HomeMy WebLinkAbout026-938-17-5201-SAN-2023-255 _ ��Y � " � Department of Safety c°°°n v?
. �� �c�.w yG�' �
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. � � �: & Professional Services, �
E� .,, $ Sanitary Permit Number(to be filled in by
t �, �� "� Industry Services Division
�'_ (�51 lr��-i� ��
w
Statc Transaction Number �
Sanitary Permit Application s�
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fortn to the appropriate governmental unit �
is required priar to obtaining a sanitary permit.Note:Application forms for state-owned POWTS aze submi[ted to Project Address(if different than mailing:
the llepartment of Safety and Professional Sercices.Personal information��ou pro��ide may be used for secondary �� ���'��
purposes in accordance with the Ptivac��Law,s 15.04(1)(m).Stats.
I.Application Infnrmation—Please Print Afl Information � M u�I� 1�T' �''_
Yropert}'Ow�ner's Name Yarcel#
S��s ,� ���.� ►v y b�� a i��3£'s � ��2� �
Property Owner's Mailing Address Property Location
PG c��� �S Uo�.t.Lo� a
City,State Zip Co3e Pho1e Number
s �O� ���� �J� s�,�.�T� Ya, '/,, Section � 7
II."I"}*�1C i3if'B+uiiE��ltg{iClteelC 8�t t68$81'tP�3} „ Lot# 'r 3�' N R �l E or '`
,j�'I or 2 Family Dwelling—Number ofBedrooms
� '�� Subdivision Name
Block# �—
❑Public/Commercial—Describe Use
�
❑Citv of
❑State Owned—Describe Use — CSM Number ❑Village of
-- �'Cow�of �fcNL� �G�.
III.T�ype of POWTS Permit:(Check either"New"or"ReplacemenN'and othcr applicabie on line A. Check one box on line B.Complete line C.if
• a 3icable.)
A.
�New System ❑ Replacement System ❑ Other Modification to Existing S�stem(cxplain) ❑ Additiunal Yretreatment Unit(explain)
B.
Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
• _ist Previous Permit Number and Date Issued
, C• ❑ Renewal Before ❑ Revision ❑ Chan7e of Plumber ❑ Transfer to New Owner
Expiration
TV.Dis ersaUl'reatment Area and Tank Information:
Design Flow(gpd) Design Soil Applicazion Rate(gpd/st1 Dispersal Area Required(s� Dispersal Area Yroposed(s� System Elevation
. �� �� �� `
CapaciTy in Total #of Manufacturer
Tank Information Gallons Gallons Units L ` c � �
� New Tanks Existing Tanks � � « � � � � �
0. :� V] v, V: Cx. � y
Septic or Holding Tank ��7 ?•zC� �e� �- �l��d �
J
Dosing Chambet
T�,Respansi�ility Statement�I,tlte undersigned,assume responsibllity fcrr insialla�ion of the PQV4''TS shawa on thr attached pians.
Plumber s Narne(Print) Plumber's Signature � MP�YiPRS Number Business Phone Number
Jerry Ruid Excavating, LLC � C` � 2�iz��,- 7�5--�y z-2�r��
Plu (� . t ip Code)
Stone Lake�WI 54876
VL Coun /llepa�ent Use Only
� Oy Permit Fee Date Issued Issuing A�eent Signature
:1pp �(� ❑Disapproved $ dp 'L � S �r�� � _
❑O�vner Gi�en Reason for Denial �`�'v� �����r'��"z
Conditions of ApprovaUReasons for Disapproval �
� � �� ���i��� ��� �+ �
;� �
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�hk#.� 3_c�..i_�.. OCT 0 3 2023
�_ .�._.-�.�.�......
C� �d� � �'C��"�_ 3 al�'I �A�YER COUN�Y
_..
