HomeMy WebLinkAbout020-639-23-5704-SAN-2022-148 Department of Safety �°""ty �
� & Professional Services, �Q w � �
: , Sanitary Permit Number(to be filled in by
�_ _ Industry Services Division � 3�, r�i 5
.. �
Sanitary Permit Application State Transaction Number �
-
In accordance with 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 a �,
the Department of Safety and Professional Scrvices.Personai inf'ormation you provide may bc used for secondary pn
purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats.
I.Application Informallon-Please Print All Information a-in�
Property Owner's Name Parcel#
� ��= , �i��. � �-� o ��-�3g �3-s 7��l
Property Owner's ailing Address Property Location
P4c� �7
S 7 �- � C � � Govt.Lot �
City,State Zip Code Phone Number
�� � ��✓r'l� �� ��� 1 V '�-- '�Section ��
C �
II.Type of Building(check all that apply) � Lot# T 3 ( N R � E o
(�l or 2 Family Dwelling-Number of Bedrooms '�- Subdivision Name
Block#
�Public/Commercial-Describe Use _ --
❑City of _
❑Sta[e Owned-Describe Use CSM Number ❑Village of
�- I �Town of l��6���
IQ.Type of POWTS Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one boa on line B.Complete tine C if
a licable.
`�' ❑ New S stem Re lacement S stem
y p y ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain)
B' Holding Tank ❑In-Ground ❑ At-Grade
❑ Mound ❑ Individual Site Design ❑Other Type(explain)
(cooventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner � Previous ertnit Number and Date Issucd
Expiration �73 gl�''�b ��7cl� - ��
IV.DispersaUTreatmeot Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(st) Dispersal Area Proposed(s� System Elevation
30� � F� N� N�- l4 �
Capacity in Total #of Manufacturer
::
Tank Information Gallons Gallons Units � a� U b �
New Tanks Existing Tanks � c y " � A � �
y � �
C4 C.1 V] v� V] W C7 0.
Septic or Holding Tank 3�.L � �.J u�
t I
Dosing Chamber
V.Respons'Ibility Statement- I,the undersigned,assume responsibility for installadon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumbe ignature J MP/MPRS Number Business Phone Number
C~r�.�, �.� � �� � '�.. �� a�2vU�a `7l����-��'Zlo2
Plumber's Address(Strcet,City,State,Zip Code)
S���-� �r ��� � r���-� (� �C�'� .
VI.Count /Department Use Only
�App 6C/ �Disapproved Permit Fee Date Issued Issuing Agent Signature
_ / $ j� �y0 ^'� /', f�O,
�7'�/ ❑Owner Given Reason for Denial y�v� �( �3 �'��'' ' "���^""�"
Conditions of ApprovaUReasons for Disapproval _ __ �._ =..1
_ , i �
yI ' ! : � 0 r
.._ �11���ti�i � s��+ _ i:
G S.� N �� :; ;
�� �.'- ��' ,��. a 7 2022 +
O�
�GI
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SAVVYER CO TRATI ��
Attach to complete plans for[he system and submit to the County only on pnper not less than S V2 x 11 inches in size
saD-639s�R.o3i22� NO RE�JNDS AFTER
13SUE OF PERMI"f
Rea�l Estate Sawyer County Property Property Status: Current
Listing
Today's Date: 6/30/2022 Created On : 2/6/2007 7 : 55 : 36 AM
Description Updated : l0/28/2011 Ownership Updated : l0/17/2018
Tax ID: 21427 GREGORY J MENOMONIE WI
P� N : 57-020-2-39-06-23-5 05-007- SHUFELT
000040
Legacy PIN : 020639235704 Billing Address: Mailin4 Address:
Map ID : : 7 .4 GREGORY J GREGORY J
Municipality : ( 020) TOWN OF OJIBWA SHUFELT SHUFELT
STR: S23 T39N R06W E6597 610TH AVE E6597 610TH AVE
Description : PRT GOVT LOT 7 MENOMONIE WI MENOMONIE WI
54751 54751
Recorded 4. 890
Acres: Site Address * indicates Private Road
Lottery 0 5785N COUNTY HWY G WINTER 54896
Claims :
First Dollar: Yes
Zoning : (RR2 ) Residential/Recreational Property Updated : 5/6/2021
Two Assessment
ESN : 427 2022 Assessment Detail
Code Acres Land Imp.
