HomeMy WebLinkAbout002-103-08-1600-SAN-2022-237 _ �'' � Department of Safety c°""�' �
� `��� � & Professional Services, ��``�' Y�'° �
i s� ���� � ��'j Sanitary Permit Number(to be filled in by�
,�, � .� Industry Services Division
:z; � � Co 3°I � �.�f �
Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �— W
is required prior to obtaining a sanitan�permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diff�rent than mailing a J
the Depar[ment of Safet}�and Professional Services.Personal information}'ou provide may be uscd for secondary � L�Z�� V� C����� S �
pucposes in accordanee«°ith the Pricacv La�r_s. 15.04(1)(m),Stats,
I.Application Information—Please Print Alt Infor�nation
Propert� Chvner's Name Pazcel#
1�� �„� 1��5 ��sK < <%�Ziv3�� iLcc�
Property Owner's Mailing Ad ress PropeRy LocaYion
7��� i�g..d�_ �,`ff-, � Iv� �% c�e��
City,State Zip Code � Phone Number
�S 1 C � '\ �t- �5 ��� ,� �Section 3 �
�.:'I"yp�u�B�ild#ag{checic.al!t6at appl�') ' Loc a T�f C N x .�'i E or�i
�1 or 2 Family Dwelling—Number ofBedrooms � �(� -_.. Z,(� Subdivision Name
B�o�k# /���� r�'�s�� t3�r-`.c_G-.
❑Public/Commeroial—Describe Use �
❑City of
❑State Owned—Uescribe Use CSM Number ❑Village of
__ �Townof ���e5�� L�=. ��
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other appticable on line A. Check one box on line B.Compiete(ine C if
a licable.
�.
�New Stistem ❑ Repl�cement St�stem ❑ Other Modification to Exishne S�stem(explain) ❑ Additional PreVeatment linit(explain)
B.
Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C'. ❑ Renewal F3efore ❑ Revision ❑ Change of Plumber ❑ Transfer to Ne�� O�+ner
_ist Previous Permit Number and Date Issued
Expiration
I'tfy ' ;. ,�#ment Area+�nd'�ank In€armatlura;
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Requircd(sf) Dispersal Area Proposed(s fl System Elevation
2�� � ,— -- —
Capacity in Total #of Manufacturer
«:
Tank Information Gallons Gallons Units � ` o � c�
New Tanks Existing Tanks � C � � � � � �
0
a`. U tn �, • v� w C7 0.�
Septic or Holding Tank �Gv _ 2
c� I Lc�t C'�S C'� x
Dosing Chamber
V.Respan�ihility Staternent- I,the undersi�ncd,assnme':reaponsibtiity fer iustallation of the POWTS shawn on the attached ptans.
Plumber's Name Prmt Plumber's Signature MP/MPKS Number Business Phone N�mber
Jerry Ru�d E�xcavating, LLC ,�� , Z,_� Z��� .� 7i� �<<:t z- Z-��-���
Plu t , ip Code)
Stone lake� WI 54876
VI.�Cou ty/Department LTse Only
Permit Fee I��te Issucd [ssuin�Agent Signature
��p � ❑llisappro�cd � ,q� -
Lj�'✓ ❑Owner Given Reason for Lenial `vv•� � I� / a� �
Conditions o�Approval/Reasons for Disapproval ,J �l�����f �[+'
V �'��� ��
� ►� ��t��.,._�-�-�-�- � ��I
f��il I ��'► r __�_ � �EP 0 � 2022 r-:
�
�,hk#
C S� N�� �• +����t#�[�I,�...lC�����.333? �aWY��t �.:�,e,�;��`�
� ZONING ADMI;ViS?�F�<;t��,;�^.�
Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inches in size
P10 REFJNDS AF�'I��i � �ICo
SBD-6398(R.03/22) �c.,SUE OF PEFiMiT
Sawyer County Zoning & Conservation Administration
```"� � 1 10610 Main Street, Suite 49
�_Q . �; w , i � Hayward, Wisconsin 54843 �
' � �� � lI (715)634 8288
� , ����� �';',% FAX (715)638 3277
� � - s.._.sri i,,.� � ti-�vlt , n�C -ccni52nyY_•�r'
� �� -, ,, r ;� , � E mail z��i13n�.��c,�;,;i�t���ic,cui?t �o� _grr.
