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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 " '�`" , " ---�;r�-r—.._. 1�_... J �k��j� 1 � � � � � c�a-c�-- � '_ '__ �}' i ��� . . , � �1 a�—� .......-_�_..,-..__... . f��� k ����; �� - _. OCT 2 1 2Q22 , ._ S . Ne�n/ war t d �S4 8�� �.---- 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���(� J i � 1 � � i � � �: � ; 0 ; � �, � ° � � � � � � � � � � - w � _ � 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 ,,.:..,�,���.�,�.ro ��a��,.�..�m.»M�..�.. Pt a� # ,�.�-�� s�%y S� > (73�?-SS'b - 2 > • S/D y Le,ql D�S�. � S�d iv.e Sw ScalL 1 '�= y0 � PLOT PLAN PAGE a OF � �� OW Al C r 5 ° Yo � ^I-homas E RebrN �j.!✓M�Cr Yio4 p:.✓e G�w,c AR . Rh;n.aG�.Lv t✓t S4soi ._ ---� ,P.�ol�tr �.A�ll..t R.O�. -- — � �83r8N � �L P� I_ � I 3 5 a�''''S � I �°°�,,ls � r � �oo���"` p�y,o '�pw<.►�to�� � � , �� �- a ,�� p . ti,,e�� �ro�oSr '.l B(l F�w 4�`�� � I p� � Cnsk�of iL Gl�+;P�. 2� ,,.e.v �M = 1Q0 . G' lun.bc ,^ A Y�'Ltke. �oK�oMa�y � .�oP �� cAp rtP. �'azsl b9 aF f4 f� A S�5 Sa�-tc4 .� 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 ' � �j � � • . �: ., � - - " � I I. f ii� � ' ? i' 7 . i .�i di .,,{ , � 1 ' _:l f �'.i:!_ ..t _ t�_ � ��1-",� ` =_� �t1:= ti � ;Y ' � - r � : .:i�e - 't fl•- :�.:' ._ e' 'tr1=' : u . ` .� i�.:. �`� 1." � 1�� 1 . :l �` }' " . - 't , . : ..�. . , _ ` _ ':K /�� • .t.t.F: �t's._ :s •i.: .• r_i ::� _ � .. . . . i. .r �-_, � _ �r ::.1 . . 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'.if�il�ft .t `. {:}y ' •� ' �:F1 tC- r•:� :�iY " .�i� - ;�f .• N� �f�;;�' � " : ithS C� �5 :tl e-1 [I{I._'A .'.S Iti � ❑:�L i:[�h '_� � _ t �"{::f�.� f '_ = t C f�.f� .� - - - 1[i • : i,e-If- c-• ���_ #� , � �,^� .� �� � �' ':.( t�_ �- 1 � _ _ �:._ " ' _ . tii L.� n_�:e _ -= i e� f Ss � =_t]rt�s� ' _ `f _ � _ 1.•.�:._. �'t"i� ' � i ._ ' ...l."'_ . • T •. 1 _ - �_.( - 11 ii! � � �: :.i I�: t �rI ti � ._ �c _. . {"-�3� ia . i, l:fY_ . .:.l�f�i ... G'..� _ _t r , . .. , - •:It-fi� tt. •�. � - - - �:rt��:.:}f i �It •t,i � : - :ii!�.: :il - ' '.�. � � la_ - 1� �:7�:=.�. .:1. - ' N>_.:�1! •,( [s _ .t ? .: :.; - . �� .--� �` �t. .�'+- � . # - ,�, - i• ,.�n .�., _.� � � c<�:: ' ♦s 1 I s, .y t . . . - ;�, _ i� ' • a-.s . Y� . . - - i;. ! : � - - � _ . r . >�:.: -�� � t' t 1(` • ' . • : �:r! . " tC.; n 1 i� � :- 1 C+' � _ '-f::: =:a 3a�'r_.r'-• •' - .e'�: �.C Y tt f :; v• ' ♦i,ua. � c:r��l s�. �r.:�.�at � - ~` �I -;c.a �� � r •'� �`. -.e.l ;:( , � •.�, f= "U 'h. t i��: '` [-r`ft?i • . i:. _:� ♦r, i:' . ii �' 1:4' '1a'. '.�:H'�# �'PI'- �i f: � •. ;� �e r '_ f [:r'; s: r .;..rc, _���� .t f' i�. '�. • *�' 1•=i- s-' - -p[-♦ t il�� _i:'�I �' �• . � i - i[: � o"�.ci ...: � _ bN, s�" �P' r.it v•: � uli-i� ♦s-.s:= • t: 's��.��i�� .���� ). : �c [ _: �. ! "-� " " c.a ♦r.� :� • '" r •; ' � t • .•. • "�a ..t t r:' �; �. c _ �.:.,. __� - �_.7 r[ :._�.-- - - _,e� -.�� f ;.i 1,�= -' I�' �it .:� '♦ Ei'_ .�s . rr :V':,w :• .• _:s�e •�'�r � ^`T('�.t�. � i.-� .��•�(!-4F..'�. 1 _ ' �t r_i . ( ' _ •�.��rs' '.1.. o.• r�_ : r; .•�I� _� :'��•- ��]' �'. �.it �'' ':1. '�G � I"� � �' FI l:� 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 'yi ?� �.,�..:r. ���{ {l' �( �„ � �� � f +l: � �f'�' ::K `� 1 '� r r�' r..: aF : �! �y]�t � '� . v' � � 9 et�t�. , � A,�" � g ..�x+ � �^�l .. 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' '�� '�`�ti.� , �'S yy". r� � �..'. � 't �a . � 'k ,K�.{� e��F r V1 ('pn'r �`�,�ry��� .� g,lY p;�i t� il ` � 9' . y 6 F`�,f/ ' d .' z'Y� 2 L�} � �. .+ .a 'c� `�'}r' _ .r's� :�f�����`^ ; . y. $�, i �y �y��� a� .' 1 Y' a.� � .' c '� t^',�{4re .ti � v . l, .r @� .. �� s .��.�`.=.- F�vr�,v"t�. $ � � �M a � � t ��v .' - "��' !_'� �.:!7� a�i,�-� - � �s "._ +. ' ,..�i4�`� '� . . � :�'a ` `w.� _ -• �`, � r�`�...� ,�"�. , ` �'�.. � �, �P' ? 4 . -,r r ": o—.,t } 5' tr i � �"°'t y� . �' ..iil ! - . w�� l� . ����.� R� Eti��. xb��..� u ` � . � �a���v<3,a '� � � r�� ���a�4 \..-�, '" �_ ��f��, �t .� ��+� 6. �� � � � � �• klin S:'J�i- y r � � t � �-� :�, r «��, r6�6 � ^-�r $ ` i� <`f`: .. �. , , , � • �g .. , .._ : ., _ � � - U5E 8�v� F�i� ;�3idL�f _ I� I II IIII �I I) ( I II I)II 1 II) �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 . . �c,�.l�e,.� Z�L /1cY . . � . �� ���t� � � . , I � �v ` �� �� � �1p� � , 0�� � v, � - a �z� � B � ��i� - � c�'` s ; ..-- � `�� � � . � � _- , . �� - � r � � -o� $•e�3 � .