HomeMy WebLinkAbout014-941-04-5602-SAN-2023-286 ' Department of Safety c°°°ty
0 & Professional Services,
S�.wYei �
s Sanitary Permit Number(to be fillcd in hv(
PS Industry Services Division
�s) � �� W
State Transaction Number i
Sanitary Permit Application v�
In accordance with SPS 3832I(2),W is.Adm.Code,submission of this form to the appropriaTe governmen[al unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ac_.____,
the Department of SaFet}�and Professional Sen�ices.Ycrsonal information you provide may be used for secondary �� 9pJ N �e� ,
purposes in accordance��ith the Privacy La��°,s. 1�.04(I)(m),Stats. �-�
1.Application Information-Please Print All Information
Property Owncr's Name Parcel#
�a-��,�k � �Co,�i� e�,+o,-� a►y-`l y1- o�s 6oZ
Property Owner's Mailing Address Property Location
Il 40�N rG+�^ � �
Go�vt�cLot � � �
City,State _ Zip Code Phone Number
�0.Yw�� / �✓� �L��� 3 ��^ �i. Section ��
IL Type of Building(check all that apply) I Lot# � '� y 1 N R �9 E or
I or 2 Family Dwelling-Number ofBedrooms Subdivision Name
Block# I��'� 1� e J`"`�`'�.
❑ Public/Commercial-Describe Use
^— ❑City of
❑State Owmed-Describe Use CSM Number ❑Village of
y/`Q �r 7�� 6�Town of LQI�l�Dl'��
IIL Type of POWTS Permit: (Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A. - -
�1 New System f�Replacement System L� Other Modification to Existing System(etplain) _, Additional Pretreatment Unit(explain)
B' n Other T e ex lain)
�I-Iolding Tank ❑ In-Ground � At-Grade � Mound ❑ Individual Site Design yp ( p
(conventionap
C• .i Renewal Defore i J Revision Change of Plumber I.I Transfer to Ncw Owner� 'st Previous Permit Number and Date Issued
Expiration uh� �
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation
!oo �I/q- �'a� NA— —
Capacity in "Cotal #of Manufacturer
l ank Information Gallons Gallons Units � � o � �
� � � �
New Tanks Fxisting Tanks � c � � � ro �
n. U v: �, cn u. C7 0..
Septic or Holding Tank ��D�D ��0� ! W c�CS C/ �
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumbers Name(Print) Plumber�s Signature MP/MPRS Number Business Phone Numbar
o I�., s���� �s�6�j� �s- ��8- sy��y
Plumber's A dress(Street.City,State,Zip Code)
1c98� U r�e�u,IC �1 s-�dr� /41.� w� �Y��,�
V1.County/Department Use Only
�3 Permit Fee Date Issued Issuing Agent Signature
J� � rd e ❑Disapproved
❑Owner Given Reason for Denial $ ��.� 1 v� 3� � `� � ���`���'���`'��� / '""�t��-
Conditions of Approval/Reasons for Disapproval -
1 �' � � � � ..e,._.�-.,o • '-l' f'�' ' '
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L� /��� 3 S� g `--- ------;
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C . . . �C','��(F;' �"i��`�TY
°: . .. ',r. . '� `;1
Attach to complete plans tor the system and submit to the County only on paper not less than S V2 x I 1 inches in size
n�o��Fu�v�:�arr�R i � �.� �
SBD-6398(R.03/22) I�S�.��OF �FSA/;l i
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
���R cp�� Hayward,Wisconsin 54843
`�l,� ��(� l� (715)634-8288
��� `Z I� FAX(715)638-3277
�Q/
��, . �_' ,�/ www.saw�crcounty_g�v.nr�
� o i �;� p i E-maiL sa,nit u_ian n'�saw crcounlY`����
I g, ; y i � Toll Frce Courthousc/General Information 1-877-699-4ll0
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp I n / 3� / ���-3
ParcelID# C� i K - 9 �( ( -�Y -S (�o�
II. Plot Plan:
� Property Lines �Benchmark BM ♦
�Site Address �p North Arrow
�GStructures �Scale
�Well J�<25' to Service Road
�Legal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
�p Index Page with Original Signature
�C Mai7ageinent Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement Fonn ($30 to ROD)
IV. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: �¢�s- Gallons: ��°
�Tank Anchor Calculations [SPS 383.43 (8) (g)]
KLocking device, chains/locks
XAlarm, 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� Plumber: �- 5��1`��
Application Review Date: (a�3/ � 20��
POWTS Reviewer: '
Namc
(��'i�(� Rev. 4/27/2023
Credcntial#
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 Piot 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): �``�```�` � �`��'e r��0n Phone: - - _
Owner Address: �I9o�N E_�„r, r� , l�(�,y�,,�,z �„�` Zip; s-�rg y3
Project Address:
Govt. Lot:�� � 1/4 of 1/4, Section d�( , T ��I N-R G k E�or W�
Township: I �� p� �nr���' County: s°`"'y��'
Project Parcel ID #: Df�( q y� oyS� �07
Designer Information
Designer Name: Dylan Schultz Phone: 7�5 _ 558 _ 5904
Designer Address: 16880W Metcalf RD Zip: 54876
E-mail: Dylanschultzl8@gmail.com ,,: , `ti ;`,t ` :,; , , .1 ,,:;
.E�.
License Number: 1516129
Remarks:
Signature: Date: I d -2, I� 2�
Or al signature r ir on each submitted copy.
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.0 ft above
Junction and Approved Established Flood E�evation
Alarm Box Vent Cap (typical)
Electrical must comply with � Approved Locking Manhole
SPS 316 and NEC 300 4"fd Vent Pipe with Waming Label Attached
Conduit >1Q ft from (typicai) 4"Min.or 2.0 ft above
Building I Established Flood Elevation
i (rypical)
-- �Airtight Seal �
a Finished Grade
18"Min.
��PICeI) .- '�a . . .. � ' - e
. ° , ' i
e e � .. d . - - � -
Inlet Inlet Invert Watertight
Approved Joints with Plug
Approved Pipe 3 ft onto Max. 12"or 90%of total volume
Solid Ground � if more than one tank
a
" Alarm-0n
:
e
HOLDING TANK
VOLUME = 3�i� gal �,.
a � . a . - .o . . • . . . � . . : .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER:
�< <S � �
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(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.)
� 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 FREGIUENCY
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: n Y�"^ , ��'��� Z Phone: 7�S- .fsg's90'�
Local government unit: 7~wY�� �`"��'� z'"�1 C Phone: 1��-�3�— gZ88
Local government unit address: �0 6�U ��.;n S�rac-� U.,y wwr� �.�� Z�p: 5�f gy� _
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 383.33, Wisc. Admin. Code.
- USE BLACK INK ONLY
_ i� iiiii� ii�ii ii��i i!iiii
Coci7:80��1��5
POWTS MAINTENANCE AGREEMENT Tx:4047705
For Holding Tanks 446607
FAULA CHISSER
Owner's Name(s)as shown on deed: REGISTER OF DEEDS
SAWYER COUNTY, WI
� � � r__�� 09/29/2023 1Q:45 AM
Parcel Identification Number:
fiA �IECORDING FEE 30,Ofl
(12 Digit Legacy ID) � ' `/ - 9 �'� �- d �"� - S 6 0 3
— — -- 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 neanr 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 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.
����NTY'C���i�
-Onl one owner signature requir �-0�••""""•�F �i� ACKNOWLEDGMENT
r's i . ` ��-'� ;o State of: �_� �S c��
� nSr n
=�' ' �M County of: �.Sc�,,�y r�"
wner's N me (Print): ��zs ��� Subscribed and sworn to before me on this
� 2" %-�-� �'r' : !• 02�} dayof Pn.. �lr-- , 20 �.3
Date: / � �_.q� '�ii �C'p...Ni����� BY(Owner's Name): o.tr� c A E� , —
� !
� � ��►������ Notary Public Signature: ,,o.� .�
Drafted by: Public Notary Name (Print): �.su /-��ft,,, �'t% ����L�
D I��'1 �C"�✓ �Z My commission expires on: /— d -?��S
otarial Officer by Wis. Stats.
140.10 (1) (f) and (2) County Clerk
Personal information you provide may be used for secondary purposes[Privacy Law, §15.04(I)(m)] Rev.03/26/13
That part of Government Lots 5 and 6, and part af Lot 1 of Bartels Subdivision, Section 4, Township 41 North,
Range 9 West, located in the Town of Lenroot, Sawyer County;Wisconsin, more particularly described as Lot 1
as recorded in Volume 4 of Certified Survey Maps, page 68-69, Survey No. 701 as Document No. 152944.
HOLDING TANK SERVICING CONTRACT
Contract Date: �l Z G l �L
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
�—�,� a..�
S G�� �����
Parcel Identification Number:
(12 Digit Legacy ID) �� `� - R �� �- C� � _ S' � �' L,
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 tl�e 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 submit to the Governmental Unit, Sawyer County, a report for the
seivicing 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 the report:
a. The name and address of the person responsible for servicing the holding tank;
b. The hame 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 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 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 SlgriatUl"e: (Only one owner signature required)
�`t��C� �+pr`I��►
Pumper's Name: (Print) Pumpe 's Si natur �
�L G�T �°`�� �
Pumper's Registration Number:
s3I8 C� ,
Rev.03/26/13
9/29/23, 10:42 AM Real Property Listing Page
Real EState Sawyer County Property Listing Propertystatus: Current
Today's Date: 9/29/2023 Created On: 2/6/2007 7:55:30 AM
�Description Updated: 2/3/2022 '� Ownership Updated: 2/3/2022
Tax ID: 17581 PATRICK A&KATIE A EATON HAYWARD WI
PIN: 57-014-2-41-09-04-5 05-006-000020
Legacy PIN: 014941045602 Bitling Address: Mailing Address:
Map ID: :6.2 PATRICK A&KATIE A EATON PATRICK A&KATIE A EATON
Municipality: (014)TOWN OF LENROOT 11901N EATON RD 11901N EATON RD
STR: SO4 T41N R09W HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT GOVT LOTS 6&5, PRT LOT 1
BARTELS SUBD, LOT 1 CSM 4/68#701 � Site Address * indicates Private Road
Recorded Acres: 4.260 11901N EATON RD HAYWARD 54843
Calculated Acres: 4.263
Lottery Claims: 1 :.-� Property Assessment Updated: 9/26/2014
First Dollar: Yes
Waterbody: Smith Lake Z023 Assessment Detail
Zoning: (RR2) Residential/Recreational Two Code Acres Land Imp.
ESN: 400 G 1-RESIDENTIAL 4.260 124,300 135,600
2-Year Comparison 2022 2023 Change
� Tax Districts Updated: 2/6/2007 �and: 124,300 124,300 0.0%
1 State of Wisconsin Improved: 135,600 135,600 0.0%
57 Sawyer County Total: 259,900 259,900 0.0%
014 Town of Lenroot
572478 Hayward Community School District
001700 Technical College �
Property History
� N/A
+ Recorded Documents Updated: 2/3/2022
WARRANTY DEED
Date Recorded: 1/14/2022 437128
TERMINATION OF DECEDENTS INTEREST
Date Recorded: l/14/2022 437127
ROAD MAINTENANCE AGREEMENT
Date Recorded: 9/17/2020 426522
CERTIFIED SURVEY MAP
Date Recorded: 9/29/1975 152944
WARRANTY DEED
Date Recorded: 9/22/1975 152821
QUIT CLAIM DEED
Date Recorded: 9/10/1975 152673
WARRANTY DEED
Date Recorded: 4/23/1973 143730
https:lltas.sawyercountygov.org/Isystem/frames.asp?uname=Eric+Wellauer ���
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�" "�',�. PRIVATE ONSITE WASTE TREATMENT county
�;��`o$ ���� SYSTEMS
,<<;�� �s �- ( POWTS) Sa.Wyer
.\.�k� `-_ `�.i:,
`,'�=�����"„ INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � .-�.g�
Personal infonnation you provide may be useci for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
PG��k �u- "e ���� �-�,.,�-� r—
Insp BM Elev: BM Description: Parcel Tax No:
�oo.�' T�P a�- FE.�. cis�r- �;� o(�( �`iY(-DY� S�oa
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �p ,p�
Dosing � c� b.Y �
Aeration Bitlg. Sewer ,2 c� ,S �
Holding tr ie�r- 3,� St/Ht Inlet �s �
TANK SETBACK INFORMATION St I Ht Outlet 5 S,�,�
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
A�R INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding +�o` fi$a` ( o .}-�O` L,2S Dist. Pipe
PUMP 1 SIPHON INFORMATION infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bidg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-- . __-- --- ----- —---------
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes
� Spacing ❑ Yes ❑ No �
Length Dia Length Dia_ Spac �,� __ __ _
SOIL COVER
_ _ _ _ - - ___ _
Depth Over 1 Depth Over Depth of Seeded/Sodded Mulched �
Celi Center � Cell Edges Topsoil _ ❑Yes ❑ No �Yes ❑ No
COMMENTS: (Indude code discrepancies, persons present,etc.)
� �s��(�� << �4fa3
� �^� �r �� �a�1hS
I �— --. . _ , —
Plan revision required?❑Yes ❑ No I p3 ;2� �YJ � -�j� '�(�
� � — I_— -- � -----
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITI�NAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: _�_�__a$�_
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