HomeMy WebLinkAbout032-539-10-4301-SAN-2022-161 c/1
_ Department of Safety c°""ty �
�� = & Professional Services, ��� �{ �
_ : Sani[ary Permit Number(to be filled in by C�
�_ . Industry Services Division �� 4�
�, ?� I I S � �,
. � ,
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental 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 ad� —
the Department of Safety and Professional Services.Personal information you provide may be uscd for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ����_� � � � /�
L Appltcation Information-Piease Print All Information (�L(� )'1'1 C.�,�
PropeRy Owner's Name Parcel#
(.(Jol� ��crr�.; L ��'� 5 n3�,-S `1- �0 �- L! c
Property Owner's Mailing Address Property Lceation t�t�o
lv6l� Cv�mF,� ��.� i�� �
City,State Zip Code Phone Number S�
�t-(�1 �Ct�� �h. �� L Z� ��c7t�gipl�C�LII �%<, 5� %, Section�
II.Type of Building(check a(1 that apply) � Lot# T � N R 5 E W
�1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block# ^
❑Public/Commercial-Describe Use �
❑Ciry of
❑State Owned-Describe Usc CSM Number ❑Village of
� �Town of L(/ �� e.�
III.Type of POWTS Permit:(Check either"New"or`Beplacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A' ❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' �Holding Tank ❑ In-Ground ❑ At-Grade f, yp ( p )
❑ Mound ❑ Individual Site Desi m ❑ Other T e ex lain
(conventional)
C. ❑ Renewal Before ❑ Rcvision ❑ Changc of Plumbcr ❑ Transfer to New Owner
ist Previous Peanit Number and Date Issued
Expiration �7 — 1�� ��'�. $7
iV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sY) Dispersal Area Proposed(s� System F,levation
a. �a � � �c � N�
Capacity in Total #of Manufacturer �
Tank Information Gallons Gallons Units � � o 'd �
�.,� New Tanks Existing Tanks � o � � y � ;a «s
�� �ii
a U in � v� t�. C7 a.
Septic or Holding Tank � ���v ��C
Dosing Chambcr y '�C�1 ' �/��C,,,.�.-}-- x
/� JV ( 7 �� v
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Piumber' gnature MP/MPRS Number Business Phone Number
Cr�,: � �►�P.��► �� a�o�Cv ��s��6-��sya
Plumber's Ad ress(Street,City,State,Zip Code)
�� �',�1- l�l `�� Sr�n � �i r�.Zt er, �� ��(�`l(o
Vl.Coun /Departroent Use Only
�Ap tc>Ge ❑Disapproved $ermit Fee Date Issued � Issuing Agent Signature
❑OwnerGiven Reason forDenial -1,"—'� �'�'�`�` �t��'+v-
Conditions of App o aUReasons for Disapproval
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ZC��i���lu ADti1WISl'Rl;I'i'vN
Attach to complete plans for[he syatem and submit to the County only on paper no ss than 8 1/2 x I1 inches in size
NO REFJNDS AFTER
SBD-6398(R.03/22) 13SUE OF PE#�MIT
3y &S��
Sawyer County Zoning & Conservation Administration
�������� 10610 Main Street,Suite 49
� .- 1�, Hayward,Wisconsin 54843
� � - � (715)634 8288
� ���� � � FAX(715)638�277
i ; �""''c- �' `,i' <�
/ �-. ��� / a�}�;1 e:yc t i u:�,ur:;
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- � Toll Free Courthouse/General[nformat�on 1 877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp �� / �� /_ o� �
Parcel 1D# 6 3 � - S�3 `j - � � - Y 3 0 (
II. Plot Plan
�Property Lines �Benchmark BM ♦
�Site Address �North Arrow
�Structure �Scale
Well '��to� <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 fonn
IV. Holding Tank Specifications
'x Cross-section—Manufacture, Gallons: ��„�-�.�'�
�a-��'7S'D''�r�a
x Tank Anchor Calculations [SPS 383.43 8) g)]
y(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-10855-P (R.3/07), , ,
�,(
Owner: ���� 1�`^S� Pluinber: C•�-
Application Review Date: �7 ��-�- ��-�
POWTS Reviewer: ��`',���
Namc � '� I�
Liccnsc#
Revised 4/11/2013
CONCRETE HOLDING TANK DESIGN
sln-� _ �
INDEX AND TITLE SHEET
Project Burlum Rd
Owner Wold Family Trust
Address 10612 Country Club Rd
Bull Valley,IL 60098
Legal Description PRT.SESE S-10 T 39-N R-5-W
Township Winttter County Sawyer
Subdivision Name Lot No.
