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Home My WebLink About024-641-13-2415-SAN-2024-071 � � Industry Sen�iccs Di��ision CounN � 4822 Madison Yards l�'a} SBWye►' � _ �S� - Madison,WI �370� Sanitary Permit Nwnber(to be tilled in bV Co) i - P.O.Qox 7302 -" Madison. WI 53707 �p s � �Uj 3 � State Transaction Number Sanitary Permit Application o In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note�Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing addiess) the Department of Safery and Professional Serviees.Personal information cou provide mac be used for secondan� 7rJ47W RIV2f RC�. Ha WafC�, W� rJ4843 purposes in accordance�vith the Privac��La�c.s 1>.0�3(I)(in).Stats. y I.Appiication Information-Please Print All Information Property O��ner�s Name Parcel# Jeffrey & Elizabeth Leschensky 024641 1 3241 5 Property Owner's Mailing Address Property Location 2335 Oak Hill Rd. ��t�v°t' _ City�,State Zip Code Phone Number Decorah, IA 52101 5�3 - s;� - 3o�Z sE ,,,,Nw y,, Section 13 II.Type of Building(check all that apply) t.ot# T 41 N R 06 E or Subdivision Name � I or2 Family D�velling-NumberofBedrooms 3 2 _�� Block# ❑Public/Commercial-Describe Use ❑Ciry of �State Owned-Describe Use_ CSM Number �Village of 25/97 #6697 Or°„n°t R°u�d �ake IIL T�•pe of PO��'TS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i a licable.) `�� New S�stem Re lacement S stem Other Moditication to F.sistin S�stem ex lain Additional Pretreatment Unit ex lain 7 � P Y � B 5 ( P ) ❑ ( p ) B' �Holding Tank ❑In-Ground �At-Grade �Mound Individual Site Design Other Type(e�plain) (conventional) C• ❑Rene«�al Before �Revision Chanee oY Plumber �fransYer to Ne��Owner List Previous Permit Number and Date Issued Expiration NA t,.�h�� . IV.Dispersal/Treatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Reyuired(sf) Dispersal Arca Proposed(s� System Llevation 300 NA NA NA NA Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units L ` o y � Nc�c TTnks Existinp Tank< �`—° � V � u u v m — :J v; v: ri� r. C: G SepdcorHold�n�Ta„k (2)1530 3074 2 Infiltrator 0 �/ Dosing Chamber � O O V.Responsibility Statement- 1,the undersigned,assume responsibility for install�tion of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature� MP/MPRS Number Business Phone Number Jason Kuettel --� .�,�� 675751 715-798-3355 Plumber's Address(Street,Ciq�,State,Zip Code) �� - PO Box 66 Cable, WI 54821 �7.C u ty/Department Use Only �A pr �ed ❑Disappro��ed Permit Fee Date Issued Issuine Aeent Signature $/,�y� �-� ❑Owner Given Reason for Denial "��V•� � � � ��( ��L.(��- �(Ul/i,l� Conditions of Approval/Reasons for Disapproval �"i Sr . � _ �i ? �y r� `� � ; ; �, �. � . `' I � , �t ,�=_� � _______ , : � �� " � ;�;#.