HomeMy WebLinkAbout016-637-20-3203-SAN-2023-039 Department of Safety c°°"ty �, ��
0 = & Professional Services, `��`G`J �'� �
< S' = Sanitary Permit Number(to be filled in b Z
_ , Industry Services Division
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Sanitary Permit Application State 7ransaction Number w
In accordance with SPS 383.21(2),Wis.Adm Code,submission ofthis form to the appropriate governmental unit �
is rcquired prior to obtaining a sanitary pernut.Notc:Apptication forms for state-0wncd POW7'S are submitted to Projcct Address(if different than mailing �
the Depamnent of Safety and Professiona►Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s.15.OA(1)(m),Stats. ����p _n
I.Application Information-Please Print All Information
PropcRy Owncr's Namc Parcel#
�,.n� � T�r�► � f�o �Ll c���-�� 7-ao- 3av 3
Property Owner's Mailing Address Property Location ��T
�
- J c�{�n5�n � Ga�.�ot -
City,State Zip Code Phone Number (,�r��
l� ��I��GL (�l/'y v���<<tc� ��l`I- �Sa����I� �4J'/a.�%a, Section_�(J
[L Type of Building(c6eck all that apply) Lot# T 3 7 N R � E o W
�I or 2 Family Dwelling-Number of E3edrooms
a r^— Subdivision Name
Block#
❑Public/Commercial-Describe Usc
❑City of _
❑State Owned-Describe Use CSM Number ❑Village of _
�— �Town of ,'(FCCc�f�� V/�L��h —
IIL Type of POW1'S Permit:(Check either"New"or"Replacement"and other applicable on tine A. Check one box on line B.Complete tine C if
a licabte.)
A' ❑ New S stem Re lacement S stem
y � p y ❑ Other Malification[o Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B" �Holding Tank ❑ In-Ground ❑ At-Grade gn yp ( p )
❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration ? c,l r1 1�-• ?
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
��0 t� � rl/-�- N F� N�
Capacity in Total #of Manufacturer
Tank[nformation Gallons Gallons Units D �; v ,�, � �
New Tanks Existing Tanks � o y � w p � c"'a
a V va � cn w C7 a
Septic or Holding Tank / ,3iv:1 / � u� �,;�� �«� �
vi.V
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installstion of t6e POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's S ature MP/MPRS Number Business Phone Number
Cr��z �r o sv�l � �� S�l ���C� "7l s-�6� ���5�
Plumber's Address(Street,City,S tc,7_ip Code)
S�%� - -l`� �u 5��rt � ��? e'' �..� v�� �'1�o
VI.Coun /Department Use Only
�p ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $ `O�"� � I 1�I�3 1/V(��" �.�-
Conditions of Approval/Reasons for Disapproval
� � � ���� `���..�a 3 �._ p � ��'�;�
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�;r�;-�e.ii�a �___,��. APR 2 6 2023 �-,
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SAWYEr� CrJ:_;��'-� �
ZONI -
Attach to complete plans for the system and submit to the County only on paper not less than B tn x 11 inches in size t�1 ���
f
SBD-6398(R.03/22) NO REFUNDS AFTER
1�5UC OF fJERMIT
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
������11
� �R Cp 1� Hayward, Wisconsin 54843
'��'- ��<i l� (715)634-8288
�Q� ������ FAX(715)63R-3277
�� , � _ ,�� wwwsawvercount �ov.o�
� � E-mail:sanita�ianCa sawyercountygov.org
�I,�1� '—�_' ��� Toll Frce Courthouse/General Information 1-l377-699-4110
I�L J �_ry.`�_
���SCoNy�
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp �`�/ �. �o / �3
Parcel ID# O � �_ 6 3 7_ � _�a o 3
II. Plot Plan:
�Property Lines �Benchmark BM ♦
p(Site Address �North Arrow
�Structure �Scale
�Well �<25' to Service Road
p(Legal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
�Index Page with Original Signature
� Management Plan/Contingency Plan
� Servicing Contract
�Holding Tank Agreeinent Fonn ($30 to ROD)
IV. Holding Tank Specifications:
x Tank Cross-Section: Manufacturer: Gallons: 3, �
�C Tank Anchor Calculations [SPS 383.43 (8) (g)]
�Locking device, chains/locks
�Alarm, electrical per SPS 383.43 (8) (e)
�j 3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: �oqq,� Plumber: C��
0
Application Review Date: �Y I �-7 1 � �
�
POWTS Reviewer:
Natne
�j 9 �� �� Rev. 4/20/2023
Crcdential#
Concrefe �OLDING TANK DESIGN
Srngle Tank Option
INDEX AND TITLE SHEET
Project Old School House
Owner Randy&Terri L Rogall
Address 1098N Johnson Rd
Exeland Wi 54835
Legal Description Prt W112 NWSW S-20 T-37-N R-6-W
Township Meadowbrook County Wi
Subdivision Name Lot No.
