HomeMy WebLinkAbout020-638-14-2201-SAN-2023-063 �''� �� Department of Safety SAWYER � �
� - & Professional Services, Z
< _. _ - Sanitary Permit Number(to be filled in b�
�: Industry Services Division
{�e 3� �3� �
State Transaction Number �'�
Sanitary Permit Application o
—
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the approptiate govemmental unit 6'
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing a �j
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance wiUt the Privacy Law,s. 15.04(1)(m),Stats. � $Qg�jW SQU�RES RQA�7
I.Application Information-Please Print All Information
Property Owner's Iv�aine Parcel#
TIM AND HILARY MICKELSON 020638142201
Property Owner's Mailing Address Property Location
6528 210TH STREET c-„+w..�r�"� !'2
City,State Zip Code Pl�one Number
CADOTT WI 54727 NW �,,�NW �,,, se�non 14
II.Type of Buiiding(check all that apply) Loc# T 38 N R 6W E or W
� l or 2 Fvnily Dwelling-Number ofBedrooms 3 �' Subdivision Name
Block# `�
❑Public/Commercial-Describe Use �,.1
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
_ �Ta�af OJIBWA
III.Type of POW'I'S Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
"4� �New S stem
y ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' �Holding Tank ❑ In-Ground ❑ At-Grade gn yp ( p
❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain)
(conventional)
C• ❑ Renewal Before r' Revision �' Change of Plumber ❑ Transfer to New Owner �st Previous Per[nit Nuuiber and Date Issued
Expiration
IV.DispersalITreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(st) Systein Elevation
�
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units � V U '$ n ;
New Tanks Existing Tanks � o a��, � � � a �
a U v: � v� t�. C7 0.
Scptic or Holding Tank 3000 1
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW'I'S shown on the attached plans.
Plumber's Name(Print) Plum r Signature � MP�'MPRS Number Business Phone Number
DAVID THOMPSON ' ' 'y� 221377 715-532-5892
Plumber's Address(Street,Ciry,State,Zip Code)
703 W FRITZ AVE, LADYSMITH WI 54848
VI.County/Department Use Onty
� r ❑Disapproved Permit Fee Date Issued. Issuing Agent Signature
��O���� S��J '�� ���lGC�iJCX.t.i-17�/'./U4--
❑Owner Given Reason for Denial � I ��
Conditions of Approval/Reasons for Disapproval �
r),���r �'�9' '��i�1;7".�
���� �.,i_� � ' '
� � �Date s��S�a 3 �4� s`— - ----
� ' � � .�
� � MAY 2 5 Z "
�� ��►� �,� 02 ..
�°1 �hk# �4 �� 3 J-
n — _____._.----�
C 5T �oT Ke�, Rci?t�_._.I 5�1�-_ .� _ . ��1i��`vc.�' c�;:;:; .� �:
M�':�" ZOiViNG tit�NliNiSi'i-ilN"I"i;Jf�
Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x ll inches in size
,�L�� �
SBD-6398(R.03/22)
Sawyer County Zoning & Conservation Administration
������,'
10610 Main Street, Suite 49
��R cOG�, Hayward,Wisconsin 54843
%� .- 2�, (715)634-R288
��� FAX(715)63R-3277
��� _ � ��� wwwsawvercountY o� v.org
� o� �_�,�,��,�.: '� � E-mail:sanitarian a�-sawycrcount ov.o�
I � _�,;_����� Toll Frec Courthousc/Gencral[nformation 1-877-699-4110
�
,���,`O'1�1��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp`�s / a2 s / .��-3
Parcel ID# �aO_ C�3'8 - 1 �( - 2�� 1
II. Plot Plan:
� Property Lines �Benchmark BM ♦
� Site Address )( North Arrow
�( Structure � Scale
)�Well �(< 25' to Service Road
�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 Agree�nent Fonn ($30 to ROD)
N. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer:�, Gallons: �c�
� Tank Anchor Calculations [SPS 383.43 (8) (g)]
�? Locking device, chains/locks
�Alarm, electrical per SPS 383.43 (8) (e)
�3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: {�1�1;��(e�So�n Plumber. J •��So�
Application Review Date: o��a,�( �.3
POWTS Reviewer: �� �it� /�
Name
6`���� Rev. 4/27/2023
Credential#
CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project Mickelson
Owner Tim and Hilary Mickelson
Address 6528 210th Street
Cadott W154727
legal Description NW-NW-S14-T38N-R6W
Township Ojibwa County Sawyer
Subdivision Name NA Lot No. NA
Parcel ID Number 20638142201
Plan Transaction ID Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Designer Dav' Thom son
Signature (�;'(��,�C� �U11KV1�s1 Phone No. 715-532-5892
License Number 221377 Date 05/22/23
Designed pursuant to�.
Holding Tank Component Manual For POWTS Version 2.1
(MAY 2022-2027)
Version 7A(03/12)
Page 1 of 4
HOLDING TANK SPECIFICATIONS
3 Number of bedrooms
Non-residential estimated flow(gpd)
_OSC o Minimum holding tank volume required (gal)
3000.0 Proposed holding tank capacity (gal)
SKAW Tank Manufacturer
3000 Tank model number
SJ Electro Alarm manufacturer
Tank Alert Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X tor round tank 17930 Ibs Weight of tank and cover
56.0 Liquid depth below inlet invert(in) 1.20 Safety factor
8.0 Maximum depth of soil cover(ft) 21548 Ibs Weight of anchor required
64.0 Height(in) Gutside 262 in Soil cover req. for anchor or
182.5 Length (in) Dimensions 5.3 yd' Concrete counter weight
78.0 Width (in) Only
HOLDING TANK CROSS SECTION
manhole cover with
locking device and finished ��ent cap
junction � warning label grade
box —� �
4"mia � 12"min.
�—� �23 in. —
Manhole and vent locations T
conduit � vent pipe
18"Imin.
y
� telherweight --
building sewer
� service � 12.0 in. inlet
blind plug alarm on Note: All tank j0ints, and
toseai joints between tank
ounet openings and piping are
Electrical as per 44.0 in. sealed watertight. All
NEC 300 pipe and vent materials
and SPS 316 comply with SPS 384.
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project: Mickelson
Transaction Number: Page 2 of 4
PLOT PLAN
— BM_ — _ — _— __ _ _ ___— _ —_—SquiresRoad _— _ — _—_ — _ —_ —_ — _ _— _ —_ —
�
3000 gallon
Skaw holding
tank wl alartn
�
O
4"Sch 40 PVC �
Proposed Cabin Driveway
m
c
�
�
m
¢
� 20 acre parcel
a All other property lines are>100'away
I 44� I
��
Scale 1" = 40' Timothy and Hilary Mickelson
8095W Squires Road
� = Benchmark- ELEV. 100' NW 1/4 - NW 1/4 - S14 -T38N - R6
Centerline of road at west propert line-also HRP Town of Ojibwa
� = No well at time of evaluation Parcel# 020638142201
PAGE3of4
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), and the Sawyer County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow o 60.0 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% 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 Service 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 surtace, 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......................... Russ Thompson Excavating Phone: 715-532-5892
b. Service Provider............... Northwest Sanitary Phone: 715-943-2650
c. Co. Zoning or Health Dept. Rusk County Zoning Phone: 715-532-2156 _
11.
Project: Mickelson
Transaction Number: Page 4 014
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TIM OR HILARY MICKELSON �(��1hi+�4?5t Sc3f1!tr7'y Ittt. �
''Q f3GX 155 �
' � R�d�Sst�n, W1 54867
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Tx:4045133
� POWTS MAINTENANCE AGREEMENT i 444641
j For Holding Tanks PAULA CHISSER
REGISTER OF DEEDS
�Qwner`s Name(sj as�hown an deed: ""--�—'--'�' SAWYER CQUNTY, WI
� i 05/25J2023 89:�&AM
! TIM OR HILARY MICKELSON � RECORDING FEE 3O.UO
�Parcei Identification Number� w��� T�� �
� (12 Digd legatY 101 0 2 0 _ 6 3 B _ 1 4 _ 2 2 0 1 � PAGES: 2
;
�Legal Description ot Property: �
� -SEE A7TACMED SHEET-
jWe ackrtowledge that application is being made tor the installation oi a holding tank(sj on the j
f property desc�bed on ths attached sheet. �
i
_�
� Retum Ta Sawycr Courtty Zoning and Conservatlon Ar#ninisteatlon �
10614 Maln St Suite�9,Hayward,WI 54843
l
I . r�__ _.._ ____ _ ____
As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the awner is
responsible for the operation and maintenance of the holding tank, locking device, atarm and access,and agrees to conform to all
applicabie requirements nf SPS 383,Wis.Adm.Code retating to ho{ding tank management,inctuding the folkrwing:
1. The owner agrees to cantract with a person wfio is licensed under Ch. NR 113,Wis. Adm, Code,ezcept as pravided by
5ection 281.48(3)(d),Stats.,to have fhe holding tank properly serviced and to fite a copy of the seroice contract with the
govemmentai unit. The owner further agrees to fiie a copy af any changes ta the service coniract,or a copy ofi a new service
contract,tn+ith the govemmenta!unit within ten(1Q)husiness 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 reparts lo
the govemmentai unit in accordance with SPS 383.55,Wis,Adm.Code,for the servicing of the holding tank. in the case o#
exemptian under Sec6on 281.d8(3)(d), Stats.,the awner shall submit ths report to the governmental unit, The gover�mental
unit may enter upon the property ta investigate the condition af the holding tank when pumping reports may indicate the
haiding tank is not being property maintained.
.
3, If the owner faiis to have the hoiding tank praperiy serviced in response ta orders issued by the governmenta!unit to prevent
or abate a human heaith hazard as described in Section.254.59, Stats.,the governmental unit may enter up�n the property
and service, or cause the tank to be serviced. Pursuant to Section 145.24)(4)Wis. Stats., a govemmentai unif may assess tl�e
owner of a private sewage sysCem for costs related to the pumping of a ssptic or holding tank.The charges wiil be assessed
as prescnbed by Section 66A�03,stats. The owner agrees to pay aiV charges and cost incurr�d by the govemmentai unit tar
inspection,pumping, hauling,or otherwise senncing and maintaining the holding tank in such a manner as to prevent or abate
any human heaith haza�d caused by the holding tank.
4. This agreement wiU�emain in effect oniy�nti!the govemmental unit responsible for the regulation of private sewage systems
certifies that either a so'st absorption system that compties with SPS 383,Wis.Adrn. Code,or a rnuniclpal sewer serves the
propeRy. tn addition,this agreement may bs cancelied by executing and recording said certif►cat+on with reference ta this
agreeme�t in such manner which will permit the existence of ihe cQrtification to be determined by reference ta the property.
S. This agreement shall be binding upon the owner,the heirs of the owner, and assignees of the owner.The owner shail submif
the agreement ta ihe 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 reterence to the property where 1he holding tank is instai(ed.
-Onl�r one owner signature required- ACKNOWLEDGMENT
Owner's S� nature: � i w�sCons�n
,� � State of:
1 ���������''�� �� County of: Rusk
; Ow�ne s Name tPrint : � Y��t�� ` ����� ¢�nd swom to before me on this
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i-Date: ,,�'�Qj�• �er�'N�'Aie): ,
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f �'2.2'2b a3 : �.� otary�Ii�SiL�hatureCk-,
E— '� '• � Danna Holzmer
1 Drafted by: =�;� PuB�+c Notary.T�aii�e {Print):
! Dav►nq �o��2t-' r ;• yco issj5n�xpireson: 1-1-zozs
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♦�,��r�". ►. •:�!^`�s-�ti:i.
