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HomeMy WebLinkAbout24-45S Villarin.<^m "w Department of Safety & Professional Services, Industry Services .Division County B<yP^ {j- Sanitaiy Permit lumber Qo bejilleiiin by Co,)1/7 \/l/f^ •'-If)U'"^\. '')^^Z_~r< Sanitary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitaiy permit. Note: Application forms for state-owned POWTS are submitted tothe Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. l5.04(l)(m). Stats. State Transaction Number I. Application Information - Please Print All Information Project Address (if different than mailing address) l^^^o ^,1 ^: /( ^J,. Property Owner's Name -Te^' ^^.i~i~^ \j : I ParcdT Cf V I ^\-r-K n>' ^gs~^~<7" Property Owner's Mailing Address :LC3C\ [ f^K^eJc^ /-) ^ City, Stale J-K^ ^•-€- ^1 L. >^'J -/- Zip Code ^<r 3 7 II. Type of Building (check all that apply) 1 or 2 Family Dwelling - Number of Bedrooms. 0 Public/Commercial -Describe Use D State Owned - Describe Use Property Location GovtLot. Phone Number -7 lS~~7^ /-5"65"^ -r3dt/&-<:-/O^C^ t.^^A-^ I^^V^t y:'Section /^ Lot #^T ^7 N R__7_Xo<® Subdivision Name Block # CSM Number -i-l ^ Z- a City of, _ a Village of 5S Town of f 1 I S c -I TII. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if] applicable.) JSI New System D Replacement System D Other Modification to Bxisting System (explain)D Additional Pretreatment Unit (explain) B.D Holding Tank J3 In-Ground (conventional) D At-Grade D Mound D Individual Site Design D Other Type (explain) c.D Renewal Before Expiration D Revision D Change of Plumber D Transfer to New OwnerlIList Previous Permit Number and Date Issued IV. Dispersal/Treatiixent Area and Tank Information; Design Flow (gpd) 1.5~o Design Soil Appticatioj»'Ratc(gpd/sf) .^7 ^ Dispersal Area Required. •Z-/S" Dispersal Area Proposed (sj 2--^S~ System Elevation 7$-.^ Tank Infonnation Capacity in Gallons Total Gallons # of Units Manufacturer New Tanks Existing Tanks "s E 5 SuptiuBriioWwgTank 7^' c ^^S-tt J Uh'^S-O.^ C.e'^C-.^~ naringffhmnlrT V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print)All^ T^(^s^Plumber's Signature <-"WP/MPRSNumber 2.2.<90C? 0 Business Phone Number -?/ s" 2.9 z.-i//<r^ Plumber's Address (Street, City, State, Zip Code) _ .,no B^ ^-'2.^' ^o^<?^^ .^^ ^^Y7 VI. Ceuiity/Department Use Only Approved ^ f£T.6~^ 0 Disapproved D Owner Given Reason for Denial ^S)c /<»7^'/o? Conditions ofApttfoval/Reasons for Disapproval}W\ ^o mjaoJU feitaw 3:) M<^-fvvwr ?lftM tc fliu' Attach to complete plans for the system and submit to the County only on paper not less than 8 l/i x II Inches In size SBD.639S (R, 03/22) Wisconsin Department of Safety and Professional Services Division of Industry Services Page.-of_ SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code Attach complete site plan on paper not less than 81/2x11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope,scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). Property Owner j^;. ^ ^ TT<C L// / / ^ ^.^? MAY 0 'l? ^<- ^ -^> * '"/ tis? \ '^i/^..y^\tf^t~County Parcel I.D.r^ K 2 ^ ~'_$ ^^ ^-^ Reviewed by W5 Date 5.^-^- Property Location A ^ "-<- ' ° -^ /c "v <' /<" cc-t^ Govt.Lot /J^'% <^ % S ( f T V7 N R 7 Property Owner's Mailing Address | c" 3 <'H ^ v ec <^ '" >IA (-/f ^'^D s"^r%n^i sz/ 4-t, ^^sc.^ ^.//^/ City | ^^iL^e.v /£L State^^Zip Code^IK3^Phone Number(7/<>T^/^D City [-3 Village |3-To<fl/ "- I 5^-^ Nearest Road . ."ST. TW ^//^ I New Construction Use: B Residential / Number of bedrooms J- lacement . |_| Public or c;ommercial - Describe: Parent material ($-/^&.*'s«.