � ,-� � �� � Fil` �,: . ' �+
J n b� � ���1�-�a 4� �
..�,� � � �ti,.' I ; I �' . ��
�..� .�* � 5 �
L �L v' 3' ���'. . �,
: :.� ` f y�` �,�.: „ : y , �. .
� s � ';
�.t i t� ` .', a�+3 P.� L v ,� . ,
L� � "'4� �., }� .fi � ,.� ��: . �
4 �,; _ ', �\�- � �[ t
'� � ' S S .'c., e. 45
����J r �� � . 1� ..
t � �
.� �c ,� � _..i' � .r1�-
��, � : a
'� `�� �� . �yy`. . • , . .
� i e"Er� ' �:�v -.Y �,� '� ` t�-*�� �'S. +� . .
�, ��� � � , s �$�� f� �V�'
.' .I� +�~ yy _y� '.. 7 ,� - �� � ts� 4..` " �"� .
s � ` ^3.�� 'b"� r�' : � ! � s „'Fa .1`. * � , �r.\ � �. »�'
�^+� „� 's
-+. �;'� "�` ,'��,A tc . �� � . (a y� Fr'?' f ,n
,N w
i -) � S. y. t.' n ,�e L� •��(��� �'yy��.y
..iH.. .16 ='d�� � �'� �/� �� � � '#L�S� � �.A�I� '�'iTqi3.�1FiA' I�„
i ii iiis iii iii �i � ii�i
8 Q 6 G 4 ' 1
Tx :4U3891�
- USE BLACK INK ONLY - 439864
POWTS MAINTENANCE AGREEMENT PAULA CHISSER
For Holdin Tanks REGISTER UF DEEDS
g SAWYER COU11[TY, WI
� O�,vner's Plame{sj as sn'vvm on d�sd: 06J24j2{I22 01:47 PM
RECCIRDING FEE 30.00
2o r�r�-L� ti-�C ti � �
Parcel identificafion Mumb�c F'AG�S: 2
(12 Oiqit Cegac� ID) � �� 7 �3 q _� 9 - � y � �
Legal Description oF Properl�:
- SEE ATTACHED SHEET -
b'/e acknowledge that applicaUon is being made for the installation of a holding tank(s)on lhe
property described on the attached sheet.
Ratum To: Sawyer County 2oning and Co�servation Adminfstration
10610 Main St. Suite 49, Hayv�ard, WI 54B43
As an inducement to the County of Sa�Nyer to issue a sanitary permit for a holding tank on the above-described property, the o�omer is
responsible for the operation and maintenance oF !he holding ta�k, locking device, afarm and access, and agrees to conform to all
applicable requirements of SP5 383, U/is. Adm, Code relating to holding tank management, including lhe following:
1. The owner agre�s to contract arith a person �riho is licensed under Ch. NR 713, 4Vis. Adm. Code, except as pravided by
Section 281.48 (3) (d), Stats., to have tl�e ho�ding lank pruperly serviced and fo file a copy oF the se�iice contract with the
govemmenta� unit. The oavner further �grees to file a copy of any changes to the service contract, or a copy of a neav service
confract, aiith tha govemrnental unit within tzn (10} business days From the date of change to the service contract.
2. The o�mer agrees to cr�ntract �vith a person licensed under Ch. NR 113, V�/is. Adm. Code, who shall submit pumping reports to
the govemmenial unit in accordance with SPS 383.55, Wis. Adm. Code, for lhe servicing of tne holding tank. In the case of
exemption under Section 281.�18 (3) (d), Stats., the owner shall submif the report to the governmontal unit. 7he governmental
unit ma� enter upon the property to irn�estigate the condition of the holding tank when pumping reoorts may indicate the
holding tank is not bzing properly maintained.
3. If the owner fails to hava the holding tan!< properly serviced in response to orders issued by the governmenlal unit to prevent
or abate a human f�ealth hazard as described in Section. 254.59, Stats., the governmentai unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4) 4Vis. Stats., a governmental unit may assess the
o�,�rner of a private sasvage system for costs related to the pumping oF a sep(ir, or holding tank. The charges v��ill be assessed
as prescribed by Section 60^.0703, stats. Tha owner agraes ta p�y ali charges and cost incurred by the governmental unit for
inspecfion, pumping, hauling, or otherNise servicing and maintaining the holding t3nk in such a manner as ko prevent or abate
any human heaith hazard caused by the holding tank.
4. This �greement aiiU remain in efFect on(y untii tha govemmentai unit responsible for the regulatiun of pri�iate sewage systems
certifies that either a soii absorptian s�sfem fhat complies with SPS 383, Wis. Adm, Code, or a municipal se�,ver serves the
property. In addition, fhis agreement may be cancelled by executin4 and recording said ce�tificatien 4�,�',h refe;enca to this
agreemen[ in s�;�h manner �vhich nvill permit the existence of the certification to be determined by reference to tne property. � ¢ �
5. This agreement shall be binding upon the o�vner, the heirs of the o�vner, and assi nees af the o�vner. The o� � W �
the agreemenl to lhe ragister of deed�, and lhe a_ reemenl shall be record�d b� � o �v��r shall submit � z ?
