HomeMy WebLinkAbout032-539-34-1110-SAN-2023-184 ��'� "'. , tndustry Services Division Counry � L r �
4822 Madison Yards W ay '[�
= -�S' - Madison,W I 53705 Sanitery Pertnit Number(to be llled in 6y Cc
S - P.O.Box 7162
_ Madison,WI 53707-7162 (�S �V'a S �
Sanitary Permit Application StateLansaclionNumber `i'
In accordance with SPS 38321(2),Wis.Adm.Code,submissan ofNis form to tAe appmpriate govemmcnlal unit �'j
is requircd prior m obtaming a sanifary pertnit.Note:Application fo�ms for smle-owned POW7'S are submitted[o Project Add�ess(ifdiRerent than mailin¢ad� -rr
the Ueparm�ent of Safety a'd An(essional Services.Personel inFormation you pmvidc may be used Por secondary
purposes in accordance wiU Me Privary Law,s.15.04(I xm),StaR. S 7 7 a w �r0� �`�• �� h
1.Application Informatioa-Pkase Print Ali loformafion
Property Owner's Name Parcel N
G � �* ��c•'S e� 6�2—539—3S/-//�a
Property Owner's Mailing Add1ess �Propem Location
�S�� � �-C.. � � O l^�.�Sy�j Govt.Lot
City,Stale Zip Code Phone umber �
�� fl �$ �y O P? /YF '/.,��'/.,Section�
O O 8
IL Type oT BuiWiag(c6eck all that apply) � Lot k � T 9 N R E
I or 2 Family Dwelling-Number of Bedmoms Subdivision Name
Biock#
❑Wblic/Commercial-Describellse
❑City of
❑Sta[e Owned-Describe Use CSM Number ❑Village of ��/�
Town of (/���/1�[�
IU.Type of POW75 Permi�(Check either"New^or"ReptaeemeM"and other applicable oa liae A C�eeck one boa on Gae&Compkte lioe C i
a licabla)
A.
�New Sys(em ❑Replacement SysRm ❑Otlier ModiFicatioo to Ezisting System(explam) ❑Additional Pretreatment Unit(explain)
B� 00 Holdin Tank ❑In�'irourd ❑A[-Grede
�` B ❑Moimd ❑Individual Site Design ❑OIAer Type(ezplain)
(conventional)
r� ❑Renewal Before ❑Revision ❑Change of Plumber ❑Tiansftt to New Oavner ���'�ous Permit Number and Date Issued
Expiration
IV.DispersaVCrcaMent Arta aed Tank loformation:
Design Flow(gpd) Design Soil Appiicabon Rate(gpd/s� Dispersal Ares Required(s� Dispersal Area Pro�sed(sfl System Elevation
Capacity in To�l #of Man�fachuer
Tank Intonna0on Gallons Gallons Uni6 �
New Tauks Existing Tanks V� -
a`U in� D C; a
Sept�c w Holding T�k O 2� /
oo�cbmnna
�' G
V.Respoosibility Sfatea�eot-I,the oadersigoed,aseme rtsponsibitity for inshlhtieo o(t!c POW7'S sh oo ihe aturhed plaoa
Plumber's Name(Rin[) Ylumber's Si naNre PRS Number Business Poone Number
en�' MG� oZo25/6 f -7/.S'c�14-3o5�a
Plumber's Address(Shee4 iry,Smt ip Code) n
'-l3yo,�.� Lr4/Lt �;,1'�lr .Y_ �1:.1'��v� l�J�- ���1%
VI.Co e /Deparlmeot Use Ooly
�, ❑Disapproved P�y°p Frs Uate Issued Issuing Agcnt SignaNre
�Q Owner Given Reason for Deoiel s l�.� '?J I�"�I�-5 ��li-G(..c1�.�i�iT�"�.
