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Home My WebLink About028-642-19-3106-SAN-2023-201 ' Department of Safety Counh� � \ � - & Professional Services, Sawyer S : Sanitary Permit Number(to be filled in by C� � �: ,, Industry Services Division µ; (Q S � ��};� F� ' W Sanitary Permit Application State Transaction lvumber � In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �— � is required pnor to obtaining a sanitary permit.Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing a '� the Department of Safety and ProYessional Services.Personal information you provide may be used for secondary purposes in accordance with the Privacy Law;s. 15.04(Ixm),s�t5. �13012N Landing Camp Rd I.Application Information-Please Priet All Information Property Owners Name Parcel# John H. Clark III Trust 028642193106 Property Owner's Mailing Address Property Location 5920N Bottom Rd Govt.Lot City,State Zip Code Phone Number QuIt1Cy, IL 62305 217-653-5997 NE y, SW y., section 10 II.Type of Building(check all that apply) Loc� T 42 N R 06 E W � 1 or 2 Family Dwelling-Number ofBedrooms 3 � ��, Subdivision Name Block# �'— ❑Public/Commercial-Describe Use — ❑City of ❑State Owned-Describe Use CSM Number ❑Village of �I 33� ��(3�� 0 Tow�of Spider Lake llI.Type of POWTS 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 � Re lacement S stem P ) p y ❑ Other Modification to Existmg System(explain) ❑ Additional Pretreatment Unit(ex lain B' � Hoiding Tank ❑ In-Ground ❑ At-Grade g yp ( p ) ❑ Mound ❑ Individual Site Desi n ❑Other T e ex lain (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permii Number and Date Issued ❑ Transfer to New Owner Expiration �,(y`k� IV.DispersaUTreatment Area and Tank Information: , Design Fiow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Reyuired(s� Dispersal Area Proposed(sfj System Elevation 300 -- r-- -- — Capacity in Total #of Manufacturer :: Tank Information Gallons Gallons Units � U U „ � New Tanks Existing Tanks y a " � V � � `� � U v� v� v� w C� L1. Sep[ic or Holding Tank 2000 2000 1 Wieser Concrete X Dosing Chamber V.Responsibility Statement-I,the undersigned,assome sp sibil' fo installatioa of the POWTS shown on t6e attached plans. Piumber's Name(Pnnt) Plum er's S n re . MP/MPRS Number Business Phone Number Douglas E. Manthey MP 230722 715-739-6868 Plumber's Address(Street,City,State,Zip Code) PO Box 196 Drummond, WI 54832 VL Cou ty,/Department Use Only � prov ❑Disapproved Permit Fee Da(e Issued Issuing Agent Signature �, �l. : �/� ❑Owner Given Reason for Denial $ �,� 6 � �� ' f��.ju Conditions of Approval/Reasons for Disapproval �� - , � � "� �� ' a�--- - __. . _ I� ��% ��'�� ! �� -� C � r��' ��.+�i► �;hk#__y 8 �' _____r_._ �, � � � AUG 15 2023 Gs� �.3- i � 1 : �� _ . ��ti�_��_ _ � sAtn/Y�� r�(.3��"�-�r Z(7N1NG ADMIlVIS"1`Rr'�i f0!�! Attach ro complete plans for the system and submit to the Counry only on paper not less than S v2 x 11 inches in size SBD-6398(R 03/22) �� A��h�s�T�R ISSUE OF PER�It1T 3U ► �t �i Sawyer County Zoning & Conservation Administration �� 10610 Main Street, Suite 49 �ER Cp��, Hayward, Wisconsin 54843 �� (715)G34-8288 ��' FAX(715)638-3277 \�I %y � - _ - �i�% www.sa�crcounty'ck)v.�rg � o` �o � E-mail:sanitarian��i�sawycrcount >ov.��rg I� \ �� 'y j � Toll Frcc Courtliousc/Gcncral hiformation 1-R77-699-4110 I�Z ��Y `� `"-��.