HomeMy WebLinkAbout010-841-36-5412-SAN-2022-261 �'�g`-=-�'-�'t�r� Department of Safety c°°°�' �
f� S�c.:� '�l' �
f,z�'f� & Professional Services, Sanitary Permit Number(to be filled in by
€s �y �
�, ; � �� Industry Services Division �
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�.,,�,...
• • State Transaction Number �
Sanitary Permrt Application _ �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing a �
thc Department of Safcry and Professional Services.Personal information you provide may be used for secondary � �� � (��3 w �J ���� �
purposes in accordance with the Pri�acc La«�,s. 15.04(1)(ml,Stats.
I.App(ication Informatiun—Please Print Atl Information
Propert� (?wner s Nazne Pazcel#
�5h e � `�4� e-1 l� �5 .� ��r c�to�� t 3C�s-�tl Z,
Propefty Owner's Mailing Address PropeRy Location
�v �os-- 3 3 ��� A vc;. Go�t.Lat �
City,State Zip Code Phone Number
C'L t �9ct �u—�`S �L � c� 72c� '/e, '/<, Section 3 v
I[.TypC t1f Btlitlt�inkg{ett�e#[All tb8t�Ppiy) Lot# T `-(� N R � E o �
�1 or 2 Pamily Dwelling—Number of Bedrooms��� � _ '�l Subdivision Name
Block#
❑Public/Commercial—Desc:ibe L?se
❑City of
❑StaYe Owned—Describe Use CSM Numbcr ❑Village of
2��3 v`� f,�i'own of I"t�tiC� (A�cL,Cl
�'��`j�,)
III.Type o€P{?WTS Permit:(Check either"New"or"Replacement"and otl�cr applicable on line A. Check one box on Gne B.Compiete line C if
a licable.
`� Ne�� S}'stcm
� /� ❑ Replacement Sy�stem ❑ Other Modilication to Existmg Systcm(explain) � Additional Prctrcatment iJnit(explain)
dG
B' Holding Tank ❑ In-Ground ❑ At-Grade
❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner
ist Previous Permit Numbe;and llate Issued
Expiration �'� —�� ��'�1 I q g
�.
': .r�p�nt Area and'�'an}�InFarmation:
Des�gn Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elecation
/�U
Capacity in "rotal #of Manufacturer
Gallons Gallons Units � o $ �
Tank Information � � •
New Tanks Existing Tanks ` eo � � y D �y �
n. U v� v, v: t�. C7 G.
Septic or Holding Tank �(�j�Z, ,� �/ DO � ���S��
V
Dosing Chaznber r
V.Respon�ibiiity Ststement—I,the undersigned,asaume responsibili#y for installaHon of the-POWTS shown on the attached plans. •
Phimber's Ncmie(Print) Plumber's Signature h1Y�'I�'1PRS Number Business Phone Number
Jerry Ruid Excavating, LLC �� z�Z��6 � ��S��E�t Z- 2�/0`l
Plu , ' t , ip Code)
Stone Lake� WI 54876
v�.c u� m��e��nt usc Qo�y
� �A�ro�• � ❑Disapproved $ermit Fee Dale Issued Is�uing Aeent Signature
�Ll/ �W.� 1 '�'Z'�� ���G��-��/Wi—
❑Owner Given Reason for Denial
Conditions of ApprovaUReasons for Disapproval
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Attach to complete pla s for the system and submit to the County only on paper not less than 8 1/2 x 11 inches iu size ' ( �� �
NO R�FJNDS A�1'ER
SBD-6398(R.03/22) ISSUE OF PEkMl�
Sawyer County Zoning & Conservation Administration
������ � � � 10610 Main Street, Suite 49
�, ,�_ � �;, � Hayward, Wisconsin 54843
, " �} � • �I (715)634 8288
� �' ������V`' � I� FAX (715)638 3277
� f , �1,�mC' � ' � wy:tit , .�c cou+it�_��c.�n�
/ � = , . i E-mail zont7 «c�,�i ��ic ��unt ��ot oi��
�� `-�' � Toll Free Courthouse/General Information ]-877-699-4110
I � '-� '�' �"� —
f � �`'..
