HomeMy WebLinkAbout24-40S RomanIndustry Services Division
4822 Madison Yards Way
Madison, ^37^:5 KP.O. Bo^t?302^ y
Madison, ^5302APR 1 8^024
CountyBAYFIELD
Sanitary Permit Number (to be filled in by Co.)
iiilAn;UJ fU.r-^1UsWe Transaction )<Juml u^»^
Sanitary Permit Application
In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofthis form to the appropriate go!wtnmetrtal!,unit|
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats.
0^l^V
Project Address (if different than mailing address)22465 PALMER ROAD CORNUCOPIA WI 54827
I. Application Information - Please Print All Information
Property Owner's NameKENNETH ROMAN Parcel #
04-010-2-50-06-03-2 01-000-30000 "J
Property Owner's Mailing AddressPO BOX 267
City, StateCORNUCOPIA WI Zip Code54827
II. Type of Building (check all that apply)
X 1 or 2 Family Dwelling - Number of Bedrooms _3_/
D Public/Commercial - Describe Use
D State Owned - Describe Use
Phone Number
715-742-3255
Lot #
Property Location
Govt. Lot
yV 1/4. Section 03
T 50 N R_06_WSubdivision Name
Block #
CSM Number
a City of.
D Village of
X Town of BELL
m. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C
applicable.)
A.D New System iS Replacement System •J1 D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain)
B.D Holding Tank D In-Ground
(conventional)
D At-Grade iS Mound 7 D Individual Site Design D Other Type (explain)
c.a Renewal Before
Expiration
D Revision D Change of Plumber D Transfer to New Ownerl ,ist Previous Permit Number and Date Issued
IV. Dispersal/Treatment Area and Tank Information:
Design Flow (gpd)450 ~ . |V
Design Soil Application Rate(gpd/sf)
0.6
Dispersal Area Required (sf)750 Dispersal Area Proposed (st)1365 System Elevation
103.83
Tank Information
Capacity in
Gallons
New Tanks Existing Tanks
Total
Gallons
# of
Units
Manufacturer
trtS S£ 0
g
•I I •o .2E 0
Septic or Holding Tank 1000 '1000 WIESER
Dosing Chamber iQO 600 WIESER x
V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print)ADRIENCADY y^c^ ^v°
MP/MPRS Number922139 Business Phone Number
715-373-2378
Plumber's Address (Street, City, State, Zip Code)31160 BIRCH GROVE ROAD WASHBURN WI 54891
VI. County/Department Use Only
Approved
/3-'/ it
D Disapproved
D Owner Given Reason for Denial
Permit Fee / I Date IssuedWM^J-^i/
conditions ofApproval/Reasons for Disapproval'-"'^^ ~^^-~F -r^r(/ ^ ^^(>'^-
..^WI^C/TIC^ p(^ ^ d^/).';,^
o'P^pc^ ^c^ar^ ^'r+^5 S/^m
,. <^-ic./^ ^o ^^i ^'r^^/ic/^
Attach to complete plans for the system and submit to the County only on paper not less than 81/2x11 inches in size
SBD-6398 (R. 02/22)
Private Sewage System Maintenance Agreement
Owner(s) Name ,
t^er->o^--\V\
Owner(s) Mailing Address
^o "Box <Z.G7
Site Address ^-, , ^i . „A3 y^ /^/^^ x^/.6^^^^^ ^^
TaxlD# 3^-e<^
As owner, I (we) do hereby certify the private sewage system will be installed in
accordance with the certified soil tester's report and approved plans and specifications
on file with Bayfield County Planning and Zoning Department. The system will be
operated in such a manner as to meet the designed plans. I (we) agree to maintain said
private system at the below listed location in accordance with rules established in the Wl
Adm. Code, as from time to time amended. (COMPLETE Lega! is required)
J /4 of _1 /4 Section C? "S> Township 5~° N. Range u<o W.
Additional Legal Description: p^ ^ <f>- ^u ^ ^°<- 2--^<? -^5€^
Town of _&e^\_l _ (Acreage) _ Gov'tLot,
Lot Block Subdivision
Lot _ CSM # _ Vol. _ Page _ CSM Doc #.
DOCUMENT NUMBER2024R-602960
DANIEL J. HEFF-NER
REGISTER OF DEEDS
BAYFIELD COUNTY, Wl
RECORDED04,18/2024 AT 1 0:30 AM
RECORDING FEE: $30.00
PAGES: 3
Recording Area
Return To:
Planning and Zoning Department
D In-ground gravity
Mound
In-ground dosed In-ground pressure distribution Sewage System:
D At-grade Sewage System D Other.
