HomeMy WebLinkAbout026-939-21-5110-SAN-2023-214 �
`-''-".;� Industiy Services Division Counry �
=�\� ;:, -4822 Madison Yards Way Sawyer Z
-. , � �:' Madison,W[5370J Sandary Permit Number(to be filled in by
� P= P.O.Box 7302
'-_ _ Madison.W[�3707 �O�3� �O� ��
Sanita� PeY,ml+ AnpllCa*l�n State Transaction Number ;
i, r i. �
In accordance with SPS 38321(2),Vr'is.Adm_Code,submission ofthis form to the appropriate govemmental unit �
is required prior to obtainina a sanitary permiL Note:Application forms for state-o�vned POWTS are submitted to Project Address(if different than mailing ac
thc Department of Safery and Professional Sercices.Personal information you provide may be used for secondary ������ L+/��� �/��� p�
pur�oses in accordance���ith the Privacy Law.s I�.Oa(I)(m),Stats `���� �-� ��
I.Application Information-Please Print All Information
Property�O�vner's Name Parcel#
LAWSON JOINT REV TRUST 026-939-21-5110
Propeity Owner's Mailing Address Propert}�Location
6200 FLOTILLA DR UNIT 301 Ga�� �.ot
City,State 7_ip Code Phone Number
HOLMES BEACH, FL 34217 ''. '' szC11O1, z'
II.Type of Building(check all that apply) Lo�� T 39 N R 09 E or W
�I or2l�amil��ll�cellin,-1�umbcrofBedroonti 4 � SttbdivisionName
Block#
�Public/Commercial-Describe Use
�Cit�'of
�Statc Owned-Describe Use CSM Number �Village of
3 / �209 �p592 0✓ ["""of Sand Lake
U
III.Type of POWTS Permit:(Check either"New"or"Replacement"and othcr applicable on line:1. Check one box on line B.Complete line C if
a licable.)
�� New System �Replacement S��stem Other Moditie ation to h'xistin�System(explain) �Additional Pretreatment Unit(explain)
B' �Holding Tank �In-Ground �At-Grade �Mound ❑Individual Site Desion Other Type(ex��lain)
(conventional)
C. �Renew�l Before � List Pre��ious Permit Number and Date�ssued
✓ Revision �Chanae of Plumber �I�r�nsfer[o Ne�c O���nrr Q
Expiration 22-2�7 (��22�22
1V.DispersallTreatment Area and T'ank Information:
Design Flow(�pd) Desi�n Soil Application Rate(gpd/st) Dispersal Area Required(sfl Dispersal Area Proposed(st� System�levatiun
400 NA NA �- NA -� "
Capaci[y in Total #oY Manufacwrer
'fank fntormation Gallons Gallons Units � � v ,�0, �
1'tw Tanl:s Eusting Tanl:s "� o y � � � =
_ U ✓: v: v� .` .� _
Septic or Holdi„g Tank (2) 1250/750 4000 2 WIESER CONCRETE ✓ �
Doain�Chamber � � �
V.Responsibility�Statement- 1,the undersigned,assum sponsibility fo in allation of the POR'TS shown on the attached plans.
Plumbers Name(Print) Plumb� _i�naturc MP/A�iPRS Number Business Phone Numher
Travis ButterField 652879 715-634-8176
Plumbei's Address(Stree�Cit}°,State,Zip Cude)
14346W St. Rd. 77, Hayward, WI 54843
VI.Coun -/Dcpartment Lise Onl��
�A i� ❑Disapproved �ennit Fee� D3t�Issued I,suin,,leent Si�nature
O O��ner Uiven Reason for Denial ��' � �� �� 3 �����--�c,�r--A
Conditions of,Approval/Reasons for Disapproval �' � � N n �_!, L ' �
� � :;a��_ `.� ►']���,3... . , ��� �= `'il
� ' ' � �i�-o t!G 3 0 2023 ` .
