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Home My WebLink About032-540-13-2303-SAN-2024-067 `'"""'�% Department of Safety c°°„`y � �,.. �� S a�..� e r Z '� � �`- & Professional Services, � a � � Sanitary Permit Number(to be filled in by G � �, �s i i Industry Services Division 4� ,' -/ E�S I �1 lv�� -c �� -- ., -:�i � ., Sanitary Permit Application s`a`eT'a„sa�t`°°N°°,ee` � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to die appropriate governmental unit "� 'J is required prior to obtaining a sanitaiy pciniit.Note:.Application fom�s for state-owned POV�'TS are submitted to Project Address(ifdifferent than mailing adm�ess� the Department of Safety and Professional Sen�ices.Personal infoiTnation you provide may be used for secondaiy � purposes in accordance with the Pr'ivacy Law,s. 15.04(I)(m),Stats. i3v�•�i � 1.Application Information-Please Print All Information ��(�� Propc�ty Ownci's Namc Parccl# �-tve�c. .� el; SSa IC pecc �3a-5`/O - l3 a303 Prope�ty Ownei's Mailing Address PropeiTy Locat� ❑ 1� l,a �o a � CZ� G�� City,SLate Zip Code Phone Number W�C17t C" � w= rJy g9 �p I .SI.J '/<. N� '/, Scction_� 3 IL Type of Building(check all that apply) �ot# T �j/!� N R DS .�er �"1 or 2 I�amily Dwclling--Nwnbcr ofE3cdrooms _7 � � Subdivision Name I�lock# �" ❑Public/Commercial-Describe Use �.� ❑City of ❑Statc Owncd-Dcscribc Usc — CSM Numbcr ❑Village of C.��`1 � $77 � �'J[own of �Il�"G� _ ve �.38 p a185/ - III.Typc of PO��TS Pe►•mit:(Check either"New"or"ReplacemenC'and othcr applicablc on line A. Check one box on line B.Completc line C if applicable.) A. �New System ❑ Replacement System ❑ Other Modification to Esisung System(explain) ❑ Additional Pretreatment Unit(explain) B' �Holding Tank ❑ In-Ground ❑ At-Grade yp'( I ❑ Mound ❑Individual Site Desion ❑ Otlier T c cx�lain) (conventional) C• ❑ Renewal Before ❑ Change of Plumber List Previous Permit Number and Date Issued ❑ Revision ❑ Tran;fer to 1�ew Owner Expiration IV.Dispersal/'I'reatment Area and Tank Information: Desien Flo�c(gpd) Design Soil A�plication Rate(gpd/st) Dispersal Area Required(,t) Dispersal Area Proposed(s� System Elevation ` 3 � _ ..- � Capacity in Total #of Manufacturer °: Tank Information Gallons Gallons Units 9 � V �° N � � ' New Tanks Existing Tanks v o �-' C � -� `� t° �'��j 0 C_ U v� � � u. C7 a. Septic or Hulding Tank � 5��,�5..� �� .w1 � � �� /� �� LJ6JLJ C,<!'n Dosing Chamber V.Responsibility Statement- I,the undersiened,assume responsibility for installation of the POW'I'S shown on the attached plans. Phunber's hame(Print) Plumb��. Signature MP/VIPRS I�umber F3usiness Phone Numbu� T�r�o�..�i's ��tr�+tJd - --- G5�97�3 7�5- Co3y -81�lc Plumber's Address(Strcet,City,State,'Lip Code) l Y !o� S e (tbad 7 N�. �wc.r�� wz' S*��y3 VL C unty/Department Use Only �A� �o c Pcnnit Fec Datc Issucd [ssuing Agcnt Signaturc �1 ❑Disapproved �w $ `fc�•°° �t I I ��4 �'��-�-t�'�`��— ❑Owncr Givcn Reason for Dcnial Conditions of A roval/Reasons for Disa rb��al C` �� ' �"` PP PP �) I � �'1 �`•; ��- _ ii � � �' I � � �y___. . �� d �►� � �� _�� .. �PR 1 1 2QZ4 ::k�F. 35Uq - - �s�-- �U6-� �e i�� gAV1fYER GOUNTY XANING AUMEP.tSTR"aTiON Attach to complete plans for system and submit ro the County only on paper not Iess[han 8 Vi s I1 inches in size sBD-639a cR.o3i22) NO R�FUND6 AFTER y $�.�.