Parcel ID Number 016 637 20 3203
Plan Transaction ID Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site pian Page 3
Maintenance and contingency plan Page 4
Designer Craig Thompson
Signature ��, /���f��'% Phone No. ?l-S- �G:b a$`l�
�—�—�,
License Number 220810 Date 04/26/23
Designed pursuant to:
Holding Tank Component Manual For POWTS jVersion 2.I)
S80.10855-P(N.03/07,R.01/12) /�a_���
\
version�.o�t vi z> Page 1 of 4
i
HOLDING TANK SPECIFICATIONS
�Number of bedrooms
Non-residential estimated flow (gpd)
�.^t? � Minimum holding tank volume required (gal)
3000.0 Proposed holding tank capacity (gal)
Skaw Pre Cast „�Tank manufacturer
3000 Tank model number
Tank Alert � Alarm manufacturer
101 jAlarm model number
Tank Dimensions and DaW Tank Anchor Calculations
56.0 Liquid depth below inlet invert (in) 17830 Ibs Weight of tank
8.0 Maximum depth of soii cover (ft) 1.10 Safety factor
180.0 Length (in) 14510 Ibs Weight of anchor required
76.0 LJ„p+h (in)}' Outside Dimensons �g.3 in Soil cover req. for anchor, or
3.6 yd' Concrete counter weight
HOLDING TANK CROSS SECTION
manhole cover with
locking device and
vent finished junction �—Warning label
cap � grade �X � �
12" min. � E-23 " min. 4" min.
vent pipe�� �nduit --� tether
weight 18"Imin.
blind Note: All tank joints, � W
and joints belween -'""-"------
plug tank openings and 12 in� building
to seal piping are sealed W �Nice sewer inlet
outlet Water tight. Pipe and
vent materiais comply
with SPS 384. qq.0 in.
Manhole and vent iocations Electrical is as
may be reversed. per NEC 300
and SPS 316.
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Because of this tank's rounded surface, soil cover alone may not be adequate to prevent Flotation.
Project: Old School House
Transaction Number: Page 2 of 4
HOLDING TANK SITE PLAN
Project: Old School House
N Legal Descriptfon: Prt W1/2 NWSW S-20 T-37-N R�-W
Subdivision Name:
Scale: 1" = 30 ft Parcel ID: 016 637 20 3203 Lot No.:
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3 �5,u,,,. N T-
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am. i,� �� well 6 �'�l �u�,t�
Transaction I.D.: Page 3 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P
N. 03/07, R. 01/12), and the Wi County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow of 40.0 to 600.0 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°h of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm activates), 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 from this hold-
ing tank to the ground surface, including intentional discharges and discharges caused by neglect, consti-
tutes 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 repiacement). Connection 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 shali 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 should be contacted:
a. Installer............... ......... ....... Don Thompson & Sons Exc LLC Phone: 715-266-2842
b. Service Provider...... ............... NorthWest Sanitary Phone: 715-943-2650
c. County Zoning or Health Dept. Sawyer County Zoning � Phone: 715 634-8288 _
11. — _ _____ --
Project: Old School House
Transaction Number: Page 4 of 4
HOLDING TANK SERVICING CONTRACT
Contract Date: / /
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
����Y d. T-� rr ; � l��J� l' Northwest Sanitary, Inc.