Septic Tank (system types A through E): The septic tank shall be pumped by a certified septage servicing operator within three (3) years of the date of
installation and at least once every three (3) years thereafter unless, upon inspection by a licensed master plumber or other person authorized to make
such inspection, the tank is found to have less than one-third (1/3) of the volume occupied by sludge and scum.
Pump Chamber (system types B, C, D, and E): The pump chamber shall also be rinsed and pumped out when the septic tank is serviced as provided
above. The switches and pump controls shall also be inspected and maintained to ensure operability of said components.
Septic Tank Effluent Filter (system types A through E): The septic tank effluent filter shall be inspected and maintained as necessary and in accordance
with manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin. Code.
Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually inspected by a certified
septage servicing operator, POWTS inspector, or licensed master plumber within three (3) years of the date of installation and at least once every three
(3) years thereafter to determine whether wastewater or effiuent from the system is ponding on the ground surface.
Mounds, At-orade, and In-around Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbed if needed when
the wastewater distribution cell component is inspected as provided above.
Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs incurred by Bayfield County for
inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate any
human health hazard caused by the system. Bayfield County shall notify the owner of any costs which shall be paid by the owner within thirty (30) days
from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges
may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law.
The terms and conditions of the agreement shall be binding upon and inure to the benefit of all current and future fowm
Owner(s) Name(s) - Please Print
T^/A^W ^O^A/^
Notarized Owner(s) - Signat4re(s)
^/^^'
Subscribed and sworn to before mejon this d^^ "'' 'UfifQ
^-^3 L-s^^:'^
Notary Public // . . i -
//^^ ^.
My Commission Expires:
^^^,3^ 7. ^^?.5"
Drafted bv:0<ATt<s^ ^2aa^ Date: ^''Z^-ZoZj
Proofed by:
u/forms/sanitary/septicmaintenceagreementRevised July 2020
Document Number
State Bar of Wisconsin Form 3-2003
QUIT CLAIM DEED
Document Name
THIS DEED, made between Larry A. Roman
("Grantor," whether one or more), and Kenneth E. Roman
("Grantee," whether one or more).
Grantor quit claims to Grantee the following described real estate, together with the
rents, profits, fixtures and other appurtenant interests, in Bayfield
County, State of Wisconsin ("Property") (if more space is needed, please attach addendum):
See attached.
DENISE TARASEWICZBAYFIELD COUNTY, WIREGISTER OF DEEDS
2020R-583056
07/09/2020 01:24PMTF EXEMPT #: 5RECORDING FEE: $30.00
PAGES: 2
Recording Area
Name and Return Address
Spears, Carlson & Coleman, S.C.
PO Box 547
Washburn,WI 54891
04-010-2-50-06-03-2 01-000-10000
Parcel Identification Number (PFN)
This >s not homestead property.
^ (is not)
Dated July 8,2020 ^,_(SEAL) .A^^rA/.^<<* Z^wy A %»/<^J
_(SEAL)
(SEAL)
_(SEAL)
Sign.t.rel,) ^'^^
.^ ^••"""••^^%.|^^vv^~authenticated q6'«»/..'j?( ^y^£, I21=A\ '^,..i\y f^Ei^\ ^~7^i~
TITLE: MEM8^J^3^T£..B^SWWISCONSINu(If^t:^^3^
authorized by WiTSat. § 706.06 )
THIS INSTRUMENT DRAFTED BY:
Atly. April K. Splittgerber, SBN 1117654
PO Box 547, Washburn, WI 54891
ACKNOWLEDGMENT
STATE OF WISCONSIN )
BAYFIELD )ss.