Conditions of App�ovaUReasons for Disapproval
0�?�GII�,�� �' �v� ?��'�
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.aedmrocompe�ephest�m�syaemaoambmrtromeceaery�y�ooPaperoa��m.oa�rs:�t' m� 7
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NO R�FUh�S AFTER
15SUE OF PERSAlT
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
������11
R C 1 Hayward, Wisconsin 54843
� E,--_ O t
"'�,- -�Ci �� (715)634-8288
� �� FAX (715)638-3277
i Q� �:2�I�
jy ` ` - I� % wwwsawvcrcounty ov.org
� o� :� � � r o � E-mail: sanitarian(ci�sawyercounLygov or�
/ ��y;�� �� � Toll Frec Courthouse/Gencral Information 1-877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp d$ / ��7 / �3
Parcel ID# 0 3 � _ �' 3� _ 3 � - I � I a
II. Plot Plan:
� Property Lines �Benchmark BM ♦
� Site Address �C North Arrow
�Y Structure �(Scale
� Well �< 25' to Service Road
� Legal Description �j 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 Agreement Form ($30 to ROD)
IV. Holding Tank Specifications:
D� Tank Cross-Section: Manufacturer: 1-1 ., Gallons: �, �a
�Tank Anchar Calculations [SPS 383.43 (8) (g)]
�Locking device, chains/locks
XAlann, 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: �°`� Plumber: ���^
Application Review Date:
POWTS Reviewer: ��,,,;,
Name r
6 R � ��o Rev. 4/27/2023
Credential #
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
���►n�,a�r�.�,►�: �2--�- �
v�;o�, sBo-��M_o�o�;R o���za �
Pg 1 of 4 •� irxiex 8�Cover Sheet
Pg 2 of 4 Plot Pian
Pg 3 of 4 , H�ding Tank Specifications
Pg 4 of 4 Managernent Plan
Attachmerris: Enclosures:
POWTS Application for Review
Soil Evaluation Report 8�Site Map(if appiic�ble)
Holdi Tank Pum in Contract if a licable)
Holdin Tank A reemenf if a licable
Project Name/Description
owner Name(s):_��e P h e�, � 11ct H Q�.-SD.•J Phone:
Owner Address: W S 18S (.��a)e�. L�ua R lI. -{'r'e9 a W�Zip: $Y S8�
Project Address: s�7 70!�) . -fro M ��, 1iLl:�q�t.v W Z 5S/gy'(o
Govt Lo���� 1/4 ofit!� 1/4,Section�_,T�N-R s E Q or W�
Township- �i�.�2 v County: s4 u.�v�P�
Project Pa�cel ro�:_D__32 - 53� -3 y-���o
Designer Information
Designer Na�: M1 I�.e Y�'16 Kf�o,�,,,�� Phone;'7iS -d(ob -�_
Desig�rAddress• `13Nanl [.�-u�w-.�f�.�� R�• l�r.�.�ry W� Zp: Sy 6�!'
E-(Y181�: This space reserved for approval stamp.
License Number: �D ��S/ � `1
Remarks:
5ignature: ���� -- Date: 8-3 � 3
.,.�Q..�.w.e,o; ,.�..,a. ....._.
CMECK 80X AS APPLICABLE. CHECK BO%fS APPLIGBLE.
� SOIL EVALUATION o s�ie: 40 ao� � � � SYSTEM PAGE 2 OFy
SITE MAP PLOT PLAN
PROJECT NAME: �p, DESIGN FLOW'. Z s o cao
�j�lQ�!n� KQ� �—QVSO � Attach design flow calculations for commercial plans.
PROJECT ADDRESS'. S77D y/ �r�M {Z� • Wyrav Pipe Material/ASTM Standard(Tables 384.303 8 384.3P5)
� /or. n � N 5�,���,,,a�'�
8M S/mbW BM Elevation'. Fpce Main /
BM Descrip�ion: A�ni � i h A-0Pn1[ '�Tf t
S�o cratliera q) �^e�^a+�bf' IMPORTANT:
� � Weu Symbd(Aapplicacle): � a�a..���9 e�aRw� Show grourM elevaUon conlours at suifable intervals.
of TeSIeA Area: on Ne approprile Ine.
