HomeMy WebLinkAbout032-540-21-5104-SAN-2022-315 � ' "' Industry Services Division County C�w�� � (n
- 4822 Madison Yards Way `� �
�_ : Madison,WI 53705 Sanitary Permit Number(to be filled in by �
�= P.O.Box 7162
__ Madison,WI 53707-7162 �y �� �9 � �
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to ihe appropriate governmental unit �
is required prior to obtaining a sanihary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing �•��
the Deparhnent of Safety and Professional Services.Personal infortnation you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(I xm),Stats. q?� C� at��iv /•••_ ,/)Qr
I.Application Information—Please Print All Ioformation
l!J d c.�..�� r—��
Property Owner's Name Parcel#
Tho mi5 # Ra b;� Crern�u�' 0 3 Z - Syo- Z. /— S'/o 5/
Property Owner's Mailing Address Pro�r�Location
y�o5' F'i n� G.v,o v� !7 r t v� �o�t� I
City,State 7.ip Code Phone Number
N.�t '/., S L•r �/4, Section�
�►��N�-lan�.��- �,,rt Syso i ��s -Y � r 3
II.Type of Building(c�eck all that apply) � ►.ot# � T �� N R s E
�'1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name �
Block#
❑Public/Commercial-Describe Use
'—" ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
28(��b, �7�6q To,�of G✓��-�.��
111.Type of POW"I'S Permit:(Check either"New"or"Replpcement"and other applicable on liee A, Check one box on line B.Complete line C if
a licable.)
A �New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' �Holding Tank ❑ In-Ground ❑ At-Grade g ype( p )
❑ Mound ❑ Individual Site Desi n ❑ Other T ex lain
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration �-
IV.DispersaUTreatmeot Area and Tank Ieformatioe:
f�sign Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Requ'ved(s� Dispersal Area Proposed(s� System Elevation
2on ,� — �
Capacity in Total #of Manufacturer
I'ank Information Gallons Gallons Units p � o � �
New Tanks Existing Tanks v c � � Y � � �
r� v° rn � v� i�» C7 a.
Septic or Holding Tank ����� Z�r ' � _L PC��+ �4-�G x
N'rT ...L_
Dosing Chamber
V.Responsibility Statement- 1,the andersigned,assome responsibility for installation of the POWTS wn on the attached plans.
Plumber's Name(Print) Plumber's Signature MP PRS Number Business Phone Number
M,t�. �v1 or► o,u�• `�c.�cc T/Y� a.�s► l� 5 �tis- �GC�- �o�o
Plumber's Address(Street,City, tate,7.ip Code) ��8��
�3�0 1�1 � ��Gt. (n/t►�t''}'�¢.ri �o�►�Y, w :►.��'e� l�t��
VL Coun /Department Use Only
� o Perutit Fee Date Issued Issuing Agent Signature
App ov ❑Disapproved
�c�p�,b� I � 13� � �� �y�.G�.�-e-Q��u.�
��=v ❑Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval " '�`"
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C T ��� � yy1 SAWYER C�?Utv i Y
ZOfVING ADMINiSTRAI'iGP•�
Attach to complete plans for the system and submit to the Couoty only on paper not less than 8 tn a 11 inches in size 2���(�
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Sawyer County Zoning & Conservation Administration
�������� 10610 Main Street,Suite 49
��,� .�;z ��� Hayward,Wisconsin 54843
�� � � (715)634 8288
i ;�'�t����\".��j FAX(715)638 3277
� 7i � �� l�.'� „�_�n� , ti�<:auiv}-�n__�i�,
/� � ''' � � j i E mail ?on3,i,,s�c,cl�siu��jc,�ant��o�.nr��
� `�' � Toll Free Courthouse/General Informat�on 1-877-699-4110
� �r ��
/'��1\�i���
Holding Tank Approval Checklist
L Sanitary Cover Sheet Date Stamp I d / a 1 / ��
Parcel ID# 0 3 2- �Y 0- � I _S I o Y
II. Plot Plan
�Property Lines �Benchmark BM ♦
�C Site Address �North Arrow
�Structure �Scale
�Well �25' to Service Road
�,egal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
IIL Required Plans ,
!�' Index Page with Original Signature
X Management Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement form
IV. Holding Tank Specifications
D� Cross-section—Manufacture, Gallons:��'� �,,,�, ��c4�
�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),.,
2•\
Owner: _��S-,,,,�— Plumber: (N�o„�
Application Review Date: � r��o2����
POWTS Reviewer: ��,,` �+/
Name
G� ���
L;���s�#
Revised 4/11/2013
PAGE 1 OF 4
Hoiding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version$�,SBD-10855-P(N.03/07;R 01/12) ..