� ISSUE OF PERIIRIT Sawyer County Zoning & Conservation Administration ``�� ' 10610 Main Street, Suite 49 � �R c� 1 � Hayward, Wisconsin 54843 ��'�i� VC�� (715)634-8288 � � �� FAX (715)638-3277 � y � , � - _ � � j wwwsawycrcounty *ov.or , � o � � i � � E-mail: sanitarian a`saw crcoimtygov.org I � '� ' �i � Toll Free Courthouse/Gencral Information I-877-699-41]0 , " f�.��t,S / I I �'L`` � �- �%�c� �� SCONS� � � � �� Holding Tank Approval Checklist I. Sanitary Cover Sheet: Date Stamp �/�/ 2 `� Parcel ID# 6 �� - S `'�� - I 3 - -23 �3 II. Plot Plan: l Property Lines � Benchmark BM ♦ � Site Address _ y� North Arrow x Structure � Scale � Well � < 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 � Management Plan/Contingency Plan Servicing Contract � Holding Tank Agreement Form ($30 to ROD) IV. Holding Tank Specifications: ➢� Tank Cross-Section: Manufacturer: '-�1e�� Gallons: �� 7� �( Tank Anchor Calculations [SPS 383 .43 (8) (g)] � Locking device, chains/locks � Alarm, electrical per SPS 383 .43 (8) (e) J( 3" Bedding Material < 1 /2 " V. POWTS Component Manual Reference: � Holding Tank Version 2. 1 (May 2022-2027) Owner: ��r Plu�nber: �'J' Bw�, Application Review Date: o `� � ( � � �`� POWTS Reviewer: �. �y,��j�, N3111e cry 6� � �;� Rev. 4/27/2023 G�cdential # CONCRETE HOLDING TANK DESIGN Single Combo Tank Option INDEX AND TITLE SHEET Project Perry-Burd Ln Owner Steven D&Melissa K Perry Address 5284W Log Lodge Rd Winter,WI 54896 Legal Description SW 1/4,NW 1/4,Sec.13,T40N,R05W Township Winter County Sawyer Subdivision Name CSM#8771 vol.38,pg.284 Lot No. 1 Parcel ID Number 032-540-13 2303 Plan Transaction ID Number Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Designer Travis Butterfield -- - ---- -- -- __ — Sign"�aTure Phone No. 715-634-817 License Nu ber 652879 Date 04/08/24 Designed pursuant ta Holding Tank Component Manual For POWTS(Version 2.1) May 2022-2027 vers'�on zi(on2z) Page 1 of 4 , HOLDING TANK SPECIFICATIONS �Number of bedrooms Non-residential estimated flow (gpd) 2000.0 Minimum hoiding tank volume required (gal) Side A Side B Total 1250.0 750.0 2000.0 Proposed tank capacity (gai) Wieser Concrete Tank manufacturer 09-AM1R h/ �1� rti Tank model number SJE Rhombus Alarm manufacturer 101-10H Alarm model number Tank Dimensions and Data Tank Anchor Calculations X for round tank 13540 Ibs Weight of tank and cover 47.0 Liquid depth below inlet invert(in) 1.10 Safety factor 8.0 Maximum depth of soil cover(ft) 20505 Ibs Weight of anchor required 66.0 Height (in) Outside 27.3 in Soil cover req. for anchor or 151.0 Length (in) � Dimensions 5.1 yd' Concrete counter weight 86.0 Width (in) Only HOLDING TANK CROSS SECTION Electrical complies with NEC 300 and SPS 316 optional vent pipe vent pipe manhole cover with � finished location � bcking device and grade junction waming label � — box � �4"min. 4"min. r� �23 in. conduit � 18"min. thether -- � � we�9nt Note: All tank joints, and joints - 7� — between tank openings and buiid�ng sewer / seN�ce piping are sealed watertight. All iniec blind plug alarm on co seai pipe and vent materials comply ounet with SPS 384. Manholes with 90% Full 34.5 in locking device are typical for each manhole opening . Side B 750.0 gal Side A �250.0 gal 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project Perry - Burd Ln Transaction Number: Page 2 of 4 . :, � HOLDING TANK SITE PLAN Project: Perry- Burd Ln N Legal Description: SW 1/4, NW 1/4, Sec 13, T40N, R05W Subdivision Name: CSM #8771 vol. 38, pg. 284 Scale: 1" = 40 ft� Parcel ID: 032-540-13 2303 Lot No.: 1 � • - p �0 4a HSa ao6o9..