ING ADMIN�STRATiO
Attach to wmplete plans for the spstem and submit to the County only on paper aot less than 8 1/2 x I1 inches in size
�-1��3-"�i
SBD-6398(R.03/22)
Sawyer County Zoning & Conservation Administration
������� � 10610 Main Street, Suite 49
� �R Cp �� Hayward, Wisconsin 54843
�='��' ���i �� (715)634-8288
��� ��Z�I� FAX (715)638-3277
/�� _ ' - 'i � / www.sawYCrc<�untvkov.<n'Q
� I � ` � — _ � j E-mail: sanita�ian r�;saw crcountvaciv.o�
/ o \ ��_:'.. :" / o
I � =y ;;Y�� � Toll Frcc Courthousc/Cencral Information I-877-699-4110
,,���5 C O NS��
� ������.
Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp � o / 03 / �a�3
Parcel ID# O .�- (, _ �C 3 g _ � � _ �a � (
II. Plot Plan:
� Property Lines D� Benchmark BM ♦
� Site Address D� North Arrow
�Structure � Scale
xWell � < 25' to Service Road
XLegal Description � Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
�Index Page with Original Signature
Management Plai�/Contingency Plan
�Servicing Contract
�Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: W� aS�'r Gallons: ��
� Tank Anchar Calculations [SPS 383.43 (8) (g)] �. 3�
� Locking device, chains/locks
� Alann, electrical per SPS 383.43 (8) (e)
� 3" Bedding Material < 1/2 "
V. POWTS Coinponent Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: Plumber: ��+ ��I
Application Review Date: I o ( �l��c��_
�
POWTS Reviewer: �,� ���--��
Name
�`�' � � � Rev. 4/27/2023
G�cdential #
PAGE 1 OF 4
Holding Tank Plan
Index 8� Cover Sheet
Component Manua!Design References: 'IV���\
Version�,SBD-1085rP(N.03/07;R 01/12)�a� -a-� �
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 Re rt&Site Ma if a plicable)
Holdin Tank Pum in Contract if a licable)
Hoidin Tank A reement if a licable
Project Name/Description
Owner Name(s):�o�es :� ����C'- N 4bz�`� Phone:
OwnerAddr�s: i�o l3ox 55` Zip: ��f81(�,
ProjectAddress: 162zs�w 1�4,s�y F�-r �r.
Go�rt.Lot: � 1/4 of 1/4,Section �� ,T 38 N-R R E❑or W�
Townahip: S�t...rS �-�-�� County: �4�.,"�y�'
Project Parcel ID#: c� 2 6�3 f3 i 7s�o I
D�igner Information
Jerry Ruid Excevatirtg,LLC
Designer Name: Phone:��'J� -`'�� 2`-lcFl
Designer Address: Stone L9ka-uw 5�{876 Zip: S�-t 8 �6
E-R181�: 1 C V lcs� ��..,��r�r�e.,( ./vG� 7l�is.�race rccerved for apprnva!stamp.
Licenae Number. �-`����2
Remarics:
.
Signature: �,�,�-c� Date: �-2��z�
pinai cipna4ue reqWred on each suhmitted mpy.
o���
12SD/9SG �
Ie I� . -_� 3 2.�
f'�r�peK.�c!
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la V 12'�t � 20'` �Zb Q�k
4. rth Ba 1-t- —ioe�. c>
Gw<.>gc.. — �17.0
1�a„oL- _ Iv) �-t
�ie LC �o ,,,�e�'b" S��cs�-c�CC�
pr� e.rd- i- . `
P `I �^-e5 �re -t �G�
Jerry Ruid Excavating, LLC � � 38 �� `��,,.,2s � ����,�„e
W208 County HWY A
Stone Lake, WI 54876 Go� lG� 2, / ivybe�
�S�T -- 2 +-lz`l(o� 1'�1-F�.. Gfc��S �c 13ojC S(�S/
�'��s $'jp�U� V-c-K�' L✓L
.�.�(-. 7SQ �GFG�j
,r-�" '-1 B?(o
PAGE 3 OF.4
HOLDING TANK SPECIFICATIONS
(No Scale)
4'0 Venl Pipa
Wee�herproof >7 D fl from
Junction and Alarm Box Approved Building
A mved Lodcin Manhoie Vent Cap �2"Min.or 2.0 fl above
ElecMcal musl camply xnlh PP g Established Flood E�eva�ion 4"Min.or 2.0 ft above
SPS 376 and NEC 300 wilh Waming Lehel AllacM1ed (typiral) Estahlished Flood Elevalion
(rypiral)
(ryPirap
Canduil
Airtight Seal � " ��
Finished G2de
18"Min. �
(NPicap ��. . , 'n��.'
