HomeMy WebLinkAbout026-939-21-5110-SAN-2022-217 � ^QTj Industry Senices Division n' (/�
;�<�__�\, Coun
��~ 4822 Madison Yards Wa� SaWyef �
� Madison.WI �370� �
. S� '= Sanitar}'Pennit Number(to bc tillcd in by(
� _ _ P.O. E�ox 7302 ?
`_- - Madison,WI�3707 � J ��� �
"�,-.:_ p�
SanitaY,y PeY,11,11* AppllCa*l�n State Transaction Number 7�-+
l. L �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis fonn to the appropriate govemmental unit �� Q,..)
is required prior to obtaining a sanitary pennit Note:Application fonns for state-o�vned POWTS are suhmittcd to Project Address(if dit�ferent than mailing ac
the Department ofSafety and Profcssional Services.Personal infonnation you provide may be used for secondary �����W �and Lake pd .�
purposcs in accordance���ith[hc Privacy I.a�v,s. 15.04(1)(m),Stats_ �
I.Application Information-1'lease Print All Information
Propem O��ner s\ame Parcel#
Mark Forrest 026-939-21-5110
Propert�'Owner's Mailing Address Property Location
N6061 Weigland Ln. Uo�t Lot P���t,
City,State Zip Code Phone Number
Stone Lake, WI 54876 t� �, seC���„ 2'
11.Type of Building(checic all that apply) I.ot# T 39 N R 09 E:o W
�I or 2 1�amih�Dw�elline � Numher oCl3edrooms�_ 5 Subdivision Name�
[31ock#
�Public/Commercial-Describe Use_
�City of
�State O��ned-Describe Use CSM Number �Village of
[o��n oC Sand Lake
37/209#8592(Zawistowski JT Rev Trust) � _-_._.. _.
III."I'ype of POWTS Permit:(Chedc either"New"or"ReplAcement"and other applicable on linc A. Check one bo�on linc f3.Complete line C if
a licable.)
� �New S stem �Re lac�ment S�stem �Other Ntudilication to Eaistin�S��stem(c.a I�in) �Additional Pretreatmcnt Unit Ics I�in
✓ Y- �, .. ��. �, P< )
�' �Holding Tank �ln-Ground �At-Grade �Mound ❑Individual Site Dcsien Other Type(explain)
(conventional)
��• ❑Renewal Before �Revision �Change of Plumber �Transfer to Ne�c Owner��ist Prerious Permit Number and Date Issiied
�xpiration
IV.Dispersal/Treatment Area and Tank Information:
�esign Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sf) Dispersal Area Proposed(s� System Glevation
4 ck� NA NA NA
Capacity in "Ibtal #of Manufacturer
l�ank Information Gallons Gallons Uuits � � o "� �
•w � -� � � � r s
New Tanks F.xisting Tanks � o � � � � � �
., :J J: �: U. _ .... 1
SepticorHolding7ank 2000 2000 1 WIESER CONCRETE ✓ �
Uu�im�Chainber � � �
V.Responsibility Statement- I,the undersigned,assume respunsibility for installation of the POW'I'S shown on thc attached plans.