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PAGE 3 OF�
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-r�►e�r�t���cts�s�at�e�t��s�o��a���
�a�sPs�384�w��dmi�t.t�, Pt���S�52¢b�isc Ach�.t,1�ttis Nold��ic(s}
�i 6a oo�ed a t�s�s t�l�azaaa�r�ot�a�ed"s►��ce�t t��rl�r�tet�p�t.
F�������be pe�fo�ed b�►a�P011f1�S 1��
�ideu�e wifft SPS 383.52(3j,ifl�Ad�►.t�o� - .
E�dOa@y-UIf�rHa�= _ZQ-D gpd • . _ .
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o iype af use �
o �e a�system - _ ' .
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o n�e�t�i�p�u�e t��.eccee�g����++�e�} _ -
o �c�n�t��.������e�3 . .
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� Tbe�sj sl�a1 be pu�tiped by a c�ar66ed se�ge se�ic�rg�oir�d t�s.�'[�8�S'E�
- ro�en f�e��t�e�sj e�a fe�ret�f auis�oot balow fha iat�irY+�ert a�8�s�sj. - �
_ D�of tao�ds s[m�6e pas�ttt�l�2113.1Ai�Adr�n.t�d�
T�Nc�repocEs sim�be�ad��e pcnper Ioea1 gav�rt em�in ataco�ew�#e SPS�5 Vf�s. .
� . Admit�.Oocle. i�e�ort�l compone�f�e��b�:�
�Name a��arcz�mpai�r, M�e MOn�gOmery - - � 71�266-k30$0 . .
t�cet�+r�an�aa�it�������9 � p�,�; 71�-6.34-8288
t��,rer,�r���aac� 10fi'IO Main Str+eet Sui�e 49, Hayward, VIT! �, 5484.�
Arty de�dive�t a¢t�is sys�sha/b�r�ed.�or tet�pt�rt�o�S 383.51(f}.Vft�Ad�.
(:od�Repair or r�ier�o�fa�ed or n�c�pot���y w�SPS 383,V4�.�R�t.Code. -
NQ�fot d�or p#�y�ai res�ira6on c#fl�e PtriYTS tt�/be u�d uni�a�o�ved by�e�tte�'ss
- a�ww�h S�'S 384,V1fisG A�r�t�oae.
• Cori�rtctr Ptae� ' -
in�s en�ett ft�assy f��ot�afi�s ttoi�ng t�[c(s)�6e t�.��ait ve repZac�ed pts�#i�a � .
�pl�t�ed�athe ap�op�e�e a�ifaceyiew�d apponrai, - .
- �rs�etn Ab�ndonet�ttt � - .
� if use a�th�faNc(s)is�cWed,�s�l be ab�doned in�oe wi�t S`PS 383,33,WisG Admin.Code. �
HOLD►NG TANK SER�7CING CONTRACT
Contract Datc: S I�1 2 3
This cantract is madc bctwccn thc Holdin�Tank Owncr and thc Pumper.
Holdin�!Tank Owncr's Name: Pumper's Name:
�c1_P�QN � � ` �Se� Northwest Sanitary,Inc.
-Tr� �'Q- PO BOX 155
Radisson,WI54867
Parcel IdentiGcation Number:
(12 Digit Legacy ID) ��Z -�.3 S -��-���D
I. Thc owncr agrccs lo filc a copy of Ihis contracl wilh thc govcmmcntal unit,Sawycr County,
which has acccplcd and recordcd wilh thc Officc of thc Rcgislcr of Dccds,thc Maintcnancc
Agreement for a Hofding Tank required under tlie Sawyer Coimty Private Sewage System
Ordi�ance for the issuance of a Sanitary Permit for the installation of a holding tank(s).