.COUNTY)
Personally came before me on July 8, 2020
the above-named Larry A. Roman
to me I known
mstrmiieat ai
the gerson(s) who executed the foregoing^^T^A^
Notary Put
My commission (is permanent) (expires:
(Signatures may be authenticated or acknowledged. Both are not necessary.)NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAIM DEED £•2003 STATE BAR OF WISCONSIN FORM NO. 3-2003
"Type name below signatures. INFO.PRO™ Legal Forms • (800)655.2021 • jnfoproforms.com
Attachment
A parcel of land located in the NE 14 of the NW '4 of Section 3, T. 50 N., R. 6 W., in the Town
of Bell, Bayfield County, described as follows:
Beginning at a 2-1/2" iron pipe with a 3" cap at the North 14 corner of said Section 3, run S
00°59' 19" E, 1025.16 feet on the East line of said NE !4 of the NW 1/4 , to a 1" iron pipe at the
SE 14 of the NW 14. Thence leaving said East line and on the South line of said NE !4 of the NW
IA, N 89°22'44" W, 721.30 feet to a 1" iron pipe. Thence leaving said South line, N00°59'19"
W, 1032.30 feet to a 1" iron pipe on the North line of said Section 3. Thence on Said North line,
S 88°48'44" E, 721.54 feet to the Point of Beginning.
Said parcel contains 741,733 square feet which is 17.03 acres, including that land lying within
the Right of Way of Palmer Road.
^Kot^O W^SO
POWTS OWNER'S MANUAL i
APR "I 8202^u;
FILE INFORMATION
Owner:
Permit #
to^MG^ EOI^A^
& MANAGEMENT PLAN
SYSTEM SPECIFICATIONS
Page.i_ofl
DESIGN PARAMETERS
Septic Tank Capacity ( 000 gal DNA
Septic Tank Manufacturer \^^ j ^/t^^j"^
Number of Bedrooms
Number of Public Facility Units
Estimated flow (average)
i Design flow (peak), ( Estimated x 1.5}
Soil Application Rate
T [NA
INA3o0-gal/day4^gai/day
Standard tnfluent/Efftuent Quality
Fats, Oil & Grease (FOG)
Biochemical Oxygen Demand (BODs)
Total Suspended Solids (TSS)
Pretreated Effluent Quality
Biochemical Oxygen Demand (BODs)
Total Suspended Solids (TSS)
Fecal Coliform (geometric mean)
I Maximum Effluent Particle Size
Other:
gal/day/ft2
Monthly average*
S30 mg/L
<220 MG/L D NA
<150 mg/L
IVIonthly average
>30 mg/L
£30 mg/L L<tfNA
$104 mg/L
% In dia
NA
D
DNA
*Value typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
Effluent Filter Manufacturer
Effluent Filter Model
R><^o\6^i.s^'s
Pump Tank Capacity ^ OQ
Pump Tank Manufacturer t^l &^G<^>
Pump Manufacturer
Pump Model IA/(S OS 14
Pretreatment Unit
n Sand/GraveI Filter
n Mechanical Aeration
n Disinfection
DNA
DNA
DNA
INA
DMA
DNA
DNA
Peat filter
D Wetland
D Other:
-I^TNA
Dispersal Cell(s)
n In-Ground (gravity)
D At-Grade
Drip -Line
DNA
D In-Ground (Pressure)
'Mound
Other:
Other:DNA
Other:DNA
Other:dNA
Service Event Service Frequency
Inspect conditions of tank (s)At least once every:month (s)
year(s)(Maximum 3 years) II NA
Pump out contents oftank(s)When combined sludge and scum equals one-third (1/3) of tank volume
month (s)
D year(s)Inspect dispersal cel!(s)At least once every:Ifc (Maximum 3 years) Q NA
At least once every:1^month (s)
year(s)DNA
Inspect pump, pump controls & alarm At least once every:month (s)
Dyear(s)DNA
j Flush laterals and pressure test At least once every:i3_month (s)
D year(s)NA
Other:At least once every:n month (s)
Dyear(s)DMA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying on of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must
include a visual inspection of the tank(s) to identify any missing or broken hardware. Identify any cracks or leaks, measure the volume of
combined sludge and sum and a check for any back up or ponding of effluent on the ground surface. The dispersal celt(s) shall be visually
inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding
of affluent on the ground surface may indicate a falling condition and requires the immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any treatment tank equals one-third (1/3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
and any servicing at inten/als of = 12 months, shall be performed by a certified POWTS Mafntainer.
A service report shall be provided to the local regulatory authority with 30 days of completion of any service event.
'2/2-
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting prodycte oir crther.chemicals that
may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations jafe deteiste^hav&th^contents of the
tank(s) removed by a septage servicing operator prior to use. jii, ;|||;ji! ^pp -) g 9094 i-ySystem start up shall not occur when soil conditions are frozen at the infiltrative surface. ' i-."L-- i.»'
