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HomeMy WebLinkAbout24-58S Shamla.ys. V'lh\ .j Kepartment of Safety & Professional Services, Industry Services .Division County ^Y^:^[A Sanitary Permit Nt^nber (to be filled in by Co.) i;/ /- /y^ ' ''>^-/QX<S/'y '^6(^ 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 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. State Transaction Number I. Application Information - Please Print All Information Project Address (if different than mailing address) i-?s~^ po <L^^ (S-cL Property Owner's Name ^T^^i^l-/-^^ S^ Parcel# Cc t-^-V T^. ^^1>~~^^ ^^-5^~ Property Owner's Mailing Address ^c\^<\ s '^^.1. City, State / ^cr^>'i~U ^t ^ 6- L^3'^ •^ Zip Code^^7Lf II. Type of Building (check all that apply) ^ 1 or 2 Family Dwelling - Number ofBcdrooms D Public/Commercial - Describe Use D State Owned - Describe Use ^ Property Location Govt. Lot Phone Number •^ig- -r'/o-95/^^JA,_^L'A, Section _Z_ Lot #_s/_^_N_R__5L_Xo<®Subdivision Name Block # a City of. CSM Number a Village of P Town of.<0\-> i o ^ III. TypeofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if applicable.) A.JS New System D Replacement System D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain) B,S Holding Tank D In-Ground (conventional) D At-Grade D Mound D Individual Site Design D Other Type (explain) c.E] Renewal Before Expiration D Revision D Change of Plumber D Transfer to New OwnerlIList Previous Permit Number and Date Issued TV. Dispcrsal/Treatment Area and Tank Information: Design Flow (gpd)jy-0 Design Soil Application Ratc(gpd/sf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System Elevation Tank Information Capacity in Gallons New Tanks Existing Tanks Total Gallons # of Units -T Manufacturer ia 11SSm 'S3 ^ J3SQ BcptteW Holding Tank ^.^Tey-o zJ&o UJt'e-setr (^Lc.n.fi.^ Besmrehamtrer V. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print)All^ T^l^sk.' Plumber's Address (Street, City, State, Zip Code) K^ B& ^ .$"2-2- ^(^o'-i Plumber's Signature^^-^•NP/MPRS Number &£.^OC? 0 Business Phone Number -7tS~ 2.?Z.-^/^ VI. County/Department Use Only ..^<r ^}-X ^^V7J ^ -feApproveds/23/zy D Disapproved a Owner Given Reason for Denial Conditions bfApproval/Reasons for Disapproval Permit Fee^Jm'y-iUUV~ )atc Issuedy '^/"'"^9! Conditions bfApproval/Reasons for Disapproval '<» "To^ ^ ^oee^- ^! ^^k<; , <• P-P^a^ ^<^X/<^ ft^<rdvd Oc}?^^[ ^rW)c^f^v^\ ?njGOt-ot/f»^ -m^ ^ ^^^r Is^uinjg Agent Signature {SS^f^l h Attach to complete plans for tile system and submit to the County only on paper not less than 81/2x11 Inches In size SBD-6398 (R. 03/22) Document Number/Plan I.D. No. Owner Na^e {s\ /^ /-Jr./.^^a^ '^hA^\^- Parcel Identifier Number (PIN) Z<^(c 2-5 ^ Vs 3?Jl -/3yio / /o i o .'^ /' (?