��,
Pg 1 of 4 Index&Cover Sheet
Pg 2 of 4 Piot 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 appticable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
Owner Name(s): �or+,a s � Rob:.0 Ga�n�ed Phone:`7�5 - y90_ f z y3
OwnerAddress: Y/o� ►�;N� G�o�� anve R4,;�Ie.landn�Zip: Syso i
Project Address: 831 S N �4rl�e� �-M�- R�� w;� w�L. ry�IG
Govt.Lot: ,l,� 1/4 of 5'� 1l4,Section a 1 ,T`�� N-R s E Q or W 0
Township: W�'^��'' County: Sa U'��
Project Parcel ID#: D 3 Z -Syo-Z�-S/0y
Designer Information
Designer Name: m��. w�e��-,oua�y Phone:l�S -dGla - 3of�o
DesignerAddress: `I3yoN L,alce wrKfe.— �-•9. W:wk..r �.JTZip: Sy�fYv
E-n7a1�: �Lhis spocc re5ecved tor apptovul;tatnp.
License Number: MP 2-�5 I (� 9
Remarks:
Signature: ��iiv Z ����� Date: l��,3-Z Z
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.0 R above
Junction and A���� Es�ablished Flood Elevation
Alartn Box Vent Cap (tyPical)
Eledrical must comply witti � Appmved Locking Manhole
SPS 316 and NEC 300 4"0 Vent Pipe with Waming Label Attached
f—Conduit >10 ft Trom (typical) 4"Min.or 2.0 ft above
Building I Established Flood Elevation
� (tYPical)
Airaght Seal �
e Finished Grade
18"Min.
(ba��)
♦
e �
Inlet Inletlnvert fWatertight
Approved Joinfs wi�h P��9
Approved Pipe 3 ft onto � Max. 12"or 90%of total volume
Solid Gmund � if moie than one tank
e
Alarm-On
<
e
HOLDING TANK
VOLUME = o 0 o gal .
a ' a . . . . . . .. . .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: �U��Cu'f � Z�'`�G
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibslcu.ft)- Ibs.tank.wt]x 1.5
Ballast Weight= [( �e�3 cu.ft. x 62.4 Ibs/cu.ft) - Z ��d Ibs] x 1.5 = a 7 3 P2 Ibs
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HOLDING TANK SERVICING CONTRACT
�Con[rac[Datc: /O 1�/ ?L �
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owncr's Namc: Pumper's Namc:
T�Jo/YJ4,5'¢ n06;N G Northwest Sanitary,Inc.
�r/HQY PO BOX 155
Radisson,WI 54867
Parcel Identification Number:
�i z���,�t Le�a�y i�> 0 3 2 - S y a - 2 i- S / o y
1. Thc owncr agrccs to filc a copy of this contrac[with thc govcrnmcntal unit,Sawycr County,
which has acccptcd and recordcd with thc Officc of thc Rcgistcr of Dccds,thc Maintcnancc
Agrccmcn[for a Holding Tank rcquircd imdcr thc Sawycr County Priva[c Scwagc Sys[cm
Ordinancc for Ihc issuancc of a Sani[ary Pcrmit for Ihc installa[ion of a holding[ank(s).
2. Thc owncr a�ccs to havc thc holding tank(s)scrviccd by thc pumper aod guaranrecs[o
permit thc pumper to havc acccss aud to cntcr upon thc property for thc purposc of scrvicing
thc holding tank(s). Thc owncr agrccs to maintain thc all-wcathcr xccss road or drivc so
that thc pumper can sen ice thc holding tank(s)with the pumping equipment. The owner
furthcr a�rccs ro pay thc pumper for a chargcs incuiTcd in scrvicing Ihc holding tank(s)as
mutually aSReed upon by the owner and pumper.