During extended power outages pump tanks may fill above normal highwater levels. When power is restored the e^oeisa/wastewater will
be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump rank removed by a Septage Servicing Operator prior to restoring power
to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal
levels within the pump tank:
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS:
antibiotics; bay wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain
(sump pump) discharge; fruit and vegetable peelings; gasoline; grease, herbicides; meat scraps; medications; oil; paining products;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that ht system is property
and safely abandoned in compliance with chapter SPS 383.33, Wisconsin Administrative Code:
• Alt piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid materials.CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the code compliant
replacement system:
D A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from e)dsting and proposed structure, tot lines and wells. Failure to protect the replacement area will result in the
need for a new soil and site evaluation to establish the suitable replacement area. Replacement systems must comply with the
rules in effect at the time.
Q A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology, a
holding tank may be installed as a last resort to replace the failed POWTS.
Q The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed
, as a last resort to replace the failed POWTS.
Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.«WARN1NG»
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICENT OXYGEN. DO NOTENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT, RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK IS VERY DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS:.^'"1!'
\ ' ^ ^ ,-'A' '- <*t'-"' '•*' s^'A''."-
^r/- HALF
ILL/ „wr
POWTS INSTALLER
Name
Phone
f^OS.^^ CAO-f^-^3-2^~)a
SEPTAGE SERVICING OPERATOR (PUMPER)
Name
Phone
J)^>(-L c\ ^elrt^o^^Btfti. ?i(-. fi^^p. -
POWTS MAINTAINER
Name
Phone
0^r<.^C^-^_
ni^-V^-^-?^
r)t:r- 37 3- sT<-<?3
LOCAL ?SULATOR AGENCY,LOCAL ?SULA
Nairn.F=ie^'—C' ^-*:s ^-£>tw>
Phone '7I5-7^4$^&-^-
This document was drafted in compliance with chapter SPS 383.22(2)(b)(l)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. Revised 3/29/13
n
Wisconsin Department of Safety and Professional Services
Division of industry Services
SOIL EVALUATION REF'O'RT
APR -i 8^4 C'Pasel of 3
^..^s^f^^"-'-"-
aiiRS?*'' In accordance with SPS 385, Wis. Adm. Code
'""Attach complete site plan on paper not less than 81/2x11 Inches in size. Plan must Include,but not limited to: vertical and horizontal reference point (BM), direction and percent slope,
scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)).
I Countypayfield
|ParceU.D._ _____ _____^ .;[04-010-2-50-06-03-2 01-000-30000
Reviewed by m Date
property OwneriKenneth Roman Property Location
Govt. Lot %% 303 T50 N R06
-D«—TDT
w
'roperty Owner's Mailing Address'OBox267 Site Address or CSM and Lot #:
^2465 Palmer Road Comucopia Wl 54827
City
Cornucopia
State
WI
Zip Code
54827
Phone Number
715-742-3255
D City
Bell
D Village Q Town Nearest Roai
Old Hwy 13
~n~.New Construction
ieplacement '—' Public or commercial - Describe:
Parent materiaL Sandy ouhwash above clavev deoosits
Use:'--1 Residential/Numberof bedrooms'a,Code derived designfiow rate..
Flood Plan elevation If applicable.
450 GPD
General comments and recommendations: Holding Tank or Mound System at 104.3' EL
Boring #BoringX Pit Ground surface elev. 102.B ft Depth to limiting factor 24 in. / elev._
Horizon
•^
'3
4
Depth
In.
0-7
7-24
24-36
36-60
Dominant ColorMunseii
7.5yr/3/2
5yr/4/4
5yr/4/4
5yr/3/4
Redox Description
Qu. Az. Cent. Color
Cd2d spots yr7.5/4/6
M2d bands yrS/5/2
Texture
SL
SL
SL
SCL
Structure
Gr.Sz.Sh.
IMGfi
2MGR
2MGR
2SBKF
Conslstence
ML
ML
MFI
MFI
Boundary
GW
GW
cw
Roots
3M
2M
IF
1VF
Soil Application Rate
GPD/Ft2
*E»1
0.6
0.6
0.6
0.4
•EfBS
Boring i»QBoring
QX Pit Ground surface elev. 102-8 ft.Depth to limiting factor 18 in. / elev._
Horizon
1
2
3
4
5
Depth
In.