<••> r^. HOLDING TANKAGREEMENT Owner(s) Mailing Address i^^ G ^n^^-/ ^' ^ .t-t / ^ ^ •-, <-',, 6-^^" ^^? Agreement Date (sapW as Notary Date)'^-^ 2 Wa acknowledge that application is being made for the installation of (a) holding tank(s) on the following property or that continued use of the existing premises requires that aholding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code or Ch. 145, Wis Stats. F 1/4 of A/£ 1/4 Section ^ 7 Township t^ N. Range _ '7 W. Town of _0^1(^ Additional Legal Description: Gov't LOt_ Lot_Block_Subdivision_CSM#_ Lot_CSM #^ Vol _Page._CSMDoc#. DOCUMENT NUMBER2024R-603224 DANIEL J. HEFFNER y REGISTER OF DEEDS BAYFIELD COUNTY, Wl RECORDED 05,13/2024 AT 1 1 :07 AM RECORDING FEE: $30.00 PAGES: 1 Return To: ^"0 v\ ^y "pc-' I U- •"•'5' k. < r^.. 3'oy -3- ^ o. ^ '^^ e ^ ^SX r^^^7 As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property, we agree to do the following; 1. 3. 4. 5. 6. Owner agrees to conform to all applicable requirements of Ch, SPS 383, Wis. Adm. Code relating to holding tank installation and maintenance. If the owner fails to have the holding tank properly serviced in response to orders issued by Bayfield County or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats., Bayfield County may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. Owner agrees to pay all charges and costs incurred by Bayfield County 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. 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 owner agrees to contract with a person who is licensed pursuant to s.281.17 (3) Wis. Stats., and chapter NR 114 Wis. Adm. Code, to have the holding tank serviced in accordance with Ch. NR113, Wis. Adm. Code, and to file a copy of the contract with Bayfield County. 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 county within 30 days from the date of change to the service contract, The owner agrees to contract with a person licensed pursuant to s. 281.48 (3) Wis. Stats., and Ch. NR 114, Wl's Adm. Code who shallsubmit to the county within 30 days a report detailing the servicing of the holding tank. Bayfield County may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank Is not being properly maintained. This agreement will remain in effect only until Bayfield County certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. SPS 383, Wl's Adm. Code. In addition, this agreement may be cancelled 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. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this 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. Owner(s) Naine(s) - Please Print Jwfly~ S^-/71/^ Subscribed and sworn to before me on this date: ^ M^ W^ K»"t"""»>»^ Nolarized Owner(s) - Signature(s) ,, C^^A- Notary /^^^ My Commission Expires:pTA/?jLLL"3^^^^L^^^\\• \ Drafted by: "to h.^/ F^o ^ R'OS'.k.t Personal Information you provFde may be used for secondary purposes [Privacy Law, s.15.04 (l)(m)] Date; ^^- Z-/'. /•• -.vo / u/forms/sanitaiy/holdingtankagreement.docOJune 201.8' ,^[-5 ^* ".'>'~^ HOLDING TANK MANAGEMENT PLAN 1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 400.0 gpd. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the alarm wilt activate), the pumper listed in the current Servicing Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and 3'PS 383 and?84 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 10 business days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with $PS $63.33 Wis. Adm. Code. 10. If there is a problem with, or question about this jnstallation, the fojjowing persons should be contacted: a. \ns\a\\e{.............................Pol^es^ Ptuim^^ /n.RAA •2.2.0oci0 Phone: 7, A" 37%-'- ^^'fo b. Service Provider.. .....