� � � Toll Free Courthouse/General Informahon 1 877-699-4110
t� �'_ ;= '_ ��
; .t �
t � � \������
Holding Tank Approval Checklist
L Sanitary Cover Sheet Date Stamp �� / b � / � �
Parcel ID# D O Z_ � 6 3 _ p g _ � (�, D O
II. Plot Plan
�Property Lines � Benchmark BM ♦
x Site Address � North Arrow
� Structure � Scale
�Well � �C� 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
Management Plan/Contingency Ylan
� Servicing Contract
�Holding Tank Agreement form
IV. Holding Tank Specifications
x Cross-section — Manufacture, Gallons: w i��' �r�
x Tank Anchor Calculations [SPS 383 .43 8) g)]
� Locking device, chains/locks
�j 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: ''"3y� � S�-; Plumber: S . 1`���1
Application Review Date: O� � 0`f� �- a
POWTS Reviewer: /�_ "(�
Namc ��� � �
Liccnsc #
Revised 4/11/2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version 2�,SBD-10855-P(N.03107;R 01/12) . , .
Pg 1 of 4 a'� 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): �e��n," �-�Y�NS K� Phone: - -
OwnerAddress:7<<� t�����tt- /�U�N� �si��y� Mry Zip: •�� ��'
Project Address: i`I 2 Z Z l.J r�n,�Si. J l���i i-:-��ti'�� �✓-j- .5 `/�`(3
Govt.Lot: 1/4 of 1/4,Section 3� ,T yL N-R �,� E�or W�
Township: �3�s5 L�-k"� County: ����---=yr-Ef
Project Parcel ID#: vo-Z��%30�%/C^�C-
Designer Information
Jerry Ruid Excavating,LLC phone: ��J -��`�a- �-`��l
Designer Name:
Designer Address: Stone Lak�;Wi,aa�g Zip; 5�l£3 76
E-11181�: � C v l�� G��v�vcr'�1/(t'—� •�v�( r�i_;yuce reserved fnr ai�pznval stauip.
License Number: �-`��-`���
Remarks:
� -�/- ?Z
Signature: - -, � �- Date: �
Ongina� ature required on each submitted copy.
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Jerry Ruid Excavating, LLC 13�k � 7G`tg t��.�����'�����
W208 County HWY A � v � tf�.. � ;,c/ Gs i ecSc� jr�,,, 5 5�3 �
Stone Lake, WI 54876 � bE,�d p�S� /3E�c G�
c=s � _ z �{ Z`Z � z ,
/ylr�/ ! ,�5 �
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, PAGE30F4
HOLDING TANK SPECIFICaTIONS
(No Scale)
We�a,erpoor ,r Mb.�Zo n a�e
JunUbn ard p��p,� Esla66eF�ed Fbod Elevalbn
Alartn Bmc VeM Cap lhP��)
EMCOfeW muai cartD�Y wXh 4'0 VBnt Plpa � w tl�+Waming�Label9 Atlad�ed
SPS 816 md NEC 300 >10 R fiom (typtcal)
�� 4'Mfn.w 20 R ebws
BuOmng EslabOehad Fimd Eleva�on
(tYP�D
Alrtl9ht S�I .
Fmishad Cxade
18'Mm.
(Hq�) , Y.:.
