HomeMy WebLinkAbout010-841-32-1105-SAN-2022-188 �
,:�;"•„`.;, Industry Services Di�ision Count� �
_ ` 4822 Madison Yards Way SaWyef
���' Madison,WI 53705
' ���,�5� Sanitary Pennit Numbcr(to be filled in by Co.) (� �
� j P.O.Box 7302 ��"�
�`'-,,y —-�;:�i'� Madison,W I 53707 �,3 � � � � �
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Sanitary Permit Appl ication s`a`e T`a"sa°``°"Nu'_be` .—
In accordance with SPS 383.21(2),Wis Adm.Code,suhmission ofthis form ro the appropriate go��ernmental unit �
is required prior to obtaining a sanitap�pennit Note: Application forms for state-owned POW�I�S are submitted to Project Address(if different than mailing addres;
the Department ofSafcty and Professional Scrvices-Personal in�onnation you provide may be uscd for secondary ��p��W �+����� ��� p
purposes in accordance��ith the Privacv Law,s_15 01(I)(m).Stats U �� ��
L rlpplication Information-Plcase Print All Information
Property Owner's Name Parccl#
HAYWARD PROPANE INC 010-841-32-1105
Property Owner's Mailing Address Property Location
10456N SKYLINE BLVD G��� �ot PRT
City_State Zip Code Phone Number
HAYWARD, WI 54843 NE �� NE �,,, Se�,;on 32
[L 7'ype of I3ailding(check all that apply) I.ot# T 41 N R 08 L or W
lor2PamilyD�celling- h`umbcrofBedroums _ � SubdivisionName
�
(� �� Qlock#
�Public/Commercial-Describe Use O't""!�CQ- ,,._
�-�� �City of
�State O�med-Describe Usc CSM Number �Village of
.- ����������� HAYWARD
IJ
III.7'ype of POWTS Permit: (Check either"New"or"Replacemcnt"and other applicablc on line A. Check one box on line B.Completc line C if
a>>licable.)
�� �Ne�� S stem �Re la�ement S stem Other i�todilication to Fsisting S�stem e� lain �/�dditional Pretreatment l�nit es I�in
✓ � Y' P" ' Y Y� ( P ) ( P" )
B' �Holding Tank �In-Ground �t-Grade �Mound �h�dividual Site Design Other Type(explain)
(conventional)
I ist Previous Permit Number and Date Issued
��• ❑Renewal Before �Revision �Change of Plumber �Trans�er to he�c O�cner "
Expiration �
IV.Dispersal/Treatment Area and T'ank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Arca Required(sf) Dispersal Area Proposed(st) System Elevation
50 N� 1.� IF}-
Capacity in Total #of Manufacturer
Tank Information Gallons Uallons Units „ � o � �
-' � U _ � r
hew Tanks I:�isting Tanks "� o ^��, � Y � :� �
a. U cn � v� r:. :7 a.
SepticorHoldineTank 2000 2000 1 WIESERCONCRETE ✓ �
Dosing Chamber � � �
V.Responsibilit��Statement- I,the undcrsigned,assume responsibility for installafion of the PO�VTS shown on the attached plAns.
Plumhers Naine(Print) Plumber's Signati � MP/MPRS Numher 13usiness Phone Number
Travis Butterfield 652879 715-634-8176
Plumber's Address(Street Cit��.Statc 7ip Code)
14346W St. Rd. 77, Haywar , WI 54843
VL Cou ty/Department Use Only
� Permit Fee Date Issued Issuing Agent Si�nature
�Ap r �e� ❑ Uis'appru��ed �
�i,, $ �1�0.°� �I S I a a- ��:��,�i_n��,�,,,,��-
❑O�cner Gn�en Rcason for Denial
. ,
Conditions oY Approval/Reasons for Disapproval
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C��_ �`� �l� � � SAWY�R COUNTY
7_ONING ADMINISTRATI N
:\ttach to complete plans Tor the system and submit[o the Counh�only on paper no[less than S UZ r l l inches in size
s���-639s�iz.ozizz� Mp REFJNDS A�'�R
�c�UE OF PE�iMt� .