^.......... T^e^y^y S.^fif Rsg ^ ^2-7, Phone: '7/j~ 3-7-^ - ^offlfo c. Co. Zoning or Health Dept. Qea.y-f-i^.i^ C.o.^wkt "t^in.^ _ Phone: •7j^i_SL33^-M3S-. n. U^L^^. ^^LJ^^ ' ^^-7 -T^^ ^C^J TO u» n d-F ^ C? u t ^ r»u^ o f' (^^ ^ -y-. -^ / ^&filzo-"l»r0^^-^±-^^ Project Transaction Number: HOLDING TANK SERVICING CONTRACT Contract Date jf^-^ ivi^ This contract is made between the Holding Tank Owner(s) Name(s) "r- .,^/] /J ^/.' c: /_r^/\ ^\ ^/i^\ !a- Pumper's Name (Print)-j^n^A.^5 pofl^c.skl'1 "J-^e.^ '^t>/^.<T $'^p+(t» Pumpers' Registration # ^i^-7/ We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION legal Descrifition: (UseTax.Stateroenyi 4 Tax IDS i\^:,^^(c.^^i;'i.': ^ .,,/: : Sectton11 _2_Z—^_'.Tto""st'lp1.11' ^ ^'!^i ! 1'1:111:1 ':, N,,lfangel.___jL__-_, W:;-1:!, Gov'tLot lot <f CSM#Vol. Page CSM Docff lot(s)No.Block(s)No. ::_^_WJ^-!1/4.:, ^nll°fy,-l::ll^::l^l^;,1'^-%|y^^^^^^^^^^^^^^tatShe^:'^.^^Acreage.^w^ Subdivision; 1. The owner agrees to file a copy of this contract with Bavfield County as required in SPS 383.55, Wis. Adm. Code. 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 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 all 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 local government unit which has signed the pumping agreement required by SPS 383.55, Wis. Adm. Code, and the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: 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 location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. 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 the local government unit and the County named above within (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) '^Jcr.ni^ S7?^/^ Owner's Signature(s) •« ?/71y/^^f^^y^ ^ /'/^°1 Subscribed and Sworn to me: on this (^ day of /V?A^ ^^ lHMyWMft 2r^r ^Y^^jfcgmljnissi^h expires •^•^— I s Notary Public n: /Y^^on: Revised: May 2016 (®May 2018)Personal information you provide may be used for secondary purposes [Privacy V^S^^/^/'^^...."'^/^s3^ Drafted by -£B_ 0 a >* '-t1 y• -t0•€ •.~c| • 1-. s. ^si•' ^"r BAYFIELD COUNTS SANITARY PERMIT (#04)-24^8S STATE SANITARY PERMIT OWNER: JONATHAN F & JENNY SHAMLA GOV'TLOT: LOT: BLK: NE 1/4 NE 1/4 SEC: 7, T 48 N, R 9 W TOWNSHIP: Oulu SOIL TEST: 58-24 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: Allan (Tony) Polkoski ALESSANDRO HALL DATE: 5/30/2024 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 #: 12-0316 (COUNPQ LICENSE: # 220090 Condition: Tank to meet all setbacks. Management plan to owners. Properly maintain system per recorded agreement. Must be 25' from an all weather road. THIS PERMIT D(PIRES 5/30/2026 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION cp~:'vyy^•!; ';; ••'••^'\j'\ ' ? / / i • \ . lviAV 2U?02/1^'^'1 Bayfield County Soil Test #l.5S^_ Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) 