HomeMy WebLinkAbout028-742-21-4101-SAN-2024-104 "�" � ]ndustry Services Division County (�
4822 Madison Yards Way ��W �
_ , _ �
_ =p - Madison, W I 53705 Sanitary Permit Number(to be filled in by(
= P.O. Box 7302 �
�.�;.�_,
Madison,Wl 5302 (,l' .5 ` � ��� �
Sanitary Permit Application State Transaction Numbcr U
ln accordance with SPS 383.21(2),Wis.Adm.Code,submission orthis forni to the appropriate governmental unit �
is required prior to obtaining a sanitary perniit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin�aaarr�s�
the Department of Safen�and Protcssional Services. Personal infonnation you provide may be used for secondary
purposcs in accordance�cilh lhc Privac��La���_s. 1�.0�1(1)(m)_Stats. 1� o�� 1.1 ��
I.Application Information-PI ase Print All Information � W
Propem�O ie �s�lame Parcel#
�'o,►.g �'�, � � _ oa,��y�. � o
Property Owners Mailing Address Property Location
�"��`�1 ��� � � ��� .
City.State Z.ip Code Phone Number }�-
�� ���� �������r 1 l �� � '/4, �+- '/<, Section ��
II.Type of Buildi g(check all that apply) � Lot# T �� R E o W
�1 or 2 Family Dwelling-Number ofBedrooms �� Subdivision ame
� Block tt �—
❑ Pubiic/Commercial-Describe Use ,�
❑City of
❑Slate Owned-Describe Use CSM Number ❑Village of
� (,�'Town of
[IL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
`�' �New S stem
y ❑ Replacement System ❑ Other Modification tu Existing System(esplain) ❑ Additional Pretreatmcnt Unit(explain)
�' Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Chanae of Plumber l ist Previous Pennit Number and Date Issued
❑ Revision ❑ Transfer to New Owner "
Expiration
IV. Dispersal/Treatment Area and Tank Information:
Desi��w(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(s� Dispersal Arca Proposed(sfl System lilevation
� -�_ �� �.�
Capacity in Total #of Manufacturer
�
l ank In}ormation Gallons Gallons Units q a� o 'D v �
'v
Ne���Tanks Esis[ing"I�anks i G � � y y cv �
�1. �J ✓: v� ✓� � :i C.
Septic o Holding Tank ` Q — ��O , \,� �
V\!
Dosing Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibiliry for installation of the POWTS shown on the attached plans.
PI mbefs Name(PrinQ Plum � �s Si�nature MP/MPRS Number E3usiness Phone Number
�R�1�orJ'q V;SoL� �,302�3� 11S 63� ��
Plumbers Address(Street.Cit}�.State.�.ip Code)
� aa.a, � _ (�3 W; Sy�gy3
VI.Coun y/Department Use ly
1� p �e ❑Disapproved Permit Fee Date lssued Issuing Agent Si�nature
�,,� ��(w.°' S r�i'�y �'��.,G����'L�z,wt��.
❑Owner Given Reason for Denial
Conditions of Approval/Reasons"for Disappro�al �����ai��N��+rt�rjlv��.l�?Z
� e� � , t.1N�1C" _' ','.'�-
,; '�::�:
�GI ����. � � _____.___
�� r� �ate S� 1 `� ", ,-?
a +�ZOZ 8 0 ���� �
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k��
,Q� �hk# S I�7 �;�;�r`.
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Rc�tN 1�.2..._..__._ ..__�«.: �.