Tax Districts Updated : 2/6/2007 G1- 4. 890 10, 700 111 , 200
1 State of Wisconsin RESIDENTIAL
57 Sawyer County
020 Town of Ojibwa 2'Year 2021 2022 Change
Comparison
576615 Winter School District Land : 10, 700 10, 700 0 . 0%
001700 Technical College �mproved : 111 , 200 111 , 200 0. 0%
Recorded Total : 121 , 900 121 ,900 0 . 0%
Documents Updated : 7/21/2014
WARRANTY DEED Property History
Date 414907 N/A
Recorded : 10/16/2018
WARRANTY DEED
Date 405055
Recorded : 1/23/2017
WARRANTY DEED
Date 153609 266/225
Recorded : 11/25/1975
:` �:� • � t �,-z � - 1 �� 3
Sawyer County Zoning & Conservation Administration
� ������� ]0610 Main Street, Suite 49
" 1� Hayward,Wisconsin 54843
� � � � �� (715)(i34 82A8
� � FAX(715)638 3277
�
i �� ,,� �x,e�a .i°:rc t :u�.�.ni4
j '�'_' i E-mvl i�t; � .�r,,,i t���,�,in3 ,� r,:S:):
�� ��.c� � Toll Free Courthouse/General Informat�on 1 877-699-4110
�� : .���
t��\\�����
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Sta�np �� / O�/ �-�
Parcel [D# c� ot O- b 3 9'-2-3 - �� � �
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: Properiy Line, Well, Structure, Water bodies, Roads
IIL Required Plans
�,Index Page with Original Signature
�(Management Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement fonn
IV. Holding Tank Specifications
?� Cross-section— Manufacture, Gallons: ����-}�' 3,t��
�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 ]01.862(2) and ]01.862(3)
�3" Bedding Material < 1/2 "
V. Holding Tank Plans per Component POWTS Manual
�Version�7SBD-10855-P (R.3/07) , , ,
2-�
Owner: �����'� Plumber: �T-
Application Review Date: �j� �\3 � aZ 2
POWTS Reviewer: ��.{�
�va�»�
����31 b
L;o�ns�u
Revised 4/1 1/2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Holding Tank Version 2.1 (May 2022-2027)
Pg 1 of 4 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 ing Contract (if applicable)
Holdin Tank A reement (if applicable)
Project Name / Description
Owner Name(s): �('��af'� � � �a.��"j" Phone: - -
Owner Address: s7�=rl �� �w f � ����+,v�. Zip: �;t��`�(�3
Project Address: �a-�`'��
Govt. Lot: �_ 1/4 of 1/4, Section �3 , T ��� N-R�E❑or W �
Township: ��i��Jz�. County: v�'i.a,i���-
Project Parcel ID #: �`�:�Z� ��C� �� v���`�
Designer Information
Designer Name: l� 1'���C ��t'�. � Phone: ��-a2��: - ��.���
� �,
Designer Address: ����� 1"1``� �1�J''l � s'� �e�1,�f! Zip: ��� (,-�
E-mail: CQdn'�!�'t�"� /�C�' /;u�_Ci��'n ,
License Number: ��c�G �� /(�
Remarks:
Signature: �-� �� Date: �— ���
Origina ' na ure required on ea h submitted copy.
CHECK BOX AS APPLICABLE. CHECK 80%AS APPLICABLE.
� SOIL EVALUATION s��e:r�=ao� �SYSTEM PAGE 2 OF
SITE MAP � � � � PLOT PLAN
PROJECT NAME: oesicN F�ow: 3�� cao
L 10'
G-f`�_�, 5 hu��l-` AHach design flow calculations for commercial plans.
Paodec7 nooaess: S7�J'N � NwY � Pipe Matenal!ASTM S[andard(Tables 384.30.3 8 384.30-5)
l ua.� N sa�nary�we, �t'` � P uc
BM Symbol:� BM Elevatlon: FT
n ,�1p Force Main'. /
BMDescAption: U�G�=��� O� S;GI�/� St CJCNP^
sio ecraa��ent�% .--, i�a��ie�oan� IMPORTANT:
P ) Well Symbd(if applicab�e�: 0 arawi�q a� Show ground eleva6on contours a�suifable intervals.
of Tes�etl Area: on Ne epproprite line.
�
U
�
� L
. �'�' j. h�. v
w
�L ?� =
"',,,` '' ,� ��,
w �
6�` -Uy
O
z �
�.,� x
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f
I
1� = 1 c.t).� 5 t' Co�Zr�er c�r ���.cSL bt)�"�LM �� 5=cx.',rt-
PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12' Min. or 2.0 fl above
Junction and qPPro�� Esfablished Flood Elevabon
Alartn Box Vent Cap (NPical)
Electrical must comply with 1 Approved Lodcing Manhole
SPS 316 and NEC 300 4"0 Vent Pipe � wjth Waming Label Attached
�Condui[ >10 ft from (typical) 4"Min. or 2.0 ft above
Building I Established Flood Elevatlon
� (tYPical)
- �AirOghtSeal "
1 e Finished Grade
18" Min.
(tyPical) ..
: . f .
a
Inlet Inletlnvert fWatertight
Approved Joints wilh Plug
Approved Pipe 3 8 onto � Max. 12"or 90%of total volume
Soiid Ground ' if more than one tank
a
" Alarm-0n
e
HOLDING TANK
VOLUME _ _�CY� gal
a .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: H��"�:�.-c-
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.wtj x 1.5
Ballast Weight = [( 6 � cu.ft. x 62.4 Ibs/caft) - a3� 56� Ibs] x 1.5 = l � �(� 3 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 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 perfortned by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Estimated Daily Wastewater Flow= 3 (� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance fadors (i.e. odors, user complaints, etc.)
o mechanical malfunction (r.e., pumps, valves, switches, floats, etc.)
o materiai fatigue (i.e., leaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o electrical compone�ts(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 faiture or malfunction to:
Name of individual or company: �J��� ��f'��6\ ,� ��a4-S L�.G Phone: �js' a�%� '��L��
Localgovernmentunit: SQ�YNr �u�`� �FiR=^�, Phone: �(5' �c5�{— �-���
—�
Localgovernmentunitaddress: ������ Yj1��n S�. Sk:`�.��(L �yl�✓«.� ZIP: S`���1�
Any defective part of this system shail 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.
Svstem 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
Contract Date: / /
This contract is made between the Aolding Tauk Owner and the Pumper.
Aolding Tank Owner's Name: Pumper's Name:
Gre o� S S�.u�lf �-�"� ��a�- Sew� h�X.
Parcel Identification Number:
(12 Digit Legacy ID) n ��- �0 3 � -��- S 7 � �
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
Agreement for a Holding Tank required under the Sawyer Counry Private Sewage System
Ordinance 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 to
permit the pumper to have access and Yo enter upon the property for[he purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access road or drive so
that the pumper can service the holding tank(s)with the pumping equipment. The owner
further agrees 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 the Governmental Unit, Sawyer Counry, a report for the
servicing of the holding tank(s)as required under SPS 383.55,Wisconsin Adminishative
Code and the Sawyer County Private Sewage System Ordinance. TLe 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. 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 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 tlris contract. In
the event of a change in this contrac[,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 service contract.
Owner's Name: (Print) ��'S S1g[latLLiC: (Onty ooe owner sigoature required)
Gp���-y T� s�U���T � ,/�
Pumper's Name: (Print) Pumper's 'gnahue:
S�� c����� ;� �
Pumper's Regisffation Number:
��-�
Rev.03/26/]3
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POWTS MAINTENANCE AGREEMENT Tx :4G3928�
For Hoiding Tanks 44oi43
PAULA CHISSER
Owner's Name(s)as shown on deed: REGISTER OF DEEDS
SAWYER CC?llNTY, WI
�re or Sh��� �� 07� �31��2z oz:�z pM
RECt}RDIlVG FEE 3Q.t30
Parcei Identifica ion Nu ber. �y
(12 Digit Legacy IDj � � � - � � L _ � � _ � � (� �
--- --- -- -- PAG�S: 2
Legai Description of Property:
- SEE ATTACHED SHEET -
We acknowledge that appl'ication is being made for the installation of a hoiding tank(s) on the
property described on the attached sheet.