� �����W cnk# a - A
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CS�;�� �.� , �0� SRWYER C;;�.s;,;'i�Y
� I� ZpNWG ADM�N�Sl'RA710N
A[tach[u complete plans for the system and submit ro[he Counq•only on paper no[less than 8 V2 x 11 inches in size ������
sB�-��9s�x.ozizz� (�Q REFUN��AFTER
IS�UE OF PERMI"i
Sawyer County Zoning & Conservation Administration
�������'
10610 Main Street, Suite 49
R C 1 Hayward, Wisconsin 54843
�� �- --�0 1
'�� �,Ci�� (715)634-8288
�' ���� FAX(715)638-3277
iQ
��; -_ - i�% wwwsawYcrcount >ov.org
� E-mail:sanitarian cnsaw rrcounlvfZ<�v.o�
�I o � ` /°� Toll Frcc Courthousc/Gcncral Information 1-877-699-4110
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp � / 3 c� / 23
Parcel ID# U� � _ �3`� _ 1 � _ S- 1 ( �
II. Plot Plan:
?�Property Lines �Benclimark BM ♦
�Site Address � North Arrow
Structure � Scale
�Well k<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/Contingeilcy Plan
Servicing Contract
�Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
ot�
X Tank Cross-Section: Manufacture :� ���� Gallons: �
DC Tank Anchor Calculations [SPS 38 .43 (8) (g)]
�C Locking device, chains/locks
�C 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: `-a�^'�� �^� Plumber. �_ � _
Application Review Date:
POWTS Reviewer:
Name
�,`�'��C 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:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicable)
Holdin Tank Pum ing Contract (if applicable)
Holdin Tank A reement if a licable
Project Name / Description
Owner Name(s): LAWSON JOINT REV TRUST phone: - -
Owner Address: 6200 FLOTILLA DR UNIT 301, HOLMES BEACH, FL Z;p: 34217
Project Address: 16002W SAND LAKE RD, STONE LAKE, WI 54876
Govt. Lot: � 1/4 of 1/4, Section 2� , T 39 N-R 09 E ❑or W ❑✓
Township: SAND LAKE County: SAWYER
Project Parcel ID #: 026-939-21-5110
Designer Information
Designer Name: TRAVIS BUTTERFIELD Phone: �15 _634 _8176
Designer Address: 14346W ST. RD. 77, HAYWARD, WI Z�p: 54843
E-mail: OFFICE@BUTTERFIELDDRILLING.COM ����,,;,�,���� ,-tSe�,,.E� r,,, ���>,-�, ,i ;+�,;���
License Number: 652879
Remarks:
Signature: Date: ��''��_ � 3
Original signature required on each submitted copy.
CYECK 00X AS APPLICABLE. � CHECK 00XA5 APPLICABLE.
� SOIL EVALUATION o s�'1e: 50 5d 75 �o� a SYSTEM PAGE 2 OF�-�-
SITE MAP PLOT PLAN
PROJECT NAME: , DESIGN FLOW; ! � GPD
—� ;�� 12.5
L�V.��.�c�� J�751�)1 K`� V ( �`�S� Attach design flow calculations for commercial plans.
PROJECTADDRESS: sa"� �e�e � Pipe Matenal/ASTM Standard(Tables 384.30-3&384.3�-5)
NSanitary Sewer: /
BM Symbol: � BM Elevation: ���� � FT �
/ Force Main:
BM Description: n`"� �'� 36 N Q�`�
Ind:cate north by IMPORTAN7':
Siope Gradient(%) Well Symbol(if applicable): Q drawing an arrow Show ground elevation contours at suitable intervals.
of Tested AI�eB: on the approprite line.
:Su�� �u,�
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PAGE30F4
HOLDING TANK SPECIFICATIONS �
(No Scale)
4"fd Vent Pipe
Weatherproof >10 ft from
Junction and Alarm Box Approved Building
Vent Ca 12"Min.or 2.0 ft above
Approved Locking Manhole p Established Flood Elevation
ElecVical must comply with With Warning Label Attached t ical 4"Mln.or 2.0 ft above
SPS 316 and NEC 300 (typical) �yP � Established Flood Elevation
�Conduit I (typical)
i
W J �Airtight Seal � " °
Finished Grade
18"Min.
�tYPical) . -,,, � • .� .�Qa � .