� ��j;`ON�� Holding Tank Approval Checklist I. Sanitary Cover Sheet: Date Stamp �g/ I S / .23 �arcel ID# D�8 - G �( �-�� - 3 ► 0 (p II. Plot Plan: �Property Lines � Benchmark BM ♦ X Site Address �C North Arrow X Structure �Scale �Well DC<25' to Service Road �C Legal Description �"Nearest Road Intersection � Setbacks to: Property Line, Well, Structure, Water bodies, Roads IIL Required Plans: Index Page with Original Signature Management Plan/Contingency Plan �D Servicing Contract �Holding Tank A��-eement Fonn ($30 to ROD) IV. Holding Tank Specifications: � Tank Cross-Section: Manufacturer: w�eSfLf Gallons: �oaa aC Tank Anchor Calculations [SPS 383.43 (8) (g)] � Locking device, chains/locks �Alann, electrical per SPS 383.43 (8) (e) �C 3" Bedding Material < 1/2 " V. POWTS Component Manual Reference: � Holding Tank Version 2.1 (May 2022-2027) Owner: C�o�{ (/`�T��3� Plumber: a e Application Review Date: 0'$�23��-0>.. 3 POWTS Reviewer: ` Name �`�' S� ((o Rev. 4/27/2023 Credential# PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual 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: ��, �TQ,.�k POWTS Application for Review Soil Evaluation Report&Site Map(if applicable) Holdin Tank Pum in Contract if a licabie) Holdin Tank A reement if a licable Project Name/Description John Clark Holding Tank Owner Name(s): John H.Clark III Trust Phone: 217 _653 _5997 OwnerAddress: 5920N Bottom Rd Quincy, IL ZiP: 62305 Project Address: 13012N Landing Camp Rd Hayward Govt.Lot: 1/4 of 1/4,Section�9 ,T 42 N-R 06 E❑or W ✓� Township: Spider Lake County: Sawyer Project Parcel ID#: 028642193106 Designer Information Designer Name: Douglas Manthey phane; 715 _739 _6868 Designer Address: PO Box 196 Drummond,WI Z�P; 54832 E-mail: norpines@cheqnet.net ,,:,,,,,� �,.�, ,,,,�_� _ License Number: MP 230722 Remarks: i � Signature: Date: 08/14/23 rigi natu requi d o each submitted copy. Sb� zS ')r7 a�7 l� dc�..ol .y� ' 7.� P""�°�5 �Cf�+'i� .o a/rnbS S6�SQ G6 -�-'�u� ��'S Z'# �!9a� 2p1 £ti lr�.�sro � y!d /,�n5�7 �h•G6 1-��y� ls � � '�� 9� � z£h -�f ��r �s� � �a�.�.no PNb -r�d Ms�N -�-�d �'910�� m 90 � N ab,1 bl S �'7N v+o P''eoq .�au��7 p�lwo�'' a ��/"'7.Oau�/d5 fo uMQ1 - � 1�_ £/,6hS )�^'�"►'� � Nro� Nt�o £� � soErg •z.t �(� u!n�9 •��, �� .�u, p _�-- ' P�y `z'o-��°8 ri � r6s a�'� S � �r"�,� zzr �i'a»�� 1� u'�°l �Aa N^'�O_ {------� — __--- Qh � � p� d„�v� S.�,,J°"v7 `— � a�'�'S Nrlo�l� 7n�ss �Qr �a qh y�s ,, y, �9 p� 6�,�,� a��.��.,�,�o, ��y, - �f.Lot -�te1G ��.A) � •� No'SJan 7'�nOlov��1o1ot, 1� �"YJYIM�O� �aN�� -+ '1`' .:.�.N �d�/S t �1, o�oL°a,S� Y:,� •�.r� n H � ' � 18 r . r# �n �8► ++;9�7 �� , � ,,,qt� �Pb r � � �. ,,_ / h � o z a6bG{ ��oq )0"'7 .GSa7 PAGE30F4 HOLDING TANK SPECIFICATIONS (No Scale) Weatherproof 12"Min.or 2.0 ft above Junction and qPP�o�� Esfablished Flood Elevadon Alartn Box Vent Cap �tyP�� Electdcal must comply with 1 Approved Locking Manhole SPS 316 and NEC 300 4"0 Ven[Pipe � with Waming Label AOached �Conduit >10 ft from (typical) 4"Min.or 2A ft above Building I Established Flood Elevation 1 (ryPicap - �AirtightSeal Finished Grade 18"Min. (�YPlcal) - �=. - � .. I a . 9 . I � Inlet Inle[Imert fWatertight Approved Joints with Plug Approved Pipe 3 ft onto � Max. 72"or 90%of�otal volume Solid Ground � if more than one tank a Alarm-0n < HOLDING TANK VOLUME = 2000 gal e . 4 . . ' e . . . . . . . n . 3"Approved Bedding Material Beneath Tank TANK MANUFACTURER: Wieser Concrete Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)- Ibs.tank.wt]x 1.5 Ballast weight= [( 501.67 cu.ft. x 62.4 Ibslcu.ft)- 23830 Ibs]x 1.5 = 11211.3 Ibs PAGE4UF4 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 382-384, Wisc.Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s) shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Estimated Daily Wastewater Flow= 300 gpd Insaection 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, alarms, etc.) o surface discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats. when the wastewater in the tank(s) reaches a level 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 reports shali be submitted to the proper local government unit in accordance with SPS 383.55 Wis. Admin. Code. Report any component failure or malfunction to: Name of individual or company: AffOf d8ble S2ptIC Phone: 715-634-3355 �ooai 9o�e��me�c ��t: Sawyer County Zoning & Conservation pnone: �15-634-8288 �oca� government unit address: 10610 Main St #49, Hayward, WI 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 shall 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. Continqencv Plan In the event that any failed component of this holding tank(s) cannot be repaired, it shall 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. WSLP2000 HOLDIN.G 184.� TANK SPECIFICA710NS � I � � DIMENSIONS: a a WALI: 3" a a BOTTOM: 5" � _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ i covER: s• o MANHOLE: 24" I.D. PRECAST CONCRETE RISER � I HEIGHT: 46" O.D. a II LENGTH: 184" O.D. � �� 4" CAST-A-SEAL II �I yNp'p-�; 102'� O.D. � BELOW INLET: 34" O.D. '� � � �I�! LIQUID LEVEL: 29" � � o `No �z4� �I �� WFJGHT: TANK - BOITOM 14,530 LBS. TYp � I� COVER 9,300 LBS. I \ J � ' �; � I' O . �I ii INLET: 4„ CAS7-A-SEAL BOOT OR E�UAL m g � - - - - - - - - - - - - - - - - = INLET BAFFLE: � � � — — — �- �=�- � — NASCONSIN, SEE DETAIL �J10 TOP I W (OTHER STATES SEE CHART) W n LIQUID CAPACITY: 69.77 GAL/IN W � HOIDING TANK: �i � OUTLET HOLE PLUGGED ACNAI CAPACITY: 2,020 GALLONS C o � LOADING DESIGN: 8' 0" UNSATURATED SOIL � z � � o I TANK CAN BE USED AS: � i N HOIDING/ PUMP � W � � COVER: MIX DESIGN �8 (NO FIBER) � � O VENTED LID TANK: MIX DESIGN �9 (SMALL FIBER) W N a0 � � CUSTOMIZED TANKS: � FOR CUSTOM TANKS CONTACT NflESER CONCRETE � � d � 3 a w � ��T� — .� .��'.. .._,'�..'.• ":. Z J INLET — _ — --i� ¢ �,< O Z d 3 _ M N �. O �2 � � _ — N U M _ �—._, ,- — -� � F a DRAWINGS SUBMITT'ED �i vwi ;� FOR APPROVAL SIDE VIEW APPROVED BY: SHEET N0. , APPROVAL DATE: '� � PRODIIRS NEFDED BY: /�F q � 'KS ARE MANUFACNRED TO MEET OR EXCEED ASTM C-7227 REOUIREMENTS � HOLDING TANK SERVICING CONTRACT Contract Date: /�/ O,2 This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Oumer's Name: Pumper's Name: John H Clark III Trust �� e�,�� Parcel Identiflcation Number: (12 Digit Legacy ID) 0 2 8 - 6 q 2 - 1 9 - 3 1 0 6 1. The owner agrees to file a copy of this contract with the govemmental unit, Sawyer County, which has accepted 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 installaCion of a holding tank(s). 2. The owner agrees to have the holding tank(s)serviced by the pumper and guarantees to permit the pumper to have access and to enter upon[he proper[y for the purpose of servicing the holding ta�lc(s). The owner agrees to maintain the all-weather aceess road or drive so that the pumper can service the holding tank(s)with the pumping equipment. The owner further agrees to pay the pumper for charges incurred in servicing the holding tank(s)as mutually ageed upon by the owner and pumper. 