HomeMy WebLinkAbout020-639-34-3301-SAN-2022-213 `"�e:;kr�_i�r'` C011n�' �aW � V J
� Department of Safety
tr� ��,;�. y �
'_ri;ll ;�'� & Professional Services,
ia( ., �f " ;� Sanitary Permit Number(to be filled in by� �
�q;�� ; ��,` Industry Services Division
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Sanitary Permit Application StateTransactionNumber �
,
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appmpriete 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 a w
the Deparkment of Safery and Professionat Services.Personal information you provide may be used for secondary ',
purposes in accordance widi the Privacy Law,s.15.04(1)(m),Stats. c�,, � � , ��� ,�,`
L A p!'tcation T�iformation,.Plea§e Ptlnt All Infqrmailan �� CJ��� �.b U h �L= �iJ
Property Owner's Name Pazcel#
� -C L r ��� Z�-' ' ��� —��--��:.
Property Owner's Mailing Address Property Location
2Z C�y� !�c'�r�f ���°�' �.�ba�—___
City,State Zip Code Phone Number � �' .� ,
� •�� :r-/, V�-, Y,, ���" `/,, Section J�
C t�? � I '' ,5���z� "::�� - c
I��yp�of Bttfldl`pg(c.�teek aIl thut:�pPly) , Lot# T�� N R r W
�}',1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name ��
(V
B��Cik tt �_
❑Public/Commercial-Describe Use
� ❑C;ry of
❑State Owned-Describe Use CSM Number ❑Village of
�- ,\�Totm of �ti�I �Lv��
IIl.Type af PUWTS Permft.(Gheck either"New"or"Itaplacemeut"and other appticable on line:�. Check one baa on line J�.Camplete line C if
a licable.
A �New S stem �Re lacement S stem ��
y p y ❑ Other Modification to Existing System(explain) �L, Additional Prea�eatment Unit(explain)
B' Holdin Tank ❑ In-Ground ❑At-Grade
S ❑Mound ❑ Individual Site Design ❑Other Type(explain)
(conventional)
C• ❑Renewal Before ❑ Revision ❑ Change ofPlumber
❑ Transfer to New Owner �gt Previous Permit Number and Date Isaued
Expiration �
i �' `(�7 �n � 00
IV.Dlspersai/'freatment Area and Tank Informattnns
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation
�� �.-.
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units A � o '�
U
New Tanks Existing Tanks w � U �p � A � �
a U v� m ri ir., C7 p.,
Saptic Holding Tank -'
�-`�; ,�`-�%C-' �,L'��7��Z-
Dosing Cl�amber
V.Responslbility 5tatement-I,the undersigned,assnme responsib[Uty for inataitation of the POVI'TS shown on the attached plans.
Plumber's?�ame(Print) Plumber's S' ture MP/AaP�Number Business Phone Number l�j
L ' ��y �yr� �e, � —"7 /�rZZ �,5' - .3��`?`
Plumber's Address(Street,City,State,Zip Code)
/C�`���r�= r�' f t�-�1-i C:���J j-�� 'c,vrtnY� (,t,7L" �Zl��-/�
VI.C u tyfDepartmeut Uae�ttly _
�A e ❑Disapproved Permit Fee Date Issued Issuing Agent Si�ature
❑Owner Given Reason for Denial $ 1 v�•� $ I i�aa � —
Conditions of Approval/Reasons far Disapproval
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��t�: �"�I g�aa ; �__a ��r ;
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- 'y i I �l _. �'� AUG 17 2A�Z �6`
C� J� �— � �� t;. Nt.w wbr�d #3QSS -- '
SAWYER f��'J^.s�,Y
?ON1NG ADMJMSI-Nti i�IC�iV
Attach to complete pisoa far the eystem and submit to the County only on paper not less than 8 1/7 x ll inches in slze
SBD-6398(R.03/22) NO REFUNDS AFTER
ISSUE OF PEkMIT
a.f (�ca�f
Sawyer County Zoning & Conservation Administration
��������� 10610 Main Street,Suite 49
i
.,,-� 1� Hayward,Wisconsin 54843
;� � ��� (715)634 8288
" ������ `^� FAX(715)638-3277
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% � � ` E�,� !'.'LV1i S t �C C'CSII}1'�_ U�'_i Ib
/ 1 �_ ' 1 , i Ema�l zon37� � ����t�c�c�,uni � r�e.o���
�� ��� � Toll Free CourthouselGeneral Informanon 7 877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp 0� � I� � ��
Parcel ID# o ��- � 3 `�- 3 Y - 3 3 � �
II. Plot Plan
�Property Lines Benchmark BM ♦
�Site Address �North Arrow
�Structure �Scale
�i Well �<25' to Service Road
� Legal Description �Nearest Road Intersection
�Setbacks to: Properiy Line,.Well, Structure, Water bodies, Roads
IlI. Required Plans _
�Index Page with Original Signature
�( Management Plan/Contingency Plan
�( Servicing Contract
�Holding Tank Agreement form to/6��aO� '�l�A
N. Holding Tank Specifications
� Cross-section—Manufacture, Gallons: �''��� 3r��
�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
'X Version� SBD-10855-P (R.3/07),. ,
�•�
Owner: ��h ei U� Plumber: �-d `e
Application Review Date: D�( ��l��
POWTS Reviewer: � �.����
Name �
6� ����
Lsoenso#
Revised 4/11/2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version'�,SBD-10855-P(N.03/07;R 01/12),.
