HomeMy WebLinkAbout004-738-06-4304-SAN-2024-080 '"=\\ Indushy Services Divisian Cowty N
,y�c',''* �.��;� 1400 E Waslvugton Ave �4�,�r t.y� �y
�,I� _ ;5' P.O.Box 7162 Sanitary Pecmit N er(to be filled in by C. `
'��Y,r:/y�� Madisou,WI 53707-7162 �S I ��� �
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µ ` Sanitary Pernut Application SteteTransaceonN=6er o
In accordancc with SPS 38321(2),Wis.Adm.Code,submission of this form W Uie appmpriete govemmental unit �
is rcquired prior to obtaining a sanitary pem�it Note:Applicadon fortns for stato-owucd PO WTS are submiked ro pmject Address(if different than mailing add
the Departmrnt of Sefely and Professional Services.Pe�sonal information you provide may be used for secondary
in accordance with the Privac �w.s.u.oa i m sm�. S 3 Q N �'�,c�,7i�k 2a°�
Iu A licaHon Information—Please Print All informaHon
Propeny Owner's Namc Parcel# f R� ) y y�
du�, t i�o � G�hir-c 5��0 Y-��38�o7-ob-yo3•OOa�UOoayo
Pmperty Owner's Mailing Address Pcoperty Location
$7Y0 �/l�ar �v� � �,�,��
City,Stete Zip Code Phwe Number C) 1/�� 6
n ./ t,/ �.��/.,Secoon�
/J�00/W�� � � /n�v S S (� �-�circle one)
IL Type of Building(c6eck all that apply) � I,o�a I T 3 g :�; R—�—E or�
�1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name
Block N
❑Public/Commercial-Dacribe Use ❑Ciry of
❑Stxte Owned-Describe Use CSM Number ❑Village of
` �Townof�0l/l�t+L6L1
III.Type of Permit: (Check only one box on line A. Complete line B i(applicable)
A' �New 5 ccm
ys ❑Replacement Sysrem ❑TmatrnenNHolding Tank Replacement Only ❑Otha Malification to Enisting Sysum(eicplein)
. B• ❑Pertnit Rmewa] ❑Prnni[Revision ❑Change oFPlumber ❑Pertnit Transfer ro New List Previous Pefmit Number md Date Issued
Before Expiretion pwner —
N.T e of POW1'S S stem/Com oneuUDevice: Check all that a 1
❑T'on-Ressurized In-Ground ❑P�essunzed]n-Gound ❑AtGtade ❑Mmmd>24 in.of suitabte soil ❑Mound<24 in,of suitable soil
�Holding'Cank ❑OUter Dispersal Component(ezplain) ❑PretreaLnent Device(explein)
V.Dis ersaVTreatment Area Informadon:
Design Flo gpd) Design Soil Application Rate(gpds� Dispersel Aree Required(s� Dispersai Arex Proposed(s� System Elevation
° N//� fr//<F /Ul/t /�l/t
.Tank info Capacity in Total #of Manufictura ,
Gallons Gallons U�its p a� �'o u
NewTanks Exis[ingTanks o U y � '^
�+ $� .x A `�
d.Ci fn m rn ii.U 6.
SepticorHoldingTank o?06Q "— o / KaW �FE-�aS%
Dosing CAamba ��.
VII.Responsibility Stetemeut-I,t6e undmigned,aasume responalAility for inalnllallov of the POWTS ehown an t6e attached plens.