� 1�,��.4��,_ ��-`�� r wd W L.. " - �� a�1� . APR 0 3 2�24 � - `°' .l_13� _ .._ �_ , __..._ � C,�j'� Np� � SR�rJYE� GC�,t:. `, ZOhili�G AGi��tv;`;��;Fii��;:�J Attach to complete plans for the system and submit ro[he Count}�only on paper not less than 8 I/2 s I1 inches in size NO REFUND6 AFTER sQ�-639a�x.ozizz� ISSUE OF P�RM1T a41y� Sawyer County Zoning & Conservation Administration 10610 Main Street, Suite 49 ��\1 � �R C� 1� Hayward,Wisconsin 54843 �'� ---\Ci �� (715)634-8288 �� FAX(715)638-3277 �y�, _ i{% www.sawyercounty�v_.c�i� � o � �— �o i E-mail:sanitarian(a)sawvcrcount=��iv.org I � `'—\� '~j � Toll Free Courthouse/General Information 1-877-699-4110 ,,�.'y�•�l-y �?� ` ��1`�CO S� ��\�N� Holding Tank Approval Checklist I. Sanitary Cover S11eet: Date Stamp �`( / D 3 / �2`'� Parcel ID#��- 6�L- I 3 -� Y� � II. Plot Plan: �Property Lines �Benchmark BM ♦ �Site Address �North Arrow �Structure �Scale D�Well D�< 25' to Service Road �Legal Description p�Nearest Road Intersection �Setbacks to: Property Line, Well, Structure, Water bodies, Roads III. Required Plans: �Index Page with Original Signature Manage�nent Plan/Contingency Pla ervicing Contract y��( � �Holding Tank Agreeinent Fonn ($30 to ROD) IV. Holding Tank Specifications: � Tank Cross-Section: Manufacture •2� � Gallons: �S�� Tank Anchor Calculations [SPS 383.43 (8) (g)] >( 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: �.eS��ec.��,c-y Plumber: �'f J Application Review Date: Y `t a. POWTS Reviewer: � � Name 6�'� 6 Rev. 4/27/2023 Credential# 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 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 Leschensky Holding Tanks Owner Name(s): Jeff&Elizabeth Leschensky Phone: 563 _517 3032 Owner Address: 2335 Oak Hill Rd. Decorah, IA Z�p: 52101 Project Address: �547W River Rd. Hayward,WI 54843 Govt.Lot: SE 1/4 of NW 1/4,Section 13 ,T 41 N-R 06 E❑or W❑✓ Township: Round Lake County: Sawyer Project Parcel ID#: 024641132415 Designer Information DesignerName: �asonKuettel Phone: �15 _798 _3355 Designer Address: 42940 US Hwy 63 S.Cable,WI Zip: 54821 E-mail: tim@andryras.com License Number: 675751 Remarks: Signature: �f`;.��=-hfJ Date: � zC `� Original igrtature required on each submitled copy. CHECK 90X 45 APPLICAOLE. CHECK BO%AS APPLICABLE. ❑ SOIL EVALUATION p Scale: 140 ao' fio 80 � SYSTEM PAGE 2 OF SITE MAP PLOT PLAN PROJECT NAME: oescN F�ow�. 3�`� cPo (10ftgrid) �p� [.�SC r+c^'S k 7 /-tr'..��U V 7Y�N Y�. Attach design flow calculations for commercial plans. aaodec7 nooRe55�. 75y>1-� �2wE2 �Z� . Pipe Matenal I ASTM Standard(Tables 384.30-3&384.30-5) sc�r 40 N Sanitery Sewer N � / BM Sym�ol: � BM Elevation- �� FT Force Mam�. — / BM Descnption: "Til� ��d'icate�onh�y IMPORTANT: Slope Gradient(/) � yyell Symbol(if applicablep. � arawing anarrow Show ground eleva�ion contours at suilable intervals. of Tested Area: � on ihe appmprite Ilne. ONNJ'�- '. fEr/=�Zc7� � �L�2A-i.�cTry LE,SC�1�^'SK-7 R��1�1 - 75v7� (Z��2K— �z�, H�YV�� , w-1= ILC(�AL_ : �� S��NW l-UT Z �M Z5�`7 �F- lc(o �77 .�� IS /� T�1/� iZo�i-' '�l.