[ ~T< ^ ^SiUVr. ^A Code derived designflow rate / ^<? Qpp Flood Plan elevation if applicable_ft. General comments and recommendations: Boring #D Boring 3it Ground surface elev.di^jt.Depth to limiting factor 7CIO.in. / elev.. Horizon / z- 3- Depth In.^^/-^ ^ - cl0 Dominant Color Munsell ic^?. 5// y.ry^v^ J.-Yi^- 5-/^ Redox Description Qu. Az. Cont. Color /-) ^I'^e. /\y o /^'e y/^/ve Texture S.L L5 ^_ Structure Gr. Sz. Sh. 1^^ Z.n'i^l^ /-(:<; L K Consistence fH- lY +-r- l-Vt^-l/' /KV'-F"' Boundary <"i.^ ^JS Roots 3' "^ 2 n'lZZE Soil Application Rate GPD/Ft2 *Eff»1IT.^~CL *Eff#2 .7 (^~7T Boring #QBoring 'it Ground surface elev.^/.^ft.Depth to limiting factor.r!Ln./ elev._ Horizon J_ 2- -1.3: Depth In. ^-3 jT-T c\ -yo^ Dominant Color Munsetl /^3/^ W 5-1 5 7.5-Y^y/^ 5^r^- ^/(^ Redox Description Qu. Az. Cont. Color /\J p /V^ p c'^e /jEV^f p c ^^ Texture ^L- s rs. L5 Structure Gr. Sz. Sh. 1^^^- c^^/ ^u K Consistence rl^l.M'f-/ WL- m v4"v 1^1. ->-t^ Boundary ^^ 5 <-s Roots ;5^ ^ ^T^FSE Soil Application Rate GPD/Ft2 *EffS1~7~ ^ *Efffi2 .^7 -L±-Z£7: ^ fame (Please.Print);^ .«», , , \^r^T^'^} To 1^5^.,Signaturew.CST Number Address 'g0. Bc.'^. S'2.2- ^yc.^ R^r'uUj: S-¥f¥7_ Date Evaluation ConductedT^T^V-t * Effluent #1 = BOD > 30 & 220 mg/L and TSS > 30 s 150 mg/L Telephone Number _7/S'~_^.^2-_- ' Effluent #2 = BOD, s 30 mg/L and TSS :£ 30 mg/L SBD-8330(R04/21) ,SD 5-^^ ^~' 3 D Boring Boring #Ground surface elev. I C'C',0 ft.T,/^F$Depth to limiting factor ' ' " in. / elev. Page £- o" _ft. Horizon / 2^ 3_x Depth In. ^ - .5 J -/0 10-tt{ ^/-(cs Dominant Color Munsell /cw/^ ^ R ^/r 7£-Y^ Hl^ j;Li^ S-/{/ Redox Description Qu. Az. Cont. Color /U Q.Y-i^ /J^/^e^ - ^^ c ,^ Texture s'^ 5~ ~L5M Structure Gr.Sz. Sh. }^^ 0 <3-^tc 1-^^k Consistence (,K v +y >KZ- kn-(-\ j,VI 1^4- y Boundary AA. ^.J ^s Roots ~^^ ^*^\T^T I ^ 'I Soil Application Rate GPD/Ft2 *EfW1 T^-T .7 _2_J: *Effff2 .'7 J_iL^Q: Boring #D BoringD Pit Ground surface elev.Jt.Depth to limiting factor_Jn. / elev._ Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr.Sz. Sh. Consistence Boundary Roots Soil Application Rate GPD/Ft2 *Eff»1 *Eff#2 Boring #D BoringD pit Ground surface elev._ft.Depth to limiting factor..in. / elev.._ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Or. Sz. Sh. Consistence Boundary Roots Soil Application Rate GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 S 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, & 30 mg/L and TSS £ 30 mg/L ^8 (^ ^ ^— ~ 0 ^ — .r " ? ', s ^' ^ - ^ ^ -5 - r - / o< r o \f ^ l ^ ^ ^ ?T I^^' ff c '<, / A 'S 3 V. / / 35 - J ^-0 s<E > 'S p ^-T &•^wf: ~s-h fl ^ t- : f c - <5 1 " ^ f^ f r^ ^ "? 1 \ S > ^ ' -^ j N» > . £ ^ v\(bs ~. ~ - t A ^B ^ p— '^^5S i^ ^! ^1H»hi S. Jp ^ Ok S ^ T U ^ ' l ^ ^ » »i ' p € . ' O . ^ - f - 6 . ? / e ?a i i ^? y § "^ a ^ J T^ t' ^ S < » " f i ; r ! Ai & T T j 1 < y^ ^ e © S . L ^ . 3 a . . ^ ' ? . 5 C - ^ - e n ^ c - s K S J. N ^ i iM - . K . " : ? ^ ' - f l - e . * * bS C ^ e - E * ' ' f t f f f t p & a t t q ' i B K . 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' " " - -< ^ ~ '^jr rMi S- s 5 . lr f r ^1 i" ^ ' " * - Si i^ <« •y ^ s^ - s ^. ^ - • •.* e^ s May, b, 201, 10;41AM BAYFIELD CO PLANNING & ZONFNfi ^... f)/Blc) In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References'. Version 2,0, SBD-10705-P(N.01/01, R. 10/12) PQ 1 Of"? Pg 2 of 7 Pg 3 of-7 Pg4of-7 No. 9975 P. 3 PAGE 1 OF 7 •t/ MAY 0 ^ WW index St Cover Sheet Plot Plan Scf^i^T^^k- <-^4S Section & Plan View Management Plan Attachments: 6? ^f 7f'c, k ^ f^7^7 Enclosures: POWTS Application for Review < SAH^ ^ p^^m'+ Ar Soil Evaluation Report & Site Map i^\^ n4<-^<£ "i <-^- A ^ i/"£'e M^'e^-^~ Project Name / Description Owner Name(s): 3"& a" i €- ^"^€ V' ^ a r/^Phona: ~7(5~- ^(- iTs-rt' Owner Address: ^ o s'? I ^.."