, � � 1\����
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp �� / ( � / � �.
� Parcel ID# �� O- �3 Y ( - 3 C - � � � �
II. Plot Plan
� Property Lines � Benchmark BM ♦
�C 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
llL Required Plans _ � �
� Index Page with Original Signature
� Management Plan/Contingency Plan
Servicing Contract
Holding Tank Agreement form
IV. Holding Tank Specifications
X Cross-section — Manufacture, Gallons: W ' e�f" �rg� /�' ���
� 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
� Version ,� SBD- 10855-P (R.3/07), , ,
�. \
Owner: �'`��_ Plumber: �. ��
Application Review Date: � � �� � � �
POWTS Reviewer: Ji�-� �`—
Namc
69sa � �
Liccnsc #
Revised 4/1 U2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version�Q,SBD-10855-P(N.03/07;R 01/12).,.
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 in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
Owner Name(s): A�hle4 .��:,w�e.( ��be,�z�� Phone: - -
OwnerAddress: lvys 33� �✓e �'���� ��S. G�<- Zip: S`f 7 z�t
ProjectAddress: 12u�!&w C �y � �-Ia-vW�d. w<- s v��3
Govt.Lot: �/ 1/4 of 1/4,Section -36 ,T �li N-R � E❑or W�
Township: u�y� � �-c� County: S�urvea�
Project Parcel ID#: o Ia�`�d i 3��s-Y��-
Designer Information
Jerry Rutd Excavating,LLC
Designer Name: Phone:7/S -Y t 2- 2 yo9
Designer Address: Stone Lake,WI 54876 Zip: s`�£7G
E-mail:S r��� �ff S^�`1��� /V�L This space reserved for approval stamp.
License Number: �,K Z`�,fo�
Remarks:
Signature:�,...� �� Date: `�- 7-z Z.
'nal signature required on each submitted copy.
Reset Page
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�oy`s % � z l o yoS' 3 3 �d /� ve_
Jerry Ruid Excavating, LLC 2 3/30� CYso L' �,p�,�,. .� �i/5 W i
W208 County HWY A
Stone Lake,WI 54876 S `/ �zR
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
4'0 Vanl Pipe
Wealherpioof � >10ftfiom
Junction and Alarm Box APP�a�� Building
Vant Cep �2"Min.ar 20 R ebove
Eleclncal must mmply wilh APPfOVed Lorking Menhole Established Flood Elevelion 4"Min.or 2.0 ft above
wilh Weming LahelAttached ((ypiral) Eslablished Fiaod Elevation
SPS 316 and NEC 300 (�yp{�I) (typical)
Canduit
AiAight Seal � "
Finished Grada
18'Min.
(NPical) y. "! !�e•'._ • , .
d.. '
� �
Inlet Inlet InveM1 Walertighl
Approvad Joinls with Plue�
Appmvetl Pi 3 fl onto Mex.12"or 90�of lolal voluma
� Solid G und if mofe lhan one tenk �
(typic�al) Alartn-0n � h.
i
Compartmenl i Vol=�gal Compartment 2 Vol= � ��.�/ gal
��• TOTAL HOLDING TANK
�
VOLUME _ �3��y gal .
.�
.
. ,a�
3"Appmvad Bedding Malenel Beneeth 7ank
i
TANK MANUFACTURER: ���5�r
Anchor tank as necessary
pursuant to SPS 383.43(B)(g)
Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-Ibs.tank.wt]x 1.5
Ballast Weight=[( � z+ d cu.ft.x B2.4 Ibs/cu.ft)- ��s�� Ibs]x1.5= � �. �Z Ibs
Reset Pa
' PAGE40F4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s)shall be responsible for its perpetual operation and maiMenance pursuarrt to
requiremerrts of SPS 382384,Wisc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin. Code,this holding tank(s)
shail be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthertnore, all inspection and maintenance activities shail be performed by a registered POWTS Maintainer in
axordance with SPS 383.52(3),Wisc.Admin. Code.