A , A
.Q . . ' • .
a- � 4 . � ' ' ' . . � a. • .
n
Inlet Inlet Invert
—Watertight
Approved Joints with� Plug
Approved Pipe 3 f[onto Max.12"or 90%ofi total volume
Solid Ground if more[han one tank A'
(typical) Alarm-On 4,
a�
Compartment 1 Vol= �250 qal compartment 2 vo�= 75O ga1
a
��� TOTAL HOLDING TANK
a
VOLUME _ �:� gal .
. �,.
e
,9 ' . . . 'e � . . . a a,: • . . . '
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: W12S21" COI1C1"@t8
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= [( cu.ft.x 62.4 Ibs/cu.ft)- Ibs]x 1.5 = Ibs
� � I
1:J I
�
<� ` VU125a/750—MR
�-� �f TANK SPECIFICATIONS � o
�z'-�i., � a
<;j DIMElVSI0N5: w ��„
� WAL�: 2 1/2" a�. a
1 4" CAST-A=SEAL 4" CAST-A-SEAL BOTTOM: 3"
'� � - __-___ -" COVER: 6,�
� --�T�----_=� MANHOLE: 24" LD. PRECAST CONCRETE RISER R
` �� i�%-1 II II :• HEIGHT: 66" �
���i I I'I I � ��
��
�� , ilii � ��� LEfVGTH: 12'-11" >
1 �� ,_ 2� i i 1 i: ��• W1DTH: 7'-2" �
�j _ r � \ �'.�yF' �'-' i i i � ���--���� BELaVd lNLET: 53"
� j' I� ( r,-/��� � LfQUID LEVEL: 48" o
� � \ � � �� y �i 1T '\ � WEIGHT_ 14,860 LBS. o 0
C \ ^ o �n
I \1 -1�— �I11 � —�� lI- II a
��\ II II �`l. iNLET AND OUTLET: - I � o i
FILT�R OR j i i i ,�! 4° CAST A-SEAL BOOT OR EQUAL GASKET " m o �
t �\�,\`` BAFrLE itli �i�
o -
iu � �
� i I I ��' INLET pNQ QUTLET BaFFLE AND F1L?ER: Q � � ,�;
"__ _____=��___��'� WISCO�ISIIV, SEE DETAIL �r10 ,��, o p �
�'I (OTHER STATES SEE CHAR7)
f � o
I TOP VIEW LIQUI� CAPACITY: 27.66 Gr�L/W (SEPTIC) � n
16.12 GAL/IN (PUMP) � �
� Y CrJ
�OADING DESIGN; 8'-d" UNSAIURATEQ SOIL � c �
� TANK CAN BE USED AS: � w I
w
a
�� SEPTiC/SEPTIC, SEP11C/SIPHON, a �
! w /-4" VENT OR SEPTIC/SIPHCN $ r�Nj
o �
�` � COVER: hlilX DESIGN �8 (NO FIBER} �a
- -_ TANK: MIX DESIG� �10 (STRUCTURAL FIBER) _ °�
I --- , � ---- [�,� cn
. . � I �wrrn �
---- � � ---- � � ' --�L CUSTOMI.ZED TANKS: � �
��INLET - �--�,,� FOR CUSTOIN TANKS CONTACT 1NfESER CONCRETE ;
�� - - — - ---�—N;-; � _ _ - OUTLET
�� I i I ! II
� ¢ �_J r �-T
in � dU j - i�Il - � �� n¢
_l U
`O i� �d- � � � I I � n_ � ��
in � �- �� � v � �'a- = ,
I �. � �-_ �n
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�
.I J h I g �
21.� ,�,_ �.� I �
�` i. i �
---- - ---- ---��'�------.��.=_'_� Q -z2
� �
� REVIEWED BY � v
I - o
``> PUMP PAD REVIEW DATE � �
� , QRAWINGS SUBMITT-ED � `�
SIOE VIEN
FOR APPROVAL
i
APPROVED BY: SHEET ND.
� APPROV�L Di�TE: � /
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTh1 C-1227 REQUIREMEf�TS PRO�UCTS NEEDED BY: /oF
1
PAGE40F4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s)shall be responsible for its perpetual operation and maintenance pursuanl 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 maintafned in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shall be performed by a regislered POWTS Maintainer in
acwrdance with SPS 383.52(3),Wisc.Admin.Code.