Sawyer County Zoning & Conservation Administration
````"��1 10610 Main Street, Suite 49
���R_ Cp��, Ilayward, Wisconsin 54843
�� � ,��� (715)634-8288
� Q� ��� I FAX (71 S)638-3277
%y -- ',,� � «�c��.sa�avcrcountveo�.or<�
�� � �� ��,, - � �, i E?-maiL roninesecl�csa�i°yercountygov.or�
� ��� ,�:� ;� � 'Coll Free Courthouse/Gencral Information 1-877-699-4ll 0
I�2- = _
l�i;\oN:��
Holding Tank Approval Checklist
L Sanitary Cover Sheet Date Stamp ��d / 03 / ��
Parcel ID# 0 1 0 - 8 4 1 - 3 2 - 1 1 0 S
II. Plot Plan
J� Property Lines �( Benchmark BM ♦
� Site Address � North Arrow
� Structure � Scalc
J� Well � < 25' to Service Road
� Legal Description � Nearest Road Intersection
� Setbacks to: Properiy Line, Well, Structure, Water bodies, Roads
III. Required Plans
�Index Page with Original Signature
JC Management Plan/Contingency Plan
� Servicing Contract
� Holding Tank Agreement form
IV. IIolding Tank Specifications
� Cross-section — Manufacture, Gallons: 2000 , wiP��
�( 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 < I/2 "
V. Holding Tank Plans per Component POWTS Manual
�C Version�SBD-10855-P (R.3/07), . ,
�. \
Owner: HAYWARD PROPANE, INC. Plumber: Travis Butterfield
Application Review Date: fl��a `���-�
POWTS Reviewer: �ti.�. l
Name �� � ��
Liccnse#
Revised 4/ll/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)
Holding Tank Pum ing Contract (if applicable)
Holdi�_Tank Agreement (if applicable�
Project Name / Description
Owner Name(s): HAYWARD PROPANE INC Phone: - -
Owner Address: 10456N SKYLINE BLVD, HAYWARD, WI Zip; 54843
Project Address: 13843W COUNTY HWY B, HAYWARD, WI 54843
Govt. Lot: PRT NE ' 1/4 of NE �1/4, Section 32 , T 41 N-R 08 E ❑or W ✓❑
Township: HAYWARD County: SAWYER
Project Parcel ID #: 010-841-32-110�}
Designer Information
Designer Name: TRAVIS BUTTERFIELD Phone: 715 _634 _8176
Designer Address: 14346w ST. RD 77, HAYWARD, WI Zip: 54843
E-mail: OFFICE@BUTTERFIELDDRILLING.COM r,�„�, ��.tv ,,�.�� r„-��,�,<<,<<,i ;r,a„«,
License Number: 652879
Remarks:
Signature: Date: '1 • 2�t- 22
inal signature require o eac submitted copy.
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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)
Electrical must comply with 1 Approved Locking Manhole
SP5 316 and NEC 300 4"OJ Vent Pipe � with Warning Label Attached
--Conduit >10 ft from (typical) 4"Min.or 2.0 ft above
Building I Established Flood Elevation
� (typical)
Airtight Seal �
1 _- � a Finished Grade
18"Min.
�h'Pical) �� . � � . °
�'e ' a
°. '' 9
e a"" � d . '
Inlet Inlet Invert
--Watertight
Approved Joints with � Plug
Approved Pipe 3 ft onto Max. 12"or 90%of total volume
Solid Ground if more than one tank
d
'° Alarm-On
<
a
HOLDING TANK
VOLUME = 2000 gal ,
� d . � � . ' � � . �,a.. e
: d . . ' a . ' . .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: Wieser Concrete
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
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 performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Estimated Daily Wastewater Flow= 50 gpd
Inspection Checklist INSPECT EVERY 3 YEARS
c type of use
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
, The tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 Wisa 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:
Nameotindividua�orcompany:BUTTERFIELD, INC. Phone:715-634-8176
�oca�9overnment unit:SAWYER COUNTY ZONING phone:�15-634-8288
Local government unit address: 10610 MAIN ST.SUITE 49, HAYWARD,wl _ZiP 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.