Plumber's Name(Print) Plumber' �gnature MP/MPRS Number Rusiness Phonc Number
Travis Butterfield � 652879 715-634-8176
Plumber's Address(Street_City�_Statc,7ip Co
14346W St. Rd. 77, Hayward, WI 54843
VI.C un �/Department Use Only
�A_ roce G Disapproved Pennit Fee Date[ssued Is�uing Aeent Sienanire
� ❑O�vner Given IZeason for Denial $ �Q`-'"�� ��'����'a �'�%�-��`�' "
Conditions of Approval/Rcasons for Disapproval (� , �,y��
� _._ �--��Y �l _C:'.�/�}
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�� aa��a .�. !,
;. ,,� ' 'r' AUG 2 2 2022
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� S� N o�- lee�, � wo�� d.��3�oo SAWYER C�Jl�IT�:
. ZONING ADMiNIST�i;aTii�;��
A�L+
A[tach to comple[e plans for the sy°stem and submit to[he Counh-onh�on paper nut Iess than S V2 s 11 inches in size
�-s� a-a-- � s��
si3�-�39s� . zi2z> NO REFUNDS AFTER �y03 g
ISSUE OF PE�'sMtT
Sawyer County Zoning & Conservation Administration
�������� 10610 Main Street,Suite 49
�y: ^� 1� Hayward,Wisconsin 54843
� /� `���� (715)634 8288
�
� � '��� ,�,,/ FAX(715)638 3277
� �-,
/ , i.-� ,=:`� �,_w�� , ��c,c�,u� oe.:i�
/ � . _ � '/ - _ _
I� � : - � E-mail.zonf i S�c�r�a��t�ucuu»i <,�t»�
� �7 �� Toll Free Courthouse/General Informahon l 877-699-4110
� w:.,;.�
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1��\"��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp o� / I g / �.�
Parcel ID# o a � - 9 3 9_ 2 � - S I 1 6
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 . �
�i Index Page with Original Signature
�Management Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement form
IV. Holding Tank Specifications
Cross-section-Manufacture, Gallons: 2�`��
Tank Anchor Calculations [SPS 383.43 8) g)]
Locking device, chains/locks
�Alarm and Electrical per NEC 300, SPS 316 & 3�3.43 (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),,,
��l
Owner: �o c�r-etS'� Plumber: ���T�
Application Review Date: 0���-� � 2 2
.
POWTS Reviewer: � ` �i��
Namc
6��i�
Liccnsc#
Revised 4/11/2013
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
Mark Forrest
Owner Name(s): M8►"k FOt"I'eSt Phone: - -
owner Address: N6061 WEIGAND LN, STONE LAKE, zip: 54876
Project Address: 16002W SAND LAKE RD, STONE LAKE, WI 54876
Govt. Lot: 1/4 of 1/4, Section 2� , T 39 N-R 09 E ❑or W ✓❑
Township: SAND LAKE County: SAWYER
Project Parce� �� #: 026-939-21-5110
Designer Information
Designer Name: TRAVIS BUTTERFIELD Phone: 715 _634 _8176
�esigner Address: 14346W ST. RD 77, HAYWARD, WI zip: 54843
E-ma;i: office@butterfielddrilling.com ��1�1,�, >>�,� �t,�r��at,� ��r,�:, ��,ta�11E�.
�icense Number: 652879
Remarks:
Signature: Date: � � � Z2
Original signature re ired on each submitted copy.
CHECK 90X AS APPLICA9LE. CH ECK 00X AS APPLICA9LE.
� SOIL EVALUATION o Scale:150 50 �s �oo � SYSTEM PAGE 2 OF!{-
SITE MAP PLOT PLAN
PROJECTNAME: �esicNF�ow: `�SZ� cPo
(''� 125'
n'�qj� tp/y�s57' Attach design flow calculations for commercial plans.
PRodec7aooRE55�. Sa^�Q �u�e � Pipe Material/ASTM Standard(Tables 384.303&384.30-5)
� N 5a�itary5ewe�: - �
BM Symbol'.� BM E!evatlon'. l�O, � FT
Force Maln'. /
eM oes��Puo�: n 4�( �n 36�O�le
slo ecraa�ient/) indicaienonhby IMPORTANT:
P ( Weu Symhoi(�if appiicahie)�, � araw��9 a�arrow Show ground elevation contours at suitable intervals.
of Tested Nea�, on tne appmprite i�ine.