Parcel ID Number 032 539 10 4301
Index and title sheet Page 1
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Designer Crai hom son
r
Signature � v�,t� Phone No. 715-266-2842
License Number 220810 Date 07/15/22
Designed pursuant to:
Holding Tank Component Manual For POWTS(Version )
SBD-10855-P(N.03/07,R.Ot/12), ,
�•
version s.0(t0lt3) Page 1 of 4
HOLDING TANK SPECIFICATIONS
2 Number of bedrooms
Non-residential estimated flow(gpd)
OO G Minimum holding tank volume required (gal)
Side A Side B Total
750.0 1250.0 �Proposed tank capacity(gal)
Huffcutt Concrete Tank manufacturer
1250/750 Tank model number
SJE Rhombus Alarm manufacturer
Tank Alert 1 (101-01H) 120 VAC Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 16100 Ibs Weight of tank and cover
54.0 Liquid depth below inlet invert(in) 1.50 Safety factor
8.0 Maximum depth of soil cover(ft) 20725 Ibs Weight of anchor required
67.0 Height(in) , . 35.3 in Soil cover req. for anchor or
146A Length (in) � 5.1 yd' Concrete counter weight
69.5 Width (in) nnly
HOLDING TANK CROSS SECTION
Electrical complies with NEC 300 and SPS 316
vent pipe manhole covar with
�j locking device and
warning label finished
iunction � grade
box —� � —
4"min.
�23 in. 6"max.
conduit —� sealed water +a"m��
tight
thether -
/wei9nt Note: All tank joints, and joints -
� IG between tank openings and building sewer
aiam,o pip�ng are sealed watertight. All inlet
btind plug i e and vent materials com I
to seal p p p y
ounet with SPS 384. Manholes with
90% Full 39.6 in �ocking device are typical for each
manhole opening .
750.0 gai 1250.0 gal
3 in. bedding untler tank. Tank is anchored as necessary to negate buoyancy.
Project: Burlum Rd
Page 2 of 4
HOLDING TANK SITE PLAN
Project: Burlum Rd
N Legal Description: PRT. SESE S-10 T-29-N R-S-W
Subdivision Name:
Scale: 1" = 30 ft Parcel ID: 032 539 10 4301 Lot No.:
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QTn; To C-� well C:�s: �3m= /�;�;.�r Page 3 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be insta�led and
maintained according to SP 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P
N. 03/07, R. 01/12), and the Sawyer County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow of 40 to 400.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 30 days.
6. The owner may not remove any of the wastes from the hoiding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shal� be abandoned in
accordance with SPS 383.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the folfowing persons may be contacted:
a. Installer.............................Don Thompson & Sons Exc. LLC Pho�e: 715-266-2842
b. Service Provider.................. NorthWest Sanitary Phone: 715-943-2650
c. Co. Zoning or Health Dept. Sawyer County Zoning Phone: 715-634-8288
11. If this building is used as a year-round dwelling a mound system will be installed.
Project: Burlum Rd
Page 4 of 4
HOLDI.\G f;�VK SER\'ICI\'G CO\'1'RAC"f
Contrxt Datc: / /
Thic cnnir:�ct ic madc bchvicen thc ►Ioldin� T:�nk O�rncr:uid thc Pumper.
Holding l�ank O���ncr�s Namc: Pumper's Name:
Northwest Sanitary, Inc.
1,���J� ��.n, � T��st POBOX ,sS
Radisson,WI 54867
Parcel Idenlification Vumber:
��� ���.�r L���.��� ro� 0 3 a - s 3 �-� o - Y 3 0 (
I. Thc o�vncr a�_rccs to lilc a copy of Ihis contracl �vilh lhc goccmmcntal unit. San ycr Coumv.
which has acccptcd mid rewrdcd ���ith Ihc Officc oPlhc Rc��istcr of Dccds. thc A4aintcnancc
Agrccment I'or a Holdin�Tank rcquircd wider the Sawycr County Pri�ntc Scwagc S�s�em
Ordinancc for thc issuancc oCa Sanitary Pcrmii for thc installalion of a liolding tank(s).