��v oF �c-r-D L�'Lct � .S�4uY� C1' . ,—. � `i'�� oZN6yi13Z�/ S " � 1---� � � I I I �. �;�tn �� J�z„��v�'r'l/ --- i1 —�`—_ � -- � S�G�t f" I _ � � I �"�"�� v � � { - - I � I ti � I I v � , � - I I _ - , ��t , . �_ , _ I � � .. I I ' _ I Wc� - I �L7 IwFi�TR..trs,t OO � . _rf I i�n �S7o 'rlOt.��.W e�D �j.�� I _• Ty N�.f . 3�c� _ �p 6 l5 75" / ( _ I �,�t _ _ . �i��` I I ' � I I � �/� w �f� I i . _ � _ �. ,so� c. �+,Pceu4 �-��c� -. i I � �; �Jc� FL'u' � � . 1 y I I � � � PAGE30F4 HOLDING TANK SPECIFICATIONS (No Scale) Wealherproof 12"Min.or 2.0 it above Junction and Approved Es[ablished Flood Elevafion Alarm Box Ven�Cap (tYPical) Electrical must comply with � Approved Locking Manhole SPS 316 and NEC 300 4"0 Ven[Pipe with Waming Label AI[ached �Condui[ >10 ft from (typical) 4"Min.or 2.0 ft above Building I Established Flood Elevalion ` I ' 1 (rypical) — �AiNghtSeal " 1 _ • Finished Grade 18"Min. (�YPical) ':� ' .. I � ° J . 1 Inlet Inletlnvert / —Watertight Approved Join[s with J Plug Approved Pipe 3 f[onto � Max. 12"or 90%of total volume Solid Ground � if more[han one tank a • Alarm-On HOLDING TANK VOLUME = 1537 gal , LX Z� = 3�` �� a . . 3"Approved Bedding Ma[erial Beneath Tank TANK MANUFACTURER: Infiltrator Anchor tank as necessary pursuantto 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 Ibslcu.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 = 300 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 SERVICING FREQUENCY o The tank(s) shall be pumped by a certifed septage servicing operator licensed under s. 251.48 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: Alldfy RaSlT1USS@Il & SOI1S Phone: 715-798-3355 Local government unit: SBwy@I' CO. ZOIllllg Phone: �15-634-8288 �oca� government unit address: 10610 M81r1 St. #49 HayWard, WI Z�P 54843 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. 4l9/24, 10:03 AM Real Property Listing Page Redl EStdt2 Sawyer County Property Listing PropertyStatus: Current Today's Date: 4/9/Z024 Created On: 2/6/2007 7:55:40 AM �Description Updated: 1/22/2019 '� Ownership Updated: 30/30/2014 TaxID: 24192 ]EFFREY] LESCHENSKY DECORAHIA PIN: 57-024-2-41-06-13-2 04-000-000150 ELIZABETH K LESCHENSKY DECORAH IA Legacy PIN: 024641132415 Map ID: .8.15 Billing Address: Mailing Address: Municipality: (024)TOWN OF ROUND LAKE ]EFFREY J&ELIZABETH K JEFFREY] &ELIZABETH K STR: 513T41N R06W LESCHENSKY LESCHENSKY Description: PRT SENW LOT 2 CSM 25/97#6697 Z335 OAK HILL RD 2335 OAK HILL RD DECORAH IA 52101 DECORAH IA 52101 Recorded Acres: 0.690 Calculated Acres: OJ02 lottery Claims: 0 � Site Address ' indicates Private Road First Dollar: Yes 7547W RIVER RD HAYWARD 54843 Waterbody: Moose�ake West Fork-Chippewa River � Property Assessment Updated: 7/16/2019 Zoning: (RRl) Residential/Re�reational One Z024 Assessment Detail ESN: 402 Code Acres Land Imp. Gl-RESIDENTIAL 0.690 67,600 106,400 � Tax Districts Updated: 2/6/2007 1 State of Wisconsin 2-Year Comparison 2023 2024 Change 57 Sawyer County