0-7
7-14
14-18
18-22
22-51
Dominant ColorMunsell
7.5YR/3/2
7.5YR/3/2
5YR/S/2
5TO/5/5
5YR/3/4
Redox Descn'ph'on
Qu. Az. Cont. Color
Cd2d spots 7.5YK/5/8
Texture
SL
SL
s
sc
c
Structure
Gr. Sz. Sh.
ZMI^K.
2MgR
OSG
3PL
3PL
Conslstence
MFR
MFR
MVFR
MFI
MVFI
Boundary
cw
cw
a
01
Roots
3CO
3M
IF
ip
1VF
Soii Application Rate
GPD/Ft2
•EfBM
0.6
0.6
0.7
0.0
0.0
*Ef»2
CST Name (Please Prinjy'
'JEN CADY l*^
1ress
.,60 Birch Grove Rd Washburn Wl54891
S13nna^^^
Date Evaluation Conducted
7-26-2023
CST Number
922139/SP-112200036
Telephone Number
715-373-2378
• Effluent #1 = BOD > 30 S 220 mg/L andTSS>30£150 mg/L * Effluent #2 = BOO, s 30 mg/L and TSS £ 30 mg/L
& f f\CD T)I./
SBD-8330 (R04/21)
-ci^'Q Cl0t-^..
Boring #
QB°""3 Ij ;j . ^ ^./^ .[: ',! ^
DX Pit Ground surface elev. 101.2 ft. Depth to limiting factor 14 In. / etev. _ft. '; i|iill APR 18? W ^
i_2_of_3_
Horizon
1
2
3
4
Depth
In.
0.9
9-14
14-21
21-42
Dominant Color
MunseH
7.5YR/4/2
7.5YRO/3
SYR/4/4
5YRO/4
Redox Description
Qu. Az. Cont. Color
Cd2dspots7.5YjR/5/8
Texture
SL
SL
LS
c
Structure
Gr. Sz. Sh.
2MQP.
2MSR.
OSG
3PL
Consistence-
DS
DS
MFR
MVFI
Boundary
cw
cw
cw
Roots.
3CO
3M
IM
1W
SoilApplIcation Rate
GPD/Ft'
*Efl»1
0.6
0.6
0.7
0.0
*Efl»2
Boring S D BoringD Pit Ground surface etev.Depth to limiting factor.m. / elev.
Horizon Depth
In.
Dominant ColorMunsell Redox DescriptionQu. Az. Cent. Color Teirture Structure
Or.Sz.Sh.
Consistence Boundary Roots
Soil Application Rate
OPD/Ft'
*Efl»1 *EW2
Boring #D Boringa pit Ground surface elev._Depth to llmifing factor.in. / elev.
Horizon Depth
In.
Dominant ColorMunsell Redox Description
Qu. Az. Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence Boundary Roots
Soil Application Rate
GPD/Ft2
<Ef8M *Eff»2
*Effluent#1=BOD>30sS220 mg/L and TSS > 30 £ 150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS & 30 mg/L
<~
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>^v^^ . f-wC ^ ^lI-^ly3-P feaj|fcwH&y<3
Kenneth Roman
Mound System
22465 Pahner Road
803, T50N, R06W
17 Acres, Town of Bell, Bayfield Co.
PIN 04-010-2-50-06-03-2 01-000-30000
II APR 1 8 'IQU lu!
Page 1-2: Bayfield Co. checklist for sanitary applications
Page 3: Tax statement of owner
Page 4-5: Conditional Approval letter from WI DSPS
Page 6: Plot plan, Mound plan & Calculations
Page 7: Tank section. Distribution, Dose & Pump calcs
Page 8: Pump curve details
Page 9-10: Mound System Management Plan
Page 11-13 Soil Evaluation Report
Page 14: Wisconsin sanitary application
Reference material;
component manual; Mound Pressure DistV 2.1 May 22/27
These plans prepared by ;
AdrienCadyMP922139
31160 Birch Grove Road
WashbumWI. 54891
phone:715-373 2378
fax:715-373-0646
Wisconsin Department of Safety and Professional Services
Division of Industry Services4822 Madison Yards Way
PO Box 7302
Madison, WI 53707
APR 1 8 20?"
