HomeMy WebLinkAbout014-842-14-3208-SAN-2022-273 '" Department of Safety cO°°�' vi
0 - & Professional Services, s`�"'�7�� �
S - Sani t a ry Permit Number(to be filled in b� Z
rs Industry Services Division
� 3� asc� �
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental 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 �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary W
purposes in accordance witl�thc Privacy Law.s. 15.04(1)(m),Stats. ��
l.Application Information-Please Print All Information
Propert}Owner's Name Pazcel#
���10, S�ec d- �a�bQs'� '�. �Coeh�S�e.,c� or y-$y�f y�3 2 0 8
Property Owner's Mailing Address Property Location
I 3 y yS'N S N:�Is �h. c��r�.���''�—
City,State 7.ip Code Phone Number `
},�'"`(*t,►�� 4/' S-Y$L(3 Nw '/<, s w %<, Section � �
I�e of Building(check all that apply) Lot# � T yZ N R �$ E or�
1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block#
❑Public/Commercial-Describe Use
'� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
13I�� �3�83 ❑To�,of �M�•�-
(II.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
�' e-�-? �e lacement S stem ��� Other Modification to Fxistin Svsttm cx lain �.__�� Additional Pretreatment Unit ex lain
D 1J p Y � ���. � ' (' P" ) ( P )
B' olding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
��• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration 2, .,32$ �- (�( , ��r
IV.Dispersal/Treatment Area and Tank Information: o ,� 13. q0
Design Flow(gpd) Design Soil Apptication Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Propose (st) System Elevation
'ZGO �/� — '— �
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units A � o $ �
New Tanks Existing Tanks w c � � � � � `�
.� cd
a U ci� v, V� G�. C7 C1.
Septic or Holding Tank �00� !Zdp(� � �"/��,�
Dosing Chamber
V.Responsibility Statement- !,t6e undersigned,assume responsibility for ins atioo of t6e POWTS shown on the attsched plans.
Plumbers Name(Print) Plumber's Si tu MP/MPRS Number Business Phone Number
I S��,r �-Z �S"1612`1 7�S-SS8'- S�.y
Plumber's Add ess(Street,City,State,Zip Code)
70 7;C N S��� (h GC r es. � �'I'on°� I 4�G �v: ��1�T Y
VI.C unt /Department Use Only
� ro ❑ Disapproved $ermit Fe� Date Issued Issuing Agent Signature
�� ❑Owner Given Reason for Denial `�� � I a�/�� ��'�i�T�-�-�-/ ��"v('`�'
Conditions of Approval/Reasons for Disapproval f` �,�,,
a �/'i�.l��`!l�'-�� �"`'l
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CS� � , — 3�U \ �;;;�t�#_N2w__lnlorl d � Cc IQ SAWYER COUVTY
� �# � � � � m µ Z�(JNING ADMINiSTR/�TfCJ�
Attach to complete plans for the system and submit to the County only on paper not less than S tn x 11 inches in size
1 i.e�t(e I
NO R�FUNDS AFTER
SBD-6398(R.03/22) ISSUE�F P��t�1111�1�
Sawyer County Zoning & Conservation Administration
�������� 10610 Main Street,Suite 49
� w: y. 1� Hayward,Wisconsin 54843
���;`��I (715)634 8288
��� �� ��� z\;;�/ FAX(715)638 3277
�
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� .,A - � � , i E-mail zony i � ,�:-,=ai����cou��*��o�c,r���,
�� '7 - � Toll Free Courthouse/General Information 1 877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp�/ �-� /_�
Parcel ID# D�1-� �( �- I �_3 a o �
IL Plot Plan
�Property Lines � Benchmark BM ♦
�? Site Address �North Arrow
�(Structure Scale
_�Well D�<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
i�Management Plan/Contingency 1'lan
�Servicing Contract
�Holding Tank Agreement form
IV. Holding Tank Specifications
� Cross-section—Manufacture, Gallons: �,�,I�5�� ����
�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: S�hG `'�
Application Review Date: q' �o�-�I��
POWTS Reviewer: �� �
Nam�
�`t �l(o
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 in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
Owner Name(s): T'n� s'�'<<- £N°'�"r}��5�d Phone: � - -
Owner Address: �3 y`�S N s¢�lY �,;(ls' l h Zip: �v�V j
Project Address:
Govt.Lot: r U 1/4 of S�✓ 114,Section �`� ,T yZ N-R a� E❑or W Q
Township: A� lt,,�oefi County: SSwyc�
Project Parcel ID#: �)�l gy Z I y 3 2 a g
Designer Information
Designer Name:Dylan Schultz phone:�15 558 5904
Designer Address:�076N Stone Lake RD ZiP:54876
dylanschultzl8@gmail.com
E-ITlal�: This space reserved for approval stamp.