�• Pwf..b Ccne+v-fc haso�7sey.�. Cc.«�bM.�)ron� lio�a�.y 7....K r.,a.e e by ' �JPeSGC Co�+C+�.l-� InG. �d ?�,t�a y0 t�rop.see u �^'f�"��i 3 �d�-�» �wc��,r� � . NS O , gfls Af►71 �t C'cbban in 10" Pw- _ �Ot�.O� 4 A � � o �87Fs�N � � �, � � Q Transaction I.D.: Page 3 of 4 HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to SP 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P N. 03/07, R. 09/12), and the Sawyer County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow of 60 to 400.0 gpd. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the a!arm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each seroice event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by negiect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons may be contacted: a. Installer......... ..... .............Travis Butterfield Phone: 715-634-8176 - ---- b. Service Provider..__............ ScotYs Septic Phone: 715-634-7279 c. Co. Zoning or Health Dept. Sawyer County Zoning & Conservation Phone 715-634-8288 11. _ Project: Perry- Burd Ln Transaction Number: Page 4 of 4 , - _ , W1250/750—MR TANK SPECIFICATIONS � � � o o a 155" DIMENSIONS: a � WALL: 2 1/2" � o BOTTOM: 3• a a COVER: 6� o MANHOLE: 24" I.D. PRECAST CONCREIE RISER � HEIGHT: 66" O.D. n LENGIH: 155' O.D. a � — � WIDTH: 86' O.D. / � BELOW INLET: 53" O.D. � w � LIQUID LEVEL• 48" � � o 4" CAST-A-SEAL 4" CAST-A-SEAL ��GHT: 14,860 LBS. SEPTIC o �zq" � INLET AND OUTLET: w o � O� 4' CAST-A-SEAL B00T OR EQUAL y � � °J T� � GASKET, CAST-A-SEAL B00T OR EQUAL } � C INLET AND OUTLET BAFFLE AND FILTER: m � � \ FILTER OR WISCONSIN, SEE DETAIL #10 � � � \ BAFFLE / (OTHER STATES SEE CHART) `'' 0 0 � _ - LIQUID CAPACITY: 27.66 GAL/IN (SEPTIC) 4, o 16.12 GAL/IN (PUMP) � N LOADING DESIGN: B' 0' UNSATURATED SOIL y.� TOP VIEW � � MN TANKS: � Y � WILL HAVE ONE VENT OVER OUTLET 0 � � AND WILL HAVE 1N10 VENTS IN COVER OVER INLET � o � TANK CAN BE USED AS: � � � � 4" VENT SEPTIC/SEPTIC, SEPTIC/PUMP � a � OR SEPTIC/SIPHON W � � � c COVER: MIX DESIGN �8 NO FlBER) � � � TANK: MIX DESIGN /10 �S7RUCTURAL FlBER) = � INLET -- __ OU7LET CUSTOAAIZED TANKS: � _ _ _ FOR CUSTOM TANKS CONTACT WIESER CONCRETE � 3 . N � p t�0 � � U 7 'ro � U c �-• Q N � d � d e � � � 'l�" � 7 � � � Z O Q Z � � � JOB INFORMATION : � � W � 1 3 � N PUMP PAD CUSTOMER: j JOB NAME: � SIDE VIEW DATE NEEDE�: SHEf:T N0. APPROVED BY: � APPROVAL DATE /�F � TANKS ARE MANUFAC7URED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS HOLDING TANK SERVICING CONTRACT Contract Date: oy / pg / abay This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Owner's Name: Pumper's Name: S�tven D r Mcl�ssa K P�My Sco�" �o��- Parcel Identification Number: (12 Digit Legacy ID) O ��- 5 �-I O -�3 -��O 3 L The owner agrees to filc 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 Agrcement 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) serviccd by the pumper and guarantees to perinit 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 a�rees 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 Govenunental 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 