1, ^ / I a-^S F£> 1 ^-Q6 j<. i a certified soil tester determine that in my professional judgment the following site (see below) is unsuitable for any treatment component other than holding tanks. Due to soil & site conditions, a thorough soil and site evaluation is not needed to make such a determination. dbW-Hysio a/ Property Owner ^ SL-^ ^ cib^ S ^ <:s ^\ /<^ Contractor Property Address / 7 ^~S T>^> ^ ei-r ^- <L Authorized Agent• Telephone ^( ^ ^ ° ^ S / ^ Agent's Telephone. Written Authorization Attached: Y or N Accurate Legal Description is requested: ^^ 1/4 of //£-:1/4 Section 7 Township L^ N. Range T W. Town of <"5 ^ ( ° Additional Legal Description:. Govt. Lot Lot Block Subdivision Lot _ CSM#_ Vol. _ Page _ CSM Doc # Volume_Page_of Deeds Tax I.D# -2-^^•^5 _Acreage ^ ^ Indicate reasoning for your determination: i/0 ^\~ <— < ^ Y'e~<? s cr~i ^ ^ pT^-e-r- -"Ty^-C ff-f- ^^^TS C&-^\ i>< t^Jrf^((<-^{ ^^-Signature of Certified Soil Tester 6"^-^ Date _cxf z.zoo€io .^^-.,,Certification # Signature of County Official (Submit a Plot Plan & Fee)^/-^•s /z Date u/forms/soiltestwaiver(KLK)June 2018 ZhS^^^^ft'^ ^9-AX Z-Z.5 ^<?0'©c( l^'c^r^ ^S?o^/oj Q^W^W\M ;/gf \^-nu^f^ (^yz "72 Q?/^W ~) f(rt2 ^ 3A'] *P-3^^/;2?TU^5(/t/ ^iwef.t'wo^ ^ nvj^v !^ Q^ ^ ^^1 ff ] -0 I.A •%.+-i»TW ^ </ •^ 'f-2^ (?^ 6'<-'^ S.^ 1. ( 0 U/J.SV „ /, ' ' ' ^ w:o ^->-a-'^ f r^v^/^ ^f\d Oh '^S a •&-£—£—f- ;0-00/"-3/;J « <^/\ 3 Wfif^ ^ ^-r' ^ ' y \^r o-^.^ '^g? ^-^s.^c!.^^ "ll^^ = -e- ^j>-»^fc ]^"'^ -3.0 o^y s "-pyy (S<??,Sc?^^ S^->-l»<=jf^.3<S -^H.^ ^ IP <;y.3^W^K(^?wo /-/-—. —L.—_-—.—"4; ^ u]N1NM (D '^/ .l-X- ;+^^ I ~9C^^ ya/ 5»f n<^ -J.-^ ^ f.^'/1;? wN0 b^ -f^s^Y^J^ ( ^•y/,v^ ^w.^w^ »-k , . . ^5^^-Z ^^^w^-i+^u4ST^MU% _ r/ ^'^a ^ 4--?, ' 7'- *'^-S^ww ^^^'^p,oSJ^j ' / " ^ ( no :^<? 'wo^A^^^^.^ ^.^5 1^ y^>l?i.i^ $ /7^^2-\7-3t -S^-p^J :f^ +^^">N N ^1-auw1^^^s M^.N^Jr.i^A.^'^^5 ^<'M,"£ ^/:s^Jp^;^ , :^-^^W»Gf ^^-^ ' ^^mo/4..^^ BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): El Check List E3 Index Page / Title Sheet (Optional) El Original Soil Evaluation Report (Submitted in Deed Holders Name - ngt prospective buyers) ^ Original Plot Plan D Cross Section Soil Profile Sheet (optional) D Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) El Parcel Identification Number (must be 23_digit Tax ID#) DO NOT USE 12 digit, they are no longer being used 13 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) [3 Floodplain Elevation, Flow Rate, Comments and Recommendations 0 Complete Soil Boring / Pit Information El Date Soil Evaluation was conducted 13 CST Name, Signature, Number, Address and Phone Number D :l!Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) El Bench Mark (Description, Elevation and Location) 0 Contour Lines (Example = 98.0796.0',94.0') 3\ Property Location (Sec/Twp/Range/, Accurate Legal Description) 0 Borings (Locations and Elevations) 23 Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) [/1 Location of Wetland Areas, Ftoodplain and Navigable Waters \Q Buildings, Driveways, and Structures (Location and Descriptions) El Location of Property Lines Existing