At[ach to complete plans for the scstem and submit to the Cuunh only on paper not less than S V2 x l l inches in size
i'�ai�
SBD-6398(R.02/22) N�REFl1ND6 AFTER � �
ISSUE OF PERMff 3� 1 I 6
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
������ 1
� � R C 1 I�ayward, Wisconsin54843
'� '�����Ci�� (715)634-8288
� �� `���� FAX (715)638-3277
�N��` -- _ „� � wwwsawvercount ov.org
� o � o � E-mail: sanitaiiannsawyercountygov o�
I �� � Toll Free Courthouse/Gcneral Information 1-877-699-4110
��I�� ��.=-%�
1�SC' {JS��
� ���0��
Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp ds / 08 /�
Parcel ID# D �� - � '-( � - �.1 � o (
- - - - � - - -
II. Plot Plan:
�Property Lines �Benchmark BM ♦
�Site Address �North Arrow
�Structure Scale T `
Well �-�S � � < 25' to Service Road ���' � �
�Legal Descriptioi� � Nearest Road Intersection
Setbacks to: Property Line, Well, Structure, Water bodies, Roads
IIL Required Plans:
� Index Page witll Original Signature
�Manageinent Plan/Contingency Plan
Servicing Contract
Holding Tank Agreement Form ($30 to ROD)
N. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: �'"�Q�'r Gallons: (����-�
� Tank Anchor Calculations [SPS 383.43 (8) (g)]
Locking device, chains/locks
�( Alann, electrical per SPS 383.43 (8) (e)
�J 3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
D� Holding Tank Version 2. 1 (May 2022-2027)
Owner: .7�-II� `�- '�<'o�� X Plumber: y�y
Application Review Date: ������z Y
POWTS Reviewer: � (�Z��j�z—�
Name
�9 � �(o 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
Owner Name(s): V w� sq�, JA�.r�v� �1 Phone: �SI -3$7 _ 7�?�
Owner Address: � � �'`� � m� Z�p� �Q
Project Address: � ���� �
Govt. Lot: 1/4 of 1/4, Section , T-��,�f R d7 E Q or W�
Township: � �� County: SO�1
Project Parcel ID #: � �0 �� �� �,� �� 1
Designer Information
Designer Name: �J� SO Phone:�1S _�3�{ _ ' b�q
Designer Address: (O �aa �3 �J , Zip: Sy$�3
E-mail: V ;5�� ��� � + C-� ; _
License Number: ��a3�
Remarks:
Signature:
Date: � � "7
Original sig atu required on each submitted copy.
CHECK�OX AS APPLICqBLE. CHECK 30X AS APPLICABLe.
� SOIL EVALUATION o s`a1e �Zo 20 ao Qo � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: oesicN F�ow�. ��� cao
s`
� Attach design flow calculations for commerclal plans.
aao�er.rnDoaess ��� } Plpe Material i ASTM S[andard(Tables 38430-3 8 384.30-5)
BM Symbol'.� BM Fleva�lon FT N Sanitary Sewer. /
�,Q Force Main'.�/
eM oes<�puor,�. _ \u .�--R �':�
�m �raaient i� ��d���a�e��anew IMPORTANT:
Pe �° Weti 9ymbol(If appfica le)�. � d�dwl��y d���r Show ground elevation con�ours a[suitable intervals
t Tes�etl Area. n�M1e apPropme line.
� 0�.$�1��2 t`�1 \°\
��N� �� 5�. a� `�`�a N o� 07 w
5�L.���a; �320'
. __ _----___— _ __ _ __ ___ -- — _
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� Sc.�lo P�V�a�
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1��° � '�:ea;� � -t-
0
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7500� �� �—�
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
4"(d Vent Pipe
Wealherproof >10 R from
Junction and Alarm Box Approved Bu:lding
Approved Locking Manho'.e Vent Cap �2�� �.�'^. or 2.0 fl above
Electrical musl c:on!ply tivith 9 I Establishe(t Plo ad)Eevation 4" Min. or 2A it above
SPS 316 and NEC 300 �v;�h Warnin Label Attached j Establ;shed Flood Elevat:on
�tYP�ca�)
�Conduit I (typical)
�
: �A��tight Seal � '" , •
� Finished Grade �
18" Mln.
��YPICaI) , 'n • . .a a. • 4e ,, ` ♦
: ! e ;
•d . I� . ' . • . . �
.a , � •
�•
e
���e� Inlet invert
f --Waterlighl
Approved Joints v.eth —/ Plug
Approved Pipe 3 ft onto �, Max. 12" or 90°0 of total vo'ume
Solid Grou�d � if more than one tank �'
(h'P��'') Alarm-On q,
e•
Compar#ment 1 Vol =���� gaS Compartment 2 Vol =� � gal ����
� � {��
�
��• TOTAL HOLDING TANK ��y �r
. . .;
� � VOLUME _ ���� gal . �. S � �����
. oNiq 9 \f'/
.` • ��o�c�n ���� j!