.. a ,
irdet I�dst irnaet yy�yrygM
'���'��� � �Mmc 12'or 90%ot toml vdurtfe �
ADProv�d P�e 9 R rnto K more than one mnk
Sdtd Growd e
a�+a+
HOLDING TANK
VOLUME_ ��"�' gal
.a � . � . . •_
9•qpppvW Beddtrq Materlal Berreath Tank
TANKMANUFACTURER: w`�SU
Anchor tank as neces�ry
pursuant to SPS 383.43(8)(g)
Ballast Weight=[(cu.ft.tank.vol x 62.4 Ibslcu.ft)-Ibs.fank.wt]x i S
Ballast Wei�M=[( 1 z 7 cu.ft.x 62,41bs/cu.ft)- 7''1��' Ibs]x 1.5= i 2 `'`'`� Ihs
PAGE 4 OF 4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(sj shall be responsible for its perpetual operation and maiMenance 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 accorda�ce with this approved management plan.
Furthertnore,all inspection and maintenance acGvities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc. Admin. Code.
Z.c�c�
Estimated Daily Wastewater Flow= �� gpd
Insoectfon Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complairrts, etc.)
o mechanical malfuncfion(i.e., pumps,valves, switches,floats, etc.)
o material fatigue(i.e.,Ieaks, breaks, corrosion, etc.)
o neglecc or improper use (r.e., exceeding design capacities, prohibited activities, etc.)
o electrical cornponents(i.e.,wiring, connections, switches, controls,timers, alarms, etc.)
o surtace discharge of eifluent 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) reaehes a level of one foot below the inlet invert of the tank(s).
Disposal of contents shall be pursuarrt to NR 113,Wisc.Admin. Code.
Tank pumping reports shall be submiCad to the proper local govemment unit in aceordance wkh SPS 383.55 Wis.
Admin. Code. Report any component faflure or malfunction to:
Name of individual or company: SGo7T'S SG pY� L Phone: 7�S"��`9' 72 7 R
Local govemment unit S�w y�r Co . z a^' �^'� Phone: 7/S— C 3�{' $?•�Y
Local govemmeM urrit address: �UC��O N'W.i n� S i'. 5�,�Z-p� �l�( }�y t,�`dZ�p; S�l $c('�
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 maifunctioning components shail 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.
ConUnaencv 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 sha�l be abandoned in accorclance with SPS 383.33,Wisc. Admin. Code.
HOLDING TANK SERVICING CONTRACT
Contract Date: �,/�l 2..2,.
'17�ie contract is made between the HWding Tsnk Owner and the Pnmper.
Holding Tank Owner's Name: Pumper's Name: .
K�va,v Lesy'lnsSK, S�.�Tj'� 5c y� r ! c,
Parcel Identi8cation Number:
(12 Digit LegaCy ID) G� b �2 - I G 3 - G �- / L e CG
1. The owner agrces to file a capy of this conuact with the govecnmental imit,Sawyer CoimtY,
which hes accepted and recorded with the Office of the Register of Deeds,the Maiatmance
Agrcement for a Holding Tank required under the Saaryer County Private Sewage System
Ordinance for the issuance of a Sanitary Permit for the installation of a holding tank(s).
2. The owner agrees W have the holding tank(s)serviced by the pumper and guatanteea to
permit the p�miper to have accv�ss and to enter upon the praperty for the purpose of servicing
the holding tank(s). The owner agrces to maiatain the all-weather access road or drive so
that the pumper can service the holding tank(s)with the PumP�S�Pment The owner
further agrees to pay the p�per for charges incurred in servicing the holding tank(s)as
mutuallY agreed upon bY the owner and pumper.
3. The pumpQ agrces to submit to the Goverameatal Unit,Sawyer County,a xepoxt for the
servicing of the holding tank(s)as required undez SPS 383.55,Wiar.++��,.,Adminis4ative
Code and the Saavyer County Private Sewage System Ordinance. The pumper fiather
agees W include the following in the report:
a. The name and address of the person responsible for servicing the halding tank;
b. The name of the awner of the holding tank;
c. The siu address of the holding tank;
d T'he date the holdiag tank wes serviced;
e. The volumes ia gallons of the coatents ptiunped from the holding tank for each servicing;
f. The disposal sites to which the conteats from the hoiding tank were delivered.