Plumber's Name(Print) Plumber' ign /MPRS Number Business Phone Numbcr
Lzan� �lo�.�s�, a3oY 8� �lS�3��-�a7�/
Plumber's Address(Sheet,City,State,Zip Code)
17a� t�i�E LaKf /�r/ �'i`QZs/h�Rsr , c•�� S'�-�s3
VIII. oq /De artment Use ON
�Ap,_�J,_/ ❑Disapproved PamitFee DareLssued IssuingAgentSignature `
!J"' ❑OwnerGivenReasonforDenial S [W-d� ���c/`7� � + �r,�-"'�
IX.Condidons of ApprovaVReasons for Disapproval - -----_--
�
�������W-�� �I�a63ay APR 08 2024 ;.�;
� - _
� nttach m rnmpkte pbm fw the syatem.od.mmk h the Caunry ooly on paper noUeutW 8 trz ft �o�
�� "���
sB°'639s�R.o8it4) NO REFUND6 FIFTER
ISSUE OF PEflMIT
����
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
��R c � � � Hayward, Wisconsin 54843
��- - ��Ci�l (715)634-8288
� FAX (715)638-3277
iQ ���I
% � -_- — � � % wwwsawvcrcountv ov.org
/ o , _\��..�� �' o
� E-mail: sanitarian(a�sawvcro��untygov.��
I �, ,_ �, ;�� • � � Toll Free Courthouse/General ►nformation 1-877-fi99-4110
,,����C'O N���
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stainp � `� / �g / a `�
ParcelID# o � � - � 3g _ o � _ K 3oy
IL Plot Plan:
�Property Lines � Benchmark BM ♦
� Site Address pC North Arrow
� Structure � 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
�Holding Tank Agreeinent Fonn ($30 to ROD)
IV. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: `�� Gallons: �� ���o
� 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:
olding Tank Version 2. 1 (May 2022-2027)
k•�',� C1�riS 4ti' Plum r• �
Owner: K be . �.e�a�N,��
Application Review Date: `'f f q' ( �'� .� %�(o��a.2-'� � ��(q � ��
,/ �,�.5
POWTS Reviewer: � � �
Name
6� � (� Rev. 4/27/2023
Credential #
� ,
Title and lndex Sheet
for POWTS
Project: _Gr/�i�-� ��`rR��s1'qd�-�-� Gr/�fiz a,��
Owner: ��� f /�Q� G��.;T£
Address: �7 YO ���01` �vf. S.
j��da��,,, /n�v SSyao
Site Address: _ ��3ON �5��,�nGl� ,¢�
Parcel 1D Number: SZ-Uo�f a -.��-oz-o6�y o3-000-oaoa yo
^ ���`� �Qy�yy'�o`�'Z�8�6�Y3p y�
:J
Lega! Description: S�, T�N, R O 7 �/
Township: �o�1�2a Counry: ��wy ��
Subdivision Name: -- Lot Na: '-
Cover pg Sanitary Permit Appiication
Page 1 TitEe and index Page
Page 2 Site Plan �
Page 3 ross Section & Plan �ew �N ���s5
Page 4 Management Plan/Contingency Plan �
Page� ����� r�-��-�� ��c�n��
Page r� ��;.�,. T� S�w;�f cw�i�-a��
Page 7 P�,��ar� �2a�, � iv T�s �
Page 10
Page 11
Page 12
Designer or Plumber: C,2�il-� Jah�s�v-, License Number: �7P�3D `l��
Signature:
�
Phone#: _�!S- ,��'�- �a 7 y Date:
Designed Pursuant to: �r�i�q ��K Component Manua{for POWTS
Version & Manual#: �� �_ i�_
v.��• � �
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 20 f[above
Junc[ion and Approved Es[ablished Flood Elevation
Alarm Box Vent Cap OYPicap
Electncal must comply wi[h 1 Approved Locking Manhole
SPS 316 and NEC 300 4"p1 Ven[Pipe � with Waming Label Attached
r—Conduit >10 ft 6om (typical) 4"Min. or 2A ft above
Building I Es[ablished Flood Eleva[iun
� (typical)
�Airtigh[Seal a " �
1 - Finished Grade
18"Min.
(typical) a
1 d 4 8
INe[ Inle[�nvert
�W atertight
Approved Joinls with � Plug
Approved Pipe 3 ft onto � Max. 12"or 90%of total volume
Solid Ground � if more�han one tank
d
Alarm-On
HOLDING TANK
VOLUME _ � .S gal
a
3"Approved Bedding Ma[erial Beneath Tank
TANK MANUFACTURER: Jv�/�"
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= 02�0 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 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: U�.�v�vi5ovi Phone: �IS� 3�• ���y
Local government unit: s Ca. '�bw�y Phone: �15� 63�/�gZ�
Local government unit address: �0610 vVlqa„ 37�. .7R. YI ?l�arr�"-'ZIP: S�y/
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.