3. Thc pumper agrccs[o submit to[hc Govcrnmcntal Unit,$awycr County,a rcport for Ihc
scn icing of thc holding tank(s)as rcq�ircd undcr SPS 3R3S$,W�sconsin Administrativc
Codc and thc Sa�rycr County Privatc Scwagc Sys[cm Ordinancc. Thc pumper fur[hcr
agrecs to include the following in the report:
a. Thc namc and address of thc person responsiblc for scrvicing thc holding tank;
b. The name of the owner of thc holding tank;
c. Thc sitc address of thc holding tank;
d. Thc datc thc holding tank was serviced;
e. Thc volumes in gallons of the contents pumped from the holding tank for each scrvicing;
f. Thc disposal sitcs to which thc contcnts from thc holding tank wcrc dcli�crcd.
4. This agrccmcn[will rcmain in cffcct until Ihc owncr or pumper rerminatcs this con[ract. In
the event of a change in this contrac[,the owner agrees to filc a copy of any changes to this
scn icc contract or a copy of a ncw scrvicc contract with Sa�trycr County wi[hin tco(10)
busincss days from thc datc of changc to this scrvicc contract.
Owner's Name:(Print) Owner's Signature:�uoy�o���»���.�¢o.m��•���y���ea�
�h��,��.y C����,�f - � ,�...ctiq
Pumper's Namc:(Print) Pumper's Signaturc:
Ronald L Vieceli,owner Northwest Sanitary,lnc �r /
L
Pumper's Rcgistration Nwnbcr:
#2389
Rev.Oi2G/13
10/25/22, 8:51 AM Real Property Listing Page
R2dl EState Sawyer County Property Listing Property Status: Current
Today's Date: 10/25/2022 Created On: 2/6/2007 7:56:00 AM
�Description Updated: 4/9/2020 � Ownership Updated: 7/20/2020
7ax ID: �� ��� 36038 � THOMAS M&ROBIN A GERMER IRREV RHINELANDER WI
PIN: 57-032-2-40-OS-21-5 OS-001-000040 TRUST
Legacy PIN: 032540215104
Map ID: :1.4 Biliing Address: Mailing Address:
Municipality: (032)TOWN OF WINTER THOMAS M &ROBIN A THOMAS M&ROBIN A
STR: 521 T40N ROSW GERMER IRREV TRUST GERMER IRREV TRUST
4104 PINE GROVE DR 4104 PINE GROVE DR
Description: PRT GOVT LOT 1 LOT 3 CSM 28/216 RHINELANDER WI 54501 RHINELANDER WI 54501
#7269 MFL CLOSED 13.577 AC Ol/2013
Remrded Atres: 14.640 m
Calculated Acres: 14.697 r Site Address * indicates Private Road
Lottery Claims: 0 6318N BARKER LAKE RD �WINTER 54896
First Dollar: Yes
Waterbody: East Fork Chippewa River J property Assessment Updated: 6/21/2018
Zoning: (RRS) Residential/Recreational One 2022 Assessment Detail
ESN: 421 Code Acres Land Imp.