4. This ageemmt will remain in effect until the owner or puinper terminates thia contact. In
the event of a cliange in tivs coatract,the owaer agrees to file a copy of any changea to this
service contcact or a copy of a new service contract with Sawyer County within ten(10)
busiaess days from the dau of change to this service conuact.
Owner's Nsme: (Print) Owner's Signature: (ony one own �e ewwea)
_ -���
U �ti� LeS �v�S�-
Pumper's Name: (Pcint) 's si ' � ,,
� � ��-���'
��<<-%T�
Pumper's Registxation Number:
��,' 1,��
Rev.0326/13
9/9/22,835 AM Real Property Listing Page
Redl EStdt2 Sawyer County Property Listing Property5tatus: Current
Today's Date: 9/9/2022 Created On: 2/6/2007 7:55:01 AM
�Description Updated: 7/10/2019 � Ownership Updated: 8/30/2022
TaxID: 46 KEVIN A LESYINSKI OTSEGO MN
PIN: 57-002-2-40-OS-30-5 15-155-081600
Legacy PIN: 002103081600 Billing Address: Mailing Address:
Map ID: -12.8.16-26 KEVIN A LESYINSKI KEVIN A LESYINSKI
Municipali[y: (002)TOWN OF BA55 LAKE 7698 PADGETT AVE NE 7698 PADGETT AVE NE
STR: S30 T40N R08W OTSEGO MN 55330 OTSEGO MN 55330
Description: ABENDPOST BEACH LOTS 16-26 BLK 8
Recorded Aaes: OJ58 w Site Address * indicates Private Road
Calculated Acres: OJ58 14222W PINE ST � HAYWARD 54843
Lottery Claims: 0
First Dollar. No J property Assessment Updated: 9/13/2012
Zoning: (RR2) Residential/Recreational Two Z022 Assessment Detail
ESN: �5 Code Acres land Imp.
G1-RESIDENTIAL 0.758 10,600 0
�� Taz Districtr Updated: 2/6/2007
1 � SWte of Wisconsin 2-Year Comparison 2021 2022 Change
57 Sawyer County Land: 10,600 10,600 0.0%
002 Town of Bass Lake Improved: 0 0 0.0%
572478 Hayward Communiry School Distrid Total: 10,600 10,600 0.0%
001700 Technical College
• Recorded Documents Updated: 8/30/2022 C3 property History
QUIT CLAIM DEED N�q
Date Recorded: 8/22/2022 440914
QUIT CLAIM DEED
Date Recorded: 11/16/2015 398682
]UDGMENT
Date Recorded: 9/16/2015 397639
WARRANTY DEED
Date Recorded: 11/5/1986 202552
https:Ntas.sawyeroountygov.orglsystem/fremes.asp?uname=Eric+Wellauer 1l1
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-USE BLACK INK UNLY• 441246
POVYTS MAINTENANCE AGREEMENT PauLa cHiSSeR
For Holdin Tanks REGISTER OF DEEDS
9 SAWYER COUNTY, WI
Owners Name(s)as shown on deed: 09I09/2022 08:54 AM
` _ RECORDING FEE 30.00
�e-J/N �LS � lNS^ !
Parca;Ident�cation Number. PAGES_ 2 �
(12 Digit Le9�Y ID) U c^ 2.,- 1 U�- O�- l (� C c 5 .
legal Descripiion of Pioperty:
-SEE ATTACHED SHEET -
� We acknowledge that application is being made for the insfallatior.of a holding tank(s)on the
property tlescnbed on the attached sheet. .
Relum 70:Sawyer LouMy Zoning and Conservation Administration
10610 Maln St Sulte 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,tl�e owner is
responsible for the operatlon and maintenance of the holding tank, locking device,alarm and access,and agrees to confortn to all
applicable requirements of SPS 383,W is.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,excep[as provided by
Section 281.48(3)(d), Stats.,to have the holding tank properly serviced and to file a copy of the service�nntrad with the
govemmental unit. The owner further agreas to file a copy of any changes to the service contract,or a copy of a new servica
contract,with the govemmental unit within ten(10)business days from the date of charge 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 M
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 Seclion 281.48(3)(d),StaLs.,the owner shall submit the report to the govemmental unit. The govemmental
unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the
holding fank is not being properly maintained.