Phone:608-266-2112
Web: lmp;//d:st:is,wi,goyEmail; dspsfiT'wisconsin.gov
Tony Evers, Governor
Dan Hereth, Secretary
March 25,2024
CUSTffl NO.: 1469067
DALEASCHLIEVE
312CONROST
RHINELANDER, WI 54501
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 03/25/2026
MUNICIPALITY:TOWN OF BELL
BAYFIELD COUNTY
SITE:
KENNETH ROMAN22465 PALMER RD
CORNUCOPIA, WI 54827
N1/2 NW DOC 2020R-583056 S3 T50NR6W
FOR:
Design Wastewater Flow Value: 450
Bedrooms: 3
Limiting Factor(s): 14 Inches
Maintenance Required: Effluent Filter
Identification Numbers
Plan Review No.: PWTS-032400480-C
Application No.: DIS-032411453
Site ID No.: SIT-127978
Please refer to all identification numbers in each
coirespondence with the Department.
CONDSTiONALLVAPPROVED
DEPT. OF SAF6Ty AND PROF£SSiO?<IAL SBRViCESDiViS^ON €t? iNDlESTRV SSRVIGES
Mound Component Manual - Version 2.1 (May 2022-2027)
Pressure Distribution Component Manual - Version 2.1
(May 2022-2027)
SITE REQUIREMENTS
• A fall size copy of the approved plans, specifications, and this letter shall be on-site during construction and open to inspection
by authorized representatives of the Department, which may include local inspectors. A Department electronic stamp and
signature shall be on the plans which are used at the job site for construction.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• Preserve dispersal area prior and during construction to avoid disturbance, compaction and use of the site.
Any tail grasses, leaves and shrubs shall be cut short and removed prior to tilling the surface for installation to prevent matting
under the dispersal area. All loose organic material to be removed from POWTS Dispersal Area.
• Prior to construction of the dispersal area. check the moisture content of the soil to a depth of 8 inches. Smearms and
compactine of wet soil will result in reducine the infiltration capacity of the soil. Proper soil moistuie content can be determined
by rolling a soil sample hetween{he_hands. If it rolls into a_l/4-_mch wire, the site is too_wetto_prepare. If it cmmbles. site
preparation can proceed. If the site is too wet to prepare. do not proceed until it dries.
» Abandon Existing System per SPS 383.33
* P£nlll£!2!l{SJ£l!ejrtJ>i!!lji£!if?ilMllJiiai^^
S^ec[!]£al|ojis.
• Divert surface water from POWTS Area.
• All piping shaU conform to SPS Table 384.30-3 and SPS Table 384.30-5
• Insulate building sewer beyond 30 feet per SPS 382.30 (1l)(c)
• Tank Installation to follow all manufacture's recommendations.
• Verify property line(s) prior to installation.
APR 18 2 024 ^
. Well setbacks to meet chs.NR 811 & 812. -: -i,-,;;:, , ,,,^';l-':.l
^ Are?<§ tlmt ^re <?CHplecl with rock firagrnenrs, tree root's, stiEmps and boulders reduce t'he amount of soil svailgbie for proper
treatment If no other site is avaihble. I'rees in the basal cH'ea ofl1~te POWTS Dispersal Area m?j:st be CUT off at ground iev'rel. A
larger fill area is necessary when any of the above conditions are encountered, lo provide sufficient infikrative area.
OWNER RESPONSIBILITIES
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use
and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/'or
owner's manual for the POWTS described in this approval and Wis. Admin. Code 5 SPS 383.54fli.
• In the event this soil absorption system or any of its component parts malfimctions so as to create a health hazard, the property
owner must follow the contingency plan as described in the approved plans.
The submittal described above has been reviewed for confonnance with applicable Wisconsin Administrative Codes and Wisconsin
Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constmcted and located in accordance with
the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10),
Wisconsin Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in (he state unless licensed to do so by the Department per s.145.06, stats.
All permits required by the state or the local municipality shall be obtained prior to commencement of
constmction/installation/operation.
In granting this approval, the Division of Industry Services reserves the right to require changes or additions, should conditions arise
making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the
responsibility for designing a safe building, structure, or component. The Division does not take responsibility for the design or
construction of the reviewed items.
Inquiries concerning this correspondence may be made to me at the contact information listed below, or at the address on this
letterhead.