_'. Thc o���ncr;v�rccs to ha�c Ihc holding lunk(s� scrciccd bp thc pumper nnd �uarantccs lo
pennit thc pumper to ha�c aceess and Io cntcr upon the property for thc purpose of sen fcin!_
ihc holdin�� tankls). Thc o�vncr a�rccs lo mainlain lhc all-�ccothcr acccss road or dricc so
lhal Ihc pumper c;�n scn icc lhc holdin�� Iank(s) ��ith Ihc pumpin�,cquipmcn�. Thc owner
I�urthcr;�crccs tu pav ihc pumper for a d�arv�cs incurrcd in scn icing thc holdin, tanklsl as
muto;illy a��rccd upon by thc o�vncr and pumper.
�. fhc pumper aerccs to submit to thc Go�'crmncntal Unit. Sa«ycr County. a rcport lor thc
scn icin�� of thc holdine tankls) as rcquircd undcr SPS 3ti3.��, N'isconsin Actministrati�c
Code and the Sn��yer County Pricate Se�rage System Ordinance. "I he pumper f'urther
❑��rccs to includc thc follo�ring in thc report:
a. T'hc namc and address of ihe person responsiblc For scil icing thz holding tank;
b. 'I'hc n�mc of thc o��ncr of thc holding tank:
c. 1'hc sitc address of thc 6oldim�Ianl.;
d. Thc datc thc holdine tm�k was scn iced;
c. The �olamcs in gallons of�hc con�cnts pumpcd from thc liolding tank tor cach scnicin�_:
C "I hc disposal sitcs to�shich �hc contcnts I'rom thc holding tmik �eerc dcliacrcd.
4. l�his a,rccmcnt �cill rcmain in cflcct until thc owncr or pumper tcrminatcs this contract. hi
thc cccnt of n chamze in this conu�nct, ihe o�vner aerees to filc a copy ol'an}� changes to this
scrcicc contract or a copy of n nc�� scn icc contract ��ith Sa�cycr Coumy��ithin tcn (I0�
busincss days from thc datc of chanec �o this scrvicc contract.
O��ncr�s Namc (Print) Owncr's Sianaturr �o��i. i�uc�mnrr�i�n�mrereyuin•Jj
�� L 7N �<itf�' � ��'%
Pumper�s N�mc: (Print) Pumper's Sienanirc:
Ronald L Vieceli,owner Northwest Sanitary,inc �
G,
Pumper's Rc,istration Numbcr:
#2389
Rc�. u:?r, I?
7/22/22, 225 PM Real Property Lis[ing Page
Real Estate Sawyer County Property Listing Property5tatus: Current
7oday's Date: 7/22/2022 Created On: 2/6/2007 7:55:56 AM
�Description Updated: 6/24/2016 '� Ownership Updated: 1/18/2019
Tax ID: 34883 WOLD FAMILY TRUST BULL VALLEY IL
PIN: 57-032-2-39-OS-10-4 03-000-000010
Legacy PIN: 032539109301 Billing Address: Mailing Address:
Map ID: .15.1 WOLD FAMILY TRUST WOLD FAMILY TRUST
Municipality: (032)TOWN OF WINTER 10612 COUNTRY CWB RD 10612 COUNTRY CWB RD
STR: 510 T39N ROSW BULL VALLEY IL 60098 BULL VALLEY IL 60098
Description: PRT SWSE m
Recorded Acres: 17.890 r Site Address * indicates Private Road
Calculated Acres: 23.276 5808W BURLUM RD WINTER 54896
Lottery Claims: 0
First Dollar: Ves 1..� property Assessment Updated: 10/10/2016
Waterbody: Barber Creek 2022 Assessment Detail
Barber Lake
Zoning: (R-1) Residential One Code Acres Land Imp.