Estimated Daily Wastewater Flow= Y� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o rype of use
_ age of system
nuisance factors(i.e.odors,user complaints,etc.)
.. mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
., material fatigue(i.e.,leaks,breaks,corrosion,etc.)
� neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
„ electrical components(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
„ 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,VJisc.Admin.Code.
Tank pumping reports shall 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: BUtt21�12ICI, �f1C. _ Phone: 7�5-634-8,�76
�oca�govemment unic SBWyef COUnty ZOC11Clg Phone: 7�5-634-H2HH
10610 Main St. Ste 49, Hayward Z,P 54843
Local govemment unil address:__,_____ .
Any defective part of this syslem 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 oT the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
ContingencV Plan
In the eveni 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.
System Abandonment
If use of this tank(s)is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisa Admin.Code.
HOI.DI1�'G TANK SERVICING CON'TRAC"C
Contract Datc: � / � / 2.Z
This contract is rnade betw•een the Holding 7'ank Owncr and the Pumper.
Holding Tank C)wncr's Namc: Pumper's Namc:
�'Yl a r k S . Fo �R.��-�- 5c-o-l�" �a P�-
Parcel Identification Number:
(12 Digit Legacy ID) � 2 tP - � 3 � - Z � - � � � 0
l. "I�he owner agrces to tile a copy of this contract with the governmental unit, Sawycr County,
which has accepted and recorded �r•ith the Office of the Register of Dceds, the Maintenance
Agreement for a Holding Tank requit-ed tinder the Sa�vyer County Private Se���a��c System
Ordinancc for the issuance of a Sanitary Permit for the installation ot'a holdine tank(s).
2. "Chc owmcr agrees to have the holding tank(s) serviced by thc pumper and guarxntces to
permit thc �umper to havc acces� and to entcr upon the propert}� for Ihc purpose of servicing
thc holdinz tank(s). 7�he o��ner agrces to maintain the all-��cather acccss road or dri��e so
that the pumper can service thc holding tank(s) with the pumping equipment. Thc owner
fiu-ther a�recs to pay the pumper for charges incurred in scr��icing the� holding tank(s) as
mutuall� a��rccd upon by thc o��ncr and pumper.
3. "I'he pumper agrees to submit to the Governmental Unit, Sawyer Cuunty, a report lor the
scr� icing of the holding tank(s) as required under SPS �R3.», Wisconsin Administrati�e
Code and the Sawyer County Private Se�vage System Ordinance. �i�hc pumper further
agrees to include the follow�ing in the report:
a. The namc and address of the perso�t responsible for scr�icing the he�lding 1ank;
b. The name of the o�vner of tt�c l�olding tank:
c. The sitc address of the holding tank;
d. The datc the holding tank «�as scrviccd;
c. The volumes in vallons of the contents pumpcd from the holding tank for each servicing;
t: The disposal sites to �vhich the contents from thc holding tank were delivered.
4. �I�his agrcement will remain in effect until thc owner or pumper tenninates this contract. In
the event ot�a change in this contract, the owncr �grees t�� tile a copy of any changes to this
ser� ice contract or a copy of a ne�� service contract ���ith Sa���yer County ���ithin ten ( 10)
business days from the date of chanee to this service contract.
Owner's Name: (Print) ��Vtlef'S Sig11c1LlICC: (Onl}' onc n��ner signature required)
Y1�lar �. S • �6YZ�ST ,^�.�._
Pumper's Namr. (Print) Pumper's Signaturc:
�� � X
P�unper's Registrati Number:
dl� 13
Re��. 03/Zb/13
8'22122.8'.48 AM Re21 P�operty L�stinq Pa4e
R2dl EState Sawyer County Property Listing �roperty5tatus: Current
Today's Date:9/22/2022 Created On:10/25/2021 6:4629 AM
�'Description Updated:7i12R022 �Ownership Upda[ed�7/12/2022
Tax ID: 44309 MARK 5 FORREST STONE LAKE Wl
PIN: 57-026-239-09-21�5 OS-001-000100
Legacy PIN: 026939215110 Billing Address: Mailing Address:
Map ID: MARK 5 F00.RE5T MARK S FORREST
Municipality: (026)TOWN OF SAND LAKE N6061 WEIGFND W N6061 WEIGAND LN
STR: 521 T39N R09W STONE LAKE Wl 54S7G STONE LAKE NA 54876
Destrip[ion: PRT GOVT LOT 1 LOT 5 CSM 37/209 m
}8592(ZAWi5TOW5K]JT REV TRUST- r Site Address 'indicates l�nvate Road
LC) 160026V SAfJD LAKE RD STONE LAKE 54876
Remrded Acres: 2.250
Calalated Acres: 0.000
Lottery ClaimS: 0 �Property 0.5sessment Upda[ed:7/6/2022
First Dollar: No 2022 Assessment Detail
Waterbody: Sand Lake Code Acres Land Imp.