Suh,� �icK�
-- ! — — _-�—_—>
/l�ar,� Y�rer�
N 6 0 6 i w e;y a..� �.�
Sh-� 4.� ,c�� �Yg��
��s-- 699-���a
e�u _ Qa��el �oa6-939-�I'S//O
aM 5 �� 739 N R��c.�
Tw„ oF Sa�� �.Lc�
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Wealherpmo( 12"Min.or 2.0 f[above
Junction and Approved Established Rood Eleva�ion
Alarm Box Vent Cap (�YPical)
Electrical mus[comply with 1 Appmved Locking Manhole
SPS 316 and NEC 300 4"P1 Vent Pipe � with Warning Label Attached
--Conduit �10 it from (typical) 4"Min.or 2.0 ft above
BuilAing � Establishcd Rood Elevation
(IypicalJ
�Airtight Seal �
� _ ., Finlshed Grade
18"Min_
��YPical) - ..
� 4 9 .
Inlet Inletlnvert
—Watortight
Appraved Jaints witYi � Plug
Approved Plpe 3 ft oNo � Max. 12"or90%of total volume
Solid Ground - � if more than one tank
a
Alarm-On
HOLDING TANK
VOLUME = 2000 gal
' . d . . . . . . . . .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: WIESER CONCRETE
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight= [(cu.fttank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt] x L5
Ballast Weight = [( cu.ft. x 624 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, Wisa Admin. Code. Pursuant to SPS 383.52 (2), Wisa Admin. Code, this holding tank(s)
shall be considered a human health hazard if not malntained 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= � Y� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o rype 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.)
„ 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 seroed
SERVICING FREQUENCY
o 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, VUisc. 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:
Nameofindividualorcompany: BUtteYflelCl, �IIC. _ Phone: 715-634-8� 76
�oca� government unir. SaWyel" COUCIty ZOf11Clg Pno�e: 715-634-8288
�ooa� 9o�e�nment �nit address: 10610 M8ir1 St. Ste 49, Hayward 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, Wisa Admin. Code.
Continqency 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.
System 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: � / j� / 22�
This contract is made betwecn the Holding Tank Owner and the Pumper.
Holding Tank Owner's Na�ne: Pumper's Name:
�'Vla r k S . � �R��-i� Sc�rl�- �� p,P�e-
Parcel Identification Number:
(Iz ��g�t Lega�y 1�� a 2 �O - � 3 `� - 2 I - � 1 I 0
1 . The owner agrees to file a copy of this contract with the govermnental unit, Sawyer County,
which has accepted and recorded with the Office of the Register of Deeds, the Maintenancc
Agreement for a Holding Tank required under the 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) serviced by the pumper and guarantees to
permit the pumper to have access and to entcr upon the property for thc purpose of servicing
the holding tank(s). The owner agrees to maintain the all-wcather access road or drive so
that the pumper can service tbe holding tanl<(s) with thc pumping equipment. The owner
further agrccs to pay the pumper for charges incurred in scrvicing the holding tank(s) as
mutually agreed upon by the owner and pumper.
3. The pumper 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 System Ordinance. The pumper further
agrees to include the following in the report:
a. The namc and address of the person responsible for servicing the holding tank;
b. The name of the owncr of the holding tank;
c. The site address of the holding tank;
d. The date the holding tank was scrviced;
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 rcmain in effect until the owner or pumper terminates this contract. ln
the event of a change in this contract, 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) Owner's Signature: �o��y o�e o,��e�� s�g�ar�re reyu�rea>
YYlar k S • 'F6TZ.��ST ,^��.�.
,
Pumper's Naine: (Print) Pumper's Signature:
c�� �p �
Pumper's Registrati Number: �
6 I� 13
Rev. 03/26/I 3
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- USE BLACK INK ONLY - � �x�41�4U223
POWTS MAINTENANCE AGREEMENT �4E?�313
For Holding Tanks P���-� �����ER
REGISTEEi OF DEEDS
Owner's Name(s) as shown on deed: SAWYER C�UI�ITY, WI
fl8J22/2{}2� Q1:29 PM
mr�rk � • 'T � ��-�GS-�-- RECORDING PEE 30.D0
Parcel Identification Number: t _ q
12 Di it Le ac ID � 2 w 2 � � ' 1 0 ����� z
� 9 9 Y ) - - - l —� - - - - - -
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 access, 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 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 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 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.