(RRl) Residential/Recreational One Gl-RESIDENTIAL 3.000 137,500 101,900
ESN: 428 G6-PRODUCTIVE FOREST 14.890 19,700 0
�� Tax Districts Updated: 2/6/2007 Z-Year Comparison 2021 2022 Change
Land: 157,200 157,200 0.0%
1 State of Wis�onsin Improved: 101,900 101,900 0.0% �
57 Sawyer County Total: 259,100 259,100 0.0%
032 Town of Winter
576615 Winter Sthool District
001700 Technical College
�Property History
a Recorded Documents Updated: 1/18/2019 N�A
QUIT CLAIM DEED
Date Recorded: 1/14/2019 416172
QUIT CLAIM DEED
Date Recorded: 3J30/1981 177529 328/194
QUIT CLAIM DEED
Date Re�orded: 9/14/1970 135119 226/332
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- USE BLACK INK ONLY - � �, � ; � � �
POWTS MAINTENANCE AGREEMENT 'x :�����5t1
For Hoiding Tanks 44U�36
PAULA CHISSER
Owners Neme(s) as shown on deed: REGISTER OF QEEDS
SAWYER C�9UNTY, INI
� � n ��� tr ��� � 07jZ2J2fl22 02:31 PM
���- � RECORDING FEE 30.O�D
Parcel identification Number. q )
(12 Digit Legacy ID) G `� '� - 5 � ! - L (� - ��U,L
— PAG�S: �
Legal 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.
Retum 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, locki�g 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 fallowing:
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 Section 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 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 heatth 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
own�r of a private sewage system far 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 seroicing 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 municipa! sewer serves the
property. In addition, this agreement may be cancelled by execuUng 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 properiy.
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 che register o(deeds, and the agreement shall be recur�ad 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 uired - ACKNOWLEDGMENT
Ow ' Signatu e: State of: L
�.� �SL.�% ������u��iuuu��,
� ��i, County of: l.V' r Y
Owne ' Na e (Print): `� ; •••""'• , � �'�
�S�%� ��L '\• ��l�Tq . ' �y%$L p� �Q�nbed�ay o sw m ef�re me on this ��
.,
Date: _ � � ��� ? �y (Owner's Name): L S � �7 U L �
� 1 � � %�� �°�� �� :Notary Public Signature: -
' � .
Drafted by� ` / � �'''',.�,c ��SCo' \�`o`` Public Notary Name (Print): (� �i c' Y
�'4 f/� �`���mii„<«���`` My commission expires on: � GG �'vS
Personal information you provide may be used for secondary purposes [Privacy Law, § 15.04 (Ij (m)J Rev. 03126/13
The Southwes� Quarter of tlie Southeast Quarter (SW ]/4 SE 1/4) of
Section TEN (10), Township T�irty-Nine (39) North, Range Five (5)
V�est, exceptin� the VVest 200 feet thereof.
'""t"'"`-"���; PRIVATE ONSITE WASTE TREATMENT County
;,;
�,��;,Sp SYSTEMS Sawyer
�-�� S ( POWTS)
��,� �— �/`
'''"-��'���°� INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ (b I
Personal infonnation you provide inay be used for secondary purposes[Privacy Law,s. 15.04(1)(m))
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
Wn�� ��„1 T�,S� w�� '_
Insp BM Elev: B Description: Parcel Tax No:
� oo .a ' � ��r we,1� 032 - �3 _ - Y.361
TANK INFORMA ION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark o�
Dosing
Aeration Bldg. Sewer °(�,2.'
Holding �� -7 St/Ht Inlet q7_7 �
TANK SETBACK INFORMATION St/Ht Outlet .Y6 �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom 93.66`
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding .}{� �' Ny� �(K� �,�.,5" Dist. Pipe
PUMP 151PHON 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 � #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
_ - -- - -- - ---
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia _ Length Dia_ _ Spac _ � Spacing ❑Yes ❑ No _�
SOiL COVER
— -- - - - --__--
fDepth Over Depth Over �epth of Seeded/Sodded � Mulched
Cell Center � Cell Edges ! Topsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inciude code discrepancies, persons present,etc.)
��s?��i�� �'12����
�F �T
Plan revision required?0 Yes❑ No I'103 � a��3 I�'I � - -- �' �j �'� �
Use other side for additionaf information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
l
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBER: �-��-_�_�___
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