Contingencv 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,Wisa Admin.Code.
HOLDING TANK SI+:RVICING CONTRACT
Contract Date: � / � / 2022
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
HAYWARD PROPANE, INC. SCOTT POPPE
Parcel Identification Number:
(12 Digit Legacy ID) 0 1 0 _ 8 4 1 _ 3 2 _ 1 1 0 S
1 . The owner agrees to file a copy of this contract with the governmentat unit, Sawyer County,
which has accepted and recorded with thc Office of the Register of Deeds, the Maintenance
Agreement for a Holding Tank required under tl�e Sawyer County 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) scrviced 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-weather access road or drivc so
that the pumper can service the holding tank(s) with the pu�nping equipment. Thc owner
further agrees to pay the pumper for charges incurred in servicing the holding tank(s) as
mutually agrced upon by the owner and pumper.
3. The puinper agrees to submit to the 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 Systein Ordinance. The pumper further
agrees to incLude the following in thc 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 adciress of the holding tank;
d. The date the holding tank was serviced;
e. The volumes in gallons of the contents pumpcd from the holding tank for each servicing;
f. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement wi1L remain in effect until the owner or pumper terminates this contract. In
the event of a change in this contract, the owner agrces 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: (o��y ���e o.��er s���arure r�q��r���
�6�� �, a��s
Pumpei's Name: (Print) Pumper's � atui- •
SCOTT POPPE �
Pumper's Registration Nuinber:
81813
Rev. 03/26/13
�i II I�II I�IIIIII�II (II�I
8 C! r ' � -,� 4
- USE BLACK INK ONLY - j x;��'�gg��
POWTS MAINTENANCE AGREEMENT 440564
For Holdin Tanks PAi�LA CHISSER
g F�EGISTER UF t)EEDS
Owner's Name(s)as shown on deed: SAWYER C�U11[TY, WI
Ofi/04/20�2 0�;�4 AM
I���uJO:►'� �res�c�v�� � �r1 � . REC�RDING FEE 3fl.0{}
Parcel Identification Number:
(12 Digit Legacy ID) v � (� - (� 3 L � � S �A��S� �
- �L-----�--- T
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.
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 ac::cess,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 iri 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 reqister 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' r � State of: I�ISCia-Y�`aii�1
County of: _� v->
Owner's e Print : Subscribed and swor to before me on this
GY � � �GY �/l ` -- 2�'O day of U.�' , 20 2Z
Date: C/ By(Owner's Name): od d Si dc��n5
D" Z' 22- Notary Public Signature:
Drafted by: Public Notary Name (Print): IC.t, �-`-'�
K ���-�j�� My commission expires on: . Z�
Personal information you provide may be used for secondary purposes[Privacy Law,§ 15.04(I)(m)] Rev.03/26/13
"That part of the Not•theast Quarter of the Nol-tlleast Quarter (NE'/�NE'/�), Section Thirtv-t�vo (32),
To��nship Forty-one (41) North, Ranve Eight (8) West 'I�o��n of Haytaard. Sawyer County.
��'isconsin, more particularl�� described as Lots One (1) and T�vo (2) as recorded in Volume
T��ent��-two (22) of Cert�fied Sui•ve�� Nlaps. paQe 182, Sui•vey No. 6199 as Document �10. 288�30.