Continqency 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.
System Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
lNLET
67.00
7t00
77.00
i —�
/
� `�� WARNINGDEATHb1AYOLGURIFTANKISENTERE�
� O � ✓✓IThIOUT PP��r6N tWIPIAEM 754.00
I
I
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1��` � NOTE:SEE INNER WALL PHOTO ON THE"EXCLUSNELYA7 SKA W5"PAGE i 48I.00
i
144D0
TOP VIEW OF MANHOLE COVER NorE:wHEN rHE our�Er is acu�,,Eu rNE iir�ui��
DEPTH ISWCREASED TO 491NCHES.
4C0 �
� G"PVC SCHEOULE 4C COUPLING(VENT)
� I L \
'00 I ' ' � TOP VIEW OF TANK (TAPERED)
I—,e.ou—I ,.00�
w�zoo
,N�� � , n ; ��.N,000 ;
� �
I— b9 5� I
4 W.^,H FHE35 I I
SEAL GASKET � � � �
I I
INSTALLEO � �
WHEN POURED I I � �
i i
49.00 � � I I
w � � � I� �i i
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—C O �____________'__'_________J
�
O4 s ao� SECTION VIEW OF TANK AND COVER — —s oc OUTLET END V(EW OF TANK
�
Model Number. ZOOO HQLDING SKAW PRE-CAST ( ) 96�-22��
Approved for. HOLD/NG Phone: 715
,n,z� ;� �; � ��� �x �d� 26255 105th Street, Naw A��wn Toll Free: 1-800-924-8625
Weight Outlet Dim. 4' N Gal. /In. Wisconsin 54757 Fax: (715) 967-2707
16,1001bS. 52.� N/A 49- 44.19 21859�� wwwskawprer,asCr,om
HOLDING TANK SERVICING CONTRACT
ContractDate: �l !Jl / o2Gbz
This contract is made between the Holding Tank Owner �nd the Pumper.
Holding Tank Owner's Name: Pumper's Name:
�-� �� , ��� Northwest Sanitary, Inc.
� � � V) S PO BOX 155
Radisson, WI 54867
Parcel Identi�cation Number:
(12 Digit Legacy ID) � Q � - � .3 � - d � - � .3 0 `�
1 . The owner agrees to file a copy of this contract with the governmental unit, Sawyer Counry,
wnicil has accepteci and recoraed with �ne ufGce ot tne Fcegister of 17eeds, the iviaintenance
Agreement for a Holding Tank required under the Sawyer County Private Sewage System
Ordinance for the issuance of a Sanitary Perniit for the installation of a holding tank(s).
2. The o�vner agrees to have the holding tank(s) serviccd by the pumper and guarantees to
permit the pumper to have access and to enter upon the property far 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 thc holding tank(s) with the pumping cquipincnt. The owncr
further agrees to pay the pumper for a charges incurred in servicing the holding tank(s) as
mutuaply agreed upon by the owner and pumper.
3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the
servicing of the holding tank(s) as reguired 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 repo�t:
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 contcnls pumped from the holding tank for each servicing;
£ The disposal sites to which the contents from the holding tank were delivered.
4. This agreem�nt wili reinain in effect untii the av�c�er or �,u�tip�r t�rj;;inates th:s contra:,t. 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 scrvicc contract.
Owner's Name: (Print) OW11eI�S SIgI11lUT'e: (Only one owner signature required)
�/1 V �) V � � ✓WV � � �( V! J�' ��� �
�" - - V
� � �
Pumper's Name: (Print) Pumper's Signaturc:
Ronald L Vieceli, owner Northwest Sanitary,lnc '� � �
:��� �� c� �� �
Pumper's Registration Number:
#2389
Rev. 03/2G/13
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4/9/24, 11:52 AM Real Property Listing Page
Real Estate Sawyer County Property Listing Property Status: Current
Today's Date: 4/9/2024 Created On: 2/6/2007 7:55:09 AM
�' Description Updated: 3/16/2011 � Ownership Updated: 11/13/2023
Tax ID: 4297 ADAM & ROGER WHITE BLOOMINGTON MN
PIN: 57-004-2-38-07-06-4 03-000-000040 HEIDI L & DEXTER CHRISTOPHER ELK RIVER MN
Legacy PIN: 004738064304 BRIAN WITZANY BLOOMINGTON MN
Map ID: .15.4
Municipality: (004) TOWN OF COUDERAY Billing Address: Mailing Address:
STR: S06 T38N R07W ADAM & ROGER WHITE ADAM & ROGER WHITE
Description: 51/2 SWSE 8740 ELLIOT AVE S 8740 ELLIOT AVE S
Recorded Acres: 20.000 BLOOMINGTON MN 55420 BLOOMINGTON MN 55420
Calculated Acres: 19.808
Lottery Claims: 0 � Site Address * indicates Private Road
First Dollar: No 4530N SHEPTICK RD COUDERAY 54828
Zoning: (RR2) Residential/Recreational Two
ESN: � Property Assessment Updated: 8/19/2013
2024 Assessment Detail
� Tax Districts Updated: 2/6/2007 Code Acres Land Imp.
1 State of Wisconsin G6-PRODUCTIVE FOREST 20.000 26,000 0
57 Sawyer County
004 Town of Couderay 2-Year Comparison 2023 2024 Change
576615 Winter School District Land: 26,000 26,000 0.0%
001700 Technical College Improved: 0 0 0.0%
Total: 26,000 26,000 0.0%
.r Recorded Documents Updated: 11/13/2023
WARRANTY DEED �
Date Recorded: ll/9/2023 447294 t'J�' Property History
WARRANTY DEED N/A
Date Recorded: 6/28/Z021 432927
PERSONALREPRESENTATIVES DEED
Date Recorded: 5/20/2008 353735
https://tas.sawyercountygov.org/systemlframes.asp?uname=Eric+Wellauer 1/1
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- USE BLACK INK ONLY- �;c'LTr;�����a'�;.���
TY.:��?5,1G;'_
POWTS MAINTENANCE AGREEMENT �4�z�7
For Holding Tanks ����A �r��ssER
��:�a5 i E�i �F �EED�
owner's Name(s)as shown on deed� H21CI1 L af1C� D@Xt@f hristopher �:aVV�YER �O�N i Y, VI�I
Adam and Roger White -- ���l�12024 ii:2�.a�r
Brian Witzany �?s���?���� F�E 3�.t��
Parcel Identrfication Number: �
(12 Digit Legacy 10) � � K - �1 3 �- � lo -�f 3 0 �-1 ��{���. _7
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 Adrninistration
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 new se�vice
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 rep�rts 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
an c mont in c��r mg�+naf�,./hi�ti,;,;i!! normit 4hc avic4onrc�nf}hc�o.-fif�r�t�n�tn kc.��a!nrminar� L�•r rofaronrc 4!i tho nrnnor,-t�_
`.yf.�:. ...._.., __.:�1 r_.. . ..._ ,...__.. ..... ... ,... �_.....w .,...., .....__ � ...._......._ ._ _...
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.
-Onl one owner si nature re uired- ACKNOWLEDGMENT
O er's Signature: State of: /"I/✓
c County of: C�/N��S -�
Owner's Name (Print): Sub��ribed and rn to befor,e me on this
}"�G� I l/�Y l S'r"U �n t/�' �,b �, d a y of � , 20 �
Date: By(Owner's Name): }�%� i.S ob�1l✓'
?i' Z(p ' �`�' Notary Public Signatur .
Drafted by: Public Notary Name (Print): l► //�f
�r�L W�-Ilql,i�— My commission expires on: d ' �i
°`�`�,r Shahn R. C�ilt��f
Personal information you provide may be used for secondary purposes(Privacy Law,§ NOTARY PUgL�� ev.03/26/13
- MINNESOTA
9` .".v .
My Commission E�Iree��n,�{�5� �
/ � � -
"I�he South Half of thc Southwest QuaiYer of(hc Sou�hcast Quaiter(S I/2 SW I/4 Sl:l Rl),Section Six(6),Township Thirty-
eight(38)North,Rarige Scve�i(7)West,located in the Town of Coucteray,Sawyer Coun[y,Wisconsin
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