HomeMy WebLinkAbout032-438-16-1201-SAN-2023-212 ' [ndustry Services Division Counn • �
� 4822 Madison Yards Way ��r I.l� �Y- b
- , _ : MadiSon,WI 53705 Sanitary Permit Number(to be filled in by �
'= P.O.Box 7162
Madison,WI 53707-7162 �S � ��i �
Sanitary Permit Application State Transaction Number W
�
In accordance wiih SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
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� �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �
purposes in accordance with the Privacy I.aw,s. 15.04(1 xm),Stats. 6p
I.Application Ioformation-Please Print All Information �D 0 51.1� �G�•1 /�W• �,,J (,JI.t
Property Owner's Name Parcel#
I�ev• �w rvl- �F�+ ��a h�H�;., b o32 - � 3��I6 - �Z� �
Property Owner's Mailing Address Property Locatan
W358 N � � r rn �N � .
City,State "Lip Code Phone Number
��Y�D ��� � • C /_r_ �'/4,�[�'/<, Section��
[I(�
II.Type of Building(check xll that apply) Lot# T � N R E o
�1 or 2 Family Dwelling-Number ofBedrooms �_ Subdivision Name
Block#
❑Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�Town of W�/b �t�'
lll.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 y � eP Y g Y ( P ) ( P )
❑ New S stem R Iacement S stem ❑ Other Modification to Existin S stem ex lain ❑ Additional Pretreahnent Unit ex lain
B' �i Holding Tank ❑ In-Ground ❑ At-Grade gn ype( p )
❑ Mo�md ❑ Individual Site Desi ❑ Other T ex lain
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Pemtit IVnmber and Date Issued
Expiration c.(Y�1/L �
IV.DispersaUTreatment Area and Tank lnforma6oe:
Design Elow(gpd) Design Soil Application Rate{gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation
rl 0�� '--
Capacity in Total #of Manufacturer
r.'
Gallons Gallons Units � � 'D u
Tank Information .n v v •�
New Tanks Exis[ing Tanks � o y � Y A �
� U m cn k. C7 0.
Sep[ic or Holding Tank o� t'� / J �,J ,L ��
/� �r•T
Dosing Ct�amber
V.Responsibility St�tement- I,the aodersigaed,assame respoosibility for iestallation of the POWTS s wn on the attached plaos.
Plumber's Name(Print) Plumber's Signature /MPRS Number Business Phone Number
rh;� rvt�.1-� n.� ��� ��5�� � �S-� - 3��
Plumber's Address(Street, .ity,Sta e,Zip Code)
�-t 3�� .N f.�c�. �,.<<��- r�. �✓, K+�.- c✓.� S y f F�
VI.C u ty/Department Use Oniy
�Ap ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
� Yvo,.e � I� I �3 ��.� ���
�y✓ rO Owner.Given Reason for Denial
Conditions of Approval/Reasons for Disapprov�
''� �� �'i �::_. `� �7.�..�3
� �� ���ai � r � ['���
�� �y �r���1 . 1 �
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_.._���C�:.-__ _ _ ' " 1
`'� �'�� A!!G 3 0 2023 � �
Attach to complete plans for the system and submit to t�e County only on paper not kss than 8 tn x I 1 inc�es �¢e--'--� �- -•• �
; �'-� �,U1 �:.,:�,`
:JN.:'V � -- �
NO REFUND�AF7'ER zo�iie�G F�DMiNI�f�RA'������ 3 3 ;� I 1
!SSlJE UF PERNCIl'
Sawyer County Zoning & Conservation Administration
������ � '
10610 Main Street, Suite 49
� �R c0 � � Hayward, Wisconsin 54843
��'��� ��fi�� (715)634-82R8
� �� �� ��� FAX (715)63R-3277
� � 1 . _ - _ - � % wwwsawvcrcountv �o� v.�rS
� o - / o � E-mail: sanitarian(msaw crcount� ov.rn'g