County Private Scwage System Ordinance. The pumper further agrees to include the following in the report: a. The narne and address of the person responsible for servicing the holding tanlc; b. The name of the owner of the holding tank; c. The site address of thc holding tank; d. The date the holding tank was serviced; e. The v�lumes in gallons of the contents pumped from the holding tank for each servicing; £ The disposal sites to which the contcnts from the holding tank were delivered. 4. This agreement will remain in effect until the owner ar pumper terminates this contract. In the event of a change in this contract, the owner agrces 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 Signature: � y one o��n r s�gnar�re requsrea� T- � �% � Pumper's Name: (Print) Pumper's Signature• Sco��' Poppc -�j - �� Pumper's Registration Number: $I S13 Rev.03/26/13 4112124,823 AM Real Property Listing Page Redl EStdt2 Sawyer County Property Listing Proper[y5tatus: NextYear Today's Date:4/12/Z029 Created On:2/29/2024 4:01:05 PM �Description Updated:2/29/2024 �Ownership Updated:2/29/2024 TaxID: 45072 STEVEN D&MELISSA K PERRY WINTER WI PIN: 57-032-b40-OS-13-2 03-000-000030 Legacy PIN: 032540132303 Billing Address: Mailing Address: Map ID: STEVEN D&MELISSA K STEVEN D&MELISSA K Municipality: (032)TOWN OF WINTER PERRY PERRY STR: S13 T40N ROSW 5284W LOG LODGE RD 5284W LOG LODGE RD WINTER WI54896 WINTER WI54896 Description: PRT SWNW LOT 1 CSM 38/284#8771 Recorded Acres: 10.000 Calculated Acres: 0.000 �Site Address 'indicates Private Road Lottery Claims: 0 8760N BURD RD WINTER 54896 First Dollar: No Zoning: (C-1)Commercial One J property Assessment Updated:N/A (RR2j Residential/Recreational Two ZpZ4 Assessment Detail ESN: 421 Code Acres Land Imp. N/A �Tax Districts Updated:2/29/2024 1 State of Wisconsin 2-Year Comparison 2023 2024 Change 57 Sawyer Counry Land: 0 D OA°/o 032 Town of Winter Improved: 0 D 0.0% 576615 Winter School District Total: 0 0 0.0% 001700 Technical College +� Recorded Documents Upda[ed:2/29/2024 'L!+ Property History CERTIFIED SURVEY MAP Parent Properties Tax ID Date Recorded:I/31/2024 448433 57-032-2-40-OS-13-2 03-000-000010 35879 WARRANTY DEED Date Recorded:10/16/2023 446866 WARRANTY DEED Date Recorded:11/25/2002 305688 Child History Remrd Count:1- . HISTORY O Expand All History White=Current Parcels Pink=Retired Parcels O Tax ID:35879 Pin: 7-032-2-4- -1 -2 0 - - 001 Leg,Pin:032540132301 Map ID:.7.1 45072 This Parcel Parents Children https:l/tas.sawyercounrygov.orglsystemlframes.asp?uname=Eric+ypellauer �� — • II I . II; �I�I�IIt I�IIIIII�II�IIIII� cI�.807 $�37 448433 Tx:4049956 PAULA CHISSER REGISTER OF DEEDS SAWYER COUNTY, WI O1/31/2024 10:59 AM Saw er Gounty Zoning Approval - Jay Kozlowskt RECORDING FEE 30.00 -- --_�'`��" — — �! �f —a L---- PAGES: 2 VOL: 38 PAGE: 284 Gertified Survey Map No-_ CSM MAP �: 8771 Parb of the Southwest Quarter of the Northwest C�uarter, Se�tlon 13, Township 40 North, Range 5 V�st, Town oF Wlnter, 5awyer Gounta�, YVls�onsln. �ge"a �``��g C � N S��i � Found 325" brass cap m'��1� ��—_..�-�� m• LUCAS J. � � Set I.O5" x 18" Iron plpe I_I31bs/If � � — NW Gorner � MEIER = O Sectlon 13 ■ �o�nd 1.315" iron plpe � $-27� 1 � m 9 �ound 1.05" Iron plpe �� SP�ONER O�� 'A � � Found O.