3. The pumper agrees to submit to the Govemmental Unit,Sawyer County,a repoR for the servicing of the holding tank(s)as required under SPS 383.55,Wisconsin Administrative Code and the Sawyer County Private Sewage System Ordinance. The pumper further agees to include the following in the report: a. The name and addtess of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The site address of the holding tank; d. The date the holding tank was serviced; e. The volumes in gallons of the contents pumped from the holding tank for each servicing; f. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect uuril the owner or pumper terminates this contract. In the event of a change in this contract,the owner agees to file a copy of any changes to this service 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 Name: (Print) Owner's Signature:(ony one own�.st�namre reqwrea) oi.� H. �I � � � _ � Pumper's Name: (Print) Pu r's Sign re: R ,� �e crc� � �,��(� Pumper's Registration Number: � 8 0 � �� a xe�.osiz6iis AUG 2 2 2023 S,qWYER COUNTY ZONING ADMINISTRATION i iiiiii�i i i iiiiii DocI 8073132 -USE BIACK INK ONLY- Tx:4046972 446046 POWTS MAINTENANCE AGREEMENT PAULA CHISSER For Hoiding Tanks REGISTER OF DEEDS SAWYER COUNTY, WI Owner's Name(s)as shown on tleed: 08/22/2023 01:45 PM RECORDING FEE 30.00 John H Clark III Trust Parcel Identificafion Number: PAGES: 2 (12 Digfl LegacY ID) 0 2 8 - 6 4 2 - 1 9 - 3 1 0 6 Legal Description of Property: -SEE ATTACHED SHEET- We acknowledge that aDdication is being made for the installation of a holding tank(s)on the property described on the attached sheaL Retum To:Sawyer County 2oning arM Consanation AdmiMatration 10670 Maln St.Suke 49,Hayward,WI 54843 As an inducement to the County of Sawyer to issue a sanitary pertnit for a holding tank on the above-descnbed property,the owner is responsible for the operation and maintenance of the hdding tank,locking device,alartn and access,and agrees to confortn to all applicaWe requirements of SPS 383,W is.Adm.Code relating to holding tank management,induding the following: t. The owner agrees to coniract 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 hdding taok propedy serviced and to file a copy of the service contract with the govemmental unii. 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 fhe service contrad. 2. The owner agrees to coniract with a person licensed under Ch.NR 113,Wis.Adm. Code,who shall submit pumping reports to the govemmental unit in accordance with SPS 383.55,W is.Adm.Code,for the servicing of ihe holding tank. In the case of exempUon under Section 281.48(3)(d), Stats.,the owner shall submR the report to ihe govemmental unit The govemmantal unit may enter upon[he property to invesdgate the condition of the hdding tank when pumping reports may indicate the holding tank is not being properly maintained. 3. If the owner fails to have Me holding tank propetly serviced in response to ordars issued by the govammental unit to prevent or abate a human healih hazarcl as described in Section.254.59, Stats.,the govemmental unit may enter upon the property and service,or cause the tank to be serviced. Pursuant to Sedion 14520(4)Wis.Stats.,a grnemmental uniY may assess the owner of a privale sewage system fw costs related lo the pumping ot a seplic or holding tank.The charges will be assessed as prescribed by Section 66.0703,sfats. The owner agrees to pay all charges and tost incurted by the govemmental unR for inspectio�,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 effed only until tha govemmental unit responsible for the regulation of private sewage systems certifies that etther a soil absorpGon system that complies with SPS 383,Wis.Adm.Code,or a municipal sewer serves the property.In addition,this agreement may be canceiled by executing and recording said certifiplion with reference to this agreemeM in such manner which will pertnit the ewstence of tlie certfication to be determined by reference to the property. 