HomeMy WebLinkAbout002-112-06-1800-SAN-2023-277 �``=""� Department of Safety �°""�' �
'� � & Professional Services ��''"'y�
;��:w ,� �, � Sanitary Permit Number(to be filled in by�
�yx` � �'� Industry Services Division �
,�.�,�- ��r� C� S � l�l� �7 W
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Sanitary Permit Application State Transact-ion Number �
In acwrdance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is requued pnor to obtaining a sanitary permit.Note:Application Ybrms for state-owned POWTS are submitted to Project Address(if differ�nt than mailing adur�j�s')��
the Department of Safety and Professional Services.Personal information you provide maq be used for secondai}� '� ,Gt Cj c�n/ Gh,�J e ce.�et /t�,ci
putposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.
°�i:��p�lica�►�I�formaiaon-��"1,�ase Frint Ait InformaYion
Property Owner's Name Pazcel#
KrGi1'!�v �..@. Ir�JS � t ��.Z\� ZO� ( �C?C�
Property Owner's Mailing Address Property Location
7� � �Cc. �71-' VG�'. /V� G
City,State Zip Code Phone Number
� � �� v i..(� � ,rJ-3��, � '���Section 3 C7
I'1,
�.'�'y?p��'��14�g(Ch€+BC1C�I t68€t BPP�F) Lot# T `'7�0 N R g E o��
�1 or 2 Family Dwelling-Number ofBedrooms 3 i�t ...Z � / �'Q' 31 Subdivision Name
(��`��0" Q t',�c.l.��
Block#
❑Public/Commercial-Describe Use N� �
❑City of
❑State Owned-Describe Use NA CSM Number ❑Village of
.�-
1�'Town of �5`_� �-�y e.
IlI.Type of POWTS Permit:(Check either"New"or"Reptacement"snd other applicable on line A. Check one box on line B.Complete line C if
s licable.
�. �
�ew System ❑ Replacement Svstem ❑ Other Modification to Existmg System(explain) ❑ Additional Pretreatment Unit(explain)
r "
B' Holding Tank ❑ In-Ground ❑ At-Grade gn yp ( p )
❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain
(conventional)
ist Previous Permit Number and Date Issued
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �_
Expiration
�':�. r+a��rent Area and Tank Ia€ur�rsetion:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
3C�cy r`'A
Capacity in Total t!of Manufacturer
Tank Information Gallons Gallons Units � � o � �
New Tanks Existing Tanks � o � � � D � ro
a.` U v� v, v� i.z :7 0..
Septic or Holding Tank �-� 2�1C� t W I '��Ey�.. ��
Z.C�dC}
Dosing Chamber
V.Respunsibility Ststement-I,the undersigned,aasnme responsibility far insta8ation of the POWTS shown on the attaehed plaas.
Plum ers N (I;r Ylumber�s Sienature � MP/MPKS Number Business Phone Number
.�erry�uic�'�xcavating, LLC Q� Z��o��, -T�5_c,{ct;t_ `;{[��-(
Plu er s A d ess tre i tate, ip Code)
tone �a e� WI�4876
v�.cflu r���u�oa�y
L►�,App �ved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $ /w d b � U�I � �`��� �/1�`""__ _f�
Conditions of A ro��aUReasons for Disa roval
PP PP C -- �,� �_ .. . _.
L,\`i r-
�i i
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� ''���' F�_ �``.', 1
�i� �� ��� __...:l�I.`���,3___._.�n.. ; �
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�
, ��,� i OCT 1 0 2Q23--- �=---
GS� �v'�'— I� !, ; 3`1 �1 _� SAb'VYEi� G��';�t�
.ZONING ARASiN!;;fr?ATlC7t,i
Attach to complete plans for the system and submit to the Couoty only on paper not less t6an 8 trz a 11 inches in size
�I7��
SBD-6398(R.03/22) �G'R..��.F+��+��r`1i'T�FI
I�S►JE�Or P�,�+P1flf
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
������ 11
� ER Cp 1 � Hayward, Wisconsin 54843
�'�i� \G �� (715)634-8288
� �� ���' � FAX (715)638-3277
� Q \.1I
� � � - _ _ i � � wwwsawyercount ov.o�
� o � I o � E-mail: sanrtaiian��sawycrcountygoV.[11'k'
I ��s � � Toll Frcc Courthouse/General Information i-877-699-4110
I� �` =.- ' �1
/� '1`oN`��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Sta�np I ti / � � / ��� 3
Parcel ID# o � 2 - 1 � � - o (� - � g o a
II. Plot Plan:
� Property Lines � Benchmark BM ♦
Srte Address � North Arrow
� Structure p�Scale
� Well � < 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/Contingency Plan ` ��
�➢ Servicing Contract � � �3 �
�Holding Tank A�neement Fonn ($30 to ROD�
N. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: wi q;sif' Gallons: ��
Tank Anchor Calculations [SPS 383 .43 (8) (g)]
� Locking device, chains/locks
�( Alann, electrical per SPS 383 .43 (8) (e)
� 3" Bedding Material < 1 /2 `
V. POWTS Component Manual Reference:
� Holding Tank Version 2. 1 (May 2022-2027)
Owner: Le.Sv;ti S �c..`, Plumber: � , yp,.,;d�
�
Application Review Date: � � �� �� � �3
POWTS Reviewer: �;, l�i��—Z
Name
6`� � l� Rev. 4/27/2023
Credential #
, PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version �, SBD-10855-P (N. 3/07; R 01/12)
�, � � M4�2�-�� �
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name / Description
Owner Name(s): ke v,N �.�� k��+-% ��= / Phone: - -
Owner Address: �7�c�f3 ������r .1� U�. �� �'T.se��c� N��v Zip: S5 33c-'�
Project Address: `7� `� N C�h r��� � ��
Govt. Lot: 1/4 of 1/4, Section �o , T `{a N-R �3 E❑or W Q
Township: ��s� L�..lE�- County: ��� -���r'
Project Parcel ID #: �c� 2 i l�. 0 6�$va
Designer Information
Designer Name: Jerry Ruid Excavating, LLC phone: - -
Designer Address: Stone LakP wl �d�7R Z�p�
�
E-mail: l r'J� TG�.��� �.'•"?s�o�,�C.g t"i��C�����C?T'3�3�7�i���T�:ia: ..�?..
� t`u� � G,� c.�t`Y
License Number: z `��� e �
Remarks:
�
Signature: .� Date: �� ��� �� 3
ri i al signature required on each submitted copy.
�
; Reset Page'
CMECK BOX AS APPI.K:ABLE. CHECK 60X AS APPLICAOLE.
� SOIL EVALUATION s�ie:r=ao� � SYSTEM PAGE 2 OF
SITE MAP � 40 � � pLOT PLAN
PROJECT NAME: oEsicN F�ovu�. `�5�'���cr,'� cWo
G to'
��S y�1 N 5 F in Attach design flow calculations for commercial plans.
PROJECTADDRESS'. 78Q�I'�1 Lh�P/�C��-�- Pipe Matenal/ASTM S[andard(Tables 384.3P3&384.30-5)
,00.o N se��,�ry�we,: y��s�.� yv i>,,,�
BM Symbd:; BM Elevffilon: FT Force Main: /
aMoe�nw«�: ,o�� �2Pd��k.����a, s�rz:,�
ma�iraie�orcn ty IMPORTANT:
Slope creaieM�%) � Well Symbd(rf applinble): � a�awme a� � Show ground elevation contours at suitable intervals.
of Tested Area' on the approp�rite iine.
S 3 t� �l eog cr,v Z,tv il��SSy...�_ (l2, 3�v?�
-7.voo �S�ytre.v w�`�$(��- /-(olc�,:�ce �i c��,�k
J
��C����nJ� `��J.O�
t�:.>,.k S�r� �t 7 C'=
�ro�cs Q�
Dwctl�,�J
W
' j � ,,4�.
�
�7$0�1 G'/+.ppzw�.. A✓B.
Jerry Ruid Excavating,LLC 3�_��,��� '�'"" ���y i N 5�'
W208 County HWY A 3� G�s i�d�..zT A�2--
��'T" I�'�—21�1�'
Stone Lake,WI54876 ���� � �cs�.�o t-i„ ss33�
h7p/�S 2Ya�tG>�
���
RecPT Paee
PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Wea�herpmof 12"Min.or 2.0 ft above
Junction and Approved Established Flood Elevation
Alartn Box Vent Cap (�yPical)
Electriral must comply with 1 Approved Locking Manhole
SPS 316 and NEC 300 4"ID Vent Pipe � with Waming Label Attached
Conduit >10 ft from (typical) 4"Min_or 2.0 ft above
Building � Established Flood Elevation
(typical)
� �AirtightSeal
e Finished Grade
18"Min.
(�YPical) . �'a . .. y " �
a
• :
Inlet Inlet Imert Watertight
Approved Joints with Plug
Approved Pipe 3 ft onto � Max. 12"or 90%o of tolal volume
Solid Ground if more than one tank
a
" Alarm-0n
i
a
HOLDING TANK
VOLUME = z-�t�� gal .
� . a . � �, � ' � � � . .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: lJ��SrI� �<�.�4r�'�—
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= [( t2� cu.ft. x 62.4 Ibs/cu.ft) - ���r'�% Ibs] x 1.5 = ���'�`� Ibs
� Reset Pa�
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)
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 = 3�� 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 adivities, 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 certifed 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: J �' % ���c� �xt�vc Ti.v� Phone: '7i 5= `'�9.1.` 2 YO�j
Local government unit: s � �_ Phone: 7/S� �: 5�/� �S-2,�f5
Local govemment unit address ���-/U /nw w 5<< �0.`/��G� � �'-�L Zlp: � y g ��3
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.
Continqencv 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.
Svstem Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 353.33,Wisc. Admin. Code.
HOLDING TANK SERVICING CONTRACT
Contract Date: 0 / /�
This contrsct is made between t6e Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
�� Les �n � ��� S ��L
Parcel Identification Number: Z O
(12 Digit Legacy ID) � � Z _ � l __ d �o _ 1 � �
1. The owner agrees to file a copy of this contract with the govemmental unit, Sawyer County,
which has accepted and rewrded 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 Pemut for the installation of a holding tank(s).
2. The owner agees to have the bolding tank(s)serviced by the pumper and guarantees to
pern�it the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). T6e owner agees to maintain the all-weather access road or drive so
that the pumper can service the holding tank(s)with the pumping equipment. "I'he owner
fiuther 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 submit to the Govemmental Unif, Sawyer County,a report for the
servicing of the holding tank(s)as required under SPS 383.55,Wisconsin Administrative
Code and the Sawyer County Private Sewage System Ordinance. The pumper further
agrees to include the following in We 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. The 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 tlils contract. In
the event of a change in tlus contract,the owner agrees to file 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.
Owner's Name: (Print) Owner'S SIgD3YU[C: (Oely one owner s reymrea)
l�e�� h �5��i✓15� r �
Pumper's N 'nt) Pumper's Sign�hue:--'--
� ��
Pumper's Registration er:
( � �
Rev.03/26/13
i �eiii� i �ii� � i► i iiii ��i �
- USE B�ACK INK ONLY - DocI :�074989
POWTS MAINTENANCE AGREEMENT Tx :4U�8104
446924
For Holding Tanks PAULA C�tiISSER
Ovmers Name(s) as shown on deed: REGISTER UF DEE[}�
SAWYER ��UNTY, 9�'I
� �.,�� l `�� ia�is/2o2� o9:ss �,M
�� RE��RDING �EE 3fl.00
Parcel Identification Number. �J Q� j� /' �
(12 Digit Legacy ID) � O � - � � v - �� - � p v v RAGGS: Z
Legal Description of Property:
- SEE ATTACHED SHEET -
We adcnowledge that application is being made for the installation of a holding tank(s) on the
property described on the attached sheet.
Retum To: Sawyer County Zoning and Conaervation Administration
10610 Main St Suite 49, HaywaM, 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, induding 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 c�ntract with the
govemmental 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.
2. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who sha�l submit pumping reports to
the govemmental unit in accorciance 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 govemmental 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 owne�fails to have the holding tank properly serviced in response to orders issued by the govemmental unit to prevent
or abate a human health hazard as described in Section. 254.59, Stats., the govemmental unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4) Wis. Stats., a govemmental 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 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 holding tank.
4. This agreement will remain in effect only until the govemmental unit responsible for the regulation of private sewage systems
certifies that e'ither 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 cert�cation with reference to this
agreement in such manner which will permit the existence of the certfication to be determined by reference to the property.
5. This agreement shall be binding upon the ovmer, 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 s1 nature uired - - ACKNOWL DGMENT
Own r' ignature: State of: `
County of:
O er'�/N�ame (Print): Subscribed and swor to efore me on this
I'�GVi ►^ L�S� !r�< /�) ��_dayof_ ,.20 �
ate: + By (Owner's Name): �
G�1� Notary Public Signature: � � c�� �
Draft d by: Public Notary Name (Print): �_�-`�W �
��•�� Lc � � y�� �( My commission x ir
KMABERI��F�ubMc
s�
Personal information you provide may be used for secondary purposes [Privacy 1d����'� Rev. 03/26/13
Lo�s l 8, 19,20,21,28,24,30 and 31,Biock b, in Badger Beach,a Subdivision
according to the recorded Plat thereof,Town of Bass Lake, County of Sawyer,
State of Wisconsin.
Real Estate Sawyer County Property Listing Property Status: Current
Today's Date: 10/10/2023 C�-���tQd On: 2/6/2007 7:55:01 AM
Description Updated: l/3/�OC�-� ��f: O�vnc.:�hip Updated: 6/6/2023
_ ,. _...._: ___..._. .__,� __._ .._.�..___ � M__.� ....� . .. .�,�_ .� �� �. �._ _....,.._ �.,..._� �w��...� ____._,. .....,..,,
T� IDc 666 �;;'VIN �'� LESYINSKI OTSEGO MN
PIN: 57-002-2-4Q-08-30-� 1S-1S��
061$00 ���§►��j,�r.�c(i�,�Y;;: MailingAddress:
?egacy PIN: 002112061800 �C��,'. ,� �E. L�:;=;�Yllti SKI KEVIN A LESYINSKI
x�Iap ID: -5.6:18 'lo��:� i'r1P��:�?'iTA�'E NE 7698 PADGETTAVE
r�Iunicipality: (002) TOWN OF B��SS L :�KI' �.)r ;=���=c„�r�N 55:;3J NE
°�i R: S30 T40N RO�W OT5EG0 MN 55330
�l�scription: BADGEK BEACH LOTS 18-
21 BLK 6 LOTS 28-31 BL�{ 6 �i�.:: ��ddress * indicates Private Road
�.ecordedAcres: 0.550 � i�d=-'_�`� E��� � _ . ,��. �,� �-.,� . . n��s ... .,,,,. �_ ,��w. ��.��.,��,�
' ilI'1'EW� AVE HAy WARD 54843
?,�ttery Claims: 0
._ irst Dollar: No ;�� Property Assessment Updated: 9/13/2012
�-:oning: (RR2) Residential/Recreational �--___. . . . ��. .._ ... .___�_. _: _._._. ___._________ _r._. ,�__�___.__._.
TWo 2023 Assessment Detail
�SN: 445 Code Acres Land Imp.
. G1-RESIDENTIAL 0.550 7,700 0
.�` Tax Districts � Updated: 2/6/2007 Z_year Comparisnn, , 2022 2023 Change
1 State of Wisconsin Land: 7,700 7,700 0.0%
57 Sawyer County Improved: 0 0 0.0%
002 Town of Bass Lake Total: � �Q ^ 7,700 7,700 0.0%
572478 Hayward Communiry School - .
District
001700 Technical College ���,Pr�per`ty�fIistory
N/��,, �. ___r��.�. .�.�� �_�,��_� ,.�.�... ._.�._� �_
'�� Recorded Documents Updated: 9/20/2011 • -
����,� WARRANTY DEED _____ � ___ _._.�.__ . .._,._. � .�
Date 444�95
Recorded: 5/22/2023
>��: QUIT CLAIM DEED � � �
Date 2g2370 698/225
Recorded: 2/11/2000
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