Land: 67,600 67,600 0.0% 024 Town of Round Lake Improved: 106,400 106,400 0.0% 572478 Hayward Community School DistriR Total: 174,000 174,000 0.0% O01100 Technical College •� Recorded Documentr Updated: 10/30/2014 L'tf property History WARRANTY DEED N/A Date Remrded: ID/3/2014 392555 WARRANTY DEED Date Remrded: 7/12/1994 242823 536/34 https://tas.sawyercounrygov.orglsystemlframes.asp?uname=Eric+Wellauer ��7 � a �l ��h .aj,r"' p'� t6'�i �� ..-"" + �*- ' p . - ��1�3 �� .i i�` 'i�. � .. • 'J'-�' �.1 * va - • Addresses �_ ;;.A.. ' y2 N�� r.�a ir p� 1��,/ � ' '� d6�.t ... � '� � �ra �y � ,��i� �.� I�: '" �,�I��l� M � '�� ,�,� �y Parcels �J;e_ . ��,. y� � •� '� y .-�a..` . - �. ,' . 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L 1 V�� Si t � . �J� � jr'� �� + t�'�.s x �� rv�.`� � f� � �Y , .�.,. � �i;�' R�� . :IT .w ,"„."�.. �st`� �. ; �` A "it r .� � t ""'4�,' . i � . ,�� ,i� . 5� �'�.��. �..I� � � � � ' � �►� . . 'i'.,+P' - . p`. M " ._� r.:�4.�� s . r �� y � ��t '!y�_ t ''� .�5+� '� �. � '. M` . �w �+q.T �. ..2 . .M '4. '. f + � k �� '' � 9 �°_�c,,� ,�� : _ e ; _ +� 4b� �i_;t f,!' � , ,y, � i��, w �G f# �.. '�►�..� _.. ��ii�ll��i��I��l��i��I�� Dacl�:��7G95� - USE BLACK WK ONLY - TX:4051132 � PO�J�JTS �r1AlNTENA�lCE AGREEPv1ENT 449�68 i For Holdin Tanks PAULA CHISSER 9 REGISTER OF DEEDS i O�:,r.ar s��13me{s�3;sn�:•�n on d»d: SAWYER COUNTY. WI 04/09/2024 10:23 AM RECORDING FEE 30.00 �tt ,=iIL`( L��c �i�r�+!}C� ��za�3�i�� LC:.sctt�ti� Par�el idantifir_afion�lumber �I�Diyif leyeCy IDj C7 Z� - ' PAGES: 2 .�� y I � I �-��.��. Legal Descriplion oFProperty: -SEE ATTACHEDSHEET- �Va acknowlo�ge(i-at apclir_alion is being made for the installat;on of a hc'ding tanh(s)on the property describad on the aftachzd sheet. Raturn To:Sa��ysr County 2oning and Conservation Administration 1061014tain St.Suite 49,Har.vard,L'!I 5d8�43 � __ _ As an inducemenl t� tne Coun!�oF Sa�r:yer to issue a sanifary permil for a holding tank on the above-descrbed property, the o�,�ner is responsible for the opera6on and maintenance o�fhe holding taN�, locking device,alarm and a�cess,and agree; to conform fo all applicable requirements��SPS 3�53,Wis.Adm. Code r�lating to holding tank management, including tne follo�.ving: 1. The o�,vn�r agrecs to contract with a person wiho is licensed undar Ch.PJP, 113,4�/is.Adm.Code,except as orovided b� Section 281.48{3)(d), Stats., to have the holding lank properl;�serviced and to fif�a copy of the ser�ice con:�act with the ��o•�ernm�nta(unit. The owmer further agrees[e file a copy of any cha�ges to the service contract,or a copy of a n2�,v service contract,�,v�th the goverr,merfa!urit��nihin ter(10)busir,ess days from tne dat�of change to the sen�ice contract. 