G1-RESIDENTIAL 1.063 3,700 2,800
�� Tax DistricTs Updated: 2/6/2007 W6-MFL CLOSED -AFTER 13.577 134,900 0
1 � � State of Wisconsin Z004
57 SawyerCounty
032 Town of Winter Z'year Comparison 2021 2022 Change
576615 Winter School District Land: 138,600 136,600 0.0%
001700 Technical College Improved: 2,800 2,800 0.0%
Total: 141,400 141,400 0.0%
• Recorded Documentr Updated: 12/9/2020
QUIT CLAIM DEED �
Date Recorded: 6/11/2020 424306 � Property History
MFL TRANSFER ORDER N�A
Date Recorded: 11/13/2020 428008
QUIT CLAIM DEED
Date Re�orded: 9/16/2018 414424
MANAGED FOREST LAW-MFL
Date Recorded: ll/26/2012 382026
TERMINATION OFDECEDENTSINTEREST
Date Recorded: 8/23/2006 341087
CERTIFIED SURVEY MAP
Date Remrded: 7/13/2006 340193
QUIT CLAIM DEED
Date Recorded: 9/20/2004 325167
https:Ntassawyercountygov.orglsystem/frames.asp?uname=Eric+W ellauer ��1
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�I POWTS MAtNTEWANCE AGRE�MENT --1 ����1d :3�64640
' For Holding Tanks i x :4041528
� owners Name(S) as shovm on deed: -__ � 4419 8 0
PAULA CHISSER
� ; ��CISTER OF DEEDS
SAWYER COUNTY, WI
� �- �� j� �. . �', e�,�C � � 10/25/202209:OOAM
Pa"��onNurr�ber_ ` RECflRDING FEE 3Q.D0
1 (12 Oig�t�a��p) s.L��'y�,_,1 C� -f.� -���� �
PAGES: 2
�ega� Descrip6o� oi Prop�y.
-SEE FiT'i�CH�D SHEEi' -
We����'PP�n is�made for the insta�ion of a hoFda�g tank(s}on tt�e
P�P�Y d�a�U�e a�adied st�eet
Retum To:Sawyer Coarny Zo�i�g p�i��� PO BOX 676, Hayward,W154843 '
As an inducemerrt to the County of Sawye�to issue a sanitary permlt for a
r'esponsbte fa the operation� ��n�a� �{� � • � ��°��a�13°�desc�ibed property, the owner is
anpficabie �►9 k, loddng device, atarm and access. and agrees to cor�form#a all
r�ecNirements of Ch. Comm 83.VYs. Adrr� Code relating to holding taNc marr�emerrt, induding the foUowing:
1. The oWmer agrees to conbad with a person who is � under Ch NR 113, Wis. Adm. Code. except as Provided by
Sedion 281.48 (3) (dj. Sta#s.. ta have the hoW'mg tank properiy serviced arid to i�e a oopy af the servic�e contract w�h the
9ovemrnerrt-a! unit The awner further ag�ees to fite a copy of anY dsang�to the service
�onfrac�, with the govemmentai unit within te� (70) bu.siness days from the date of °On�' or a copy of a new service
change to the service contrac�
2- The owner agrees to oontracx with a person fic�sed under Ch. NR 113.Wis.Adm. Code, who st�aU submit pumP�9 �rts to
- �9�emmental un�in acoordanoe with Ch. Comm 83.55, Wrs. Adm. Code.far the servicang af fhe holding tank. In the case
of exemPtio� under Sec� 281.48 {3} (c�. Sfiais.. the owner shall subrru'E�te �port to the govemmerrta! unit. The
� �n9 �c���on the property to€nvestigate the condifion of tlie t�ng taNc rnrhen �g � may
�9 P�P�Y maintained.
3. if the ovmer faits to have fhe holdn tank �
ar abate a human heaftfi harard as desc�bedro i�Sedion. 254.59. Stafs. the� � ��9°�mmental unit to prevent
autd servioe. or cause the fiank to be serviced. Pursuant to Se�ion 145� 9���ernal unit rr�ay enter upon tl�e pr�p�m,
� owner of a ptivate sewage SYstem for oas�ts reiated to the � of a�4�Vlfis. Stats.. a govemmental unii may assess the �
as pnescn'bed by Secfion 66A703, stats. The rnnrner �P�l9 s�P��1�W'mg tank. The charges wi�l be assessed
�S agrees to pay aa charges and oost incurred bY the 9ovemmerrtal unit for
P�n, PumP�. �. w oth�:rwise serviang and ma'artaming the hotd'mg tank in suct� a manner as to prevent or abate
any human health hazard caused by the holdng tank.