3. If the owner fails to have the holding tank properly serviced in response to orders issued by the govemmental unit to prevent
or abate a human heatth hazard as described in SecGon.254.59, Stats.,the govemmental unit may enter upon the property
and service,or cause the tank to be serviced. Pursuant to Section 14520(4)Wis.Stats.,a govemmental unit may assess the
owner of a private sewaye system for oosts 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 govemmeMal unR for
inspection, pumping, hiauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate
any human healih hazarc7 raused by the holAing tank.
4. This agreement will remain in effect only until the govemmental unit responsible for the regulation of private sewage systems
certifies that either a soil absorption system that complies with SPS 383,W is.Adm.Code,or a municipal sewer serves the
property.In addition,this ag2ement may be cancelled by executing and recorcling said certifcation with reference to this
agreement in such manner which will permtt thr.exictence of the certification to be detertnined by reference to the propeRy.
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
perm8 the existence of the agreement to be determined by reference to the property where the holding tank is installed.
-OnI oneownersl naturere ulred- ACKNOWLEDGMENT
OW f 5 S19t1 � /
Stateof: WiSL��n�'Sir�,
Countyof: 'Si���`�F--1�
Ownej'�Name int): Subscribed and swom to before me on this
{ic-'vir? L�SI lY15� ! �dayof /�-vr��sr ,20zz
Date:
� ��(: rZ�'7_Z `��N�u1uq� By(OwnersName): K�� �i1. LE /NSKI
� � � ,� Notary Public Signature: .�-lr.ti��� L�.-u-�'
Drafted by: , . � � ,,....... �.
� P: ., ��Public Notary Name(Print): 1>�N/f �� K�iFsn1�SSF�-'
�t.��,�, Le-�'rNSL� I ;�e p10Tq u��Ivlycommissione�ires�n: /S �F�tivl-tiC-�t,+�
- , m:
=�c• '°� ' Z;
�v � �LIG ' �
Personal informadon you provide may he used for 4yn6�8�y purposes jpr'��ZLLaw,§15.04(I)(m)] Rev.03/26/13
���''�'` WiSGOr.`���
�n�n���a,•
Lots 16, 17, 18, 19, Z0, Z1, 22, 23, 24, Z5 and 26, Block 8 of the
Abendpost Beach Subdivision, located in the Town of Bass Lake, Sawyer
County, Wisconsin.
�"'"`-'""`:r: PRIVATE ONSITE WASTE TREATMENT �ounty
�' �r
� � \'� SYSTEMS
`;����_,J�'� ( POWTS) Sawyer
°"'-"°�'"'/ INSPECTION REPORT sanitary Permit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� - a 3�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s._15.04(1)(m)f
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transactio�ID#:
y�2V1 n L e.S 1�,5�` lc.�.S'S W�
Insp BM Elev: BM Description: Parcel Tax No:
L C�:Z�i � o�T �.�; ,(R b-e�� I�O\ ��b2_ /03-�g-/�Oc7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark /po.o'
Dosing
Aeration Bldg. Sewer ,� �
Holding ��T e� St/Ht Inlet �7,� �
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding a` �/ � ¢-(� L ,1�" Dist. Pipe
PUMP/SIPHON 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 L #of Cells 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
—---
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges _Topsoil __ ❑Yes ❑ No ❑Yes ❑ No�
COMMENTS: (Include code discrepancies, persons present,etc.)
� ��-� ���jl.� �6 (2-9(a-�
� - - - -
Plan revision required?�Yes ❑ No O�„l�� a-y I � �jt� G9 � ��
� - t �--_— ------- —_
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAt COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA: e�o1 - vZ3�
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