PO BOX 155
Radisson, WI 54867
Parcet Identification Number:
( 12 Digit Legacy ID) � � �v - � .� � - � � - � � ��-�
1 . The owner agrees to file a copy of this contract with the governmcntal unit, Sawyer County,
which has acceptcd 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 pu�nper and guarantees to
permit the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner agrees to �naintain the all-weathcr access road or drive so
that the pumper can service the holding tank(s) with the pumping equip►nent. The owner
further agrees to pay the pumper for a charges incurred in servicing the holding tank(s) as
mutual(y agreed upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
scrvicing of the hoiding tank(s) as required under SPS 383.55, Wisconsin Administrative
Codc and the Sawyer County Privatc Scwage System Ordinancc. The pumper further
agrees to include the following in tl�e report:
a. The name and address of the person responsible for servicing thc holding tank;
b. The name of the owner of the holding tank;
c. The site address of the holding tank;
d. The datc the holding tank was serviced;
e. The volumcs in gallons of thc contents pumped from thc holding tank for cach scrvicing;
f. The disposal sites to which the contents from the holdin� tank were delivered.
4. This agreement will reinain 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
scrvice contract or a copy of a new service contract with Sawyer County within ten ( l0)
business days from the date of change to this service contract.
�wI10T''S N2TriC: �PT'ltlt� �WI]0I'S SignBIUT'E: (Only one owncr signature required)
c � �� ,� � � ���� ��I �� �- �. ll
Pumper's Nai : (Print P per's Signature:
Ronald L Viece i, owner Northwest Sanitary,lnc ���� / ; /%���
�� ��- �/L
Pumper's Registration Number:
#2389
Rev. 03/26/ I 3
Real Estate Sawyer County Property Listing Property Status: Current
Today's Date: 4/15/2023 Created On: 2/6/2007 7:55:32 AM
�'Description Updated: 4/10/2023 � Ownership Updated: 4/10/2023
_ _ . _
Tax ID: 19222 RANDY&TERRI l ROGALL EXELAND WI
PIN: 57-016-2-37-06-20-3 02-000-000030
Legacy PIN: 016637203203 Billing Address: Mailing Address:
Map ID: .10.3 RANDY&TERRI L ROGALL RANDY&TERRI L ROGALL
Municipality: (016)TOWN OF MEADOWBROOK 1098N JOHNSON RD 1098N JOHNSON RD
STR: S20 T37N R06W EXELAND WI 54835 EXELAND WI 54835
Description: PRT Wl/2 NWSW
Recorded Acres: 1.840 � Site Address * indicates Private Road
Lottery Claims: 0 1098N JOHNSON RD EXELAND 54835
First Dollar: Yes
Zoning: (A-1)Agricultural One '.� property Assessment Updated: 7/8/2015
ESN: 440 -
2023 Assessment Detail
Code Acres Land Imp.
� Tax Districts Updated: 2/6/2007 G1-RESIDENTIAL 1.840 6,300 41,000
1 State of Wisconsin
57 Sawyer County 2_Year Comparison 2022 2023 Change
016 Town of Meadowbrook �„and: 6,300 6,300 0.0%
576615 Winter School District Improved: 41,000 41,000 0.0%
001700 Technical College Total: 47,300 47,300 0.0%
.� Recorded Documents Updated: 10/26/2022
� WARRANTY DEED ���Property History
Date Recorded: 8/8/1997 262431 N/A
� TRANSFER ON DEATH DEED
Date Recorded: 7/24/2020 425248
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-U S E B L A C K I N K O N L Y- � � C�ccI :80694 j6
POWTS MAINTENANCE AGREEMENT Tx:�044615
For Holding Tanks 444z4�
PAULA CHISSER
Owner's tdame(s)as shown on deed_ R��ISTER OF DEE��
���YER COUNTY, Wi
}�c:�.�c�, d- �r ' . �c7 ll i��/z7r2o2s li:���l+3
Parcei Identifi tion Number. R���RC3jNG FEE 3fl.D{}
(12 Digit LegacY��) 01�-��Z- a�.- 3 �a:�
— PAGES: 2
Legal Description of Property:
-SEE ATTACHED SHEET-
We acknowledge that appi'ication is being made for the instailation of a holding tank(s)on the
property described on the attached sheet
Retum To:Sawyer County Zoning and Conservation Administratlon
10610 Main St.Suite 49,Hayward,WI 54843
As an inducement to the Counry of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the owner is
responsible for the operation and maintenance of the holding tank,locking device,alaRn and access,and agree5 to conform to all
appliqble requirements of SPS 383,Wis.Adm.Code relatirtg to halding tank management,induding 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 senriced 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 govemmental unit within ten(10)business days from the date of change to the service contract.
