HomeMy WebLinkAbout026-939-21-5111-SAN-2023-215 ,-;���"�"_«i�, Industry Services Division County �
�� ��:,_� 4822 Madison Yards Way SBWy@f �
�'j ��f �_' Madison,WI 5370J Sanitary�Permit Number(to be filled in by
'" • PS P.O.Rox 7302
��`:�,;;;`�'—_;,�rl,' Madison.W[�3707 �p S � �p � 3 �
State Transaction Number �`�
Sanitary Permit Application �
In accordance with SPS 38321(2),Wis-Adm.Code,submissio�i ofthis form to the appropriate governmental unit ��� _.
is required prior to obtainin�a sanitary pennit.Note:Application forms for state-o�vned POWTS are submitted to Project Address(if different than mailing� �
the Department of Salety and Professional Services.Personal information you provide may be used for secondary ��� 4
purpo,e,in accordance�cith the Privac��I.aw,s- I5.0-t(I)(m).Stats_
L Application Information-Ylease Print All Information
Property O�+�ner's Nanre Parcel#
MARK S FORREST 026-939-21-5109
Prope�ty O�vner's Mailing Address Propert��Location
N6061 WEIGAND LN �a��';_�__�_
Ciry,State 1ip Codz Phone Number
STONE LAKE, WI 54876 --� �S�<<;°° 2'
II.Type of E3uilding(cheek all that apply) ���� [�f I�39 N R 09 E or W
�1 or 2 Fam ily Dwell ina-1�umbcr of Bedrooms 7 Subdivision Name
�_
L�D Block#
�Public/Commercial-Describe Use �� �
�City of _
�State Owned-Describe Use CSM Number �Villa�e of
CSM 37/209 #8592 ❑✓ T�`��,ot sand �ake _
111.7'ype of POVVTS Pcrmit:(Check eithcr"New"or"Replacement"and other applicable on line:�. Check one bos on line B.Complete line C if
a licable.)
�� �New System �Replaceiuent S��stem �Other Modificatiun to Gxistin�S}��tem(explain) �Additional Pretreatment Unit(e�plain)
�' �Holding Tank �ln-Ground �At-Grade �Mound �Individual Site Design Other Type(ex��lain)
(conventional)
C. ❑Renewal Before �Revision �Chan�e of Plumber �ransfer to Neti�Owner List Previous Permit Number and Date Issued
E�piration �--�
IV.Dispersal/Treatment�rea and'I'ank Information:
Design Flo�c(�pd) Desi�n Soil Application Rate(gpd/st� Dispe�sal Area Rcquired(st� Dispersal Area Proposed(s� System Eleva[ion
NA NA NA ��s.�
� Capacity in Total #oY Manufacturer �
"Cank Infor�ation Gallons Gallons Units � � o � �
� ;, U .
Nz�v Tanl:� Eristin�Tanks � o ;3 � Y � c� ca
G U v� � cn U. C7 a.
Septic or Holdin�Tank �250/750 1250/750 1 WIESER CONCRETE ✓ �
Dosi�g Chaml er � � �
V.Responsibilit3'Statement- I,the undersigned,assume responsibility for installation of tl�e POWTS shown on the attached plans.
Plumber's Name(Print) Plumb� s Si;nature �' MP/MPRS Number F3usiness Phone h'umber
Travis Butterfield 652879 715-634-8176
Plumber's Address(Street,City,State,Zip Code)
14346W St. Rd. 77, Haywar , WI 54843
Vl.Coun �/Department Lise Only
�,Appt��e ❑ Disapproved Pernii[Fee Da[e Tssued Issuing Agent Signature
-❑O��nzr Gi�en Reason for Denial ��� 00 �� ', I�.3 1y��
Conditions ofAppro�aUReasons for Disapproval
� � _ � � � f�3 �_..�.. _ . ° � ���`�'�� r`
�GI � � ---
� � �� . �1.
� 3
: ���____._ �,__..__._.�._ AUG ��
3 1 2023 `
CS� ►���- ��c( a�i� `:;, ,,,--;-�--_,-___�
��:�'u::vE:;:.
Attach to complece plans for the system and bmit to the Counq�onl}'on paper no[less than R I/2 z 11 inches in size "''`���
NQ R�FU�l��AFTER t-!'-13 0�F
ss�-��9s�R.ozizz� IS�UE OF f'E�SMI�f
Sawyer County Zoning & Conservation Administration
```"`1' 10610 Main Street, Suite 49
� ER cp �� Hayward,Wisconsin 54843
��'� �' VG�� (715)634-8288
��� ���� FAX(7(5)638-3277
�� -� _ �� wwwsawVercountygov.�
� E-mail:sanita�ian(msawyercountygov.org
�I°� =�_�~%�� Toll Free Courthaise/General Information 1-A77-699-4110
\ _vyr � �
��1�j1`O N:`�_
Holding Tank Approval Checklist
L Sanitary Cover Sheet: Date Stamp � / 31 / 23
Parcel ID# o� � - `� 3`� - 2.� _ �� O�
II. Plot Plan:
Property Lines �Benchmark BM ♦
Site Address �,North Arrow
�Structure �Scale
� Well �< 25' to Service Road
� Legal Description �jVearest 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 Fonn ($30 to ROD)
IV. Holding Tank Specifications:
�Tank Cross-Section: Manufacturer: wl e�- 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: �P� Plumber: �`� '
Application Review Date: `�j-7 a"�
� -T=
POWTS Reviewer: �� �
Name
6R �1� 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 Pumping Contract (if applicable)
Holdin Tank A reement if a licable
Project Name / Description
Owner Name(s): MARK S FORREST Phone: - -
Owner Address: N6061 WEIGAND LN, STONE LAKE, WI Zip; 54876
Project Address: LOT 4
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 #: 026-939-21-5109
Designer Information
Designer Name: TRAVIS BUTTERFIELD Phone: 715 _634- _8176
Designer Address: 14346W ST. RD 77, HAYWARD, WI Zip; 54843
E-mail: OFFICE@BUTTERFIELDDRILLING.COM �l�t,�,sp�1Ce CeSeC�,E� t�z��p�z{,,,a�,ra�„�,.
License Number: 652879
Remarks:
C�- ' _ .
Signature: ---- Date: � 3 j Z 3
Original signature required on eac submitted copy.
GHFCK BOX AS APP'JCABLE. CHcCK BOX AS AP?LICA9LE.
� SOIL EVALUATION o s`a1e �so 50 �s ioo I�SYSTEM PAGE 2 OF `/
SITE MAP PLOT PLAN
PROJECT NAME oesi.N F�ow� YSZ cPo
125'
����-1- �jj�r�J f Attach design Flow calculations for mmmercial plans.
PRo.IFCi ADDRESS: 5=^.( �r��.� f�..l Pipe Material/ASTM Standard(Tables 384.30-3&384.30-5)
� N sa����ary sewe�_ i
BM Symbol�.� 1�BM Elevation�./ ��'��`� FT Force Ma�in. /
dN��escription'. 1y� �� S�'"� �\
Slo eGradlent(°/ i�d���a�e�orcney IMPORTANT:
of7estedArea�. � �'eliSymboi�lfappllcabie)�. � drawlnqana�row Showgroundelevationcontoursatsultableintervals
a
n(M1e appropri�e I�ine.
—�\\ �C{it�. V\-'�l
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L� y Csrv� 37��a���2
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
4"0J 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 Establlshed Flood Elevation
Electrical must comply with With Warning Label Attached t ical 4° Min. or 2.0 ft above
SPS 316 and NEC 300 (rypical) � yP � Established Flood Elevation
—Conduit I (typical)
�
. �Airtight Seal " " . �
1 _ Finished Grade �
�
18" Min.
��YPical) . e, . ' � o', 4a '. - �.
. . � . , a
•a .. ' . • . , .
. . •
a .. . • ' . .� a. • a. • .
n
Inlet Inlet Invert fWatertight
Approved Joints with � Plug
Approved Pipe 3 ft onto �a Max. 12" or 90% of total volume '
Solid Ground � if more than one tank ^`
(rypical) Alarm-On 4,
a'
Compartment 1 Vol = � 25� gal Compartment 2 Vol = 750 gal
e
� �� TOTAL HOLDING TANK
d � VOLUME = 2000 gal .
'a
�a•
a
� • d. •
, p ' . ; . e � • �e • ': '• . • . . .
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 = [( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1 .5 = Ibs
PAGE40F4
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(:;)
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= °�'� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o rype 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 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:TI"BVIS BUtt81'f12Id Phone:715-634-8176
�o�ai 9o„e�nme�t��;r Sawyer County Zoning &Conservation phone:715-634-8288
Local government unit address: �OE�O M81n SL., SUite 49, Hayward, WI Z�P 54843
Any defective part of thls 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 depar[ment in
accordance with SPS 384,Wisc.Admin.Code.
Continqency 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.
SYstem Abandonment
If use of this tank(s)is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
W1250/750— M R
TANK SPECIFICATIONS � o
o �.
� ,
� �
12'-11 " DIMENSIONS: � o
WALL: 2 1/2" � a
4" CAST-A-SEAL 4" CAST-A-SEAL BOTTOM: 3"
COVER: 6" w
//,,_______=__-�j�L____,\\\ MANHOLE: 24" I.D. PRECAST CONCRETE RISER o
HEIGHT: 66
ii� II'II � ��� � n
✓� i t i i � ��. LENGTH: 12 —11 �
ii i i i i c� �� WIDTH: 7'-2" �
�� --- ��� �—� � i i i � r �--� �� BELOW INLET: 53"
' � "��P � i' � i �� �' �� LIQUID LEVEL: 48" � E
�I � � �` j � a WEIGHT: 14,860 LBS. -� � o0 0
� � \ Y I� \ � II V O �
��� �--' � �' i� � � �-�' 7j INLET AND OUTLET: � 3 0 0
\>� FILTER OR i i i i ,% 4" CAST-A-SEAL BOOT OR EQUAL GASKET � m o N
�� � � � � �� w z � 3
�� BAFFLE � �'� � '� INLET AND OUTLET BAFFLE AND FILTER: a Q � w
�;��-- � � � � -'�%/ WISCONSIN, SEE DETAIL 10 N o o �
__--_____��____�'� #
(OTHER STATES SEE CHART) W o
LIQUID CAPACITY: 27.66 GAL/IN (SEPTIC)
1� �
TOP VIEW 16.12 GAL/IN (PUMP) � �
� Y CO
LOADING DESIGN: 8'-0" UNSATURATED SOIL CQ � �
o TANK CAN BE USED AS: C7 0 �
� SEP11C/SEPTIC, SEP11C/SIPHON, Q N
Q � 4" VENT OR SEPTIC/SIPHON � � �
W � I
+� : COVER: MIX DESIGN #8 (NO FIBER) Y = �
� TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
WN
�
-- ' • ° . ---- � ' ' � ----
_L CUSTOMIZED TANKS: � cD
INLET - OUTLET FOR CUSTOM TANKS CONTACT WIESER CONCRETE � 3
�Q i - - - - L J '• I � - - I - ��
� � CJ �� I - I-.I � � � rU
� II
� i..� � � � � 'n I= 1 � a � � � � J
u-� I � � � � _ � � � Q
f � �I � � I � �
Z
2�, .� i. " II � �p Q
i�
�'`---- �T—.. ------� �° ---�=^-� I� �
REVIEWED BY o c�
�, PUMP PAD REVIEW DATE N �
3 cwi�
DRAWINGS SUBMITTED
SIDE VIEW FOR APPROVAL
APPROVED BY: SHEET N0.
APPROVAL DATE: � �
OF
PRODUCTS NEEDED BY: / �
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
HOLDING TANK SERVICING CONTRACT
Contract Date: / /
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
MARK S FORREST SCOTT POPPE
Parcel Identification Number:
(12 Digit Legacy ID) 0 2 6 - 9 3 9 _ 2 1 - 5 1 0 9
1. The owner agrees to file a copy of this contract with the governmental 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 installation 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 the property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access 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
tnutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
servicing of the holding tank(s) as required �inder SPS 383.55, Wisconsin Administrative
Code and the Sawyer 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. The name of the owner of the holding tank;
c. The site address of the holding tank;
d. Tl�e 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 until the owner or pumper terminates this contract. In
the event of a change in this contract,the owner agrees to tile 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.
OW118]''S N3TTle: �PClllt� �Wllel''S SigLlatllPe: (Only one owner signature required)
MARK S FORREST
Pumper's Name: (Print) Pumper's Si nature:
__.----
SCOTT POPPE S�
P�imper's Registration Number:
81813
Rev.03/26/13
Real Estate Sawyer County Property Listing Property Status:Current
7oday's Date:8/30/2023 Created On:10/25/2021 8:46:28 AM
�Description Updated:8/11/2023 �Ownership Updated:8/il/2023
. _ . __ _-___._ . _. . ..._ ._ -___-.___--
Tax ID: � 44308 � MARK S FORREST STONE LAKE WI
PIN: 57-026-2-39-09-21-5 OS-001-000090
Legacy PIN: 026939215109 Billing Address: Mailing Address:
Map ID: MARK S FORREST MARK S FORREST
Munidpality: (026)TOWN OF SAND LAKE N6061 WEIGAND LN N6061 WEIGAND W
STR: 521 T39N R09W STONE LAKE WI 54876 STONE LAKE WI 54876
Description: PRT GOVi LOT 1 LOT 4 CSM 37/209
#8592 (ZAWISTOWSKI JT REV TRUST- �Site Address *indicates Private Road
LC) ._... ..._. ._... . .._. __.._..
Remrded Acres: 4.910
Lottery Claims: 0 U dated:7/6/2022
First Dollar: No u Property Assessment P
.__._ ..... . .__... ._.------
Waterbody: Sand Lake 2023 Assessment Detail
Zoning: (RRl)Residential/Recreational One Code Acres Land Imp.
ESN: 423 Gl-RESIDENTIAL 4.910 ll4,800 J
-7 Tax Districts lJpdated:10/25/2021 Z-Year Comparison 2022 2023 Change
— ..-.-.. .--- --. --. --.— Land: 174,800 ll4,800 0.0%
1 � State of Wisconsin
57 Sawyer County Improved: 0 0 0.0%
026 Town of Sand Lake ToWI: 174,800 174,800 OA%
572978 Hayward Community School Distnct
O01100 Technical College �
'L7+ Property History
-.... _-____ __...
-+ Recorded Documents Updated:l0/25/2021 Parent Properties ��� TaxID
-- ����� - � � ���" ��-�� �-�-�--- ��-��� 57-026-2-39-09-21-505-001-000030 28773
� LAND CONTRACT
Date Recorded:7/31/2023 445635
� MAP OF SURVEY
Date Remrded:1/12/2022 21399-19
�CERTIFIED SURVEY MAP
Date Recorded:l0/19/2021 435333
�QUIT CLAIM DEED
Date Recorded:4/5/2013 384376
O QUIT CLAIM DEED
Date Recorded:2/11/2013 383451
� WARRANTY DEED
Date Remrded:1/22/1991 222005
HISTORY O Expand All History White=Current Parcels Pink=Retired Parcels
�Tax ID:28773 Pin:57-026-2-39-09-21-5 OS-001-000030 Leg.Pin:026939215103 Map ID::13
44308 This Parcel Parents Children
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- USE BLACK INK ONLY - TX :404r''25�
POWTS MAINTENANCE AGREEMENT 446Z57
For Holdin Tanks PAl1LA CHISSER
g REGiSTER OF DEEDS
Owner's Name(s) as shown on deed: SAWYER COtlNTY, WI
0�!07/�.�z3 �J8:5s 4M
MARK S FORREST ����RC�ING F�E 3�.00
Parcel Identification Number:
(�2 Digit Legacy ID) 0 2 6 _ 9 3 9 _ 2 1 _ 5 1 0 9 �'A�E�: Z
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 contractwith 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 properly 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 cost incurred by the governmental 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 holding tank.
4. This agreement will remain in effect only until the governmental unit responsible 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 4e recorded by the register of deeds in a manner which will
permit the existence of the agreement to be determined by refereri�e to the property where the holding tank is installed.
- Only one owner signature required - ACKNOWLEDGMENT
Ow er's Signature: State of: ws�°�5��
-------- -- _
COUllty Of: Sawyer
Owner's Name (Print): ���.u�k Subscribed and sworn to before me on this
MARK S FORREST � PUBC/ hl� 3,St day of August 20 zs
� '
Date: � 3 ��Q' ��tii� y (Owner's Name): ►N1o.v K 1-o�'L
� � �3 �� �lotary Public Signature: ° `
Drafted by: �F\�� Z �ublic Notary Name (Print): Keuy e� d
Kelly Butterfield � � ��'�� =�y commission expires on: 3isizs
0
S
s
Ih�+N±Tq TE OF��`�
Personal information you provide may be used for secondaryM��rivacy Law, § 15.04 (I) (m)] Rev. 03/26/13
Lot 4 of Certified Survey Map No. 8592, recorded in the office of thc Register of Dceds for
Sawyer County, Wisconsin, on October 19, 2021, in Volume 37 of Certified Survey Maps on
pagc 209, as Document No. 435333 and being part of Governmcnt Lot l, Section 21, Township
39 North, Range 9 West, in the Town of Sand Lake, Sawyer County, Wisconsin.