Together ���ith a 66 foot ���ide easement as sho���n on Ccrtified Sur��e�� Map referred to herein.
t-�or informat�onal pu�poses onl��
Property Address: H��y B, Ta� ld - 1 1 b?1 & 11622, Hav«ard. W I �48=�3
Tax Kev No • 010-8=�1-32-1 104 & O l 0-8�]-32-110�
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Real Estate Sawyer County Properry Listing Property Status: Current
Today's Date: 7/14/2022 Created On: 2/6/2007 7:55:20 AM
-_�
.�' Description Updated: 3/3/2021 �� Ownership Updated: 3/3/2021
-------� _ .__ _.._ .._ ____._ _ ._ . ._ _ _. __.__ ._ _____ _ _ _ _. ____.__._ ----- .__--
Tax ID: 11621 HAYWARD PROPANE INC HAYWARD WI
PIN: 57-010-2-41-08-32-1 01-000-000040
Legacy PIN: 010841321104 Billing Address: Mailing Address:
Map ID: .1.4 HAYWARD PROPANE INC HAYWARD PROPANE INC
Municipality: (010) TOWN OF HAYWARD 10456N SKYLINE BLVD 10456N SKYLINE BLVD
STR: S32 T41N R08W HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT NENE LOT 1 CSM 22/182 #6199
Recorded Acres: 0.840 � Site Address * indicates Private Road
�___.___ __ __ ._. __.� ..__ .___...___ _________._______�__P____.
Lottery Claims: 0 13843W COUNTY HWY B HAYWARD 54843
First Dollar: No
Zoning: (G1) Commercial One
ESN: 444 � Property Assessment Updated: 11/9/2015
2022 Assessment Detail � � � �
� Tax Districts Updated: 2/6/2007 Code Acres Land Imp.
—�--- �__.__ .. _. . . _ _ __ _ __ ____ ___ _.____,__ G2-COMMERCIAL 0.840 39,900 0
1 State of Wisconsin
57 Sawyer County 2_year Comparison 2021 2022 Change
O10 Town of Hayward Land: 39,900 39,900 0.0%
572478 Hayward Community School District Improved: 0 0 0.0%
001700 Technical College Total: 39,900 39,900 0.0%
r
+ Recorded Documents Updated: 5/26/2022
--_ —._ ___ _ ___ -_ __ __ __ -- -_ _ __._._._ ___.__.
� WARRANTY DEED ' Property History
Date Recorded: 9/21/2015 397725 - .. _ _._ __.__ __ __.__ . . _.____ ____._ _ . _ _ _ ___ .. _._ ___
N/A
� COVENANTS
Date Recorded: 5/17/2022 439165
� WARRANTY DEED
Date Recorded: 12/14/2010 370363
O CERTIFIED SURVEY MAP
Date Recorded: 1/5/2001 288530
� TERMINATION OF JOINT TENANCY
Date Recorded: 2/8/1991 222191
� WARRANTY DEED
Date Recorded: 5/18/1987 204679
___
��'-`''"'-"`����ra;. PRIVATE ONSITE WASTE TREATMENT cou�ty
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`� ���°$ ,�'��, SYSTEMS SaWyer
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�'-°°�����" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ l �
Personal infonnation you provide may bc used for secondary putposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
lop .o� ��- co�.c_ Sl�� o-F- ���(,� vlo-��l� - 3� - ((r�� �
TANK INFORMATION ELEVATION DATA _ � O '
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (oo.o�
Dosing
Aeration Bldg. Sewer
9`a.�
Holding �,�e�� ,cx�c� St/Ht Inlet °�'7_9� �
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding � �3b� S' �-S � 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 Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bidg 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 I
Length Dia Length Dia Spac , , Spacing ❑ Yes ❑ No �
-- — ---- ----- __
SOIL COVER
--
Depth Over Depth Over �epth of Seeded/Sodded Mulched
Cell Center �Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ fvo
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required.❑Yes❑ No ��� 1 �� , � �I
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Use other sitle for adtlitional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AND SKETCH
SANITARY PERMIT NLIMBEA:___���5
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