4. This agreemerrt wiU �emau� � ef�e� only until the govemmental unit responsibie for the reg�dation of prrvate sewage systems
cer6fie.s that eifher a sotl absorption system ttrat complies wifh Ch. Comm 83,Vvs. Adm. Code, or a municipal sewer serves
the property. In addtion. tttis agreement may be cancetfed bY exeafing and recording said c�:rtification with r�eference to this
a9reemer�t in such manner which Hn�l permit the e�astence of the c�er6ficatirxa to be determined by reference to the property,
5- 1'his agreement shall be bindng upon the owne�, the heirs of the ovmer, and assignees of the ownec The owne�shalt submit
the agreement#o the register of deeds, and the agreement shal! be recorded by the register of deeds in a manne�which wi11
permit the e�astence of the agrEement to be determined by reference to the property where the h�ding tank is insfatled.
� � � . � � . , �
�� -Qn� one owner ' �uired� .� p � '•,� ` qGKNOWLEDGEAAENT
� ,L�(. � ' O`�c? . '' State of: � � � S �
. d - , �
Owner's Name: � �.. "�aunty of: Ll�
. � � .
' z � � Subsaibed and s
z �rv+� c y^: � p ' � �7 m � �� me on this
Date: , •'�;�..[_day of 20��--�
. •.. . • a .
•, �,• • ... •:� ; bY , L r � r'_
Drafted b • f � ' • � . . . � . . • `� Notary Pubfic Signature: / ,
' , , , / �� Notary Public Name_ L �'�
My commission expires on: _ oU ��,�"
`—,
Personai iRfortite5on you P��Y� used for seao�tdary Purposes[p�yacY Law. § 7 5.04{� (m)I
Lot 3 of Sa�ivyer County Certified Survey Map No,7269;Document fVo.340193,recorded in Volun�e 28
Certffied Surveys,page 216,hefng part of Government I.ot One(1J,Section Twenty-one{21),Township
Forty(40)North,Range F�(ve(5)West,5awyer County,Wisconsin.
Stamp added
to
rapturo imaqe
�ilqp��
�
�un bnape
O&ced �{�1���'1?iltf'��
Sawyer Connty Zoning Administration 'I, 'J"4.�:'-_';='-_�::.
��� ���
Hayward,WI54843 �"� .1UL 0 7 2023' —!
rd rns�6�a-�a �---_____..__J
Fmc(71�638-3277 SAWYER r�;,'. :;
. �,:�py�����y� ZONING ADMiNiSTNAi,ION
Fmn7:moiu�9�wvaaountvmnv.o�e
. Tdt Fiac Caa¢�aaad'C�maat FoE�on
1,8TJS99-4110
Sawyer Co�ty Zoning and Sanitation"As-Bailt"Rorm
rmpe�iyoWra•sr�me �oNrt �Qvb,:d �v���
��x��ax�ar� 83rS f3�� L� �.
PL�rr's Name �1'1;�Gc. !m.n�t a/VtC-l��
nau�7nsmuetion /i—�2g-.23
�y��N,� zZ_ 3rS
�n;ac�a rr� ���? -54� - 2/-S/0�
n�;��an�aono�s� `�O iLler,�'e �•Y9
TankM,��r�r�+T.�a�dCapaaty f+(JtTCr�� d000
` s�-Taoxmrr�i.oc� �' 75 `
s�-T�rort�c w�n �5 '
s�-T�w s�a�o8 1 Z '
ceu wiarn
�� ----
x�arc�
s�-ceuwxe�ta�
s�-ceu�x�weu
s�-aum�
sa�aa�-cai w xac�i�b�w�er
��a��n;�,�unu
�����
r,ra��na�o�r�
-Pla�se complete other side-
1
� - �
, "As-Built Plot Plan" �
. Elevation Data _
Be�hmark `f P �h �lz /_ '� � Please include 1� followin�: �
Building S�wer �->':��
- Tank In _ �' - Location of obsezvation and vem pip�s
Tank Out �_� •3 • Feet of risers used on tank(s)
� �ose Tank In � • Loc�tion of be�chmark a�North sirow
Dose Tank Bottom - Location of all comgonents
Header or Manifold • Le�ngth of pipe belweexi componen#s
Distribution Pipe • Number of chamber units in each cell
System�levation • Loc�tion of well, tot line,s and raad .
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