I� � =� '� i � Toll Free Courthousc/General Information 1-877-699-4110
� �� ��.`ry ,`�1�
�� �1`ON��
Holding Tank Approval Checklist
L Sanitary Cover Sheet: Date Stamp � g / 3� / � 3
Parcel ID# �3 � - �( 3 g - � �o - � 2 � �
II. Plot Plan:
� Property Lines �Benchmark BM ♦
Site Address �North Arrow
�Structure � Scale
D� Well � < 25' to Service Road
�Legal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
IIL Required Plans:
� Index Page with Original Signature
x Management Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
x Tank Cross-Section: Manufacturer: � Gallons: �� ��
� Tank Anchor Calculations [SPS 383 .43 (8) (g)]
Locking device, chains/locks
� Alarm, electrical per SPS 383 .43 (8) (e)
� 3" Bedding Material < 1 /2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2. 1 (May 2022-2027)
Owner: `n++��,�Q, �� .-h`1.�., � Plumber: �o��j
Application Review Date: � �6 � �3
�POWTS Reviewer: .�
Namc
G°�' � � Rev. 4/27/2023
Credential #
PAGE 1 OF 4
Holding Tank Plan
Index � Cover Sheet
Com Manua!Des��n Refelences: "r
Version�BD-10855-P(N.03l07;R 01/12) a�"�
Pg 1 of 4 '�..� Index 8�Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Speciflcations
Pg 4 of 4 Management Pian
Attachmerrts: Enclosures:
POWTS A�rplication for Review
Soil Evatuation Report 8�Site Map(if appticable)
Hofdi Tank Pum i Contract if a licable)
Holdin Tank A reement if a iicable
Praject Name/Description
Owner Name(s): k�.�":n 1�}»w.,.-�� Pho�e•
Owner Address: ,.,-�S 8 �v G��i .aM�� �u .��aa2Ma�LP-�✓'l S 3 e(e�
Project Address: ��$'S H! L'L.. Hwr W Cv3.n l�- Gut S Y fr Pb
Govt.Lot: A//�.l 1/4 of,yL-� 1/4,Sedion /� .T ;3 ff N-R_'�E Q or W�
Township- 1.J��1=r Courrty: ,S'4.w�i.Q�-
Project Paroet ID�:-_0 3Z-Y 38-[G�/z o /
Designer Information
Desig�er Name: M�/r-� t�'lowf�a•�o-�si Phone:��S -a�(�G-3o t�
Designer AddreSS: Y 3�fO.:s/ L�4/Co (.U.`�a�P.r /Oo�. IA��:�Lv�lZ1p:_$��',�5�Y('
E-R1a1�: This sF+ace reserved for approval stamp.
License Number: ,M,o c'�2 Si (0 9
Remarks:
S�9nature= Date: �P a3
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P� N � o �2 - y3P -Ib -- 1�oi Le�al D;s�. ,��^'"2` �y�
t. 8 �
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TANK NIAt�3UF1�CTf�RER: �V�� •�-�` --�.-c/t'r�-
, �t�tc as �ry
p�� SPS 383-�3($�9}
8�Wei�={fd�.ft.t�ci�ot x 62.4�stq�ft}-ffis.�w�x t.S
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. � . - Haidirtr� Ta�k-�l�agement Ptan - :
�ra�: - - - - -
��o�������������a���
�cfsPs���.t�ode. ���5����,�ht��s}
�ise�d a��4 hsa,and�s�ot�d i��t�t#�
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�ew�t�S��IiY�Ar�t�[�• . -
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o age c�f sys�m _ _
- a �iar�ors{t�a�� - - �� .
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a r�°ra�+�use('�e,�����,e�j. '
o et�rtr.�mr�C�.����.�.�e�� -
� °' ��d�gs°��'ai���s�tae�red � . � ' . �
� � . SEEt�/It�FREQl�t1iG'�' • . . .
o Tbe�(sj s!�i�e pt�ped t�t e t����P�'�o�d�s�'i 48��
� wheneiaw���#�ad��a i�rat aFo�#o�tb�to�w�e�ta�ta#��s}, •
. D�af�o�+anes st�l be pta��I�2113.1MsG!�C,od� �
��cp��si�i������9�uc�;��w�t SPS�S.S�'i 1!� .
� . �.Coda ReportanY coa�r��os��:-
�I+�ne t��t��y�e Mott�oTt� ' . � 71J�'-�6�r3Q40 � .