P 1 of4 ���
9 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!Description
Owner Name(s): �'(,(12 T SC�-}N'��D C�I` Phone:�-���S'_Sc�
Owner Address: ZZ�/�/(c /c=0 T� yu�.f CfF�� �t� Z;P: sv�z�
Project Address: ���, L�,� f}jj eF'I�,�LS �G+4 d
Govt.Lot: ��11 1/4 of s'��� 1/4,Section�Y ,T�N-R�E❑or W�
Township:___ Q�► lg�L�� County: ��f�,cJ�C=k'
Project Parcel ID#: 6��"" (�3`I'- .�j�/` 3��-l
Designer Information
Designer Name:��'�! �,�(7LC�i' Phone:���7 -��'Y - .3 J�/
DesignerAddress:�OS�7oL'� �i�-�UC4�( ['� /-(�yt,���ty�q (;J� Zip: �1��/3
E-mail:
,.,,.,,�:. . .
License Number: �%�'j���Z
Remarks:
Signature: Date: �l�7/ Z�zZ
Original signature required on each submitted py.
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6A���.y��� �°` �� �
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Habitable Living area �
shall not be created �
in accessory structures
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�U't��-I� S�_tf'/��'( l�L-/z
6 2� - 6 39- 3� - 33�` � PAGE 3 OF 4
5[,� f/y S'w %U s 3�f T �', NI R � 1,�:
�jl,ce.�� C: t= �'.S 1 �3��+4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.D ft above
Junctlon and ppPro,�d EsWbNshed Flood Elevatlon
Alarm Box V�t�p (tyPicap
ElecWwl must comply with Approved Lodcing Manhde
SPS 318 and NEC 300 4"0 Vent Pipe � with Waming Label Attached
Conduit >10 tt from (typ���) 4'Mln.or 2.0 ft above
Builtling Established Flood Elevallon
ih/P���)
� .. �AiNgh[Seal
' Finlshed Gratle
78°Min.
�tYPical) .
y ..
a
Inlet Inlet�nvert
Watertight
Appmved Joints vritli � Plug
Approved Pipe 31t onro � Mex. 12"or 90°/of rotsl wlume
Solid Ground ' H more than one fenk
a
• Alertn-0n
:
i
HOLDING TANK
VOLUME _ �G gal
. O . a . . . . . . � .
3"Approved Bedding Meterial Beneath Tank
TANK MANUFACTURER: l-ti'!� )�{2 �-� J ��«�
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)- Ibsj x 1.5= ��
(�igr���� /�C��v, S� EZc,�n u ��,,v /�� l
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 tar�k(s)'
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthertnore, 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= �_ gpd
Insoection 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 activitles, etc.)
o electriral components(i.e.,wiring, connectlons, 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 reporta shall be submitted to the proper tocal government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company: ���� (_s�' ��py /��c� C.� Phone: �� �i� ' _3J 7 J
Local govemment unit:__ y:�C�,`�L72 � ��h-4 n;lv Phone: �3�^ ��� ��
Local government unit address: /Z7(�i��' _s1)'1�K� /{r9yu,,d/��j� G�y Z�p. G,(�/�/�
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 malfundioning components shall comply with SPS 383,Wisc.Admin. Code.
No product for chemical or physicaf restoration of the POWTS may be used unless approved by the department in
accordance wilh SPS 384,Wisc.Admin. Code.
Continaencv Plan
In the event that any failed component of this holding tank(s)cannot be repaired, ft shall be replaced pursuant to a
plan submitted to the appropriata agecy for review and approval.
ystem Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
HOLDING TANK SERVIC[NG CONTRACT
Contract Date: / j� / 2c�Z2
This contract is made between the Holding Tank Owncr and thc Pumper.