2. Thc owncr agrccs to ha�c thc holding tank(s)scrviccd by lhc pumper and guarantccs lo
pemiit the pumper to have access and to e�[er upon the property for the purpose of servicing
thc holding tank(s). Thc owncr aSaccs to maintain thc all-wcathcr acccss road or drivc so
that thc pumper can scrvicc thc holding lank(s)with thc pumping equipmcnt. Thc owncr
furthcr abTccs to pay thc pumper for a chargcs incurrcd in scn icing Ihc holding tank(s)as
mutually agreed upon by the owner and pumper.
3. Thc pumper a��rccs lo submil to thc Govcrnmcntal Unil,Sa�rycr County,a rcport for thc
scrvicing of thc holding tank(s)as rcquircd undcr SPS 3R3.55,W'isconsin Administrativc
Code and the SaHryer County Private Sewage System Ordinance. The pumper further
agrees to include the following in the report:
a. The name and address of the person responsible for servicing the holding tank;
b. Thc namc of thc owncr of thc holding tank;
c. Thc sitc address of thc holding liink;
d. Thc datc thc holding tank was scrviccd;
e. The volumes in gallons of the contents pumped from the holding tank for each servicing;
E The disposal sites to which the contents from the holding tank were delivered.
4. This agrccmcnt will rcmain in cffcct until thc owncr or pumper tcrminatcs this contract. In
thc cvcnt of a changc in this contract,thc owncr agrccs to filc a copy of any changcs to lhis
scrvicc contract or a copy of a ncw scrvicc conlract with Sawycr County wilhin tcn(I I))
busincss days from thc datc of changc to this scrvicc contract.
Owncr's Namc:�Print) Owncr's Sibm urr.�o��.���.�„�r�.���.����•��y�irea�
5-��P���1 ���5o a/
Pumper's Namc:(Pnnt) mper's Si
Ronald L Vieceli,owner Narthwest Sanitary.lnc �
�!''+f�i� / �i w,�
Pumper's Rcgistration Numbcr
#2389
Rcv.Oi/2C�'li
Real Estate Sawyer County Property Lisung Property Status:
Today's Date: 7/24/2023 Created On: 2/6/2007 7:55:59 AM
Descriplion Updated: 4/21/2010 Ownership Updated: 9/12/2019
Tax ID: 35643 ST'EPHEN T& KAY F TREGO W[
PIN: 57-032-2-39-OS-34-101-000- LARSON
000100
Legacy PiN: 32539341 Billing Address: Mailing Address:
Map ID: 1.10 STEPHEN T& KAY F STEPHEN T & KAY F
Municipality: (032)TOWN OF WINTER LARSON LARSON
STR: 534 T39N ROSW W5188 WHALEN LAKE W5188 WHALEN
Description: PRT NENE LOT 9 CSM 2/58 � LAKE RD
#252 TREGO WI 54888 TREGO WI 54888
Recorded Acres: 1.690
Lottery Claims: 0 Site Address * indicates Private Road
First Dollar: No 5770W STROM RD WINTER 54896
Waterbody: Winter Lake
Zoning: (R-1) ResidentialOne PropertyAssessment Updated: l0/10/2016
ESN: 2023 Assessment Detail
Code Acres Land Imp.