2. The o�r,ner agrees to con�ract�vith a person li�ensed unJer Ch. �1R 113,U�lis.Adm.Code,tivho shall submit pumping rzoorts to �h�gov�rnmental unit in accord�nce ti+;i,h SPS 383.55,�'/is.Adm. Code, f�r ttr�s�rvicing of tha heiding lank. In the case of exempti�n under Section 201.43(3)(d}, Sta�s., tne osvn2r shall submit tne renort to the governrnental uni�. Th�go�iernm�ntal unit may er`er upon the properiy to irniesfigate the r,�,��lition of tna holding tanl��vhen pumping reports may indir�,�=the holding tank is not baing properl�maintained. 3. I(the o�;mer fails to hav2 the holding tank prop�rly se��iced in response to orders issued by the yovernmenfal unit to pr2ven� or abale a numan healih hazard as descrbed in Section.254.59, Stats.,th�governmzntal unit may enter upon ihe property and ser�ice, or cause the tank to be s?rviced. Pursuant to Section 145.20(4)4Vis.Stats.,a governmental unit may a;sess the o��vner oF a private sesvage systern For costs related to thz pumping of a septir_or holding tan�. The charges will be assess�d as prescribed by Sacfion 60.0703,stats. The o�rmer agrees to pa/all charges and cost incurred by the gov�rnmental unit for inspecfion,pumping, h�uling,or otner,vis�se�ncing and mai�taining the holding tank in such a manner as ro preveni or abale any human hea;th hazard caused by the holding tan!<. 4. This agreement v�ill remain in effe�t oniy unlil the gov�mmental unit resporsibla(or the regulation o(pri�iat�se�,vage sysl�ms certifies tnat eitner a soil absorption system that complies�,vith SPS 383,��/is.Adm.Code,or a municipal se�rier serves the prcper�y. In addition, lhis agreement may be canceiled by execu+ing and recording said certification avith re(erence to this agreament in such manner�r�hich tivill perrnit the existence oF th�certiiication to be detarmined b;�r�ference lo the propar��. 5. Tnis agreement shall be binding upon the oavner, Ihe heirs of t;��o�,vner,and assignees o(the o�vner.The osvner shail submit th�agreement to fhe r�gister of deeds,and the agrsement shall b�recorcl•�d b�the regisier oF de�ds in a mannnr vvhich ti�;ill penTiit the existence of the agree��enl to hs d�tarmina�'by ra(:;rence l�ti��pr�p�rt�v�her� lhe holdin�� tank is inslalled •Only one o�,rner sic�na,ure re uire.l- O�,vn2r' S' �ture: —"- -- -- ACKNOWLE�GPriENT Sk�te of:�j,�__a -- -- — - - — J —. -- --- —I --- i r��, � ,��, ,� � . . — c��,,.y�J. ,h h�ck .— , , � -� —_-- � -1 C�� .E,SC��(C � 5 �'��=rio� � �n�J s<<�rom t� f��f��r� me on th�s — _ _- __._._-.-__—.. - ! p�,,, _ ___ _ __ _l.Z.�'' �a/or r _—_ ?i� d - -- _--__ Da � �Z { o20oZ� e/ (��'.;n s �lame): ��, '�P t�r. ��r,l..�r_k_Y i--- - _l- -___ _ _--- --- -- _- - -___ iVotarV Pu�li�v Si,. n_�!u��: ,v,�� - �! -rf_-.l 't;y � ^ -v�_S�`0��✓ � --- I �� G�,�� 'uhli�fJotary��larr�� (Pr �l B�ic� h CI.nJ l��l�er ' � � __ _ _ ' _ _ , °,� . .,-n�iis '-� � , .