Sincerely,Fee Required: $250.00
Fee Received: $250.00
Balance Due: $0.00
Refund Expected: $0.00
HeidiEide
Division of Industry Services
Phone:
Email: heidi.eide@wisconsin.gov
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BAYFIELD COUNT/ \n I? t ^ ' :v ;? ICHECKLIST FOR SANITARY APPLICATONS ^ I
it the fallowing (Use Permanent Ink) CTitfe 15, Section l5-l-10(e)) ''" APR ' 8 7fi L"
ick List -^vfi^',1 .':-. /,.,:pD-r
ginal Sanitary Application (Submitted in Deed Holders Name -not prospective buyers) (383.21(1)1.)
lex Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
iginal Plot Plan (383,22(2)2. 3. & 4.a)
3ss Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer
mp Tank Diagram, Alarm and Pump Curve (when applicable)
ntingency Plan / Management Plan (383.22-3(2)(b)l.f.)
lintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds)
)lding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds)
ilding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5)
ru Servicing Agreement (Recorded at Reg. of Deeds)
ie (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
l^QTOjete Sets of Plans (383.22(2)(2.) (NoteiJianira^j\DDHi:^igri..ai!d._i;^
f.McoDies}
3il and Site Evaluation Report (383.22-3(2)(b)l.e.)
tate Plan Review (when applicable)
opy of Warranty/Quit Claim Deed (Optional)
litary Application: (Include the following Information)
Application Information must include; D 23 diqit Parcel ID# - (do not use 12 digits anymore-obsolete)
a Project Address or Road Name where driveway is/will come off of) D (Owners Phone Number)
I Type of Building
II Type of Permit
V Type of POWTS System
/ Dispersal / Treatment Area Information
/I Tank Information
i/II Responsibility Statement (Plumber's Information)
*Date Stamp*
itPlan: (To Scale or To Dimension)
Signature and Plumber Information S'Address Number and Road
Surface Elevation of Body of Water B'North Arrow
Direction and Percent Land Slope S Contour Lines
Tank and Filter Information and Location [§• Structures and Driveways
Wetlands / Navigable Bodies of Water IS Boring Locations
Absorption Area (Proposed and Existing) "& Property Lines
'Bench Mark (Location, Elevation and Description) B Well Locations
Component Manual Version D Legal Descriptions
Piping Material Information (conveyance line, building sewer line, material type and diamete;
Turn Over »•
action and Over-Head Profile of the System: irt I? ^
i"^lfl\a and System Elevation ij| APR'i 8 20^"
m of Observation and Vent Pipes : , ,
isions and Depths
, Model & Number of Chamber Units in each Cell
tv Information
many systems wilt there be on this parcel of land?
this property been split? _ (Property Statement shows Property History)
ate Sewage System (Septic Tanks) $ 400.00
'ate Sewage System (Holding Tanks) $ 400.00
unds or Systems requiring Pre-Treatment $ 500.00
litary Revisions
vate Sewage System Reconnection
d Private Interceptor
sturn Inspection
laintenance Agreements ^
;hecks made out to Reg of Deeds)
$ 25.00
$ 50.00
$ 50.00
$ 30.00
"Mwrldistfiirsanilaryapps (10/Z009);(®7/20U);(®2/Z01Z)(®5/2/20t2-dc) Proofed by:
4" CAST-A-SEAL
Cc:CL-<g:
4" CAST-A-SEAL
TOP VIEW
\jjaw^i^^CUa.[u5^c^ ^ W(o-^
'pfoui/t^l^&MWif. 6w^l/c-
VENT w ft^pmuei <^.
TANK SPECIFICATIONS
DIMENSIONS:WALL: 2 1/2"
eOTTOM: 3"
COVER: 5"
MANHOLE: 24" I.D. PRECAST CONCRETE RISERHEIGHT: 69 1/2"
LENGTH: 9'-6 7/8"
WIDTH: 7'-9"BELOW INLET: 57"
LIQUID LEVEL: 51"WEIGHT: BOTTOM 8,540 LBS.COVER 3,840 LBS.
INLET AND OUTLET:4" CAST-A-SEAL BOOT OR EQUAL CASKET
INLET AND OUTLET BAFFLE AND FILTER:WISCONSIN, SEE DETAIL #10(OTHER STATES SEE CHART)
LIQUID CAPACirr: 19.61 GAL/IN (SEPTIC)11.82 GAL/IN (PUMP)
LOADING DESIGN: S'-O" UNSATURATED SOIL
TANK CAN BE USED AS:
SEPTIC/SEPT1C, SEPTIC/PUMP,OR SEPTIC/SIPHON
COVER: MIX DESIGN f6 (NO FIBER)TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT WIESER CONCRETE
> ?" ^tK< &eA PUMP PAD
SIDE VIEW
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
REVIEWED BY
REVIEW DATE
DRAWINGS SUBMITTEDFOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
c U3mlS ^1:SMIgm|[3sl° i^o|Solie 00
<3Is
us=
0-LJw
SHEET NO.
1
testewater
iTERS FEET
40 r 1301
35
30h 100j
25
20
15
10h
5h
ol-
APR 'I 6 ZOZt
U—(SERIES: WE::3/4" SOLIDS]_l_jRPM: 3500 &
ijZLiijzrj100 110 120 130 140 150 160 GPM
J-10 15 20
CAPAcmr
25 30 35 m3/hr
Item No.
1
2
3
4
5
6
7
s
Description
Impeller
Casing
Mechanical Seal
Motor Shaft
Motor
Ball Bearings
Power Cable
Casing 0-Ring
Real Estate Bayfield County Property Listing
Today's Date: 6/27/2023
Property Status; Current
Created On: 8/21/2020 8:44:07 AM
v-t' Description
Tax ID:
PIN;
Legacy PIN:
Map ID:
Municipality:
STR:
Description:
Recorded Acres:
Calculated Acres:
Lottery Claims;
First Dollar:
ESN:
Tax Districts
1
04
010
044522
001700
38280
Updated: 4/5/2023
04-010-2-50-06-03-2 01-000-30000
(010) TOWN OF BELL
S03 T50N
PAR IN N
17.030
17.030
0
Yes107
Recorded Documents
B QUIT CLAIM DEED
Date Recorded: 7/9/2020
RlSTORYB
E3 ', ,;. ;- •.-.•.;—-.-•
38280 This Parcel
R06W
1/2 NW IN DOC 2020R-583056
Updated: 8/21/2020
STATE
COUNTi'
TOWN OF BELL
SCHL-SOUTHSHORE
TECHNICAL COLLEGE
Updated: 8/21/2020
2020R-583056
Ownership
KENNETH E ROMAN
Billing Address:
KENNETH E ROMANPO BOX 267CORNUCOPIA WI 54827
Mailing Ad<
Updated:4/5/2023
CORNUCOPIA WI
•ess:
KENNETH E ROMANPO BOX 267CORNUCOPIA WI 54827
i Site Address * Indicates Private Road
22455 PALMER RD
22465 PALMER RD
-I property Assessment
2023 Assessment Detail
Code
Gl-RESIDENTIAL
G6-PRODUCTTVE FOREST
2-Year Comparison
Land:
Improved:
Total;
IS Property History
Parent Properties
White=Current Parcels Pink=Retlred Parcels
"U- Parents ^ Children
Acres
1.000
16.030
2022
33,400
59,100
92,500
CORNUCOPIA 54827
CORNUCOPIA 54827
Updated: 8/17/2021
Land
11,000
22,400
2023
33,400
59,100
92,500
8/17/2021
Imp.
59,100
0
Change
0.0%
0.0%
0.0%
Tax ID
3>-0:~0
BAYFIELD COUNTS SANITARY PERMIT (#04)-2A^QS
STATE SANITARY PERMIT
OWNER: KENNETH E ROMAN
GOVTLOT: LOT: BLK:
1/4 NW 1/4 SEC: 3, T 50 N, R 6 W
TOWNSHIP: Bell
SOIL TEST: 117-23
REPLACEMENT SYSTEM
SYSTEM T^PE: Mound > 24 in. of suitable soil
PLUMBER: Adrian Cady
ALESSANDRO HALL DATE: 5/6/2024
Authorized Issuing Officer
CHAPTER 145.135(2) WISCONSIN STATUTES
a. The purpose of the sanitary permit is to allow installation of the
private sewage system described in the permit.
b. The approval of the sanitary permit is based on regulations in force on
the date of approval.
c. The sanitary permit is valid and may be renewed for specified period.
d. Changed regulations will not impair the validity of a sanitary permit.
e. Renewal of the sanitary permit will be based on regulations in force at
the time renewal is sought, and that changed regulations may impede
renewal.
f. The sanitary permit is transferable.
History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314
Note: If you wish to renew the permit, or transfer ownership of the
permit, please contact the county authority.
PREVIOUS PERMIT #:
LICENSE: #MP 922139
Condition: System to meet all setbacks. Management plan to owner. Properly maintain system per
recorded agreement. Properly abandon old system per SPS 383.
THIS PERMIT EXPIRES 5/6/2026
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION