HomeMy WebLinkAbout014-942-28-3114-SAN-2022-323 °' Department of Safety c°""ty � �
, � & Professional Services, �— �-w
g' - Sanitary Permit Num (to be tilled in by
� Industry Services Division
C� 3 �'� 3�� �
Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm Code,submission ofthis form to the appropriate governmental unrt �
is required prior to obtaining a sanitary permit. Note Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing �V
the Department of Safety and Professional Services.Personal information you provide may be used for secondary /, �
purposes in accordance with the Privacy Law,s. l�04(1)(m),Stats Z�,�,Z,� S�� _,,,� �^„/L L�
I.Application Information-Please Print All Information i�v u P�u�-�
Property Owner's Name Parcel!t
�o C� �. ��2c1� Q.� � C���{--��Z— Z�Y — 3�c �
Property Owner's Mailing Address PropeRy Location
�v' 2 �lt1E S'� ov. ot
City,State( (_ J^ Zip Code Phone Number Z�
�Cl S h.lUi,�✓T'� � �'�I S� 7C 2 ?J l� - 2��•- z�(�2, —��Y.,�'/.. Sechon
II.Type of Building(check all that apply) Lot# T Z N R ��
'�l or2 Family Dwelline-NumberofBedrooms � �� Subdivision Name
Block#
❑Public/Commercial-Describe Use
r' ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�
�Co�m of �/7'iC
III.Type of PO�VTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i
a licable.
A.
❑ New System �Replacement System ❑ Other Moditication to Existmg System(explain) ❑ Additional Pretreatment Unit(explain)
B' �-Ioldin�Tank ❑ In-Ground ❑ At-Grade
❑ Mound ❑ [ndividual Site Design ❑ Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner
ist Previous Permit Number and Date Issued
Expiradon �c-i q s C� � �i�
IV.DispersaUTreatment Area and Tank Information:
Design Flow(�pd) Desien Soil Application Rate(epd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Eleva[ion
�v l�0 '— — `
Capaciry in Total #of Manufacturer
::
Gallons Gallons Units � o 'a _
Tank Information � V �
tiew TanF:s Ecisting I'anks '` c �, ` v L � �
c
c. U v: y rn i.s. U c.
-Sa�s�er Holding Tank � ��,�., '��c e � po0 (�{J 3 -
Dosing Chamber
V.Responsibility Statement- [,the undersigned,assume responsibility o installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signatur MP/P.4R-F�5 Number Business Phone Number
��.Sb i'� L`i.l.t'T l G� "' ` (j1 Z.s 2� ��S- ��f S ' �.�5�
Plumber's Address(Street,City,State,Zip Code)
0 - ��'X ��e ��� ��' �Z(
VI.Cou tyNepartment Use Only
� 1 Permit Fee Date Issued Issuin�Agent Signature
App� ❑Disapproved F
� ❑Owner Given Reason for Denial $��� <( �� / �'�'`' �����-*a--
Conditions of Approval/Reasons for Disappro�af
� t��_____�_r�,� �� �_�....� � � n���F����1 5���-_
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Z i� 'n;
:�[tach to complete plans for the sys[em and submit to the County only on paper not less than S t/2 z 11 inches in size � �� ��
sB�-639s�R.o�izz� NO REFUNDS AFTER
ISSUE OF PERM!7
Sawyer County Zoning & Conservation Administration
'```"�1 t 10610 Main Street,Suite 49
. 1� Hayward,Wisconsin 54843
j�� '�`�„��� (715)634 8288
i �� ���`'�s,/ FAX(71 S)638 3277
% F'� �l 3' `�' � 1�11'\l l b\C_CCSlll�.�l)YVIb
� � � �_� � � � i E-mail z��nii ��c r.,a�uc���i�it ovo�,c
�� yf `� .� Toll Free Courthouse/General Informahon 1 877-699-4110
I �..
�1��,"``��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp (b / �3 1 / �-�
Parcel ID# C� ( �- `� Y �- 2�- 3���
II. Plot Plan
�Property Lines �Benchmark BM ♦
Site Address �North Arrow
Structure � �Scale
Well �25' to Service Road
Legal Description �Nearest Road Intersection
l�'Setbacks to: Property Line, Well, Structure, Water bodies, Roads
�' �
IIL Required Plans .
�Index Page with Original Signature
�Management Plan/Contingency Plan
��Servicing Contract
Holding Tank Agreement form
N. Holding Tank Specifications
Cross-section-Manufacture, Gallons: W i �B��l�I�
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) ,, , �.�-a��7�
o�.�
Owner: ��e.V1 Plumber: �
Application Review Date: 1� �� ��r�
POWTS Reviewer: ` �i�
Name
L���ns�#
��� � ��
� Revised 4/11/2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manua/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): ������e- �} 61 ev�ny Phone: ��9 - Zq(�- Z 3�z
Owner Address: 32� Q�he S-(-- (,Wps��Jurn�S/4 Zip: S�D7o 2
ProjectAddress: 12Co22�J �Gtv� R��(�Cc�(p }-�Ctycvav�c�,WL S'-l�(,[3
Govt.Lot: '� � � 1/4 of SW 1/4,Section 2-� ,T�Z N-R � E❑or W�
Township: `—�'�T�U� County: S0.c�.''y�-�
ProjectParcellD#: ���" �4Z"Zg�3tf�
Designer Information
DesignerName: �QSL�� �t,����I Phone:7�� -7y� - 33�5
DesignerAddress: �a � ��- �0� ����E, ��'-r Zip: 5"t/�z/
E-mail: �1 �m�c�r�Vy �A s• ��''
License Number: �75?S�
Remarks:
.��".�� .,.!._
Signature: r't� ' �``� Date: �° !8 2Z
Original signa ure required on each submined copy.
HOLDING TANK SITE PLAN
Project: GLENNY HOLDING TANK
N Legal Description: PT NE, SW, S 28, T 42 N, R 9 W
Subdivision Name: 12622N HARD ROCK CIRCLE
Scale: 1" =40 ft Parcel ID: 014-942-28-3114 Lot No.:
� Sh1 = (00` ' �'-CoP cF Well �-eV. ssY,'�' $O—iG5 �����o)
Dv+l v�n-.� � �vas�ny i0' xas' Cied �
ttua Ro�kCa•r� /
�P''°X. l.e� Cu.e
�---- — ---- --- 7�
--- --- .__ i �^ sh�d �
Ih 4^Pvr- ��'
la _ �i -��� � '
( 2 BR Naxe
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�fGOCSec� ���� '�� /
1 /'
19cc�l�oo �.T. �
IU�eU-��i� i�
Ef:,s{,'o,c� ?r�tt S��zl- �� .
= q5 . 95� �
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Page 3 of 6
. /
HOLDING TANK SPECIFICATIONS
2 Number of bedrooms
Non-residential estimated flow(gpd)
2000.0 Minimum holding tank volume required (gal)
Side A Side B Total
1100.0 1800.0 2900.0 Proposed tank capacity(gal)
WIESER Tank manufacturer
180011100 Tank model number
RHOMBUS Alarm manufacturer
101HW Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 24350 Ibs Weight of tank and cover
43.0 Liquid depth below inlet invert(in) 1.50 Safety factor
8.0 Maximum depth of soil cover (ft) 37663 Ibs Weight of anchor required
67.0 Height(in) Outside 34.7 in Soil cover req.for anchor or
184.0 Length (in) Dimensions 9.3 yd' Concrete counter weight
102.0 Width (in) Only
HOLDING TANK CROSS SECTION
Electrical complies with NEC 300 and SPS 316
optional vent pipe
ventpipe manholecoverwith � fnished
location � locking device and grade
junction warning label � —
box �
�4"min. 4"min.
�—23 in.
conduit —j
18"min.
thether -
/weight Note: All tank joints, and joints -
T IG between tank openings and building sewer
/ service i in are sealed waterti ht. All iniec
blind plug alarm on P P g 9
co seai pipe and vent materials comply
ounec with SPS 384. Manholes with
90% Full 31.7 in locking device are typical for each
manhole opening .
S�ae r+ 1100.0 gal s�dc B 1800.0 gal
3 in.bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project: GLENNY HOLDING TANK
Transaction Number: Page 2 of 6
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to SP 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-�0855-P
N. 03/07), and the SAWYER County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow of 40 to 580.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 30 days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with SPS 383.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons may be contacted:
a. Installer.............................ANDRY RASMUSSEN & SONS Phone: 715-798-3355
_- - - ---
b. Service Provider.................. NORTHWEST SANITARY Phone: 715-634-2394
-- — —_ -- -- - --
a Co. Zoning or Health Dept. SAWYER COUNTY ZONING _ Phone: 715-634-8288 _
11.