Holding Tank Owner's Name: Pumper's Name:
��r� 5�����r Northwest Sanitary, Inc.
PO BOX 155
Radisson, WI 54867
Parcel Identification Number:
(12 Digit Lc�acy ID) 0 � a - � �� - 3� � - �3 � �
1 . The owner agrces to file a copy of this contract witl� the govcrnmental unit, Sawyer County,
which has acecptcd and recorded with the Officc of the Rcgister of Decds, the Maintcnanec
A: �cr.e:.t ;:^r a '.-!c„�::.� Ta�z;: ;c:�ui��U �:;�der tl�c �a�ti�ye� Co«r,ty t rivate S�wagc Sys[em
Ordinancc for tl�e issuancc of a Sanitary Permit for the installation of a holdin� tank(s).
2. Tlle owncr agrees to have the l�olding tank(s) serviced by the pl�mper and guarantees to
permit the pumper to have access and to cnter upon thc property for the purpose of servicing
the holding ta��k(s). The owner agrecs to maintain the all-weather acccss road or drivc so
that the pumper can service the holding tank(s) with thc pumping equipment. Tlle owner
further agrecs to pay the puinper for a charges incui-�-ed in scrvici�Ig thc holding tank(s) as
mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer Colmty, a report for the
servicing of thc holding tank(s) as required under SPS 383.55, Wisconsin Administrativc
Codc and thc Sawycr County Privatc Scw�gc System Ordinancc. Thc pumper fiirthcr
agrecs 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 tlle owner of the holding tank;
c. The site address of the holding tank;
d. Thc date the holding tank was scrviced;
e. The vol�nncs in gallons of thc contents pumpcd f�ro��� thc 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 ��ntil the owner or pumper terininates this contract. In
the t;V?Ilt Of 3 C}12Pbr.', iII ��l!S CiTP,tf'dCt, tl]C 4V1'.^.P,T' BoAE�eS �(1 ,fj�!' ;? CO�"1V Of t?!1t' C113!1���.'S t0 t�?IS
servicc conti-act or a copy of a new service contract with Sawycr County within tcn ( ] 0)
business days fi-om the date of change to this scrvice contract.
�WIleI''S N11T1C: �}�11I1t� �W GT''S Sl�lla ' (Only onc oH�ner signature required)
��c r-�— S ��N..e�� --
Puinper's Name: (Pcint) Pumper's Signature:
Ronald L Vieceli, owner Northwest Sanitary,lnc
`" Ir��C�c
Pumper's Registration Number:
#2389
Rev. 03/26/I 3
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Real Estate Sawyer County Property Listing Property Status: Current
Today's Date: 7/29/2022 Created On: 2/6/2007 7:55:36 AM
�' Description Updated: 1/1/2003 � Ownership Updated: 2/6/2007
Tax ID: 21664 KURT SCHNEIDER CADOTT WI
PIN: 57-020-2-39-06-34-3 03-000-000010
Legacy PIN: 020639343301 Biliing Address: Mailing Address:
Map ID: .11.1 KURT SCHNEIDER KURT SCHNEIDER
Municipality: (OZO) TOWN OF OJIBWA 22946 100TH AVE 22946 100TH AVE
STR: S34 T39N R06W CADOTT WI 54727 CADOTT WI 547Z7
Description: SWSW
Recorded Acres: 40.000 � Site Address * indicates Private Road
Lottery Claims: 0 g488W ABORNE RD OJIBWA 54862
First Dollar: Yes
Waterbody: Crawford Creek L� property Assessment Updated: 8/20/2013
Zoning: (RR2) Residential/Recreational Two
ESN: 427 2022 Assessment Detail
Code Acres Land Imr.
G1-RESIDENTIAL 1.000 6,000 126,600
Tax Districts Updated: 2/6/2007 G5-UNDEVELOPED 30.000 7,800 0
1 State of Wisconsin G6-PRODUCTIVE FOREST 9.000 9,900 0
57 Sawyer County
020 Town of Ojibwa 2_Year Comparison 2021 2022 Change
576615 Winter School District Land: 23,700 23,700 0.0%
001700 Technical College Improved: 126,600 126,600 0.0%
Totdl: 150,300 150,300 0.0%
�� Recorded Documents Updated: 4/11/2022
� WARRANTY DEED
Date Recorded: 9/7/2008 286296 ' r property History
N/A
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