���s���� �7��-63�-�2�
��ve�ne,��a.�aac� "�{�� Ma�Str�Sui�e�, Hayward,Wt �,54,g4�
Anv cis�'ec�ve�a�'�S�y�em sf�be������p�;w�A�
tbde-R�'or s�of�ed c�r � SPS 383,V�C.A�.t�.
���r��P�t11�r�ot�af�POWTS�yhe t�}ca���,y��� -
- a�t�h S�384y 1N'es�Atl�,Ccr�
� Coefil't�v Pbn - ' -
tn the��t ths��rfeied oOs�����{���te�a�+ed,��6s '
-P���aihe app��qr#���d appron�, - �A��a .
- �n A[sand�eet�t - .
• �f use a���ic(sj is�ed.�s�6e s��t�w�SP3 384 33,,VI�'At�t�ot�,. •
HOLDING TANK SERVICING CONTRACT
Contract Datc: I�/ ,23
This contract is madc be[wecn thc Holding Tank Owncr and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
�U�`n NOWQ✓d Northwest Sanitary,Inc.
L �� PO BOX 155
�VN t Il�w'f7�/� Radisson,WI54867
Parcel Identification Number:
(12 Digit Legacy ID) f�,��- y��-1�-�Z O �
I. Thc owncr agrccs to filc a copy of this contract with thc govcmmcntal unit,Sauycr County,
which has acccptcd and recordcd with thc Office of thc Rcgistcr of Dccds,thc Maintcnancc
Agreement for a Holding Tank rcquired under tlie Sawyer County Private Sewage System
Ordinance for the issuance of a Sanitary Permit for the instnllation of a holding tank(s).
2. Thc owncr agrccs to havc thc holding tank(s)scrviccd by thc pumper and guarantccs to
pennit the pumper to have xcess and to enter upon the property for tlic purpose of servicing
thc holding lank(s). Thc owncr aSTccs to maintain thc all-wcathcr acccss road or drivc so
that thc pumper can scrvicc thc holding tank(s)with thc pumping cquipmcnt. Thc owncr
furthcr a�,Rccs to pay lhc pumper for a chargcs incurzcd in scrvicing Lhc holding lank(s)as
mutunlly agrecd upon by the owner and pumper.
3. Thc pumper a�Rccs lo submit to thc Govcmmcntal Unit,Sawycr County,a rcpart for thc
scrvicing of thc holding tank(s)as rcquircd undcr SPS 3R3.55,Wisconsin Administrativc
Code and the Sawyer Counry Private Sewage System Ordinancc. The pumper further
agrccs to include the following in thc report:
a. The name and address of the person responsible for servicing the holding tank;
b. The namc of the o�mcr of thc holding tank;
c. The site address of thc holding tank;
d. Thc datc the holding tank was serviced:
e. The volumes in gnllons of the contents pumped from the holding tank for each servicing;
f. The disposal si[cs to which[he contents from the holding tank were delivered.
4. This agrccmcnt will rcmain in cCfcct until thc owncr or pumper tcrminatcs this contract. In
thc c��cnt of a changc in this contracl,thc owncr agrccs to filc a copy of any changcs to this
scrvicc conlract or a copy of a ncw scrvicc contract with Sawycr County within tcn(10)
busincss days from thc datc of chanec to this scrvicc contract.
Owncr's Namc:(Printj Owncr's Si�o����i��.w�����rta�
T,y�on.✓APP.�E H�•✓>•+�G Ccu�3
��o /�E✓i�/l�oi,/91Zb�7tZEA5.
Pumper s Nmnc:(Pnnq Pumper's Signamrc:
Ronald L Vieceli,owner Northwest Sanitary.lnc � /'
����r� G,//.�;%
Pumper's Rcgislralion Numbcc
#2389
Rcv.O}12fi�13
Real Estate Sawyer County Property Listing Property Status:
Today's Date:8/28/2023 Created On:2/6/2007 7:55:56 AM
Descripdon Updated:6/14/2010 Ownership Updated:6/14/2010
T�c ID: 33417 THORNAPPLE HUNTING OCONOMOWOC
PIN: 57-032-2-38-04-16-102-000- CLUB WI
000010
Legacy PIN: 032438161201 BillingAddress: Mail' gAddress:
Map ID: .2.1 THORNAPPLE THORNAPPLE
Municipality: (032)TOWN OF WINTER HUNTING CLUB HUNTING CLUB
STR: 516 T38N R04W ATTN:KEVIN ATTN:KEVIN
Description: NWNE HOWARD,TREAS HOWARD,TREAS
Recorded Acres: 40.000 W358 N6171 AMY LN W358 N6171 AMY LN
Lottery Claims: 0 OCONOMOWOC WI OCONOMOWOC WI
53066 53066
Fust Dollar. Yes
Zoning: (A-1)Agricultural One ,�.
ESN: 428 Site Address mdicates Private Road
3885W COUNTY EIWY W WINTER 54896
Taac Districts Updated:2/6/2007
1 State of Wisconsin property Assessment Updated:10l10/2016
57 Sawyer County 2023 Assessment Detail
032 Town of Winter Code Acres Land Imp.
576615 Winter School District Gl-RESIDENTIAL 1.500 5,400 25,100
001700 Technical College G5� 30.000 5,100 0
UNDEVELOPED
Recorded Documents Updated:6/14/2010 G6-PRODUCTIVE g.500 9,800 0
FOREST
WARRANTY DEED
Date Recorded:8/5/1959 94/633 2-Year Comparison 2022 2023 Change
Land: 20,300 20,300 0.0%
Improved: 25,100 25,100 0.0%
Total: 45,400 45,400 0.0%
Property History
N/A
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i���������� ��������i������
-USE BLACK LY- DocI :8073565
POWTS MAIN7ENANCE AGREEMENT Tx:4047238
446256
For Holding Ta�ks PAULA CHISSER
p��gy���� REGISTER OF DEEDS
SAWYER COUNTY, 1NI
�Q���N �L��Jk�'�r — `�Ii��v.4Ppk. hu�drr (.�+fj 09I06/2023 01:47 PM
RECORDING FEE 30.00
Parcei lderdifiCatia►Ntmber: +�
(12DigRlegaCylO) d��-�"7 �-...L_i-L��/ QQL'iFs: �
Legal Description of Property:
-SEE ATTACHED SHEET-
We adcnawiedge tt�t app6cation�s bei�g made far tlie ir�aBaGon of a haiding tardc(s)on the
property desc�ed on ttte�sl�eet
Rehsn To:Sawyer Cou�r Zo�n&�g and Conserratbn Admin�ation
10610 llain St Sui6�49.Flayrrard.VMI 5�843
As an inducemerrt to the Countp of SaMyer to issue a sanitary permit far a holdira,�taMc�the above-desabed property,the owner is
responsible for the aperation and main�enanoe�the hdd'mg tank�oddn9 device,atarm and ac�ess,and ag�ees to c�rn to all
applicable re�neMs of SPS 383,YV'�Adm.Code reiating to t�ldu�g Y�c�c�r�gerr�ent,indu�ng the followirg:
1. The owner ag�ees tn contra�ct with a person who is lioensed under Ch NR 113,Wis.Adm.Code,except as provided by
�dion 281.48(3)(d).Stats.,�o hanie the hold'mg tank prope►iy serviced and to file a copy af the servioe contrac:t with the
govemrne�tal unit The owner fwther agrees to file a copy a�f arry cha�to the service oontr�or a copy of a new senrice
contract,with the goveirnr�tal unit viritfiin fien(10)busv�ess�ys fran the date of change bo the servioe conhad
Z. The owner agrees to c:ontrad with a person 6censed�md�Ch.NR t93.W�.Adm.Code,who shal{submit Pumpin9 reports to
the gowemmental unit ui aocorclanoe with SPS 383.55,IAC�Rdm_Cocie,for the ssrvicing of the holdng taMc. In the c�se of
e�nption u�er Section 281.48(3)(d),Stats.,the rnwner st�}i s�ri�the report to the govermm�al unit The governmerrtal
unit may eo�er upcm the property ta investigabe the condition of�e ho�g tanlc when P�mP�9���5►�rxiicate the
holding tank�not be�g prvperhr mairrtained.
3. If the awner faiis to have tt�e hold�g taMc properly s�vic�d in resgor�ta�ders issued by the goverrvn�rtal unit to prevent
or abate a h�anan health harard as d�ed in S�_254_59.8�_,ihe go�ntal unit maY���P�rtY
and service,or cause the tank to be servioed. Pursuant to Section 1�',520(4}Wis.Stats_,a govemrr�Mal unit may assess the
owr�r of a private sewage system for costs rela�ed M the pu�r►pir�g af a sep�c or hdding tank The d�arge.s wid be ass�sed
as p�bed by Secaon 66.0703,sta�_ The owner agnees to pa�;a�drarges and cost incumed by the govemmental unit for
inspec3ion,pumping,haurmg,or othervrise servidng arnl rt�irstai��hokfmg tardc in s�a manner as to prevent or a6ate
any hurt�an he�aiih hazard ca�ed by the holding tank.
4. This agreement wdl remain in effed only w�fhe gwemm�taf unit r�spans�ble for tF�e regulation�priva�e sewage systems
ceftifies that either a sa!absorption system that�with SP5 3�i.VY'�Adm.Code,or a mun�ipal sewer serves the
ProPerh►.In aiddition,th�agreernent may be cancelkd by e�aeaatirg ar�recording said certi�ication with re�erenoe to this
agreement in such manner which wi(i pertt�it the e�dstence aFthe ce�tification to be determined by reference to the property.
5. This agreerr�t stral!be binding upon the oMmer,the heirs af the aNmec,and assignees�the uwner_lhe owner shall submit
the agree�ne�t to the re�s�of deeds,and the agreemerrt shall be reco�ded by the r�iste�of deeds in a manner wf�ich will
pertnit the existenae of the ag�eernerrt to be determined by referera�to the pr�rty where ihe hdd"mg tank is installed.
� �� - - �KNOWLEDGMENT
Owner's g re: State of�.��`' ��~ �� S�
Owne�s Name(Print): ��,� ��
v�� � � � 'bgt3 ar0 tp bbf9re me�this
: day f ' f- 20 2 3
Date: Q��� _Zp-L3 gy= � ��: �
v fW"`°s-'�abli`l's r�.'fe:
Drafted by. -/� �����`�+.N��(f�rirrt�. I�►` wn�
� �`�'�' 1�� My co �mf��bib'$�d1 t_ • 5' Z-0 Z N
'�•�,���u�����..►
Personal irrfomtation You PYovide►naY be�aed for seoorria�y P�P�I�Y�+►,§15.04(n(m)l Rev.03/26/13
The. Northwest quarter of.the Northeast quarter �(N�n�,�—� of NE4) of Section Z6, Township Thirty-eight
• �38) North of Range Four ��) West.
,
�,�
�"'�`""�-, PRIVATE ONSITE WASTE TREATMENT co��cy
�' � o � SYSTEMS Sawyer
=� ;,
,z����$P S ,�
( POWTS)
��HU,ij`._..����!.
�;"�'v�''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division
(ATTACH TO PERMIT)
GENERAL INFORMATION �� '- �� o�
Personal infonnation you provide may be used for secondary putposes[Privacy Law,a 15.04(l)(in)]
Permit Hoider's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
��M �. K��,-��. c��b W��.� `—
Insp BM Elev: BM escription: Parcel Tax No:
( a�s •o` `�' o� �-I:I� n�r- ��� 63�.. K3g-1�-(�� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark p�,��
Dosing
Aeration Bidg. Sewer q6� r
Holding �.,� � �'� St I Ht Inlet �'6•s'�
TANK SETBACK INFORMATION St/Ht Outlet �b,3 �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding � ` t Sp� �S � � L� Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weli
DISPERSAL CELL INFORMATION
DIMENSIONS �N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-- — _. -- -- ----- -- -- - - - -_
-- - -- —---
DISTRIBUTION SYSTEM X Pressure Systems Only
[ Lengthr/Manifold Dia � Dengbution Pipe(s) Dia _ Spac X Hole Size , Spacing ❑Yes at�0 NIo�—�I
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �ell Edges � Topsoii __ ❑ Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
������ ���� (�3
� �t;�,
Plan revision required?❑Yes ❑ No � 3 ' �g � ^ I
___�— _�
�_o II Y I '� __ --- -- �`' �1�
Use other side for additional inforr�ation Date POWTS Inspector's Signature Certification Number
SBD-6710(R_3/01)
A�DITIONAL COMMENTS ANO SKETCN
SAN�TARY PEAMIT NIJMBER: �3 �_�_��___.
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