T`ax Districts Updated: 2/6/2007 G1-RESIDENTIAL 1.690 58,000 0
1 State of Wisconsin
57 Sawyer Counry 2-Year Comparison 2022 2023 Change
032 Town of Winter Land: 58,000 58,000 0.0%
576615 Win[er School District Impmved: 0 0 0.0%
001700 Technical College Total: 58,000 58,000 0.0°/o
Recorded Documents Updated: 3/1/201]
Wt1RRANTY DEED p�percy History
Date N/A
Recorded: 8/30/2019
EASEMENT
Date Recorded: 2/4/2011
WARRANTY DEED
Date
Recorded: 12/10/2010
CERTIFIED SURVEY MAP
Date
Recorded: 4/17/1972
li ���ii�l�� �I Ili�� I� Il�liiiil I I��
- USE BLACK INK ONLY - � � �-� ^^,^��^
'..'OCAU :G!!!L(4L
T.. , ���r-r� �
POWTS MAINTENANCE AGREEMENT i x .4u�+o r ;4
For Holding Tanks 445854
PAULA CHISSER
AL/�TL`TCf� Ac �cvrro
OW{12�$ I1{8(�I�$�$$$rjQWI1O(1�= RCl'[LJI GR Vr �./CCV.'7
SAWYER COUNTY, WI
OS/ii/2023 11: 19 AM
��h�� � � � ��$o � RECORDING FEE 3flA0
Pat�el lde�qtion Nunber.
c12��r m> Q.3 ?— S.�1 — .,�GL,—�L 1��
PAGES: 2
Le9a1 Descaiption of ProPerlY:
- SEE ATTACHED SHEET-
We adcnowledge that app6catio�is being made tor U�e ir�on of a hoiding tar�C(s)on the
property desubed on tlte a�Ched sheet
Rehxn To: SaMryer Cow�qt Zoning and CoaservaYion Admt�on
10610 Main�.Sulbe 49'. Hayward,WI 54843
As an induoerr�errt to tfie County of Saveyer to issue a sartitary permit for a hatdicrg tank on the above�ed property, the owner is
respons��for Uie operatiort and mairrienar�e of the holding tank �oddn9 device. atarm a� acce,s.s, and agrees to confarm to all
applicable requiremenls of SPS 383, Wis. Adm. Cade relating to holfir►g tar�c�nagement, indu�ng the fo{b�wing:
1. The owner ag�ees to ca►tract with a person who is lic�ensed under C#ti NR 113. Wis. Adm_ Code. except as provided by
Section 281.48 (3) (d). Sfiats.,to have the hold'ag tank pra�riy servtced and to fite a c�py af the servioe cont►act with the
govemmental u�it The o�further agrees to file a copy of any dsanges to the service c�tr�ct. or a copy of a new service
contrad, with the g�vemmenfal unit within ben (10) bus'u�ess�ys from tl�e date �change to the servioe contrad
2. The orvner agrees to conhact with a person 6ce.nsed under Ch. NR 't33,VY'�.A�n. Code, who shall submit Pur►►Pin9 ►ePorts to
U�e govemmental unit in accondanoe with SPS 383.55, Vltis.Adss_ Cocfe,#or the serr+iang of tl�e holdirg tardc. In the case of
e�nption under Sedion 281.48 (3) td), Stats., the ovm�st�A s�sbmi�ttse �port�the governn�l �it. The govemmerrtal
unit maY erqe�upon the proP�Y� ���9a�e the condition of fhe�rx,� tatdc when Pumpin9 reporls maY indit�ie the
holding tank is not be�g propery mairdained_
3. If the owner fatls to hav�e the hatd�g taidc properlyr serv�ed � resposss�t� orders issued by tt�e govemmerrtat unit to ptevent
or abate a h�nan health harard as de.scntied in Section_254 59. Siafs�the govemme�l unit rrray enber upon U�e PropertY
ar�d serv�ce. or cause the tank to be servioed. Pu►suant to Sed�un 745.20(4)YY�. Stais., a govemme�al unit may assess the
owner of a private sewage system tor cost,s reaa�ed to fhe p�as�pir� �a septic or holdirg tank. The d�arges vnll6e assesseci
as prescribed by Secti� 66A703, stats. The owner agr�ees to pa�f a�diarges and cost incumed by the govemmental unit for
�nspection, p�anping, haubng, or oitterwise servicirxx� and mairt��nusg L':�ho�i'mg tardc in � a rr�nner as to prevent or abate
any human heaflh hazatd caused by the holding tank.
4. This agreement wiY re.rnain in effect oniy unW tl�e govemm�af ur�it c�ponsible for the �fiion ofi priva�e sewage systems
certifies that eifher a soil absorption sys�em that compGes with SPS 3�i,W�. A�n_ Code, or a mu�ipal sewer serves the
P�PenY- tn addtion, this ag�etrierrt may be cancelkd by execesfing and recording said �cation with reference�o this
agreernent in such manner which will permit the existence af the oertifrcation to be detemuned by refierence to the properiy.
5. This agr�t shaN be bind"ag upon the owr�, ihe heirs of the awner, and assignees of the owner. The oMmer shatl submit
the agreement to the r�er af deeds, and the agreemerrt sha0 be recorded by the regis�of deeds in a manner vrhich will
permit the e� of the ag��ent to be deterrnined by refesence to the pmperty where the hdd'm9 tank is installed_
' ACKNOWLEDGMENT
s re: _ � �� � ,� .
, �
Courrty of_
S .�)� � _ Subsc�ibed and swom to beiore me on this
�`` day of J L , 20 �
Date: _.._� _ � �^ ZO 2 3 By (Owners Name): � L�r So r�
Notary Public Signature: _
Drafted by: d
Pt�lic Notary Name (Prirrt): '�•���e Sh:�.w I�r-Z�Ly,�on
`(J�J 1�-� (�/l1 v�{- My commission expires on: r� R-ZS � Zo25
Pe�sonal iMorrnation Y�P��Y�used for secondary PuP�s IP�Y�-�►. §15.04 p}(m)l Rev.03/26/13
'����
��
�fl��
That part of the Northea�Quarter af the Northeast Qnarter(1�ENE'/,),Section
T6ir#y-four(34),Township'Chirty-nine(39)North,Range Five(�West,mare
particalarly described as Lot Nine(9)as recorded in Woiume Two(2)of Certifie�
Survey Ma�s,page�S,5arvey Na.252 as Dncument No.Y3998Z,in the Tow�t of
Winter,Sawyer Coanty,Wisco�s�n.
>,,
�tr`""'� ; PRIVATE ONSITE WASTE TREATMENT County
�=� �$ SYSTEMS Sawyer
% p$ 'J ( POWTS)
H �- P:v
r�'"�� INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 3-- t��
Personal infonnation you provide may be used for secondary purposes[Privacy[aw,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village CD�Town of: State Plan Transaction ID#:
S-k��,, ��, w��- .�
C�rso�
Insp BM Elev: BM Description: Parcel Tax No:
oa.a `fj a� H). �;�- l� 0 3a-s.�9-3Y- /l�o
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �po_o `
Dosing
Aeration Bldg. Sewer -
Holding ,,,� �6Up St/Ht Inlet �633 �
TANK SETBACK INFORMATION St/Ht Outlet � (,.07
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dasing NA Instailation
Contour
Aeration NA Header/Man.
Holding �,�,� N (� N —o2S 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 �N � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
P/L Bldg Well o IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO ❑ Mound � Other
- — --- -----_ _ — — ---
DISTRIBUTION SYSTEM x Pressure Systems only
---- -- - — --
Header I Manifoltl Distribution Pipe(s) X Hole Size � X Hole Observation Pipes
Length Dia___� Length Dia Spac � Spacing ❑Yes ❑ No ,
SOIL COVER
---- -- - - ---- -- -
(Depth Over Depth Over �epth of Seeded/Sodded Mulched
Celi Center I Gell Edges �, Topsoii � �Yes ❑ No 0 Yes ❑ Vo
COMMENTS: (Include code discrepancies, persons present, etc.)
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—� I �
Pian revision required?❑Yes❑ No �j 3 i3 �2c/� � I �7 �,L,�
�_��1 --- - - -
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SAN�TAAY PERMIT NUMBER __ �__'"_�_�_
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