License Number:1516129
Remarks:
Signature: Date: `�- ZI-ZZ
Original " ture �ed each submitted copy.
Reset Page
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o s��e: �30 30' 45 � �YSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: �5, oesicN F�ow�. Z GU cao
Attach design flow calculations for commercial plans.
PROJECT ADDRESS: � I 3�T rN SC��Y �-1,'/�5 Pipe Matenal/ASTM Standard(Tables 384,303&384.30-5)
NSanitery Sewer /
BM SYmbd: � BM Elevatiort FT Force Main: /
BM Oescriplion:
maiwte nonn� IMPORTANT:
Slope Gradient(%) Well Sym6W(if applirable): Q d�ew��g a�a�m.v Show ground elevation wntours at suitable intervals.
oi Tes/etl Ama: on tM1e appmprite lirie.
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.0 ft abwe
Junction and qpproved Established Flood Elevation
Alartn Box Vent Cap (tyP����
ElecGical mus�comply with j Approved Locking Manhole
SPS 316 and NEC 300 4"0 Vent Pipe � with Waming Label Attached
�Conduit �10 ft from (rypical) 4"Min.or 2A ft above
Building Esfablished Flood Elevation
(tYPiral)
a'
�_ �AirGghtSeal
• Finished Grade
18"Min.
(�YPical) �:. ' ' `
'' y .
e �" d
Inlet Inletlnvert
Watertight
Approved Joints wilh Plug
Approved Pipe 3 ft onto � Max. 12"or 90%of total volume
Solid Ground if more than one tank
c
' Alarm-0n
w
e
HOLDING TANK
VOLUME = 2 °Od gal , .
e . G . . .e . . . . . . . �
3"Appmved Bedding Material Beneath Tank
TANK MANUFACTURER: �`��
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 = 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 it not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POVYfS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Estimated Daily Wastewater Flow = Z 6� gpd
Inspection 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, vaives, switches, floats, etc.)
o material tatigue (i.e., leaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited activdies, 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
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 reports shall be submitt�to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Dylan Schultz 715-558-5904
Name of individual or company: Phone:
Sawyer county zoning 715-634-8288
Local government unit: Phone:
10610 Main Street Hayward wi 54843
Local government unit address: ZIP:
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.
Continaencv 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, Wisc. Admin. Code.
Reset Page
HOLDING TANg SERV[CI1VG CONTRpCT
�Onhact Date:
� ��
This contra���S made behveen the Aolding Tank Owner and the Pumper.
Holdin
� 8 Tanl�py�ePs Name:
=-"F �'��( `;�, Pumper's Name:
���� �ta,-� '` �C'f J��� j,[ �� '�'�'
��
Parcel IdenHfication N
�12 Di umber:
git Legacy ID� `_ p-�
'I ��-.12- 2-L�-�1 �%1
I� The ov,�e�agi.e�to file a copy of this conhact with the govemmental uiut,Sa
Which has accepted and recorded with t}�e Office of the Register of Deeds,the Maintenance
Agceement for a Holdin �'Yer County,
��d�nance for the iss g Tank cequired u�der tl�e Sawyer County private Sewage System
uance of a Sani[ary pe�t for the installation of a holding tank(s).
2' The owner agrees to have the holding tank(s)serviced by the pumper and
Pe�t�e P�nper to have access and to enter upon U�e proper[y for the
the holding tank s , b`�antees to
that tha � � T�e owner agrees to maintain the all-weather access ro d p���Mc�ing
Pumper can service the holding ta��s��til�e Pumping equipment. 'I'be owner
�tia��a�e���paY�e P�per for chazg�.s incurred in servjcing ihe Uolding tank(s)as
Y geed upon by the oqmer and pumper.