Retum To: Sawyer County Zoning and Conservation Administration
10610 Main St. Suite 49, Hayward, WI 54843
As an inducement to the Couniy 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, induding 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 govemmental 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 govemmental unit in accordance with SPS 383.55, Wis. Adm. Code, for the servicing of the holding tank. In the case of
exemption under Sec6on 281.48 (3) (d), Stats., the owner shall submit the report to the governmental unit. The govemmental
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 properiy 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 govemmental unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4) Wis. Stats., a govemmental 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 govemmental 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 govemmental unit responsible for the regulation of private sewage systems
ce�tifies that either a soil absorption system that complies with SPS 383, Wis. Adm. Code, or a municipa! 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 agree�nent shall be recordad 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.
-Onl one owner si nature r uired - �-r%V CKNOWLEDGMENT
O r's Signature: State of: � �c a�tS , iV
County of: tScxc.u�.,�c•�^
Owner' a (Pri : Subscribed and swom to before me on this
�� EGo� �'. � � L G���- day of ',Tu l 20 �
Date: ►u�u �
7 � ,�Z r, `��.� �N (Oyyner's Name}: � . J- e/f--.
`— \�� . • d�loXar��blic Signat e: '
Drafted by: � l Q • � p,r�j�ublic P�f�ry Name (Print : ��'r � ��-���r i[k/�
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Personal infortnation you provide may be used for secondary purpos�§��riy�cy L`aw�1T��@?!�(I) (m)] Rev. 03/26/13
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The South 746 Feet of Government Lot Seven(7),Section Twenty-
three(23),Township Thirty-nine(39)North,Range Six(6)West,
lying West of County Highway G,Town of Ojibwa,Sawyer County,
Wisconsin;
EXCEPTING the South 373 feet thereof.
Office of
Sawyer County Zoning Administration
POBox676 �-, ����i•�C,S�'��
Hayward, WI 54843 '-`% ` , _ _ ..____�
Tel:(715)634-8288 4 `� �
Fax: 715 638-3277 �� ��� �^�°' �f
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URL:htt�!/sawvercountygov.org ---------,.._
Email:zoning secCcr�sawvercountygov.org �;�;,,,.;
. . Toll Free:CourthouseJGenerai Infomiation �Oi�';�,�.:: .: ...... . . .:',�!
1-877-699-4110
� Sawyer County Zoning and Sanitation "As - Built" Form .
Property Owner's Name �.r����� S�K.�e��"
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Fire Number and Road Name s 7�SJ�-N C-7�
Plumber's Name �J�a-:� ���''��S�n
Date of Installation �'a� ��a
County Sanitary Permit Number ���' 1��
12 Digit Parcel Number C�i c�U �0 3 [ �� ����
Description and Elevation of Benchmark �O�' l�� m������ � '� �'�OO
'i'ank M��,�arti,�rPr anrl!`arac'lt� 1!�1��C+•l.� �•�
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Setback-Tank to Nearest Lot Line � -
1
Setback-Tank to Nearest Well 7�
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Setback-Tank to Building
Cell Width ��
cen��rn N(�
Number of Cells ��
Setback-Cell to Nearest Lot Line N �
Setback-Cell to Neazest Well � �
Setback-Cell to Building ` '��
Setback-Cell to Navigable Water � I-[
Make and Model of Dispersal Unit N �
Make and Model of Filter ��
Make and Model of Pump ��
-Please complete other side-
"As-Built Plot Plan"
Elevation Data
Benchmark /-�n0 Please include the followin�:
Building Sewer �,�DH
Tank In �'.,�� •Location of observation and vent pipes
Tank Out �_ •Feet of risers used on tank(s)
Dose Tank In — •Location of benchmark and North arrow �
Dose Tank Bottom — •Location of all components
, Header or Manifold — •Length of pipe between components �I
Distribution Pipe -� •Number of chamber units in each cell
. System Elevation — •I.ocatiom of well,lot lines and road
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