2. The owner agrees to contracf with a per5on licensed under Ch.NR 113,Wis.Adm.Code,who shatt 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 Sec6on 281.48(3)(d),Stats.,the owner shall submit the report to the govemmental unit. The govemmental
unit may enter upon the property to investigate the candition 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 govemmental unit to prevent
or abate a human health hazard as described in 5ection.254.59,Stats.,the govemmental unit may enter upon the property
and senrice,or cause the tank to be serviced. Pursuant to Section 145.2U(4)Wis.Stats.,a govemmental 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 govemmental unit for
inspection,pumping,hauling,or othervvise senricing 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 municipa!sewer serves the
property.In addition,this agreement may be cancelled by executing and recarding said ceRification with reference to this
agreement in such manner which will permit the existence of the certfication to be detertnined by reference to the property.
5. This agreement shalt be binding upon the owner,the heirs of the owner,and assignees of the owner.The owner shall submit
the agreement to the register aF deeds,and the agreeinent shall be recurdzd 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.
-Onl one owner si nature uired- ACKNOWLEDGMENT
Owner' nature: State of:�[�C6�GY►
� County of• a•u�-�_...
Owner's Name(Pri t): ��,�����, ,, Sub c, '�bed and sworr to bef re me on this
a no� �o ct�� �������� d�•� 2.� day of , 2��
Date: �/� /�3 ;��' ��A y��-�C(Owner's Narne): o l f
�.No�ary Public Signature:
Drafted by� i%i%'� �. - —•— ?Pu�lic Notary Name(Print):
��j �-- , �'�, i� � :'�I�commission expires on: o
, -�o ,�l'.,'9d��••�.........••��`°:
� "'� � �,� 0�t�\��' ���
Personal infortnation you provide may be used for secondary pur�pos��'nvacy Law,§15.04(I)(m)] Rev.03/26/13
,
That part of the Northwest Quarter of the Southwest Quarter (NW;f SW�/,), Section Twenty
(20), Township Thirty-seven (37) North, Range Six (6) West, described as follows:
Commencing at the Northwest corner of the NW�, SW�,; thence East on the North line of said
quarter a distance of 320 feet; thence at right angles South, parallel with the West line
of said quarter, a distance of 250 feet; thence at right angles West and parallel with the
North line of said quarter a distance of 320 feet to the West line of said quarter; thence
North on said West line of said quarter a distance of 250 feet to the place o£ beginning.
'""�r.;, PRIVATE ONSITE WASTE TREATMENT Cou�ry
������o$ SYSTEMS SaWyer
�;,�� p$ ;� ( POWTS)
\k `��i``�,:
°' `�' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 � 63�'
Pe�onal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
��" ���N� �a q�I /�'lP�evi�ND�
Insp BM Elev: BM Description: Parcel Tax No:
(a'.o` b� 1-�:� c;s�- 1;� o�b-637— o- 3�fl
TANK INFOR ATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �oa.o'
Dosing
Aeration Bidg. Sewer �6, 7'
Holding �j cS2Tp 3�l Ht Inlet ��, �
TANK SETBACK INFORMATION �l Ht outlet Q ,� �
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding fi�St ��oc' �' �-�7j' � �S � Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative
Surface
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 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
P/L Bidg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
- — -- _ --- � - — --�
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia _ 1Length Dia Spac _ I Spacing ❑Yes ❑ No
SOIL COVER
( Depth Over �epth Over �epth of � Seeded/Sodded � Mulched �
� Cell Center Cell Edges � Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���((� S�s-�� 3
� �f.`�1' 3�� �� �f�.,�J'
�� � �
Plan revision required?❑ Yes ❑ No Id� I�g �� � , — Gq ���—
Y
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBEA' 23 -�,3�__
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