- Only one owner signature required - ACKNOWLEDGMENT
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Personal information you provide may be used for secondary purposes [Privacy Law, § 15.04 (I) (m)] Rev. 03/26/13
Parcel 1 : Lot 5 as recorded in Volume 37 of Cerfiified Survey Maps, page 209,
Survey No. 8592 as Document No. 435333, located in the Town of Sand Lake,
Sawyer County, Wisconsin, being a part of Government Lot 1, Section 21 ,
Township 39 North, Range 9 West.
Parcel 2: Nonexclusive easement for the benefit of Parcel 1 for ingress, egress
and utility over, under and across Lot 4 as recorded in Votume 37 of Certified
Survey Maps, page 209, Survey No. 8592 as Document No. 435333, located in the
Town of Sand Lake, Sawyer County, Wisconsin, being a part of Government Lot 1 ;
Section 21, Township 39 Norfih, Range 9 West. Subject to the terms, provisions
and conditions set forth in said instrument.
B122122,8:48 AM Real Property Listing Page
Re7l EStdte Sawyer County Property Listing Property5tatus: Current
Today's Date: S/22/2022 Created On: 10/25/2021 8:46:29 AM
�Description Updated: 7/12/2022 � OwnersNip Updated: 7/12/2022
Tax ID: 44309 MARK 5 FORREST STONE LAKE WI
PIN: 57-026-2-39-09-21-5 OS-001-000100
Legacy PIN: 026939215110 Billing Address: Mailing Address:
Map ID: MARK S FORREST MARK S FORREST
Municipality: (026)TOWN OF SAND LAKE N6061 WEIGAND W N6061 WEIGAND LN
STR: 521 T39N R09W STONE LAKE WI54876 STONE LAKE WI54876
Destription: PRT GOVT LOT 1 LOT 5 CSM 37/209 m
#8592 (ZAWISTOWSKI JT REV TRUST- r Site Address � indicates Private Road
LC) ..____ ._._.. .__. . ___... . . . ._...
16002W SAND LAKE RD STONE LAKE 54876
Recorded Acres: 2.250
Calculated Acres: 0.000
.._
Lottery Claims: 0 J property Assessment _ . Updated: 7/6/2022
First Dollar: No 2022 Assessment Detail ���
Waterbody: Sand Lake Code Acres Land Imp.
� Zoning: (RRl) Residential/Recreational One Gl-RESIDENTIAL 2150 118,100 0
ESN: 423
2-Year Comparison 2021 2022 Change
Land: 0 118,100 100.0%
�� Tax Districts Updated: SO/25/2021 Improved: 0 � 0.0%
1 State of Wisconsin Total: 0 118,100 1D0.0%
57 SawyerCounry
026 Town of Sand Lake
572478 Hayward Community School District �
001700 Technical College Property Nistoty
Parent Properties Tax ID
•� Recorded Documents Updated: 7/12/2022 57-026-2-39-09-21-5 OS-001-000030 28773
LAND CONTRACT
Date Recorded: 7/1/2022 439959
MAP OF SURVEY
Date Recorded: l/12/2022 21399-14
CERTIFIED SURVEY MAP
Date Recorded: 10/19/2021 435333
QUIT CLAIM DEED
Date Recorded: 4J5/2013 384376
QUIT CLAIM DEED
Date Recorded: 2/11/2013 383451
WARRANTY DEED
Date Recorded: 1/22/1991 222005
Child11i5YapLReCOLdCount 1 -
HISTORY O Expand All History White=Current Parcels Pink=Retired Parcels
�Tax ID: 28773 Pin: 57-026-2-39-09-21-5 OS-001-000030 Leg. Pin: 026939215103 Map ID: :1.3
44309 This Parcel Parentr Children
https�Nlas.sawyercountygov.orglsystem/frames.asp7uname=Eric+�/yellauer i/1