3' The P�per agrees t�Subm�t to the Govemmep[al Unit,Savryer Coun
servicing of the holding tank(5�ys requireA under SPS 383.55,Wisconsin A
Code and the Sa �3'>a report for the
agrees to include the follow�ng��e Sep�ige System Ortlinance. 'I'he t���Strative
p P further
a, The name and address of the person responsible for servicing�e lio�d�g t�
b• The name of the owner of the holding tank;
c. The site address of Uie holding tank;
d The date the holding tanl�was serviced;
f. The d sl osa]sites to h chtthe cont ntspfrom the om�holding tank for each servicing,
P
B�nk were delivere,d,
4• Th�s egreement will remain in effect until the owner or p�per teaninates this conuact. In
the event of a change io this contract,the owner agcees to file a copy of any changes to this
service contract or a copy of a new service conRact with Sawyer County within ten(10)
business days from the date of change to this service contract.
Owner's Name: (Print) Own r's Si a
e. niyoneav�fei"e�gnoturcrcqulred)
N��'b�rT I . {�oen, s.�r�c� ,` ,� ��l -�1-�
Pumper's Name:(Print � �
) Pumper's i re:
c �°i� � S
Pumper's Registration Nmnber:
� 181'j
Aev.03R6/l3
� i' ' �� i � IIII
, � IIII�I
I , �I ,II III
II i�lli I
`��oMI� :�0�3�4�
- USE BLACK WK ONLY - ?�: :�041UO2
POWTS MAINTENANCE AGREEMENT �41594
For Holding Tanks REGFSTER OF DEEns
�AWYER C�UISiTY, Vf/I
Owner's Name(s) as shown on deed: �9/28 f 2022 09'13 AM
t,� �- � —�, \ r � �-- � 4ECL}�t[3IIVG FEE 3D.Ofl
'Vc.��'��.0�- `` `.__� V-v:;��, -- �� � -.�.., �<:a .� �`!
Parcel Identification Number. --
(12 Digit Legacy ID) � � � _ � L� c� - � `1 - �5 � C) � �����' �
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.
Retum 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 hoiding 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 soii absorption system that compiies 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.
- nl o owner signature required - ACKNOWLEDGMENT
O n s �, � State of: �,.v SC on S. `�
County of: � ��j e r
wner's Name (Prript): � i
� Subscribed and sworn to(b�efore me on this � `�
<� r�t',� �� � l � �� �� ,`` �� rrrr ay of_�2 1'�f"� �:' , 20 rTc�`
Date: �,' ,� � ,�v �2 ,,�o�` ���p� I'���me): _ f�� �J'�-1- � . ��en , 4 �:�e lc�
� :`��otar� RPu,b'Gc Signature: �
Drafted by. _ ��:� P��i�'IVb�fary.Nar�e (Print . _jc. .� �-C�Z j � w j�.
"'� � �� ``�` � - ' l�y �m'm' sio � ires on:
. � �� ���� �� �
'= PUB�\ ' ?�=
Personal information you provide may be used for seconda ur oses Privac a� " " ' ' ' O r,
rY P P � ''��� E§ �:OVN����`` Rev. 03/26/13
','��u�unuu��"N
Tract I: Lot Two(2) of Certified Survey Map No.3183 in Volume 13,
Pages 174-175 as Document No.219378,a part of the Northwest Quarter of the
Southwest Quarter(NW'/e-SW'/,),Section Fourteen(14),Township Forty-two(42)North
Range Eight(8)West(in the Town of Lenroot),Sawyer County,WI. '
Tract II: Easementfor ingress and egress in favor of Tract I,over the 30'driveway as
shown on Certified Survey Map No.3183 in Volume 13,Pages 174-175 as Document
No.219378,a part of the Northwest Quarter of the Southwest Quarter(NWY.-SW'/.),
Section Fourteen(14�,Township Forly-two(A2)North,Range Eight(8)West(in the
Town of Lenroot),Sawyer County,WI. Over Lot 3 of said Certified 5urvey Map.