. •
.d
Inlel INet Invert Watertight
Appmved Joinis xdlh Plug
Appmved Pipe 3 ft onlo M�.12"or 90°G of tolal volume i
Solid Gmuntl if more Ihan one lank
(typical) p!arm-0n Y
i
Comparlmenl 1 Vol= I�$Q Bal Compadmenl2 Vol= ?5 U gal
�
TOTAL HOLDWG TANK
VOLUME = 2Ccx: gal .
. - a.� .
3"Appmved Bedding Metanel Beneath Tenk
TANKMANUFACTURER: �^—` ��5�
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight=[(cu.it.tank.vol x 62.4 Ibs/cu.ft)-Ibs.tank.wt]x 1.5
Ballast Welght= [( ��`7 cu.ft.x 82.4 Ibslcu.ft)- 7�`l�'� Ibs]x 1.5= �Z��`� Ibs
Reset Pag
, PAGE30F4
HOLDING TANK SPECIFICaTIONS
(No Scale)
weea,erpoor �r Mm.or 2o e abwe
JwGbn ud qpptored ��t����0"
Ainrtn Box Verrt Cap ��)
Electrial mu�canqY wNh + Apptoved Loddng hleNtale
SPS 816 and NEC 300 4'H Vant Pipe whh Nhming LabN Atddrd
. �� >10 E fiom (rypice�) 4'Mh�,w 20 E ebow
BuH�mg
EsiaWehetl�
A4tl9M Ssel .
� Fmk1Md Grade
r
18'h9n.
(1!'P��) , '`�,- ' .. � • •
• .
. . ,. •� 4 • •
�rdet �rdet�m�as y��yyM � � ��
AppmvedJointswfth � .
APP��9 E on0o ' Mmc 12'or 90%of 9oQal vdume ..
3dld Gmwd ' N more tl�an ona dnk
a
� ! Alartn-On .
:
:
HOLDING TANK
VOLUME_ � Z �-' gal '.
. a . . . • • ' • . _
g•ppproved Beddtr+C MetxW Berroatl�Tardc
TANK MANUFACTURER: ��eSr�
Anchor ffink as necessary
pursuant to SPS 383.43(B)(g)
Bailast Weight= [(cu.ft.tank.voi x B2.4 ibs/cu.ft)-Ibs.�nkwt]x 1.5
sei�ast wei�nt= �� Cu.ft. x 62.41bs/Cu.ft)- Ibs]x 1.5= Ibs
PAGE40F4
Hoiding 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 = , �
gpd
Inspection 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
.i .:
3 f. .i. . �r},,,.:
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) reacb�s�arle�veb.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 govemment unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company: ���f'i'"f ��s � � � x clt_vc.,�"rr�� Phone: ���� � `���- � �`la �
Local govemment unit: �5 � �. Phone: ���5 ' � -� `� � �$�
Local govemment unit address: � �� �� 6��.�..i� Sy� f-(�.y w�tr�c� i,.��,� ZIP: �`/g`F�
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.
Continqen�y Ft�n
In the event ttiat any 'raile� ;c�m���en.+. of th'ss hoEdi� L ta���k;;:�, �.:��not '�� re�a��c;d, it shall be replaced pursuant to a
plan submitt�d ta the app�o�rriat� agecy far re�•�;,��.; .- � ; �-��;- ,,��.-;'.
System Abandonmen8
If use of this tank(s) is discontinued, it shall hP �+c=..� ' :: E; . . � ,corda� r,e �n��th S�S 383.33, Wisc. Admin. Code.