Project: GLENNY HOLDING TANK
Transaction Number: Page 4 of 6
HOLDING ��ANK SERVICINC COV'1'RAC'�
Contract Datc: �o /�/
This contract is made between the Holding Tank Owner and the Pumper.
Holding T�mk Uwncr's Naimc: Pumper's Namc:
.--�—O�LQ �' /I��� Northwest Sanitary. Inc.
C7
PO BOX 155
Radisson,W154867
Parcel IdentiTication Number:
( 12 Digit Lcgacy ID) O��- � � � - 2 � _ 3 ���
I. 'T'hc owncr agrccs to �Ic a copy of this conhact wilh thc govcrnmcntal uniL Sa�rycr('ounty�.
which has acccptcd aud recordcd with lhc Office uf thc Rrgititcr ul Dccds,thc Main�cnancc
Agrccmcnt for a Holding Tank rcquired undcr ihc Sawycr Cuunty Pnvalc Scwagc Systcm
Ordinancc for thc issuancc of a Sanitary Pcrmi� for Ihc inslallation of a holding iank(s).
2. Thc o�+mcr agrccs to havc thc holding tank(ti) scrviccd by thc pumper and guaran�ccs to
pcnnit thc pumper to ha��c acccss and to cntcr upon thc properry for thc purposc of scrvicing
thc holding tank(s). Thc owncr a��ccs to maintain thc all-wcathcr acccss road or drivc so
that thc pumper can scrvicc thc holding tank(v) wiih thc pumping cquipment. Thc owncr
furthcr sgrecs to pay thc pumper for a chargcs incurrcd in scrvicin¢thc holding tank�s) as
mutu�illy agrccd upon by thc uwncr and pumper.
3. Thc pumper a�Tccs �o sabmit to thc Govcmmcmal Unil, Sawycr Cotmty, � rcport for ihc
servicing of the holding tank(s)as required under SPS 383.55, W'isconsin Administrative
Codc and thc Sawycr Counry Privatc Scw�igc Systcm Ordinancc. Thc pumper fwthcr
a�rccs to includc thc following in thc rcport:
a. "I'hc namc and address of thc person responsiblc for scrvicing Ihc holding�ank;
b. Thc namc of thc owncr of thc holding tank;
c. "Thc sitc addrcss of thc holding tank;
J. I hc dutc thc holding tanl:wns scrviccd:
c. "Thc ��olumcs in gallons ofthc conicnts pumpcd from ihc holding Iank for cach scr��icing:
C "I'hc disposal sitcs to which thc contcnts Gom thc holding tank wcrc dclivercd.
4. This agreement will remain in effect until die ou�ner or pumper terminates this contract. In
the event of a change in this contnct,the owner agrees to file a copy of any chan�es to this
service contract or a copy of'a neu�service contract widi Sauyer County within ten ( 10)
business days from the date of change [o [his sery ice conVact.