9/26/22, 938 AM Real Property Listing Page
R2dl EStatE? Sawyer County Property Listing Property5tatus: Current
Today's Date: 9/26/2022 Created On: 2/6/2007 7:55:28 AM
� Description Updated: 4/16/2021 '�' Ownership Updated: 4/16/2021
Tax ID: 16761 TINA M STEC IOWA CIT/ IA
PIN: 57-014-2-42-08-14-3 02-000-000080 NORBERT P KOENIGSFELD IOWA CITY IA
Legacy PIN: 014842143208
Map ID: .10.8 Billing Address: Mailing Address:
Municipality: (014) TOWN OF LENROOT TINA M STEC TINA M STEC
STR: 514 T42N ROSW 840 CYPRE55 CT 840 CYPRESS CT
Description: PRT NWSW LOT 2 CSM 13/174 #3183 IOWA CITY IA 52245 IOWA CITY IA 52245
Remrded Acres: 4.080 'a
Calculated Acres: 4.077 r Site Address ' indicates Private Road
lottery Claims: 0 13445N SEELEY HILLS LN * HAYWARD 54893
First Dollar. Yes
Zoning: (RR2) Residential/Recreational Two J property Assessment Updated: 9/26/2014
ESN: 400 2022 Assessment Detail
Code Acres Land Imp.
�� Tax Districts Updated: 2/6/2007 Gl-RESIDENTIAL 4.080 40,400 135,500
1 State of Wisconsin
57 Sawyer Counry 2-Year Comparison 2021 2022 Change
014 Town of Lenroot Land: 40,400 40,400 0.0%
572478 Hayward Community School District Improved: 135,500 135,500 0.0%
001700 Technical College Total: 175,900 175,900 0.0%
. Recorded Documenis Updated: 4/16/2021 [�
WARRANTY DEED �C4 Property History
Date Recorded: 10/5/2018 414743 N�q
QUIT CLAIM DEED
Date Recorded: 9/23/1992 231189
QUIT CLAIM DEED
Date Recorded: 9/23/1992 231188
WARRANTY DEED
Date Recorded: 8/9/1990 Z19713
CERTIFIED SURVEY MAP
Date Recorded: 7/19/1990 219378
hrips:/flassawyercountygov.org/system/(rames.asp?uname=Eric+Wellauer ���
D �� ��__1�__�J�
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offi�e ot AUG 2 3 2023 `�
Sawyer County Zoning and
Conservation Administration SAWYER C��.f�,!i�f
10610 Main Strcct, Suite 49
Z�NING AUMINISTFir';i�;";�
Hayward, WI 54843
Tel: (715)634-8288
Fax: (715)638-3277
URL:http://sawvercountv ov.org
EmaiL•zoning.sec(a�sawyercountygov.org �,
Toll Free:Courthouse/General Information ,
1-877-699-4110
Sawyer County Zoning and Sanitation "As - Built" Form
Property Owner's Name I :/th Ste L 7� 11�sf�i� �/'��e�,y s�Fe I�
Fire Number and Road Name �3 yy�N �l�y h'II s l�
Plumber's Name �Y�``'� Sc�y ��Z
Date of Installation �'L(-t�
County Sanitary Permit Number ��' � � �
12 Digit Parcel Number o�y� Sy Z- �4 3�t�g
Description and Elevation of Benchmark To� ?°�'�� );d
Tank Manufacturer and Capacity ��GS� Znd� R'�9
Setback-Tank to Nearest Lot Line ± laa'
Setback-Tank to Nearest Well j 2"�'
Setback-Tank to Building
�`
Cell Width
Cell Length ��
Number of Cells ��
Setback-Cell to Nearest Lot Line '�-
Setback-Cell to Nearest Well �
Setback-Cell to Building
✓
Setback-Cell to Navigable Water
Make and Model of Dispersal Unit "''
Make and Model of Filter '--
Make and Model of Pump
- Please complete other side -
"As-Built Plot Plan"
Elevation Data
Benchmark Z• �-S Please include the followin�:
Building Sewer W, �G
Tank In S,oS • Location of observation and vent pipes
' Tank Clut S , 2S • Feet of risers used on tank(s)
. Dose Tank In --. • Location of benchmark and North arrow
- Dose Tank Bottom l' • Location of all components
Header or Manifold �' • Length of pipe between components
Distribution Pipe � • Number of chamber units in each cell
System Elevation • Location of well, lot lines and road
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