, � ' . , a . '. • . .. , • d � . . , , , , � • n-/ �'o� �
. , ' . "'9 ^,
3"Approved Bedding Matenal Deneath Tank �is�'9'VTy
. r
qT,�
TANK MANUFACTURER: K�.+r�" � \y�Sy��'�
� 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 Weiqht = �( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1 .5 = Ibs
�� W1250/750-MR
TANK SPECIFICATIONS �
� �
o a
a �
I �
12'-11" DIMENSIONS: � o
WALL: 2 1/2" a a
4" CAST-A-SEAL 4" CAST-A-SEAL BOTTOM: 3"
COVER: 6" ,;.;
,-_--_-_____��=--__`,\ MANHOLE: 24" I.D. PRECAST CONCRETE RISER o
,�%'� ii'ii � '•�� HEIGHT: 66"
�i' i i i i � ��� LENGTH: 12�-11" w
ii i i i i c� �� WIDTH: 7'-2" �
�� -� ��'� �-� �I II� r �--� �� BELOW INLET: 53"
N '� � �ye / i1 ' �� LIQUID LEVEL: 48" � �
I � � � jT Od WEIGHT: BOTfOM 8,740 LBS. � a o 0
r ��� �--'� �` -'Yi i i I ��__��� COVER 6,120 LBS. _� 3 a �
0 0
\�� FILTER OR iill ��� INLET AND OUTLET: � m o N
�� i i i i �� 4' CAST-A-SEAL BOOT OR EQUAL GASKET w
�� BAFFLE �i J 3 3
,�� I Pl I �� a a � w
��� Illl �
�-----_---_��___-�;='� INLET AND OUTLET BAFFLE AND FlLTER: N o o �
WISCONSIN, SEE DETAIL #10 4, o
(OTHER STATES SEE CHART) � �
TOP VIEW UQUID CAPACITY: 27.66 GAL/IN (SEP11C) � �
16.12 GAL/IN (PUMP) � � �
� o �
LOADING DESIGN: 8'-0" UNSATURATED SOIL O Z �
o � w I
� TANK CAN BE USED AS: a N
� �
Q o 4" VENT SEPTIC/SEPTIC, SEPTIC/SIPHON, o I
w� OR SEPTiC/SIPHON W }
� �
�o COVER: MIX DESIGN �68 (NO FIBER) �, = 00
TANK: MIX DESIGN #10 (STRUCTURAL FIBER) �1 �
---- --- ---- � �
. , , . � �
---- " --- ° . . .
INLET - CUSTOMIZED TANKS: � �
- OUTLET FOR CUSTOM TANKS CONTACT WIESER CONCRETE �
i � r
�Q �-� i - cn
� � � -� ;:, _ � � �Q
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� - �� �� - � I I � d 6 �_ '
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{ I •� � I � �
2�., .� �.^� � p �
� �� _�-.. --------�.�"I`—�-----��^=�"J � �
REVIEWED BY p v
M PUMP PAD REVIEW DATE N w
3 tn
DRAWINGS SUBMITTED
SiDE VIEW FOR APPROVAL
APPROVED BY: SHEET N0.
APPROVAL DATE: � /
OF
PRODUCTS NEEDED BY: / �
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
HOLDING TANK SERVICING CONTRACT
Contract Date: / /
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
r�a.u.,( Se,(,G,'� -�-�- C►.�t� �o
Sa,r�l r� �-�,f �P�
Parcel Identi�cation Number:
(12 Digit Legacy ID) � o�g -1�� -��-��v �
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 the 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 far 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 the report:
a. The name and address of the person responsible for servicing the holding tank;
b. The n�ame 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(]0)
business days from the date of change to this service contract.
Owner's Name: (Print) O ner's Si I'0: nly�pne owner signature required)
�. s�.u�� ���.�-�� � —�
�,�d�ra �a�,�,t � -,
Pumper's Na�ne: (Print) Pumper's Signature:
�� !�o e�
Pumper's Registration Number: '
4�1813
Rev.03/26/13
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.
FuRhermore,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 Fiow= a�� gpd
Insqection 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,vaNes,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 failur or malf nction to1: / /
Name of individual or company: v� S�� � �`� Phone:�I S b 3� I b 7�
Localgovemmentunit: ��� `� J v��A^'u1 Phone: �15 �� / ��00
Local government unit addres 0 b�� �b-^� Y� 1'�NA��' w� Z�P: S 4 g�13
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.
Continaencv 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.