� � the regist.,r of deeds in a manner Nrhich a�ill � � "
perrnit the existence of ttie agreemen( to be detarmined L�y reF�rence to the property rvhere the holding tank is installed, ¢ � ?
/� w _
y � A
- Only one owner signature required - ACKNOWLEDGNIENT � � �
O+,ti� e 's Signatu e
.� state of: �''�1\1'(�� �C�U 00 � �'
Q�vner's Name ( nnt): �.� Gounfy of; _��1V fr G �r(1 '
�c,��, y�,,,�-� S�ibsrribed and s�,�iorn ta before me on this � , � -�'�
�� �,v� � , , , 20 ' � ��
� Date: - __------ --- _1�-_d�/ of — ���:�1'� 'L� • ;�
���� By (Oavner's Name}: _ �-�A\� 11�1'1"CZ '� `�
--- --------_._ Notary Pubiic Signafure: ).
Dr�it�d by: . _
%�,1.. CL,�,,r2 � F'ublic P�lotary Narr�� (Prinl :��'��� ,
__..------... f:I f CO(71fllI:iS10(1 B::pirps on: � "' St �
_ __.__ _— ___ ___�l c�r, __S�_20�3
'' s3r?al in �rn'_:' ,r -
'i ilJ �,.(J;'����3 1l- I ' �i�1 lli'_'� L.I� a-'Ciil._�..if`� �)�11'.t,5.� - �
- J I � � 'b ��il�� 3:'� �._f./. ;� �J.L�: (�� �(l7�� r�-,.. n
. � -��.y i�.jt�ij,�� _,
T}iat p���rt of Governmeut Lot 4, Section 9, T��wuship 39 N�z�tl�, R.ar�ge 7 W'cst, loc�ted in the
Towt� ot Radisson, Sawyer C'�oi.mty, 1��i�consin; �jescrihed a�follo���s Comnlencing at a stal:e oil
tl�e nortli line of saicl Govenn���nt Lot, whic}i is locate�l �m tl�e east shore of f3luebei�y Lake;
thence rttnnirlg EasT, along the north line of said lot;350 Ceet to a stake, thence running Soutll
I OR 1.6 fee�t to�ll�c point of begii�iling; thence� continuin� south, 228 1'ect�nc>re or les� to a sla�ke or►
the soutl� linc of said U�vernment Lot; tll�ncc ruut�in� 1h'est alun� tk�c souih linc of said
Gover���mer��t Lot, h52.5 feet more or less lo a st�ik�on the shore of C3lcieberry Lal<e; tllence
runnin� Northcasterly alo�ii the shore of said Lakc;. 2�0.8 l�eet to << �take wl�iich i� locat.ed 57?
feet west of the point of beginniug; thence cunning F,nSt 5i?fect to t�hc point c�f be�in�ling_
���'�'`` PRIVATE ONSITE WASTE TREATMENT �ounty
`��.�,,,,\,f�
(��o$ �`"``�. SYSTEMS SaW er
� P ��, Y
`�������' ( POWTS)
\``F's'"`�`' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) �
2 - I��l
Personai infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�,ov►q gK� IRq,�iSSov� �
Insp BM Elev: BM Descripti n: Parcel Tax No:
coo� � � �-'� �1ec. o�--.734-� - rt�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark ��,o�
Dosing
Aeration Bldg. Sewer _
Holding ,,�,�� 3,6�0 }-( St/Ht Inlet `Z$:9S�
TANK SETBACK INFORMATION St/Ht Outlet �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Iniet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
— --_ ___ - _ _----
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No _�
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��,.�1�� $� � � aoa-a
� �.�
Plan revision required?�Yes O No v� �$ �2 �.� � — � G� �j� �
/ �c�i�--
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL C�MMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �__��'7
�'—�61�,.e.l�,,,� ��� �
,
I : �
. .
� . . , _
, . . . .
�
- -. -t----�__ :__ -.-- �_ .___; .--�- - _ _ - - __ . _ _ _ -�- __ -- _ __ ; __
�
; . _ � : . . _.._
. _ : . _ , ,_ � .. _ , , ;
, ;
.
�
; �
_ . ; _ . _ : , - � s - F -�— i-- -—, — _
(�� t
� . �, � � . v . . � �..._. , 1.. i..__._. ...;..._._. _ .,.__ ....._.i �'- ._._ . __...
.. ._.. . � � .
- -_ '
� i
, � � i
� �
. . . ., . . . � . . . . , : . . , .�_. �... ...... .' ;. _ �. ...i. �..._._. .> ;
i ,���•
3�� . I
L � �
�°
,�v� � �b�os
� � , ,w3'�„¢o��
�-2S � � m ��bn
�
� � $ a.,,�, �,�,
� �� . _�
0�' � � � —
-�P o�-�' �
—p�
-��� ��-