��r�s �3t d-o?.5_._ : , , � BRIDGET CHRISTOPHER � Commfssion Number 796862 My Commission E�Cpires °iM'' June 23, ?0�5 That part of the Southeast Quarter of the Northwest Quarter(SE114NW114), Section(13),Township Forty-one(41)North,Range Six(6)West,more particularly described as Lot Two(2)as recorded in Volume Twenty-five(25)of Certified Survey Maps,page 97-98,Survey No.6697,Doc.No.317645. HOLDINC TAyK SER�'ICINC COVTR,IC.7. Contract Dacc: 3 G `i � c��? This contract is m�dc bct�rcen thc Holding Tanl: O«•ncr and thc Pumprr. I lol�lin�, Tank Owucr's Namc: Pumper's Nantc: - � ,J C-F�'ZC � C.. L�C VtC^+.t � �' . l,=l 1 Z •� ��C %7� (_,,L 5 C 1-J C:r�,f K�' � � Gv�� J .� � Parcel ldenti�c�tion Number: --- ( I ? Di�it Lcgacy IDj � Z '-1 _ ('D y � - - - - - 1 - i 3 - _Z � � � � � 1 . The o�vncr agrccs to ti(e a cory of diis contract with ihc go��crnmcntal wiit, Sa�vycr ('c�imty. �vhich h� ;1s�c,}�Pri :uldrrc:c��•du1 witli �f;. OCficc c>fthc Rc,istc7- of L'ccd;, th�lfiiinTc�ianc� -- A�r�cment ti�r a I lulcling "I�ank rc��uircd undrr dic Sa«�vrr C�ountv I'rivatr Sc��a�c Systcm Ordinancc ti,r the issuancc of a $anitarY Pcrmit t�,r thc instalixtion ot � holcling tank(s�. 2. 'fhc utvncr a�mcs to havc thc hulding tank(s) srrviccd b�' thc pumper and cuaruntccs to ��crmit thc pt�mper to ha��e acccss an�i tc� enter upon the pruperty fur thc purposc oi' scrvi��itl,J the ho(din� tank(sl. "( hc owncr agrccs to maintain thc all-�vca[h,;r accrss ruad c,r drivc so �h�it the pum�cr c<in scrvice thc holding tank(sl u ith �h� pum�in�, cc�uipment. 'I�he awncr fw�thcr agrccs to pay thc rumEier for a char�cs incurrcd in scrvi�ing thc holding �ank(�) as mutually agrcc�l uPc�n by the o�vncr and pumper. i. Thc n«m��cr a�recs tu sul�mit ro thc C;ovci��mc»tal Unit. S,jtiyycr County. a rcport ti�r thc scrvicing ut thc ho!din� tank(s) as rcquircd undcr SPS 3�i.55. 4ljiscoJ�siu Aciministrati��r C�ocic and thc Sawyer County Privatr Scwaec Systcm t)rdinancc. Thc puniper furthcr agrees to inrludc thc follo��in+� in thc rep<�rt: �. Thc namc �nd address ol' thc persun respnnsiblc ior scrvicine thc hc�lding tanlc b. �['hc namc of thc owncr uf thc holdin�� tank; c. 'i'hc site address uf thc holding �ank; � d. The datc thc holding tank wa: scc� iccil; C. ThC vt�lulttc, in g�tllons uf thc contcnts rum�ed li•nm thc holclinc tank lor c�ch s4n icin=�: f. Thc �iis�x»al sitcs to �vhich thc cuntcnts f�rom thc holcling tanl; �4�crc delivcrcd. � �I. I�his agrccmcnt will reinain in �ftcct until thc own�r c�r pumper tct�mina[cs this crmtracl. In thc cvcnt of a changc in this contract, thc o�� ncr agrecs tu lilc a co}�y of an�� rhangc� to this >crvirc contract �ir a copy ol� a nc�v scrvice cuntract «�ith Sa�vycr ( �oun[y �vithin tcn ( 10) husincss da_ys from thc datc ofch��n�e to thi� sci,-icc cantr��ct. �)�'11L'I''s Uaii�r. ( Print) ��\1'f1Cf�� ILi1�1tUfC: (t)nl� onco.�nrr i;!nalurcrn cAI � i �� Les�ev�sl<Y � p r. - � � umper's nam��: ( Print ) Pumper'. . i�i�a�u�--� —1 , (�. ,.- ._ , c_ �..,., i 'Cj _� _...,. _ —J`�� r� � �� Pumr�r't ReKistratl0l7 NIU11hCC: -' � ` � � , ��;- o � �� C _ __ ,� R��, ��; �'"' � � APR 1 6 2024 ;Aa'VY�R CQu��y ZOiVING ADMIldfS�('�A��ON