Estimated Daily Wastewater Flow= /UG gpd
Insoectlon Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanipl 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 adivities, etc.)
o electrical cornponents(i.e.,wiring, connections, switches, controls,timers, alarms, etc.)
o surface discharge of effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s)shalf 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 inveR of the tank(s).
Disposal of contents shall be pursuant to NR 113,Wisc.Admin. Code.
Tank pumping reports shall be submilted to the proper loeal govemment unit In aeeordance vrkh SPS 383.55 Wls.
Admin. Code. RepoR any eomponent failure or malfunctlon to:
Name of individual or company: SGoYS SG-(�Y� L Phone: 7�'s-G`f�j- 7�-7q
Local govertvnent unit 5�w Y�r Co . Z ca.•� r r.+� Phone: �/$- E �`I- 8 a•��
Localgovemmentunitaddress: )OC�lO VhA.tN 5� S��rtp� �1�{ �"�q4W�'�ZIP: s`'� 8�{'-�
My 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
axorclance with SPS 384,Wisc.Admin. Code.
Contin9encv 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 approvai.
Svstem 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: p / �/ 22 �
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
SG,�,u�. l -.� ��,b 2�z� SG, �f �°FP �'
Parcel Identification Number: �
(12 Digit Legacy ID) � / O - g � � - ,3 �, - � � f 2,
l . The owner agrees to file a copy of this contract with the governmental unit, Sawyer County,
which has accepted and recorded with the Office of the Register of Deeds, the Maintenance
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 enter upon the properiy far the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access road or drive so
that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper far charges incurred in servicing 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 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 address of the holding tank;
d. The date the holding tank was serviced;
e. The volumes in gallons of the contents pumped from the holding tank for each servicing;
£ The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In
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 cl�ange to this service contract.
�Wriel'S N11T10: �PI'lrit� �WriOI''S S tUT'0: (Only one owner signature required)
' � �
✓s Ilit�° � �.) . �.(, YI,Z,Q� r —
Pumper's Name: (Print) Pumper°s�Si n e:
���;:._ � �� �' , �..���� �- ,,
� ,,�. � �, r �7 w
Pumper's Registration umber:
� � � i �
Rev. 03/26/13 �
Real Estate Sawyer County Property
Property Status: Cur�ent
Listing
Today's Date: 9/7/2022 Created On: 2/6/2007 7:55:21 AM
.�' Description Updated: 8/7/2UU9 '�f ��wn�:rship Updated: 10/21/2021
T,�ac ID: �,� �� 1�.$93 ��� � � � .i..i!�'B.'_Y R&SAMUEL J RUBENZER CHIPPEWA FALLS WI
57-010-2-41-CEt-3r�-5 0�-0� ;..
PI�� Q�fl1�� _I;�._g�:_lress: Mailing Address:
`Legacy PIN: 0108413654iZ !�!�'.�Y R 3�SAiNUEL J ASHLEY R &SAMUEL 7
M�p Id: :�#.12 r.;.+;+.c4vZ�F: RUBENZER
Municipality: (010) TOWfJ OF HAYWARD =:�� 5 3:3RD AVE 10405 33RD AVE
STR: 536 T41N R08VV CHi` PEV1�A FALLS WI j4729 C�iiPPE1h'A FALLS WI 54729
DesCriptian: PRT GOVi�LOT 4, LOTS 1 &2 CSi�1
23J305 #6450 � Site Address * indicates Private Road
Recorded Acres: 2.170 12448W COUNTY HWY B � HAYWARD 54843
Lottery Claims: 0
First Dollar: No �"
� Property Assessment Updated: 11/9/2015
Waterbody: Round Lake -- --� -�-��
Zoning: (RR1) Residential/Recreational One Z02Z Assessment Detail
" ESN: 444 Code Acres Land Imp.
G1-RESI[�ENTIAL 2.170 397,800 0
� x� Tax Districts Updated: 2/6/2007 2_Year Comparison 2021 2022 Change
1 State of Wisconsin Land: 3�7,8{}(}', 397,800 0.0%
57 Sawyer County Improved: 0 0 0.0%
O10 Town of Hayward TotaL• 397,$a0 397,800 0.0%
572478 Hayward Community School District
001700 Technical College �� .
- ��Property History
°�� Recorded Documents Updated: 9/12/2008 - -•-----------�— --� -� �-��� -
0 WARRANTY DEED " N/A
�i• i � � .'