&^ •c- ^i !> ^ f:"-" ^^t' <- u-U Zip: ^V ^ ^ "7 Project Address: / ^ ^ t/o S c^i J (4 < / / R <j yet y^-c-^l^i ip^.UA»'fv 1/4 of ^^1/4. Section^-s" . 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INLET AND OUTLET:4" CAST-A-SEAL BOOT OR EQUAL GASKET, CAST-A-SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER:WISCONSIN, SEE DETAIL #10(OTHER STATES SEE CHART) LIQUID CAPACITi': 20.28 GAL/IN HOLDING TANK: ACTUAL CAPACIT/: 790 GALLONS'OUTLET HOLE PLUGGED LOADING DESIGN: 8' 0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #6 (NO FIBER)TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT WIESER CONCRETE PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: K-\31010-1 <1ai ^1<1 U! ,<u?8 LDla. -sd- z 00EDQ |S ins CM1^0 I0!§1V}=) s Ct:s 0in1~» a- Csl]I slI 42 ^jupa. (/)|UJ(7)Q;| SHEET NO. )F 1 .; Bayfieid County, Wl 5/7/2024, 11:36:09 AM :;'.;M«~= Wetlands Road Type ; Building Footprint 2015 i"-I Approximate Parcel Boundary Town • CFR Building 0.03 0.06 Bayfieid County Land Records Department 0.11 km Bayfield County Zoning Appiication https://maps. bayfieldcouniy.wi.gov/ZoningWAB/ 5/7/24, 11:35 AM Novus-Wisconsin Access rev. 12.0206 Real Estate Bayfield County Property Listing Today's Date: 5/7/2024 Property Status: Current Created On: 8/6/2021 2:27:33 PM Description Updated: 8/25/2021 Ownership Updated: 8/25/2021 Tax ID: PIN: Legacy PIN: Map ID: Municipality: STR: Description: Recorded Acres: Calculated Acres: Lottery Claims: First Dollar: ESN: Tax Districts 1 04 040 020170 001700 38559 04-040-2-47-07-15-4 02-000-21000 (040) TOWN OF PILSEN S15 T47N R07W LOT 2 CSM #2182 IN V.12 P.392(LOCATED IN NW SE) IN DOC 2021R- 590046 6.920 6.920 0 Yes 126 Updated: 8/6/2021 STATE COUNTY TOWN OF PILSEN ASH LAND SCHOOL TECHNICAL COLLEGE JEANETTE M VILLARIN Billing Address: JEANETTE M VILLARIN 20391 FREEDOM DR FREDERIC WI 54837 FREDERIC WI Mailing Address: 3EANETTE M VILLARIN 20391 FREEDOM DRFREDERIC WI 54837 Site Address * indicates Private Road 16640 SAND HILL RD Property Assessment MASON 54856 Updated: 9/26/2023 2024 Assessment Detail Code Acres Land Imp. Gl-RESIDENTIAL 0.770 13,100 36,500 G6-PRODUCTIVE FOREST 6.150 13,800 0 2-Year Comparison 2023 2024 Change Land: 26,900 26,900 0.0% Improved: 36,500 36,500 0.0% Total: 63,400 63,400 0.0% ^ Recorded Documents Updated: 10/19/2011 Eg WARRANTY DEED Date Recorded: 7/30/2021 B CERTIFIED SURVEY MAP Date Recorded: 7/8/2021 gi WARRANTY DEED Date Recorded: 5/11/2018 II QUIT CLAIM DEED Date Recorded: 9/28/2011 S3 QUIT CLAIM DEED Date Recorded: 3/20/2008 a CONVERSION Date Recorded: 3/15/2006 Property History 2021R-590046 parent Properties 04-040-2-47-07-15-4 02-000-20000 2021R-589656 12-392 2018R-572868 2011R-540449 1069-224 2008R-519742 991-735 476857 727-341;826-659;837-65 Tax ID 27729 HISTORY B Expand All History White=Current Parcels Pink=Retired Parcels E3 Tax ID: 27729 Pin: 04-040-2-47-07-15-4 02-000-20000 Leg. Pin: 040103604005 38559 This Parcel ^Parents ^ Children https://novus.bayfieldcounty.wi.gov/access/master.asp?paprpid=38559 1/1 Co ^ J^^-t^^^l BAYFIELD COUNTY !i li MAY 0 "1 2024 CHECKLIST FOR SANITARY APPLICATONS Submit the Followjna (Use Permanent Ink) (Title 15, Section 15-l-10(e)) Bf Check List rf Original Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.) ^ Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) Bf Original Plot Plan (383.22(2)2. 3. &4.a) fi! Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer D Pump Tank Diagram, Alarm and Pump Curve (when applicable) Ef Contingency Plan / Management Plan (383.22-3(2)(b)l.f.) Ef Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) D Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) D Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) D ATU Servicing Agreement (Recorded at Reg. of Deeds) Bf Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) Ef. Complete Set of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to alt copies) 6T Soil and Site Evaluation Report (383.22-3(2)(b)l.e.) D State Plan Review (when applicable) D Copy ofWarranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) Ef I Application Information must include: D 23 digit Parcel ID# - (do not use 12 digits anymore-obsolete) B Project Address or Road Name where driveway is/will come off of) B (Owners Phone Number) 6f II Type of Building B' III Type of Permit Ef IV Type of POWTS System tf V Dispersal / Treatment Area Information Ef VI Tank Information Bf VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan; (To Scale or To Dimension) Ef Signature and Plumber Information S Address Number and Road 10' Surface Elevation of Body of Water IS! North Arrow 0 Direction and Percent Land Slope S Contour Lines Igf Tank and Filter Information and Location ff Structures and Driveways Rf Wetlands / Navigable Bodies of Water B Boring Locations E'Absorption Area (Proposed and Existing) d Property Lines ET Bench Mark (Location, Elevation and Description) ^ Well Locations Ef Component Manual Version St Legal Descriptions |^gS®i^Ji|g^|!|n&>rmat(^ Turn Over > Cross-Section and Over-Head Profile of the System; Surface and System Elevation (^Position of Observation and Vent Pipes Ef Dimensions and Depths Make, Model & Number of Chamber Units in each Cell Property Information D How many systems will there be on this parcel of land? _ A d Has this property been split? ?Jo (Property Statement shows Property History) Fees: Sf Private Sewage System (Septic Tanks) $ 400.00 D Private Sewage System (Holding Tanks) $ 400.00 D Mounds or Systems requiring Pre-Treatment $ 500.00 D Sanitary Revisions $ 25.00 D Private Sewage System Reconnection $ 50.00 and Private Interceptor D Return Inspection $ 50.00 0 Maintenance Agreements ^ $ 30.00 (checks made out to Reg of Deeds) u/forms/checktists/checkllstforsanitaryapps (10/2009);(®7/201 l);(®Z/2012)(®5/2/2012-dc) Proofed by: BAYFIELD COUNTY niCHECKLIST FOR CERTIFIED SOIL TESTS II MAY () I 7m Submit the Following (Use Permanent Ink): 0 Check List [0 Index Page / Title Sheet (Optional) 0 Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers) Ef Original Plot Plan D Cross Section Soil Profile Sheet (optional) D Additional Information (Warranty/Quit Claim Deed) (Optional) So!! EvaJuation Report: (Include the following Enformation) 12 Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used B Property Owner's Information (not prospective buyer's name) 0 Property Location (Accurate Legal Description with Sec/Twp/Range) El Road Name (where driveway is/will be coming off of) 1Z1 Floodplain Elevation, Flow Rate, Comments and Recommendations 0 Complete Soil Boring / Pit Information 12 Date Soil Evaluation was conducted 13 CST Name, Signature, Number, Address and Phone Number n *Date Stamp* Plot Plans (Include the following information drawn to dimension or to scale) 0 Bench Mark (Description, Elevation and Location) 0 Contour Lines (Example = 98.0'/96.0',94.0') 13 Ploperty Location (Sec/Twp/Range/, Accurate Legal Description) 13 Borings (Locations and Elevations) E3 Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) 1^ Location of Wetland Areas, Floodplain and Navigable Waters E] Buildings/ Driveways, and Structures (Location and Descriptions) £j Location of Property Lines Existing System Location Ef Address Number and Road Name 13 Current Surface Elevation of Wetlands and Navigable Waters ^ CST, Owner and Property Information North Arrow Fee; S3 Certified Soil Tests - Review & Filing Fee $ 50.00 u/fprms/sanitary/checklist/checjdistforcsts TfAHj i ^iJT'TPrivate Sewage System Maintenance Agreement Owner(s) Name i ; 'J CCf ^ ^ "^ 1^- ^/(\ r ' i^\ Owner(s) Mailing Address ZC- 2 c/ / ^-^ ^-t d^ m i)^- f-r-e- ^ e ric i^r^Y\I Site Address; ^ ^ ^ o S^^ J //;. // ^ ^ /^/^ s—' ^I^7s4~t '"fTaxTD#^^i^lAs owner, I (wa) 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. Ths system will beoperated in such a manner as to meet the designed plans. I (we) agree to maintain saidprivate system at the below listed location In accordance with rules established in the Wl Adm. Code, as from time to time amended. (COMPLETE Legal is required) ^^ 1/4 of ^J/4 Audiianal Lcyai Deycription: Town of P.fs^ Section / ^ Township l/7 N. Range _Z_W. (Acreage)Gov'tLot. Lot_ Block_Subdivision__ | R.O.' "Bo Xl .$~2-"2- Lot -^ CSM# <^^Vol. / ^ Page J9^sL?Doc# 26^^ rj/~?^^ ^7., ^/J^ <.J Z ^Y^^7 "> DOCUMENT NUMBER2024R-6029Q4 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY, WI RECORDED 04, 19/2024 AT 2:01 PM RECORDING FEE: $30.00 PAGES: 1 Recording Arss Return To; Je>n/ '^Q/to5~k^ P.O.' "B^)C S"^ 13 In-ground gravity D Mound D In-ground dosed D In-ground pressure distribution Sewage System: D At-grade Sewage System D Other. ,>' Septlc Tank (system types A through E): The septlc 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-thlrd (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 rlnsed 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 operablllty of said components. Seotic Tank Effluent Filter (system types A through E): The septlc 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, Wls. 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 effluent from the system is ponding on the ground surface. Mounds, At-arade. 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 prwidsd above. A Ownerfs) 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. Bayfleld County shall notify the owner of any costs which shall be paid by the owner within thirty (30) daysfrom 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 owners of such property. Owner(s) Name(s) - Please Print ^ 3'e^€"/-~^e ^ Notarized Owner(s) - Signature(s) ^dw?' rafted by:7<£7?ff / J^^ ^ < Subscribed and sworn to before me on thi; date;\c\^ ^ rf ftpr< I ^(^ 'Cb^ S^oNotac^Pfjbltf ' ' ir o)0»? My Comiplssion Expires: n^^ 0. niplsslon Expires:T^awd Date;7 Proofed by;.ff u/forms/sanltary/septicmalntenceagreementRevised July 2020 FILE INFORMATION POWTS OWNER'S MANUAL & MANAGEMENT PLAN SYSTEM SPECIFICATIONS Page _J_of Z^Af'7iw Owner Permit # &.Ct l^t ^ / f^€'VIn~tf"' t^\ DESIGN PARAMETERS Number of Bedrooms Number of Public Facility Units Estimated (average) flow Design (peak) flow = (Estimated x 1.5) In Situ Soil Application Rate Standard Influent/Effluent Quality Fats, Oil & Grease (FOG) Biochemical Oxygen Demand (BODs) Total Suspended Solids (TSS) Pretreated Effluent Quality Biochemicat Oxygen Demand (BODs) Total Suspended Solids (TSS) Fecal Coliform (geometric mean) Maximum Effluent Particle Size Other: J. DNA ^INA / co gal/day / ^"0 gal/day •• 7 gal/day/ft2 Monthly average* <30 mg/L $220 mg/L @ NA <150mg/L Monthly average <30 mg/L <30 mg/L S