HomeMy WebLinkAbout012-740-36-2116-SAN-2023-175 � .`iti��Rittl���� COUII[y `/ 1
' = '� Industry Services Division Sawyer �
=���� � 1400 E Washington Ave Sanitary Permit Number(to be Slled in by �
� �sps ti' P.O. Box 7162
J,; � � Madison,WI 53707-7162 Gy S ' V''!� �
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Sanitary Permit Application StateTransactionNumber �
[n accordance with SPS 383.2](2),Wis.Adm.Code,submission ofthis fortn to the appropriate govemmental unit � '-n�
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to proiect Address(if different than mailing, v'
the Department of Safety and Professional Services. Personai information you provide may be used for secondary
es in accwrdance with the Privac Law s.15.04 1 m Stats. ��%� � ��'S f i✓A V ��y
i. A lication Information-Ptease Print All lnformation
Property Owner's Name Pazcel# /
JAH Construction (� ��-� �^��j:+Z I ` �
Property Owner's Mailing Address Property Location
16071 3"'St
Govt.Lot
Ci 5tate Zip Code Phone Number Section��
�° circle one)
Hayward,WI 54843
T y0N ; K f E or�
II.Type of Building(check all t6at apply)
Lot# �('� � �
j h�� Subdivision Name
� 1 or 2 Family Dwell ing-Number of Bedrooms � �
❑Public/Commercial-Describe Use Block#
�6 ,�.��q ��;ri of
❑State Owned-Describe Use ❑ Village of
CSM N mber !/ � Town of �/��C �
1
III.T e of Permit: Check onl one box on line A. Com lete line B ita licable
A. �New System ❑ Repiacement System ❑ TreatmendHolding Tank Replacement Only ❑ Other Modification to Existing System(explain)
B. ❑ Pecmit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner �—
N.T of POWTS S stem/Com onent/Device: Check all that a 1
❑Non-Pressurized ln-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
� Holding Tank ❑Other Dispersal Component(expiain) ❑Pretreatment Device(explain)
V.Dis ersaUTreatment Area Information:
Design Flow(gpd) Design Soil Application Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�� Rate(SP�� .__- r— ---- �--
r
V .Tank Info Capacity in �; o,s �
Gallons _ Total #of Manufacturer � � ;; � � �
Gallons Units ;? o � � �' -
New Tanks Existing Tanks a Ci in v, v� u- C7 �.
Septic or Holding Tank 2000 2000 1 Wieser
Dosing Chamber
VII.Responsibility Statement-I,the uoderoigned,asaume respo�b tv or t tion of the POWTS shown on the attached plana.
Plumber's Name(Print) Plumber's Signatuc MP/MPRS Number Business Phorie Number
Dan Burch 253808 715.4t6.t642
Plumber's Address(Street,City,State,Zip Code)
1118N Front Street Spooner W I 54801
VIII.C u /De artment Use Onl
(�'Ap Disapproved Permit Fee Date Issued Issuing Agent Signature ,
�[��Owner Given Reason for Denial � �'{�.°� 6 �l �-3 �/ '" �
IX.Con ' i� r v �te�so s for Dis$pproval �� �( a 3 � .� '�!�
' �
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�� ���ir� .hk# � �Lo� � ��,. ' ��!C 3 _J
�5� o -��(� :�.s;,��� �-- ----- ----
AttAch to complete plans for e system snd submit to Me County oniy on paper not less than 8 t/2 x i t ia�il�k in';si;e ., ,;,�','
�or:le��..�.,.. . _ . ;�u'�7y
SBD-6398(R03/14) NO R;FUNDS AFTER
ISSl1E O(=PER�I�i-
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
�������� Hayward,Wisconsin 54843
� �R C� 1�
'� '�Ci � (715)634-8288
��� �Z�� FAX(715)638-3277
�V!'/ -_ - -- \�� wwwsa�wYercottntvepv.ore
� �� � _ � � E-mail:sanitarian(a��sawvercountva��,v.ore
�/� � '� �j�� Toll Free Courthouse/Gencral lnformation I-877-699-4110
� '-f;�r.y �
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stainp D'$ /�D�/ ,Z�
Parcel ID# O ��- 7�-(O- 3(Q - 2t � �
II. Plot Plan:
�Property Lines �Benchmark BM ♦
� Site Address �North Arrow
�Structure �Scale
�Well �<2S to Service Road
� Legal Description D�Vearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
�Index Page with Original Signature
j�Management Plan/Contingency Plan
XServicing Contract
�Iolding Tank A��reement For-in ($30 to ROD)
IV. Holding Tank Specifications:
�Tank Cross-Section: Manufacturer: W 1��� Gallons: W�-��
�C Tank Anchor Calculations [SPS 383.43 (8) (g)]
?� Locking device, chains/locks
�Alann, electrical per SPS 383.43 (8) (e)
�3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: � d� Plumber: ��
Application Review Date: OgCDy(�.-3
POWTS Reviewer: ��
Namc �
6��( (� Rev. 4/27/2023
Credential# �
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1(May 2022-2027)
Pg 1 of 4 Index&Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section&Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s): �1/T� C�D�S j Phone: - -
Owner Address:J��7� 3r`'� S� � ��� �� Zip: S�(`$`f �
Project Address: ��/,� h' Le5 i n k� �
Govt.Lot: 1/4 of 1/4,Section�,T ���N-R�E❑or W Q
Township: ��� County:_ aw t �
Project Parcel ID#: O)�� `�n 3 6� �1�
Designer Information
DesignerName: Dan Burch Phone:��5 _416 _1642
Designer Address: N5921 Cty Hwy K Spooner WI Zip; 54801
E-mail• burchplumbinginc@gmaii.com T�,;S,�,��re.ser�e�torat,�,To��.,tamF.
License Number:253808
Remarks:
Signature: Date:
� � ,�-�1 3
Original s(gnature required on each s 4mitted copy.
CHECK BO%AS APPLICABLE. CHECK BOX AS APPLICABLE.
�✓ SOIL EVALUATION o Scale: 130 30 os so � SYSTEM PAGE 2 OF
SITE MAP — PLOT PLAN
PROJECT NAME: 7 5, oesicN F�ow�. 300 cPo
JAH Construction Attach design flow calcuiations for commercial plans.
PROJECT ADDRESS: 7B�Z N LBSIf18K R(I Pipe Matenal/ASTM Standard(Tables 384.303 8 384.30-5)
NSanitarySewec /
BM Symbol�. !$j� BM Elevation: FT Porce Main'. /
BM Descriplion'.
Slo e Gradiem %) inaioate�onnq� IMPORTANT'.
P ( Weil Symbol(it apPiicable)�. � a�ewme a�a�w, Show ground elevation contours at suitable intervals.
of Tested Area'. on me appmprife Ilne.
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HOLDING TANK SPECIFICATIONS
�.�7
�Number of bedrooms
����Non-residential estimated flow (gpd)
2000.0 MMinimum holding tank volume required (gal)
��.����j
� 2000.0 �Proposed holding tank capacity (gal)
.�Wiese�����-���� �y �Tank Manufacturer
�'Y`�' ��'�— ��Tank model number
�W2�Q0 _ .r� -.�. .��
� �'"`��°"� � �Alarm manufacturer
SJE�hombus��
� _e_ , � .����,...�
ank lert �Alarm model number
�:�h��- �� ��
Tank Dimensions and Data Tank Anchor Calcutations
.�-,�_�.���
�"�"'��'�X tor round tank � 15370 �Ibs Weight of tank and cover
�, � � ,��.� �,��.
���-°�- � �=` 1.50 ; Safety factor
� 49.,0 t,Liquid depth below inlet invert (in) � �
>�;:;
� � �� .
8 0 ;Maximum depth of soil cover (ft) ��748 Ibs Weight of anchor reqwre
�66.0»Height (in) Outside 41 .2 in Soil cover req. for anchor or
=��-� d° Concrete counter weight
� 150.0 �Length (in) Dimensions 7.6 y
86 b`�Width (in) �nly
-s,��-m.,.�-.ei
HOLDING TANK CROSS SECTION
manhole cover with �vent cap
� locking device and finished
junction waming label grade
box —� „ �, ' 12" min.
4 min.
�—23 in.
Manhole and vent {ocations vent pipe
conduit —� 18" min.
y
� tetherweight _ _ _.---._._.._--•—•—•---•—•—�—�— "
� building sewer
service � 12.0 in. inlet
alarm on Note: All tank joints, and
blind plug joints between tank
to seai openings and piping are
outlet
Electrical as per 37.0 in. sealed watertight. All
IVEC 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:
Transaction Number: Page 2 of 4
PAGE 4 OF 4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s)shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-3&4,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Adrnin.Code,this holding tank(s)
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthertnore,all inspection and maintenance activities shall be pertortned by a registered POWTS Maintafner in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Estimated Daily Wastewater Flow= 3 b" 9Pd
Insoection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o electrical components(i.e.,wiring,connections,switches,controls,timers,alartns,etc.)
o surface discharge of effiuent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s)shall be pumped by a ceRified septage servicing operator licensed under s.281.48 Wisc.Stats.
when the wastewater in the tank(s)reaches a Ievei of one foot below the inlet invert of the tank(s�.
Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
Tank pumping reporls shall be submitted to the proper local govemment u�it ln accordance wkh SPS 383.55 Wis.
Admin.Code. Report any component faflure or maNuncUon to:
Burch Plumbing phone:715.416.16452
Name of individual or company: —
�o�i 9o�e�,ment��;t:Sawyer County Zoning Phone:715.634.8288
�oca�government unit address: 10610 Main St#49 Hayward Wl Z�p:54843
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning components sha�l comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Contins�encv Plan
In the event that any failed component of this holding tank(s)cannot be repaired,it shal{be replaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
Svstem Abandonment
if use of this tank(s)is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
l��
HOLDING TANK SERVICING CONTRACT
Contract Date: � ? / Z, 7 / Z. 2
This contract is made betwcen thc Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
Northwest Sanitary, Inc.
� � � � �S i`2�t �T ��J PO BOX 155
Radisson, WI 54867
Parcel Identification Number: � � 3 b
( 12 Digit Lcgacy ID) �1 � a' - _� _ _ - _ _ - � � _�
1. The owner agrees to file a copy of this contract with thc governmental unit, Sawyer County,
which has acccptcd and recorded with the Office of the Rcgistcr of Deeds, the Maintenance
Agrcement for a Holding Tank required w�dcr the Sawyer County Private Sewage System
Ordinancc for the issuance of a Sani[ary Pcrmit for the installation of a holding tank(s).
2. The owner agrces to have the holding tank(s) scrviced by thc pumper and guarantees to
permit the pumper to havc access and to entcr upon the property for the purposc of servicing
thc holding tank(s). The owner agrees to maintain thc all-weather acccss road or drive so
that the pumper can service the holding tank(s) with the pumping cquipment. The owner
furthcr agrees to pay the pumper for a chargcs incurred in servicing the holding tank(s) as
►nutually agrced upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
scrvicing of thc holding tank(s) as requircd undcr SPS 383.55, Wisconsin Administrativc
Codc and thc Sawycr County Privatc Scwagc Systcm Ordinancc. Thc pumper furthcr
agrees to include the following in the report:
a. The name and address of the person responsible for servicing the holding tank;
b. The namc of the owner of thc holding tank;
c. The site address of the holding tank;
d. The datc the holding tank was serviccd;
e. The volumcs in gallons of thc contents pumped from thc holding tank for each scrvicing;
f. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In
thc evcnt of a change in this contract, the owner agrees to file a copy of any changes to this
servicc contract or a copy of a new service contract with Sawyer County within ten ( 10)
business days from the date of change to this service contract.
Owner's Namc: (Print) OWIICl''S S1�ri12Ufe: (Only one owner signature required)
� �µ l.�r�j�Yl� ��T� t�-,J _
Pwnper's Name: (Prii�t) Pun�per's Signature:
Ronald L Vieceli, owner Northwest Sanitary,lnc l�� J � � .
��
Pumper's Registration Numbcr:
#2389
Rev. 03/2(/I 3
W2000—MR �
TANK SPECIFICATIONS o 0
� �
�2�_�� DIMENSIONS: o
WALL: 2 7/2" a
BOTiOM: 4"
COVER: 6"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER a
_= ------"--'---'�� HEIGHT: 66'
%�� �` LENGTM: 12'-7" �
i��/4" CAST-A-SEAI 4" CAST-A-SEAL\`�\ NADTH: 7�-2"
� u �� BELOW INLET: 53'
n �_ -�� � UQUID LEVEL: 46"
v �
i.i � �i i / � WEIGHT: 15,370 LBS. -�
� I � u � � E
^ e ` .�� INLET AND OUTLET: ` 3 � o
`N�-� Tr 4` i( 4" CAST-A-SEAL BOOT OR EWAL GASKET � m o 0
��\\ p FILTER OR BAFFLE ii � � �
�\\ INLET AND OUTLET BAfFLE AND FlLiER: � � � w
WISCONSIN, SEE DETAII�!10 � o =
=_-- - ---_______'� (OTHER STATES SEE CHART) NW� 4
LIQUID CAPACITY: 42.92 GAL/IN ~"
HOLDING TANK:
��
TOP VIEW WTLET HOLE PLUGGED C�v�i
ACTUAI CAPACIIY: 1,085 GALLONS �z�
� LOADING DESIGN: 6'-0' UNSATURAiED SOIL ���n
w
� g N
a� TANK CAN BE USED AS: �o�
w SEPTiC /HOLDMG /PUMP OR SIPHON �W�o0
�
� � COVER: MIX DESIGN /8(NO FlBER) �
�
____ {.�- ---- . __1 TANK: MIX DESIGN �70 (STRUCTURAL FlBER) ��
� - .. , ,� --- f
--
INLET - - OUTLET CUSTOMIZED TANKS: 3
i FOR CUSTOM TANKS CONTACT WIESER CONCRETE
- aU �'' --- �---�"--- I �cai -
'� ;,� �v j in -I i �`r voi <
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.�.------ ---_ -------�� o
REVIEWED BY N F
a REVIEW DA'fE 3 W
SIDE V1EW DRAWINGS SUBMITTED N
FOR APPROVAL
APPROVED BV: SHEET N0.
APPRDVAL DATE: 1 �
Of
PRODUCTS NEEDED BY: / �
TANKS ARE MANUFAC'tURED TO MEET OR EXCEFD ASTM C-7227 REQUIREMENTS
� � i li���'I�1�i11 ���►1ii' ii 1�_� �
�l�►I►�IIJ
ocI :ealtss5 445436
Tx:4046154 PAULA CFIISSER
REGISTER OF DEEDS
SAWYER COUNTY, WI
07/17/2023 12:49 PM
`9 RECORDING FEE 30.00
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814123.837 AM Real Property Listing Page
Real Estate Sawyer County Property Listing Property5tatus: NextYear
Today's Date:8/4/2023 Created On:7/28/2023 10:38:04 AM
�
�.�'Description Updated:7/28/2023 �Ownership Updated:7/28/2023
TaxID:� 49774 JAH CONSTRUCTION L�C HAYWARD WI
PIN: 57-012-2-40-0�-36-2 01-000-000160
Legacy CIN: 012740362116 Billing Address: Mailing Address:
MapID: ]AH CONSTRUC7ION lLC ]AH CONSTRUCTION LLC
Municipality: (012)TOWN OF HUNTER 8894N CONNER LN 8894N CONNER LN
STR: 536 T40N R07W HAYWARD WI 54643 HAYWARD WI 54843
Description: PRT N1/2 NW LOT 1 CSM 38/162#8719
Recorded Acres: 0.750 �Site Address *indicates Private Road
_.__..__.._.
Calculated Acres: 0.000 7612N LESNIAK RD HAYWARD 54843
Lottery Claims: 0 �:�7
First Dollar. No u property Assessment Updated:N/A
Zoning: (RR2)Residential/Recreational Two Z023 Assessment Detail � � �
ESN:
Code Acres Land Imp.
N/A
�Tax Districts Updated:7/28/2023
1 State of Wisconsin 2-Year Comparison 2022 2023 Change
57 SawyerCounry Land: 0 0 0.0%
012 Town of Hunter Improved: 0 0 0.0%
SR478 Hayward Community School District Total: 0 0 0.0%
001700 Technical College
. Recorded Documenis Updated:7/28/2023 Ik�Property History
CERTIFIED SURVEY MAP Parent Properties �� Tax ID
Date Recorded:7/17/2023 445436 57-012-2-40-0736-2 01-000-000040 15856
WARRANTY DEED
Date Recorded:5/11/2023 444453
WARRANTY DEED
Date Recorded:12/3/2020 428445
WARRANTY DEED
Date Recorded:7/3/2001 292132
CERTIFIED SURVEY MAP
Date Recorded:4/28/1987 204407
ChildJ�isYoryRemrdCaunt'-1=__ __ ___ — - - -.-.--
-----__-——_- --___ __ _ ___
HISTORY 0 Expand All History White=Current Parcels Pink-Retired Parcels
O Tax ID:15856 Pin:57-012-2-40-07-36-2 O1-000-000040 Leg.Pin:012740362104 Map ID:.5.4
44774 This Parcel Parents Children
https:qtas.sawyercountygov.orglsystem/iremes.asp?uname=Eric+�n/ellauer ���
i ii iii i i i � ��i i��� � �;
- USE E3LACK INK ONLY - � DCCI :80724�y
__ _ __ . _ . � Tx :404fi555
POWTS MAINTENANCE AGREEMENT 445747
Far Holding Tanks � PAULA CHISSER
____ __ _ __ _ _
REGISTER OF DEEDS
Owner s N�me(..j :�s shown on duce:: SAWYER COUNTY, WI
V��� �} �. ,� r ' ' `.� ' • � ' � �' � 08/04/2023 09:19 AM
-- .—_ ___. ._ _ ._
RECORDING FEE 30.80
Parcel Identificatlon Number�. � -� c,,� '
�iz o�i.i ���y �� y iu; (� � Z ' � / � ... � � � �� I 7_ PAGES: 2
Leyal C7rscription uf Properly�.
- SEE ATTACHED 5HEET -
We acknowied,ye lhai appli��,�tion is �einy �nede tor the insl�+ll���tivn of a ho!dinq tank(sj or�, the �
proGerty describF�d on the attacheU sheet. �
Return To: Sawyar County Zoning and Conservatior� Admfnistration
10610 Main St. Suite 49, Hayward, WI 54843
_ _ _ _ _ . •y . _ _ _ _ _ __ ._ __ _ _ _ _ . _ _.._ __.
As an inducement to ti��e County �f S�awyer io issu� a �anitary permit for a holding tank on the above-described property, the owner is
responsible for the operation and maintonance ofthe holdiny tank, locking devicr�, alarm arid access, and agrees to conform to all
applicabie r�yuirements of SWS 383, Wis. Adm. Code relating to frolding tank n�anagement, incluc�ing the fiollowing:
1, �The ownQr agroes to contr�ct with ri person who is licerased under Ch. NR 113, Wis. A�I�i�. Code, except as provided by
Seciion 281 .48 (3) (d}, St<�ts., to have the hoiding t�nk properly serviced and to file a coF�y of tiie scrvice cont��act with the
governnaental unit. The own�r fu�her agroes to file a cc�py of �ny chanyes io the service contract, or a copy of a new scrvice
contract, with the yoverrnY�ontal unit within ten (10) ousiness dnys froiY� thc date of change to the scrvice contract.
2. The owner agrees to cantraci witli a ��e�,son licensed under (;h. NR 113 Wis Adrn. Code, who shall submit pumping reports to
the govemmental unit in accord�nc� witt� SPS 383.55, Wis. A�in�. Coci�., for thc sGrvicing of the hoiding tank. In ihe case of
exc��nption tand�r Sc;ction 281 .A8 (3) (d). Stats., the owner shall :suomit the report to the yoverninental unit. The gaverrnnental
unit may �nter upon the property to investigate iht� conditior� i,f the hol�lany tank when puniping reports inay indicate� ths
,, f�iolriiny tank is not being properiy �nair7tair7etJ.
3 If the owr,!rr fails tc, ���avr� the ho{iiiriy t,�r�4< pruperiy s�rviced ir�� rc�sponse to orde+s issucd by t1��i�; yovernmenla4 unit to ��revent
or abate a h�mar� i�7e�ith i7azard ��s ciescnbed ir Snction. 254.59, Stats., the government�l unit may enter upon the property
and service, or cau�e th� tank to t�e serviced. Pursuant la Section 145.'l.0{q) Wis. Stats., a govemmcntal unit may assess the
owner of a privale sewaye system for costs relatc�i to the F��umping o� :a septic or holding tank. The charges will be �issesseu
as �rescribecl Ly Seciion Ei6.0703, str�ts. Thc owner agrees to pay ali char�.�e:�, :�n�J cost iricurre�i by the yovernmental unit fur
inspection, pumping, hauiing, or otheiwise scrvicir�c� ;jr�d rnair��2air�i��y thc hoidiny tank in such e manner as to preven! or abate
any human health h�card caused i.�y ti�e 17oidmc� 1ank.