FIOLDING TANK SER'VICING CON'I'RACT
Conlract Date: !2`�/2 0 23
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
�l}121e5 f� 9—�lcfi'nr �, �r-f�p� L,�'v�w`s ��•1c�...9u.g�R
J
Parcel Idenri£caHon Number:
(12 Digit Legacy ID) � 2 �-���-� 7 - 5 L d i
l. The owner agrees to file a copy of this contract with the govemmental unit,Sawyer Counry, _
which has accepted and recorded wi[h the Office of the Register of Deeds,the Maintenance
Agreement for a Holding Tanic required under the Sawyer County Private Sewage System
Ordinance for the issuance of a Sanitary Pemut for the installation of a holding tank(s).
2. The ownec agees to have the holding tank(s)serviced by the pumper and guazantees to
pemnt 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 putnper 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 agreed upon by the owner and pumper.
3. The pumper agrees to subtnit to the Governmental Unit,Sawyer County,a report for the
servicing of the holding tank(s)as required under SPS 38.s.55,Wisconsin Administrative
Code and the Sawyer Counry Private Sewage System Ordinance. The pumper further
a�ees to include Ihe following in the report:
a. The name and address of the person responsible for servicing the holding tank;
b. T'he 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&om the holding tank for each servicing;
£ 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 temrinates this contuact. In
the event of a change in this contzact,the owner agees to file a copy of any changes to this
service coniract or a copy of a new service contract with Sawyer Counry within ten(10)
business days from the date of change to this service contract.
Owner's Name:(Print) x Owner's Signature:�o��y one owner stgnem�e�ey��rea�
k
��Cc i'vtG �-_1��r�L'rJ
J �
Pumper's Name:(Print)� Pu.�nper's Signature�/
�— v�h ��. s c�� c�l `r^", ,�
Pumper's Registration Num er.
2 0\� �
Rev.03/26/13
9/29/23, 3:53 PM Rea� Property Listing Page
Redl EStat2 Sawyer County Property Listing Propertystatus: Current
Today's Date: 9/29/2023 Created On: 2/6/2007 7:55:47 AM
� Description Updated: 4/29/2020 "� Ownership Updated: 12/4/2017
__ _ _ _._
_ _
Tax ID: 27984 JAMES A & ELAINE NYBERG STONE LAKE WI
PIN: 57-026-2-38-09-17-5 05-002-000010
Legacy PIN: 026938175201 Billing Address: Mailing Address:
Map ID: :2.1 ]AMES A & ELAINE NYBERG JAMES A & ELAINE NYBERG
Municipality: (026) TOWN OF SAND LAKE PO BOX 55 PO BOX 55
STR: S17 T3HN R09W STONE LAKE WI 54876-0055 STONE LAKE WI 54876-0055
Description: PRT GOVT LOT 2 MFL CLOSED 25 AC
Recorded Acres: 29.750 � Site Address * indicates Private Road
Calculated Acres: 35.105 16225W MUSKY POINT DR * STONE LAKE 54876
Lottery Claims: 0
First Dollar: Yes 1�.�. Property Assessment Updated: 2/6/2007
Waterbody: Mud Lake
Unnamed Lake 2023 Assessment Detail
Zoning: (RR2) Residential/Recreational Two Code Acres Land Imp.
ESN: G1-RESIDENTIAL 4.750 9,500 1,800
W8-MFL CLOSED - BEFORE 25.000 97,500 0
2005
� Tax Districts Updated: 2/6/2007
1 State of Wisconsin 2-Year Comparison 2022 2023 Change
57 Sawyer County Land: 107,000 107,000 0.0%
026 Town of Sand Lake Improved: 1,800 1,800 0.0%
650441 Birchwood School District Total: 108,800 108,800 0.0%
001700 Technical College
•� Recorded Documents Updated: 4/29/2020 '� Property History
WARRANTY DEED __ __ _ N�A
Date Recorded: li/7/1997 264252 617/425
MANAGED FOREST LAW-MFL
Date Recorded: l2/11/2002 306266
https://tas.sawyercountygov.org/system/frames.asp?uname=Eric+Wellauer ���
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-USE BLACK INK )NLY- Tx:4G4784�
POWTS MAINTENANCE AGR;�OWCE�I' � � l �4673Q
For Holcling Tartks � REGi�TER OF DE��
__�.,..__.....-----.—.. ..__. __�_: SAWYER C'�UN�i Y. V1#I
OwnersName(s)asshownondeed: 10/05/2023 08`17 AM
.T�,.�nn�A.�" �,��i,.��L. I�I {o�Y' i RECOR�INGFEE 3fl.00
--�-- - g---
. _ _ ..___
Parcel Ident�cation Number: e-� � �A���: �
(12 Digit Legacy ID) Q 2 �p -�� � _- .` .r 5' Z d( _.