5. This agreement shall be bindirg upon the owner,the heirs of the owner,and assignees of the owner.The owner shall submit the agreement M the register of deeds,and fhe agreement shall be recorded by the register of deeds in a manner which will pertnit the existence of the agreement to be detertnined by reference to Me property where ihe hdding tank is installed. •Onl one ow'wr s� �awn re Wree- ACKNOWLEDGMENT Owner's Signature: � � jj� State of: �- County of: �11�5 Owner's Name(Pri ):� Subscribed and swor to before me on this tJU�V� �{• � ' Y"� �_dayof� 20 � Date: By(Owner'e Name): �� S � �3 Notary Public Signature: CY Drafted by: �n� Public Notary Name(Print): �'l d�-1 O`^ ' '" �D1^ My commission expires on: 0 2Z CFFICIAL SEFL BRITTANY M MAST Personal iniortnatlon you provitle may be used tor sewndary purposes�Privacy Law,§15.04(I)(m)] � NOTARY PUBLIC SAt@iAlm'@9Li�N015 My Commission Expires 10-22•2924 � Lots "A" & "C" as described on Certified Survey Map recorded in Volume 2, page 336, Survey No. 432A, Document # 145488 being a part of the Northeast Quarter of the Southwest Quarter (NE'/4SWY4), Section 18, Township 42, Range 6 West. � """E�- PRIVATE ONSITE WAS�'E TREATMENT county � � SYSTEMS '�.��Sps ( POWTS) Sawyer \k `-�P:/�� ' '=`� INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2 3 r. �O � Personal infonnation you provide may be used for secondary purposes[Privacy L,aw,s. 15.04(1)(in)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: 504,., C��k �t�.s�— S ;�- C�I,c� — Insp BM Elev: BM Description: Parcel Tax No: r tv�.� `C� o`� �E:T• �s-er- 1, ��-6�1.2- Iq �3�0(� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark (Oo.a� Dosing � � Aeration Bldg. Sewer Q �,�� Holding �,,;� a � 5� St/Ht Inlet c�s-�g ` TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding .}-�'` fi3n� fi.�p� �1-Zo` �2S" Dist. Pipe PUMP 151PHON INFORMATION Infiltrative Surface Manufacturer Demand Final Gratle Model Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dfa Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv c Aggregate P/L Bldg Well ❑ IGP ❑ Chamber — INFORMATION Waters n AG ❑ EZFIow Model Number: CELL TO ❑ Mound o Other DISTRIBUTION SYSTEM X Pressure Systems Only Header I Manifold - - -Distribution Pipe(s)— —�X Hole Size ,I X Hole Observation Pipas Length Dia � Length Dia Spac Spacing ❑Yes ❑ No � SOIL COVER �CePI CeOnter �eI�ItE gesr I T�opsoi�f __ � ❑Yed I S❑ No . .�Yesiche❑d �� COMMENTS: (Include code discrepancies, persons present, etc.) ��I ��a��a3 _— � �► :�, Plan revision required?�Yes❑ No �,�3 �g I�,c� I � _ -- ��_ Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AO�ITIONAL COMMENT ANO SKETCH SANITAAY PERMIT NUMEER �" �� I �— ��- �q��, �a� -�. ._ � : :_ _ _ _ : . _ . �_ .__ . : . __ _ _ . _ _ � ; : _ , . _ _ , ._ _; _ _� _ _ ; __ _ _. � � : � : . _ �� , a�,� � � � � �.8� �3� �,a�� G/ � �O %-� � �H 1 �b � 3t w�� I �,�a� � �,�SLP �,r Ck a�, � -�-- � �3��a� � �� b L q�,�•�f �a,�,.D � . �