Date Recorded: 10/20/2021 435372 � �, �
0 WARRANTY DEED � f E � .
Date Recorded: 8/5/2008 355156 I :
0 CERTIFIED SURVEY MAP '
Date Recorded: 7/24/2002 301$79
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- USE BLACK INK ONLY - �41498
onr,�`n �^uy�c�o
POWTS MAINTENANCE AGREEMENT REGISTER OF DEEDS
For Holding Tanks SAWYER COUNTY, WI
UJJLL%lU1L U`.�:L% /�M
Owner'sNarr�e(s)asshownondeed: RECOR[3ING FEE 3Q.00
SQ�1l�' V • �V►�Y�ZPJ� ' �`.�Yl � • ��,� PAGES: Z
Parcel Identification Number:
(12 Digit Legacy ID) O , O - ��� - '� � - � � 1�
Legal Description of Property:
- SEE ATTACHED SHEET -
We acknowledge that application is being made tor the installation of a holding tank(s)on the
property described on the attached sheet.
Retum To: 5awyer 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 o� 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 mana,yement, inGuding the foliowing:
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
govemmental 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 govemmentai unit within ten (10) business days from the date of change to the service contract.
2. The �wner 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 shali 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 senriced in response to orders issued by the govemmental unit to prevent
or abate a human health 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 governmental unit may assess the
owner of a pnvate 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 ali charc�es and cost incurred by the govemmental 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 govemmental 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 rec;ording 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, arxj 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.
-Ont one owner si natur - ACKNOWLEDGMENT
Owner's nature: State of: _ �,S[oriS?•'�
r Countyof: � C��i✓L
Own r's Name ( " t):
�. Subsc�ed and sworn to efore me on this
J - �—day of t/ , 20 2Z
Date: By (Owner's Name}: 6�nu✓
6� �q a°� Notary Public Signature: .
Drafted by: Public Notary Name (Print}: /�t,�j��,/ Z. �,,�'
A. ��►t � S• �k�GNLt� My commission expires on: D��O�.�Za23
Personal information you provide may be used for secondary purposes [Privacy Law, § 15.04 (f} (m)] AN�EV�6/13
N�tary �ublic
Stat� �t Wkc�nsin
Lots One (1) and Two (2) of Certified Survey Map No. 6450 as recorded in Volume 23 of Surveys on Page 305,
as Document No. 301879, located in and being part of Government Lot Four (4), Section Thirty-six (36),
Township Forty-one (41) North, Range Eight (8) West, Town of Hayward, Sawyer County, Wisconsin.
'�T' � PRIVATE ONSITE WASTE TREATMENT county
.:" --�r�;
I,.,. ��r�
';��$ $ ���;, sYSTEMs Sawyer
`��, `._P��` ( POWTS)
��F�,,,�,:��
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � �� `
Personal infonnation you provide may bc used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
/T$�'e �',�4v►'!"�G1 �"���� q wac� r-�
Insp BM Elev: BM Description: Parcel Tax No:
r�� .a' 'ho �� c� L, d� �rr, �10 --�(�^� —S�I �
TANK INFO MATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark po,o�
Dosing
Aeration Bidg. Sewer �7 q
Holding w�P��2r a�p St/Ht Inlet �j'�, � �
TANKSETBACK INFORMATION St/HtOutlet q�',q �
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding �30� �o' ,�-�a` L-2S- � Dist. Pipe
I PUMP 151PHON INFORMATION Infiltrative
Su rface
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 Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � 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 —�epth of Seeded/Sodded Mulched
Cell Center Cell Edges j Topsoil _� ❑Yes ❑ No ❑Yes ❑ No l
COMMENTS: (Include code discrepancies,persons present,etc.)
��,s��� t�j �o(a-�
�'� �f�T��� 5��—
Plan revision required?❑Yes ❑ No
o-� a �-3 -� �— � �9 � /�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710{R.3/01)
A�OITIONAL C�MMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA. a���-E� I
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