� Zoning: (RRi)Residential/Recreational One G1-RESIDEN7IAL 2.250 118,100 0
ESN: 423
2-YearCompariwn 2021 2022 Change
f Land: 0 115,100 100.0 ro
/Tax Districts Updated:10/25/2021 Improved: 0 0 0.0°rh
1 SWte of Wisconsin Total: 0 118,100 100.0%
57 Sawyer County
026 Town of Sand Lake
572478 Hayward Community School Dis[rict
001700 Technical College � Property History
Parent Properties Tax iD
• Recorded Documents Updated:7'1'J2022 57-026-2-39-09-21-5 OS-00I-OOOD30 28773
LAND CONTRACT
Date Recorded:7(1/2022 439959
MAP OF SURVEY
Date Recorded:1/12,i2022 21399"1q
CERTIFIED SURVEY MAP
Date Recorded:l0/19/202t 435333
QUIT CLAIM DEED
Date Recorded:4/5/2013 384376
QUIT CIAIM DEED
Date Recorded 2/11;2013 383451
WARRANTY DEED
Date Remrdea:1/22�1991 222005
Child_tGstory Remrd Count 1- _ .
--
- ——_
HISTORY O Expand All Hlstory White=Current Parcels Pink=Retired Parcels
OTax ID:28773 Pin:57-026-2-39-09-21-5 OS-001-000030 Leg.Pin:0269392t5103 Map ID::1.3
44309 7his Parcel Parents Children
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- USE BLACK INK ONLY - ��1 ;x •�4!?4U2�:; ,
POWTS MAINTENANCE AGREEMENT 440913
For Holding Tanks R GISTER OF DE �s
Owner's Name(s) as shown on deed: SAWYER COUNTY, WI
08/22/2022 �1:29 PM
mCJ�r�/ J • '1'Q �..�.�.5—�.— RECORDING FEE 30.Ofl
1�-
Parcel �dentification Number:
(12 Digit Legacy ID) � 2. �v - � 3 � - Z � - '�J_ � � Q PAGES: 2
Legal Description of Property:
- SEE ATTACHED SHEET -
We acknowledge that application is being made for the installation of a holding tank(s) on the
property described on the attached sheet.
Return To: Sawyer County Zoning and Conservation Administration
10610 Main St. Suite 49, Hayward, WI 54843
As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property, the owner is
responsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to all
applicable requirements of SPS 383, Wis. Adm. Code relating to holding tank management, including the following:
1. The owner agrees to contract 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 holding tank properly serviced and to file a copy of the service contract with the
governmental unit. 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 governmental unit within ten (10) business 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 reports to
the governmental unit in accordance with SPS 383.55, Wis. Adm. Code, for the servicing of the holding tank. In the case of
exemption under Section 281 .48 (3) (d), Stats., the owner shall submit the report to the governmental unit. The governmental
unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the
holding tank is not being properly maintained.
3. If the owner fails to have the holding tank properiy serviced in response to orders issued by the governmental unit to prevent
or abate a human health hazard as described in Section. 254.59, Stats., the governmental unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4) Wis. Stats., a governmental unit may assess the
owner of a private sewage system for costs related to the pumping of a septic or holding tank. The charges will be assessed
as prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cos: incurred by the govemmental unit for
inspection, 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 hoiding tank.