NA <104cfu/100ml ^ in dia. B NA [SNA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Tank Manufacturer yJ •' C-Ser D Septic D Dose D Holding Tank Manufacturer D Septic D Dose D Holding Effluent Filter Manufacturer 'P&i I6.1 CO.A(L, vol. -7 vol. /OC Effluent Filter Model ? L S'Z € Pump Manufacturer Pump Model Pretreatment Unit D Sand/Gravel Filter D Mechanical Aeration D Disinfection Manufacturer Dispersal Cell(s) IS In-Ground (gravity) C3 At-Grade D Drip-Line Other: Other: D D D D D D Peat Filter Wetland Other: D 5~C5 ai D NA gal NA gal NA BNA 01 D NA NA In-Ground (pressurized) Mound Other: » ^ NA NA Service Event Inspect condition of tank(s) Pump out contents of tank(s) Inspect dispersal cell (s) Clean effluent filter Inspect pump, pump controls & alarm Flush laterals and pressure test Other: Other: Service Frequency At least once every: _^ ® ^% (Maximum 3 years) D NA B When combined sludge and scum equals one-third (%) of tank volumeB When the high water alarm is activated At least once every: ^ § !neTrt(s) (Maximum 3 years) D NA At least once every: ^ g Ss)s) D NA At least once every: _^j § ^%s) _D NA At least once every: Q ^^ S NA At least once every: g month(s) g, ^ gl NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). 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 scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(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 failing 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 (14) 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 intervals of S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (12/02) Page £- of f—START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank 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; baby 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; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All 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 material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a 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 existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. D 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. ^ 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. D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltratlve surface. Reconstructions of such systems must comply with the rules in effect at that time. «WARNING»SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOTENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF APERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name Phone "7 I SEPTAGE Name •^fl^.c' Phone l€ttn f&ik^^o- '/S~ Z.^t.-^lS^ W^&S^ ?bm^t SERVICING OPERATOR (PUMPER) 7~^Z&nA,&$ 11S' 3-7 2-. TellCoski 2-- f0o(o ^ .yd n ^werS»€.; \i ^V POWTS Name Phone LOCAL Name Phone MAINTAINER A I la ^"?<p •7/S- 2-€y REGULATORY 8&^-f:€J -71 5~ 3-7 /ke,S k\(7c( i-t/s^ AUTHORITY 'r'tTU'- ^-£p(3f' ^&S<fc.''?lu-*-J» 2.0^11 i^.c, This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with chapterComm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. BAYFIELD COUNTS SANITARY PERMIT (#04)-2445S STATE SANITARY PERMIT OWNER: JD\NETTE VILLARIN GOV'T LOT: LOT: 2 BLK: CSM: Csm #2182 1/4 1/4 SEC:15,T47N,R7 TOWNSHIP: Pilsen SOIL TEST: 42-24 NEW SYSTEM SYSTEM TYPE: Non-Pressurized In-Ground PLUMBER: Allan (Tony) Polkoski MCKENZIE SLACK DATE: 5/9/2024 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: # 220090 Condition: System to meet all setbacks. Management plan to owner. Properly maintain system per recorded agreement. THIS PERMIT EXPIRES 5/9/2026 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION