HomeMy WebLinkAbout002-840-21-4201-SAN-2023-225 �t�'�'"'+; [ndustry Services Division County �
�� 4822 Madison Yards Way �'Gct,r��/C�' �
�^`�_' = Madison,Wl 53705 Sanitary Permit Number(to be filled in by� �
_ . P.O.Box 7302
_ Madison,WI 5302 (y s � �; ( �� �
- W
Sanitary Permit Application StateTransactionNumber ,
[n accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit �- �
is required prior[o obtaining a sanitary permit.Note:ApplicaYion forms for staie-0wned POWTS are submitted to Project Address(if different than mailing a �
the Departrnent of Safety and Professional Services.Personal information you pmvide may be used for secondary
purposes in accordance with the Privacy Law,s. t5.04(lxm),Stats. �
I.Application Information-Flease Print All Information ��)' �`y �
Property Owner's Name (kr����:,� ��r-e � azce
ShiG U L.LG �� `a �`�� 4�3- �rya--a/ - �j�o/
Property Owner's Mailing Address Property Location
J ay � i�� sr� �� �-�
City,State Zip Code Phone Number
C I- � s L bo /n� N� %, �'� '/a, Section—z�
�n,
ll.Type o Buil ing(check all that apply) Lot# T �a N R E o�
�1 or 2 Faznily Dwelling-Number of Bedrooms �" Subdivision Name
Block# r--
❑PublidCommercial-Describe Use --
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
� (�Town of�r� ,!!P
❑I.Type of POWTS Permit:(C6eck either"New^or"Replacemeot"and other applicable on line A. Check one box on line B.Complete line C i
a licable.
A.
New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain)
B' �Ioldic�g Tank ❑ In-Ground ❑At-Grade ❑Mound ❑ Individua!Site Design ❑Other Type(eKplain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner
ist Previous Permit Number�d Date Issued
Expiration �'
IV.DispersaUTreatment Area at+d Tank Information:
Design Fbw(gpd) Design Soil Applicaiion Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
jB0 -----_ .._—
Capacity in Total #of Manufacturer
�
Tank Informaiion Gallons Gallons Units A �; v � �
New Tanks Existing Tanks y e e� � Y y � �
4 U �n H � w C7 0,
Septic or Holding Tank 'a� (�� f ���,5�� x
Dosing Chamber (�D b�� �
0
V.Responsibility Statement-I,the undersigned,assume responsibility[or installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature / MP/MPRS Number Business Phone Number
C��P/'r..I A rd'Q'�''Q � �C'�.�� ����� /�3 '�S������'
Plumber's Address(Street,City,State,Z.ip Code)
l�S'�o� W .z.e.m� �o� I �„µ�� w-� S y�y�
VI.County/Department Use Only
1 Permit Fee Date Issued [ssuing Agent Signature
�Ap 0 Disapproved p „ _
$ yoo.� �, � ,� � 3 ,v�,�;�,�.k�_�-�^�.�
C3 0wr�er.Given Reason for Denial �^
Condirions of Appr�UReasons for�ppmval '���� ' ,
� ��
, a � ti�- a3
il ���� �Y�`� iJ i�Y.x� .._..._. i
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i�as SEP 1 1 2023 �
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C'S� �6���. -.+� �-�'l 1 SAWYER COUNTY
ZONiNG ADMINISTRATIOIv
Attach to complete plsos for t6e system and submit to t6e Couoty only on paper oot less than 8 v2:11 ioches in size ��G��
SBD-6398(R 02/22) NO REFiJN�$AFT�R
c a�l �ssuE oF F*ERAm i
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
���R C��� Hayward,Wisconsin 54843
'��—��Ci�� (715)634-8288
��' FAX(715)638-3277
� �
2��/
�V�� - _ — �% www.sawvcrcountveo�,.�
� o � � �o � E-mail:sanitarian(a��sawycrcoimtygov.�,rg
I� \ y / � Toll Frce Courthouse/General Information 1-R77-fi99-4110
I�J\ "�����
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp �`� / 1 � / �O�-3
Parcel ID# �� � - $ �{ 0 - � l _ LI � D (
II. Plot Plan:
� Property Lines ?� Benchmark BM ♦
l'Site Address �North Arrow
�Structure �Scale
�Well �< 25' to Service Road
�p Legal Description �Nearest Road Intersection
� Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
D� Index Page witll Original Signature
�Management Plan/Contingency Plan
� Servicing Contract
�Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer:W1�— Gallons: �1� Q D
�Tank Anchor Calculations [SPS 383.43 (8) (�)]
�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: �� `�V 1-� �-- Plumber: ��' �
Application Review Date: �� �t � 2-oZ 3
POWTS Reviewer: �
Namc
6�l � l� Rev. 4/27/2023
Credential#
PAGE 1 OF 4
Holding Tank Plan
l�dex 8� 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 in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
Owner Name(s): S�fG V �� Phone: - -
OwnerAddress: �(,�`lW I�S�sT C�%u�c ��� Zip; /,D60,�
Project Address: C�y �
.Lot: �1-r/ 1!4 of S t 1/4,Section � I ,T �D N-R � E❑or W�
Township: ��sf (a.Ke County: s�ye'�
Project Parcel ID#: 002� yy0�a-I- ka Ol
Designer Information
Designer Name: GP��lo� �i,?e.r e I Phone: �S_-s�-��3�
Designer Address: /,7 5-01 '� F�re�-�� l�y~'r� � Z�P: �`Yy�
E-mail: � ��_�::�„ << ,,;:,��_. ,_
License Number: `�S�!��
Remarks:
Signature: �s��'��� Date: J-//=z�
Original s�gnature requued on each sutunitted copy.
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
4"0�Vent Pipe
Weatheryroof >70 ft from
Junaion and Alarm Box APPro�� Buildlrg
Appmved Locking Menhole Ven�Cap �2"Min.or 2.0 fl abova
Eleclncal must comply w�th Estahlished Plood Elevalion 4"Min.or 2.0 fl above
SPS 316 and NEC 300 K'ilh Waming Lebel Alleched (rypical)
(h,P���) Eslablished Plood Elevation
Conduil I (typiceq
; �AirtighlSeal � ��
Finished Grsde
18"Min. I
(�YPiceq ' i '.. . , �a. �,
a .. �. •
i ,
Inlet Inlet Invert
--Waterlight
Approved Joints with � : P109
Approved Pipe 3 fl onlo Maoc.12"or 90%of lotal valume
Solid Gmund if more lhan one tenk /
(rypical) Alartn-0n y
i.
Compadmenl i Vol= .2��gal Compartment 2 Vol= 3 �� gel
TOTAL HOLDING TANK
a VOLUME = 2D0p gal .
:
e d.
3"ApproveE BeECing Matenal Benealh Tank
TANK MANUFACTURER: W(QS e�
Anchor tank as necessary
pursuant to SPS 383.43(S)(g)
Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-R�s.tank.wt]x 1.5
L�
Ballast Weight= [( cu.ft. x 62.41bs/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(s)
shaii be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthertnore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accwdance with SPS 383.52(3),Wisc. Admin. Code.
Estimated Daily Wastewater Flow= �4� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance tactors ji.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches,floats, etc.)
o material fatigue(i.e., �eaks, breaks, corrosion, etc.)
o neglec[or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o electrical components(i.e.,wiring, connections, switches, controls, timers, alarms, etc.)
o siufac€discharge of efflueni or sewage back-up into structure served
SERVICING FREQUENCY
o Thg tank(s)shall be pumped by a certified septage servicing operatc�r licensed under s.281.48 Wisc. Stats.
when the wastewater in the tank(s) reaches a level of one foot below the iniet invert of the tank(s).
Disposal of cDntents shall be pursuant fo NR 113,Wisc. Admin. Gode.
Tank pumping reports shall be submitted to the proper locai govemment unit in accordance with SPS 383.55�s.
Admin. Code. Report any component failure or malfunction to:
Nameofindividualorcompany: �0.�f f�/��� �L� Phone: 7/5=5"SS�_/ � ��
Local govemment unit: �k�y�'� 7c>.,.�--� Phone: ��,3"= f 3 Y'p��
Localgovemmentunitaddress: /'y/k��+ fl �yuv���..�1 ZIP: �I'dr`+'7
�
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51 (1),Wiss.Admin.
Code. Repair or replacement of failed or maifunctioning 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 wifh SPS 384,Wisc. Admin. Code.
Continaencv Plan
In the event that any fail€d component of this holding tank(s) cannot be repaired, it shall be rgplaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
Svstem Abandonment
if use of this tank(s) is discontin�ed, it shall be abandoned in accordance with SPS 383.33,Wisc.Admin. Code.
o GILNLATED
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HOLDING T�NK SERVICING CON'FRAC'F
Contract Date: l r I l �O� 3
This contract is made between the Hnlding Tank Qwner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
J � (y� , �L �- .S�a/ / �°'PP'"�
Parcel Identification Number:
(12 Digit Legacy ID) � � � - � � O - Z f - �l s'Z � �
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
A�re�ment for a Holding Tank required under the Sawyer County Private Sewage Sys�tem
Ordinance for the issuance of a Sanitary Pemut for the installation of a holding tank(s).
2. The owner agrees ta ba.ve the holding tank(s) serviced by the pumper and �taraniees to
pernut 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) �vith the F�P�� e4�Pment. The owner
further agrees to pay the pumper for charges incurred in servicing the holding tank(s) as
mutually agreed u}�on by the owner and gumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
servicing of the holding tank(s) as required under SPS 383.55, Wisconsin Administrative
Code and the Sawyer Caunty Private Sewage System Ordinance_ The pum�er further
agrees to include the following in the report:
a. The name and address of the person respansible far senricing 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 hc�lding tank was s�erviced;
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 file a copy of any changes to this
service contract Qr a copy of a new servi.ce ccantract with Sawyer Cauniy vvithin ten (1 Q�
business days fram the date of change to this service contract.
Owner's Name: (Print) OWriEr'S Slg[11h1Te: (Only one owner signature req�rired)
A ��.►M Ve I �:�,�t
� It P V ; LL s ��L�+ U ,�;�� ABA � I�� V L.L �
Pumper's Nasne: (Print) Pumper's Signature:
�S'�r�r p�► �P� �-�'-���'���
Pumper's Registration Number:
�/ �I 3
Rev. 03/26/13
9/11/23,2:39 PM Real Property Listing Page
R2al EState Sawyer County Property Listing Property Status: Current
Today's Date: 9/11/2023 Created On: 2/6/2007 7:55:05 AM
�'Description Updated: 5/5/2021 '� Ownership Updated: 8/5/2020
___---- -___._ _ _ _ _ _--------------- ___ _ _._ -- _ _ -- -_ -------___
Tax ID: 2290 7HGV LLC CHICAGO IL
PIN: 57-002-2-40-08-21-4 02-000-000010
Legacy PIN: 002840214201 Billing Address: Mailing Address:
Map ID: .14.1 ]HGV LLC ]HGV LLC
Municipality: (002)TOWN OF BASS LAKE 1624W 18TH ST 1624W 18TH ST
STR: S21 T40N R08W CHICAGO IL 60608 CHICAGO IL 60608
Description: NWSE
Recorded Acres: 38.691 � Site Address * indicates Private Road
_ _ . __
Calculated Acres: 38.691
Lottery Claims: 0
First Dollar: No �.-� Property Assessment Updated: 5/31/2022
Waterbody: Osprey Creek _ _______ ___.___.. _
2023 Assessment Detail
Zoning: (RRl) Residential/Recreational One Code Acres Land Imp.
ESN: 445 G6-PRODUCTIVE FOREST 38.686 58,000 0
� Tax Districts Updated: 2/6/2007 2-Year Comparison 2022 2023 Change
_ _ ___ __ --
1 State of Wisconsin Land: 58,000 58,000 0.0%
57 Sawyer County Improved: 0 0 0.0%
002 Town of Bass Lake Total: 58,000 58,000 0.0%
572478 Hayward Community School District
001700 Technical College
+L�'Property History
•� Recorded Documents Updated: 5/5/2021 N/A
_ __ __ __ ---- - -_ __ ____
WARRANTY DEED
Date Recorded: 7/6/2020 424851
MAP OF SURVEY
Date Recorded: 1/29/2021 21408-16
TRANSFER ON DEATH DEED
Date Recorded: 10/1/2015 397930
TRUSTEES DEED
Date Recorded: l0/1/2015 397929
QUIT CLAIM DEED
Date Recorded: 7/24/2006 340405
ABRIDGMENT OF JUDGMENT
Date Recorded: 7/10/1981 178655
QUIT CLAIM DEED
Date Recorded: 3/3/1964 118184
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�x :4047342
POWTS MAINTENANCE AGREEMENT 446330
For Holding Tanks PAULA CMI�SER
RE�ISTER (?F �EEDS
Owner's Name(s) as shown on deed: SAINYER COUNTY, WI
�9/ il/2023 02:51 PM
JHGV,LLC RECaRDING FEE 3D.Ofl
Parce� �dentification Number: O02 840 21 4201 �AGES: Z
(12 Digit Legacy ID) - - -
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 hoiding 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 shail 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 be recorded by the register 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.
- Onl one owner si ture required - ACKNOWLEDGMENT
Owner's Signatur � State of: I�� l N�I S
County of: C C�0�%
Owner's Nam (Print): / Subscribed and sworn to before me on this
u'",�-� V.�iL�y� � � day of v� , 20 ��
Date: / By (Owner's Name): a h'1 (/-e�CLVd1�
� I Z �l 2� otary Public Signature: �G�jlil�D,f�./ ���?/U�
Drafted by: ADRIEN AN
OFFICIAI. SEA ublic Notary Name (Print): ,��QvtyiQ .��'ll{y1Llh
(,� � � Notary Public, State of ii�no�s y commission expires on: 12//�23
y ommi i �res �
December 14, 2023
Personal information you provide may be used for secondary purposes [Privacy Law, § 15.04 (I) (m)] Rev. 03/26/13
The Northwest Quarter of the Southeast Quarter (NW'/4SE'/4),
Section Twenty-one (21), Township Forty (40) North, Range
Eight {8) West (in the Township of Bass Lake) Sawyer County,
W1
Including a 25' easement east of and adjacent to the West line o
SW'/4SE'/4, for sole purpose of access to the above described
property as shown on Document recorded 7/1/11 Doc. # 373235.