4. This agreement will remain in effect only until the governmental unit responsibie 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 be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
5. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit
the agreement to the register of deeds, and the agreement shall be recorded by the reqister of deeds in a manner which will
permit the existence of the agreement to be determined by reference to the property where the holding tank is installed.
- Only one owner signature required - ACKNOWLEDGMENT
Owner's Signatur : State of: lIJ IS G���► r'1
county ofi: Saw� �e.►�
Owner's Name (Print): ,�'.QY Ue C Subscribed and sworn to before me on this
/Y) /��L L� ^ r /' r £ t' O _ �'h day of , 20 22
Date: c KE��Y �t (Owner's Name): arlC S • �oF-iZfrfvl�
a ' T ' Z- �_ p tary Public Signature: .�,�
Drafted by: = blic Notary Name f Print): � t
K.t,� g�}t,r�j.(,�d J} �`' y commission expires on: ?j ' $ • 2 4�
- UF W�
N1�Mti`
Personal informatior you provide may be used for secondary purposes [Privacy Law, § 15.04 (I) (m)] Rev. 03/26/13
Parcel 1: Lot 5 as recorded in Volume 37 of Certified Survey Maps, page 209,
Survey No. 8592 as Document No. 435333, located in the Town of Sand Lake,
Sawyer County,Wisconsin, being a part of Government Lot 1, Section 21,
Township 39 North, Range 9 West.
Parcel 2: Nonexclusive easement far the benefit of Parcei 1 for ingress,egress
and utility over, under and across Lot 4 as recorded in Volume 37 of Certified
Survey Maps, page 209, Survey No. 8592 as Document No. 435333, located in the
Town of Sand Lake,Sawyer County,Wisconsin, being a part of Government Lot 1,
Section 21, Township 39 North, Range 9 West. Subject to the terms, provisions
and condltions set forth in said instrument.
orr���f
Sawyer County Zoning and
Conservation Administration " -
10610 Main Street, Suile 49 r �, ��'� ��=�`�""�'�
Hayward, WI 54843 ����� �'`� + ��f � _� ��
�i�� "�l r���:�''
,s';
TeL•(715)634-8288 � ��
Fax: (715)638-3277 --� SEP 2 1 ��23
URL:http://sawyerco�mty�o� v•org � .
Email: zonin�.sec(c�,sawyercountygov,org SAWYER GGf.�I`�TY
Toll Free; Cow•thouse%Genei•al Information ZC=ttiINCz Af3Pl;':i�JISTh,=4�IQN
1-877-699-4110
Sawyer County Zoning and Sanitation "As - Built" Form
Property Ownei•'s Natne _( _C<<�S h �l J��� ^� ��e(/ ��'�S�
Fire Number and Road Name ��� � a w �a-� �� �
Plumber'sNaule �^/�-vG� �3�-�-7� � R� �(
Date of Installation �� a�� � 3
County Sanitaiy Permit Numbei• � 3 � a� __
12 Digit Parcel Number �a � ` 9 3 g �'� � y`�/(O
Description and Elevation of Benchtnark __�� �`� ���.s2 r�-e'1-J
Tank Manufacturer and Capacity (� 1�� �� � a- �
Setback-Tank to Nearest Lot Line
Is r
1
Setback-Tank to Nearest Well �S
Setback- Tanl<to Building �� I__
Cell Width
Cell Length
�
Number of Cells
Setback-Cell to Nearest Lot Line
Setback- Cell to Nearest Well
�
Setback- Cel1 to Building
Setback- Cell to Navigable Water __
Make and Model of Dispersal Unit __
Make and Model of Filter
/
Make and Model of Pump
- Please complete othei• sicie -
"As-Built Plot Plan"
,' 1�levation Data
�Bench���arlc a � K Please include the followin�:
Building Sewer `(� "
� S�- �Tanlc In _��`' • Location of obseivation and vent pipes
,r,�ryk Tai�lc Out � • Feet of risers used on tanlc(s)
^� L�Tanlc In '� (6 L • Location of benchmarlc aiid North arrow
o� �'�k- �-Tai�lc Bottom �'� • Location of all components
Header or Manifold ---� • Length of pipe between components
Distribution Pipe � Number of chamber units in each cell
System Elevation �- • Location of well, lot lines and road
�crL� �a�-
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