-f5" rebar '�Lr�Q�W T �J�G,�r � �� m � Set 6' steel fence post 1251bs/If 4��I��,` � � �� m �xx) ��gd / Recorded as �1��I/16/2024 � O— ` �� Z Lucas J. Meler - PL52711 Td1N - NW SW - NYV Nb-/^25'S4"YV 143422• �— U1 /l434_q(�J _ v1 � a `t 9 Doc. �446866 m � unplatted by owner r � - - - - - N � 587'25'S4"E 727.23' � � 260.0p' �9 � 330:00' �i i c0 v, 137_23' � W u� N � m � . N tn .�. c m � � c m p p p � �v � m tr Z � p �O �O. v� � Q � � L..V� ' � � T' � z 435603 SQ FT v v _ — �4 10.00 AGR�S o 0 POB 3 � �[ G`� �� s Om " — � `� � � � <6 �m� - �ry ` - � 6j � � m �� ip � I � ` � � �� I w \ ��'^q � m � '" � � / � � . \� a N — 6I \ � \ � � p I1J m � op � \�\ � c�cr, �R m �I 51 / � \\ \/ ry > f Doc. �4 i6866 \� � \ � � � unplattad b�ownar \\ \ � O � � �.`�� \ � �� o I o�• S/ '� �i w� i i � i p- LINE BEARING DkSTANGE 1 �� O OrV/ LI h106'S1'IS"W 171.-19' � � - � > L2 NS'7"36'20"W 128.92' � 333f' 2�Y�/ L3 N62"45�-7"W 1-l5_-T8' � 146_00' 91.�5' / L4 N06'S1'IS"W 166b3' LS NS"t"36'�O"W 12"1.4-4' I1 1� N88"IS'20"W unplatted - 6y. owner _ � L6 N63"45`3"T"W I-/4.29' — — — — — — / LINE ARG DFLTA RADIUS DEC�REP OF GURVE GiiORD Gi-IORD HEARIN / Gf 23385' S0°45'O5"� 264.00' 21'4291"� 22628' 1�t32°13'4S"lV ry G2 263.08' S0'45'O5" 291.00' 19"I-/'24" 25456' N32`13'48"W a' / � G3 28.OT 9`34'2-1" 168.Oo' 34°Ob'1-I" 28.04' N6T'32'51"W r°�v / G4 4458' 12'42'26" 201A0' 28"30'Iq" 44_4�i' N6Q"0650�"W / SW - NW (i3e7.ieJ POG _ SHb=lazo°e ��e7.33' Log Lodge Road W I/4 corner � - `-�W Ma of Surve flled as #3518 Section 13 — � - - - y' - - - - - Meler Surveying, LLG GRAPHIC SCALE 1 " =200 ' W6581 Little Valley Road _. _ _ ._ _ ._ _ . . _ 5pooner, WI 5480C 115-635-8910 " Fleid work complefed 1/12/2024 Shaet I of 2 0 200 400 600 448433 � of 2 _ _ I 1 IIIII"i Illll Illllllllll USE BLACK INK ONLY DoCI :8f�u0E�59 POWTS MAINTENANCE AGREEMENT Tx:4051203 For Holding Tanks 449319 PAULA CHISSER Owner's Name(s)as shown on deed: i�EGISTER OF DEEDS SAWYER COUIYTY, WI 5'�'GVQ..r� � + Mt�i SSG. K PGr�c'� 04J12/2024 08:56 AM RECORDING FEE 30.00 Parcel Identification Number: (12 Digit Legacy ID) Q��- S�Q- / 3 -�� 3 PAGFS: 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 Recording Area-Leave Blank per s.59.43(2m) 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) (ci), 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 shall submit the report to the governmental unit. The governmentai 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 subrnit 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 n t re uired- ACKNOWLEDGEMENT Owner's Signature: State ofi ��t5['o►'>S i n _ County of: �Qu�y�.►� _ Owner's Name (Print): r � - ��••��'HEY�R�•,,�y� Subscribed and sworn to before me on this C1�I�- a` � .............0 y �'�"h day of �pr� 0 , 20 Z� s Date: �O=;'�� O,��y �� = By(owner) �- v � � = Notary Public Signature. Drafted by. z�^ �; pVB�,��' ' = Notary Public Name: n I�. �� yvor�h�M. � �.Y�,� 'c �.-` My commission expires on: a--��„ � o�-(, _ 5 �. �L��,9�;�.,o��',,`��a� ��Uuu�u��M Personal information you provide may be used for secondary purposes[Privacy Law, § 15.04(I)(m)] Rev.09/29/23 Part of the Southwest of the Northwest (SWNW), Section Thirteen (13),Township Forty (40) North, Range Five (5) West, more particularly described as Lot One (1) of Certified Survey Map#8771, Volume Thirty-eight (38), Page Two-hundred and eighty-four(284), Document No.448433.