I
4
�__'_�__.____.. ___.....__ . ....._._ �.__.._:
Legal Description of Property: i
-SEE ATTA�:F�E� SF�LE'� - i
�
We acknowled�s that application is being made for the insi�llatiar,a,�:.,:;di �: x(s)on�he
property described on the attac�ed sheet.
Retum To:Sawyer�ounty Zoning and Conservatior.ss:!rnin'ssY�a';�,n
90610 Allain St.Suita 49,Hayward,WI 54t143
, As an inducement to the County of Sawyer to issue a sanitary permit for a halding 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 riolding tank management, including the foliowing:
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 fi(e a copy of the seroice 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 govemmental unit within ten(10)business days from the date of change to the service contract.
r
2. The owner agrees to contract with a person licensed under Ch.NR 113,Wis.Adm.Code,who shall submit purnping reports to
the govemmental unit in accordance with SPS:�83.55,V11�s.Adm. Code,for the servicing of the holding tank. In the case of
exemption under Section 281.48(3)(d), Stats.,the owner shali submit the report to the governmental unit. The govemmental
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 govemmentai unit to prevent
or abate a human health hazard as described in Section.254.59,Stats.,the governmentai unit may enter upon the property
and service,or cause the tank to be serviced. Pursuant to�ec�ion 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 owne�agrees fo pay all"charges and cost incurred by the govemmental unit for
inspection, pumping,hauling,or otherwise servicing ar�d 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 governmentai unit responsible for the regulation of private sewage systems
certifies that either a soil absorption system that complies�with`�PS 383,Wis.Adm.Code,or a municipal sewer serves the
property.In addition,this agreement may be cancefled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence nf the certi5cation to be determined by reference to the property.
5. This agreement shali 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 shafi be recorded by the registe�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 nature re uired- . ACKNOWLEDGMENT
Owner's Signature:� G ' State of: �5 Q�� :�
� County nf: �S v��
Owner's Name(Print):� �� Subs r; d and sworn to before me on this
� jcxi` , � IO�r _s��day of (� , 20 a�
Date: By(Owner's Name): r' � L N�
�' Z 0 � 2 U�� Nota ry Public Si gnature: �1.
Drafted by: ���(,� � ` , r ` ` �� — I Public Notary Name(Print): O� 11'� 't r� K.t(�
'�� b J My commission expires on: '� O�}
Personal information you provide may be used for secondary purposes[Pri cy t.aw,����N���STRUNK JR Rev.03/26/13
otary Public
State of Wisconsin
Government Lot T�ao (2}, Section Seventeen {17}, Township
�Thirty-Eight (38) Horth, Range Nine (9) West, excepting
therefrom, all land lying North of the foliowing describe
reference Iine: Commencing at the Southwest corner of sai
Government Lot Two(2) ; thence North on the West line of
said Government Lot T�ao, a distance of 1,475 feet to the
place of beginning of said reference line; thence right angles to the right and in an
Easterly direction, 385 feet, more or less, to the shore of Mud Lake, said shoreline
being the point of termination of said reference line.
Also the right of the grantee, his heirs, successors and assigns, to use, with others,
certain present and existing roads, said access road running through Government Lot 7,"
Government Lot 3,-and the Southeast Quarter of the NorthwesL Quarter (SEI/4 NW1/4), all
in Section Seventeen (17) , Township Thirty-eiglit (38) North, Range Nine (9) West.