Owner's Name: (Prinl) OWfICf�3 SIb118lUfl': �Unlc nne aw ner siRnamre required�
�l �
�oYce F} . Glenn �,'����c�, �`7�'�z�aZ
Pwnper'ti Name: (Print) Pumper's Signature:
Ronald L Vieceli, owner Northwest Sanitary,lnc �' ' />_/ /
�7"v"�'�!� v L�o �
Pumper's Rcgistr�liun Numbcr:
#2389
Rc�-.(1,3,2(i/13
Page 1 of 1
Real Estate Sawyer County Properry Listing Property Status:C
Today's Date: 10/18/2022 Created On: 2/6/2007 7:5`
� Description Updated: 11/29/2010 � Ownership Updated: 2/]
Tax ID: 18452 JOYCE A GLENNY WASHB
PIN: 57-014-2-42-09-28-3 01-000-000140 DIANA R BERRY
Legacy PIN: 014942283114 WILLIAM C GLENNY
Map ID: .9.14 DEBRA K HOPPE
Municipality: (014)TOWN OF LENROOT LEO 7 GLENNY
STR: 528 T42N R09W WALTER H GLENNY
Description: PRT NESW
Recorded Acres: 0.570 Billing Address: Mailin4 Address:
Lottery Claims: 0 JOYCE A GLENNY JOYCE A GLENNY
First Dollar: Yes 323 PINE ST 323 PINE ST
WASHBURN IA 50706-1032 WASHBURN IA 50706-103:
Waterbody: Nelson Lake
Zoning: (RRl) Residential/Recreational One
ESN: 400 � Site Address * indicates Private Road
12622N HARD ROCK CIR HAYWARC
� Tax Districts Updated: 2/6/2007
1 State of Wisconsin
� Property Assessment Updated: 9/�
57 Sawyer County Z022 Assessment Detail
014 Town of Lenroot Code Acres Land
572478 Hayward Community School District G1-RESIDENTIAL 0.570 150,000
001700 Technical College
2-Year Comparison 2021 2022 C
. Recorded Documents Updated: 2/10/2022 Land: 150,000 150,000
� QUIT CLAIM DEED Improved: 59,400 59,400
Date Recorded: 2/3/2022 437438 Total: 209,400 209,400
� TERMINATION OF DECEDENTS INTEREST
Date Recorded: 11/9/2005 334847 �.Property History
� QUIT CLAIM DEED N/A
Date Recorded: 8/17/1971 137858
https://tas.sawyercountygov.org/Access/REAL%20ESTATE/listing.asp?tid=852404&pid... 10/18/2022
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- USE BLACK INK ONLY -
TYi.�tI,JY i uU�
POWTS MAINTENANCE AGREEMENT 442075
For Holding Tanks PAULA CNISSER
REGISTER OF DEEDS
Owner's Name(s as shown on deed: SAWYER COUNTY, WI
cJc�yce IA • 6=�enn� w�ll�ai.�m ��G--��n.y Lee J. Gle,,n� ii/oi/2ozz io:o� aM
D R. Pevrr D���- u� � � WAL�'�: L��n RECORQING FEE 3Q.00
Parcel Identification Numbe : Ir �y �r
(12 Digit Legacy ID) �� `�-=l `y' Z - Z 8-3� ( ��- PQ�iE�� �
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.
Return 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 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 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.
-Only one owner signature required- � ACKNOWLEDGMENT
O er's Signatu e: � Y State of: __�����g-
'� � '� � � ���'� County of: 4 �
n r's Name (Print): Subscribed and sworn o before me on this
�d ce fR, �r�eny� � day of � 1'°fi , 20 Z.Z
Date: By(Owner's Name): �/��s�Y
��G' '" �- ^✓'�. Notary Public Signature:
Drafted by: Public Notary Name (Print): S��
�.e.� �aJC�'It��n My commission expires on: Z
�^"` . LUKELESYSHEN
Personal information you provide may be used for secondary purposes[Privacy Law,§15.04(I)(m)] � COMMI N 16
4 f � .ro � �
'o�"
That part of the Northeast Quarter of the Southwest Quarter(NE1/4 SW%),Section Twenty-Eight(28),
Township Forty Two(42)North,Range Nine(9)West,more particularly described as follows:
Commencing at a stake on the north line of said forty,which is 566 feet East of the Northwest corner
thereof;thence running South,parallel with the West line of said forty a distance of 1000 feet to a stake,
and the point of beginning;thence running South,along easterly edge of town roadway a distance of
100 feet;thence running East,parallel with the North line of said forty to the water's edge of Nelson
Lake;thence running North,along the shore of said lake,a distance of 122 feet,more or less,to a stake
located 1000 feet south of the north line of said forty;thence running West,parailel with the North line
of said forty,to the point of beginning. Said tract of land is bordered on the west by the town road,on
the east by Nelson Lake,and is 100 feet in width north and south.Sub;ect to town road 2 rods in width
extending along the West line thereof,and to easement for electric and telephone lies to follow the
course of said road,and subject to any easements and reservations of record.
� � ����
D
�A�J 2 5 2023
:_�_ �
������'=R Ct�l1h,�s�r'
� S � i
HOLDING TANK SlTE PLAN
Project: GLENNY HOLDING TANK
N Legal Description: PT NE, SW, S 28, T 42 N, R 9 W
Subdivision Name: 12622N HARD ROCK CIRCLE
Scale: 1" =40 ft Parcei ID: 014-942-28-3114 Lot No.:
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