'� ��� Rev.03I26/13
Personal infarmaUon you provide may be used for secondary purposes[Privac�i����5�4(�(m)l
«
`I7,� wes�' kv1$ �'F
The Northwest Quarter of the Northwest Quarter(NW 714NWtf4�,
Section Fourteen(14),Township
Thirty-eight(38)North,Range Six(6)West,located in the Town of Ojibwa,Sawyer
County,Wisconsin.
5/25/23, 9�13 AM Real Property Listing Page
Redl EStdte Sawyer County Property Listing Proper[yStatus: Current
Today's Date: 5/25/20Z3 Created On: 2/6/2007 7:55:35 AM
� Description Updated: 8/ll/2015 � Ownership Updated: 8/17/2015
Tax ID: � 20861 TIMOTHY P & HILARY E MICKELSON CADOTT WI
PIN: 57-020-2-38-06-14-2 02-000-000010
Legacy PIN: 020638142201 Billing Address: Mailing Address:
Map ID: .6.1 TIMOTHY P & HILARY E TIMOTHY P & HILARY E
Municipality: (02D) TOWN OF OJIBWA MICKELSON MICKELSON
STR: 514 T38N R06W 6528 210TH ST 6526 210TH ST
CADOTT WI54727 CADOTT WI54727
Destription: WS/2 NWNW
Recorded Acres: 20.000
Calculated Aaes: 19.820 w Site Address ' indicates Private Road
._.__ ._ __-_
Lottery Claims: 0 8095W SQUIRES RD �OJIBWA 54862
First Dollar: No
Zoning: (A-1) AgriculNral One � Property Assessment Updated: 8/20/2013
ESN: 427 2023 Assessment Detail
Code Acres Land Imp.
� Tax Districts Updated 2/6/2007 GS-UNDEVELOPED 4.000 900 0
1�� �� State of Wisconsin G6-PRODUCTIVE FOREST 16.000 17,600 0
57 SawyerCounty
020 Town of Ojibwa Z-Year Comparison 2022 2023 Change
576615 Winter School District Land: 18,500 18,500 0.0%
001700 Techni�al College Improved: 0 0 0.0%
Total: 18,500 16,500 0.0%
�• Recorded Documents Updated: 8/ll/2015
WARRANTY DEED . . .. .... .. . ...
Date Recorded: 6/18/2015 396254 �� P�operty Mistory
TERMINATION OF DECEDENTSINTEREST N�A
Date Recorded: 5/11/2015 395546
TERMINATION OF DECEDENTSINTEREST
Date Recorded: 5/11/2015 395545
QUIT CLAIM DEED
Date Recorded: 295531 102/41 QCD774/160
https:/Itas.sawyercountygov.org/systeml(rames.asp?uname=6ic+Wellauer ���
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',"���� ,�;, SYSTEMS
�,-�,� Ps ,:;;� ( POWTS) SaWyer
\�+�\F`_-/p
�-"'"""'� INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 _O�o3
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
`��... � `�la M��V`��s�►-. ����w� .._
Insp BM Elev: BM Description: Parcel Tax No:
��o •�� d � � �� t: d� - 6�� - �y -a�b �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (op,p"
Dosing
Aeration Bidg. Sewer �g,Y �
Holding S�,L. �j �fl St/Ht Inlet Q r � �
TANK SETBACK INFORMATION St/Ht outlet �
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding ksb' 02 ' .,{.(o' .�-�O� �2 � Dist. Pipe
PUMP 151PHON 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
INFORMATION P/L Bidg Well Waters o G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
—_—-- -----_ _ _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold �Distribution Pipe(s) X Hole Size I X H�ole Observation Pipes
Length Dia Length Dia Spac �� � Spacing ❑Yes ❑ No
---——
— ___ ---
SOIL COVER
_--
Depth Over Depth Over � Depth of Seeded/Sodded Mulched
Cell Center TCell Edges j Topsoil _ _ 1 ❑Yes ❑ No ❑Yes � No
COMMENTS: (Include code discrepancies, persons present, etc.)
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�. K.`� (sk� 3,�)
� _ _ _
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Plan revision required?�Yes O No �.3 I, �Y ��,I � — ____I ��' �(�
� }
Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA: __��.-D(?�____
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