5/9/24, 1034 AM Real Property Listing Page
R2aI EStdt2 Sawyer County Property Listing Praperty5tatus: Current
Today's Date: S/9/2024 Created On: 2/6/2007 7:55:52 AM
�Description Updated: 7/16/2019 � Ownership Updated: 7/16/2019
Tax ID: 30918 PAUL 5 SELLIE HUGO MN
PIN: 57-028-2-42-07-21-4 O1-000-000010 SANDRA K PROUIX HUGO MN
Lega�y PIN: 028742214101
Map ID: .13.1 Billing pddress: Mailing Address:
Municipality: (028)TOWN OF SPIDER LAKE PAUL S SELLIE PAUL S SELLIE
STR: 521 T42N R07W 14791 FOXHILL AVE N 14791 FOXHILL AVE N
Descriptian: NESE HUGO MN 55038 HUGO MN 55038
Recorded Acres: 38.876
Calcula[ed Acres: 38.968 � Site Address * indicates Private Road
Lottery Claims: 0 11048W MURPHY BLVD HAYWARD 54843
First Dollar: Yes
Zoning: (F-1)Porestry One J property Assessment Updated: 5/6/2024
(RRl)Residential/Recreational One
ESN: 2024 Assessment Detail
Code Acres Land Imp.
�f G1-RESIDENTIAL 1.000 15,000 161,600
�7 Tax Districts Updated: Z/6/2007 G6-PRODUCTIVE FOREST 37.876 91,900 0
1 State of Wisconsin
57 Sawyer County Z-year Comparison 2023 2024 Change
028 Town of Spider Lake Land: 106,900 106,900 0.0%
572478 Hayward Community School Distrid Improved: 132,500 161,600 22.0%
O01100 Technical College Total: 239,400 268,500 12.2%
.� Recorded Documents Updated: 11/8/2019
WARRANTY DEED �Proper[y History
Date Remrded: 6/28/2019 418502 N/A
WARRANTY DEED
Date Remrded: 9/22/2016 403087
WARRANTY DEED
Date Recorded: 2/10/2015 394320
VERSONALREPRESENTATIVES DEED
Date Rewrded: 7/11/2014 391231
DOMICILIARY LETTER
Date Recorded: 7/11/2014 391230
SUMMARY SE7TLEMENT-PROBATE
Date Remrded: 12/15/1961 113083
QUIT CLAIM DEED
Date Recorded: ll/16/1951 092224 65/100 M24/388
https:lltas.sawyercountygov.orglsystem/frames.asp7uname=Eric+Wellauer ���
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-USE BLACK INK ONLY- Dorl :�����?c�8 i
Tx:�0�1740
POWTS MAINTENANCE AGREEMENT 44�7�7
For Holding Tanks PAULA CHISSER
REGISTER OF DEEDS
Owner's Name(s)as shown on deed: SAWYER C�UNTY, Wi
^ ��� � �. t Y����� fl5/09/2024 1U:40 AM
���•� �pl,� �ECORDING FEE 3{I.flfl
Parcel Identification Number:
(12 Digit Legacy ID) Q�g -���- a L- 4 �d � P����' Z
Legal Description of Property:
-SEE ATTACHED SHEET-
We acknowledge that application is being made for the installation of a hoiding 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
responsibie 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 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 governmentai 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 heaith 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 cancelied 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 shali 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 w r si nature re uired- ACKNOWLEDGMENT
wner's ign� ure� _ � State of: r� '�a
County of: �K�
Owner's Name (Print): � Subscribed and swor to before me on this
���� ,' � �day of ,r�� , 20 oZ�
Date: � By(Owner's Name): �" L
,��✓(�
�l �U> Z�Z"� Notary Public Signature: �-�--
Drafted by: Public Notary Name(Print): -� 2 G' �
S 4Y\cJM,;I. }r����X My commission expires on: � ���
� BRIAN RAYMOND GiLL
�"� � Notar7 Pubiic
Personal information you provide may be used for secondary purposes[Privacy Law,§15.04 �� ��.; Minnesota Rev. /26/13
>; ,r^�V°- ;� My Commission Fxpires
Jan 31, 2025
The Northeast Quarter of the Southeast QuarCer(NE'/4SE1/a),Section Twenty-one(21),
Township Forty-two(42)North,Range Seven(7)West,Sawyer County,Wisconsin.
For informational purposes only
Property Address: Murphy Blvd,Hayward,WI 54843
Tax Key No.: 028-742-21-4101