4. This agrEem�nt will remain in Effeci only until the governmenial unit resNonsiole 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 bc car�celle�J by executing and recording said certification with reference to this
agreemen# in such rnanner which will perrnit ti7e existe�7ce of the c�rtilir�tion to be detent�ined by reference tc> the E>roperly.
5. This ayreement shail be binding upon the owner, the heirs of the owner: and assic�nees �f the own�r. Tfte owner sl7all submit
the agreement ic� the register of deeds, an� the a�reement shall be recordE;d by the register of cleeds in a manner which will
permit the existence of the agiecment to be detr rmined by refe�er�ice to the proE�erty wherc the holdirig tank is installed.
Only one owner sic�naturo requirQd - ACKNOWLEDGMENT
Owner' � nature: _ . W t �,o , :-
State o�: s '� �
-------- —_
— _ - � (�o�.inty <�f: ---
-- ___ ..__..�_____.
� Own .r Narne (Pnntj: ��`�""'�'��' Subscri�iet! and sworn t before n�e on this
� _. _� �`n �-�- ��l �. . � � �= S�rx�=T� � —ca a y of �_ , 20�3
� �y � �
iDate: I _ _ _ . _ ��� irrr��
� �Y lC�wner's Name)� _._ �—^�,``�-dB#�E-.y����,
( . � 2 �` �� Z � _ I Nr�tary Nublic Siynature: G �^'�/��`'l" Q` ....., G' �,�
- _. __ _.� r _ _ ., ,� �
Dratted by: � F'ubiit: N�tary Narne (f'rint)� _ !� 6�M'���_NOJ� `•.� ;
1I - ,, ,� . -�l� •. r'' =
R-`� ,�lV-� `� M y cor7�rni:;sion ex pires ori: �o e yol f= �n : � 'Q : r n =
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Perconal ir7ft�rntation ynu provide may be used tor s�-�condary pur;,nyes (Privacy < <iw, � 1.i.Od (I) (m)J i�� �,tu11.3...••'� ��
� CJ
•,� � ��5���� �� ���,
Part of the North-East of the North-West(NENW),Section Thirty-Six(36),Town Forty(40)North,Range
Seven(7)West.Lot Two(2)CSM 38/162#8719 Doc#445436
� `""'"`�- PRIVATE ONSITE WASTE TREATMENT county
���, ��o$� SYSTEMS
`,�:� �s ( POWTS) SaWyer
�, ry �.._ .3-.. ;
'�=v�,�" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2.?j- —(��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Viilage Town of: State Plan Transaction ID#:
�A-K Ca�.s��� ��, ----
Insp BM Elev: BM Description: Parcel Tax No:
a�. � `�o �� I�T. �;� <i o� .-�Yd-,3� -�t l�
TANK INFORM TION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � � LP Benchmark (oa•o�
Dosing
Aeration Bidg. Sewer Ci7,S�
Holding St/Ht Inlet `�'6.S'$
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG vEN-r ro ROAD Dt Inlet
AIR INTAKE
Septic ��' N 9 �-g � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative
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 � GP ❑ Chamber Model Number:
o EZFIow
CELL TO ❑ Mound o Other
__- -- - -- -- -_ _____- -- — __- ----- ---------- -
DISTRIBUTION SYSTEM x Pressure Systems Only
Hea�der/Manifold Distgbution_Pipe(s) — p —'�X-Hole Size- - Xp oleg Observation Pipf;s�
Len th Dia �Len th Dia S ac S acin �Yes ❑No �
SOIL COVER
_ __
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center ( Cell Edges � Topsoil �— ❑Yes ❑ No ❑Yes ❑ fJo
COMMENTS: (Include code discrepancies, persons present,etc.)
��((� ��(���3
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Plan revision required?❑Yes❑ No �� ! � —�
I�03 �3 i� '� -- �� G� �l
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKE�
SANITARY PEAMIT NUMBER: '�.�_��_7
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