System Location Ef Address Number and Road Name [3 Current Surface Elevation of Wetlands and Navigable Waters 21 CST, Owner and Property Information North Arrow Fee: 1^ Certified Soil Tests - Review & Filing Fee $ 50.00 u/fprms/sanitary/checklist/checklistforcsts »^ vv iLnnnnm ()( ^.U|^"H|U P. 2 Holding Tank Plan Index & Cover Sheet PAGE 1 OF $ l';i9/- Pgl of ^ Pg2of^ Pg3ofS< Pg4of^ Attachments: Component Manml Design RQfQivnces: i lW«MiwJ' -U/r&YV€.r$S®^.J)j^Jt|^ ^02.2..-^OZ7^ I ndex& Cover Sheet i ' Plot Plan ; Holding Tank SpeoificatioSns Management Plan | ?^' ^^ ^^F^ 7 ^ ^•^i ^ Enclosures: POWTS Application forSRevjewC^^^'^"->rl/p<i-lrm< ^ A^ Soil Evaluation Report & Site Map (uf applicable) Holding Tank Pumping Contract (if applicable) Holding Tank Aareemerjit (if applicable) Project Name / Description Owner Name(s): 3^ -1 ^ "F^ •< $^« ^ [5 _ Phone: j^^ - ^0-^ ^ / ^ Owner Address: ^ Sf 5 • ^^J-« ^// ^. $ yrff4 ^c-^e ml ZJD: S^^ ^7 / Project Address: 175-^~ ^<Us /^J.. ^-^ ^ ^ ^« 1^ ^~^Y7 Govt. Lot: _ ^ ^1/4 of /J ^ ,1/4, Section^, . T L/^N-R ?' ELJor W ( Township: c? ^*t -> _ County: 'B><?-^^-e / Project Parcel ID #'. -^C^ X ^ -^LpSp-^5 _j_ Designer Information t, ' Designer Name: A / 1^ ^ T^o / ^.^.s U, _ Phone: V?/S~ -S"7'2-- L/ 'I ^ Designer Address: 'F-D. 3 Q/C ^"^-^Z^Kn ^.<\j.^ UJj:: izip: ^^<S?^7 E-mail: +'& ^.y (SL.A-e-cs. i^^, u,' d.e.. '-KS. »'-"{~~H" <-' !5» ^^ Thi^ sp&ce reserved for approval stamp.T License Number: Remarks; Z-2- o o '? 0 .Signature:Date:s~-/ >-- ^/ Orfsinal slgnaturs requl^d on aach submitted copy. ^h8A.S ^m '^fl'^! ^s?^J; ~iri3 ?<<?0'C.(4 £^.<p^ ^s^/Gy, ^owswi« :^ v^f^^7t~ (L2,92-W?^UO {(^ -9^/J- j -®T^ M^ ; f^5 ^f-ft^ ^W ^US?J»Wfi»^ ^ n-oj_^vf l^j 9^ A ^^^ ff J-of.yl'&^-M-V 3</-A? y>-2k^ 9-Add-O J?^^t C UfjL?V,,h ' ' = l^:0 /4.->-3^^ f Ffl of j-/r^ ^/W o^ Y?S a C £. £; £- ;0-00/"-9/^» d-Sf^ 9 W8 ^ ~- ', f ^ 7 w "7-+ '"S' ^^s.^c.l^-^ -1P^ =-?~ ^-^fc ]^"^ -sr^y s ^yy (^,S^<>c!^ S^31»<^^S 'UM.^ ^-to ^3'SW^t^i?/^? ^ ^r^-^-'.^'^ .^-^•^•%T^4% . r/ ^^va ^ 4-°?, ''"'"" ^^^^u^^^1^^^^^^^^^^ {1 - o^^^'uo^^^^^^^.^5 7^ 5^^ ^ +^^N ' ^ ^^^.^ $ ^-2. ^ fi"'-suw';K;",'o7w M^N^Jr <^^^'^r-'"^ ^—-^ ^/:s^J^'a^o^ ^;^+^w>Gf 'y^&^-i / ;^t.^o7^^</o^[9Jld ^••L PROPERTY OWNER; _^^ ^^\ -^^^ Si^ ^[ PLUMBER: Allan Polkoski/ Polkoski PJumhjnq SIGNATURE: ^f^ •DATE: _^'-1^ - ^ ^ ^ LICENSE # 220090 '-/• -»- HOLDING TANK SPECIFICATIONS L.-A[WWWM.MIWW.WWM^ }m'»r"l Number of bedrooms Non-restdential estimated flow (gpd) [Minimum holding tank volume'required (gal) W2TOTuu.wnuu EiTWf ;ro jAlarm mod Tank Manufacturer Tank model number [Alarm manufacturer el number Tank Dimensions and Data IX for round tank SLlquld depth below Inlet Invert (in) SMaximum depth of soil cover (ft) 51.(<<MWhvut«/-*A»»N»W»**!] y»a. RwuHWiutfcwmwwiumam189.8lwaf^rBal' SfU'AitwtUrtiyWBLWnri Tank Anchor Calculations ijlbs Weight of tank and cover Height (In) Length (in)Width (In) Outside DimensionsOnly fri*iuiwuMiiy*'<itU»a|l.i -40:8 tbs Weight of anchor required In Soil cover req. for anchor or iyd3 Concrete counter weight HOLDING TANK CROSS SECTION junctionbox manhole cover with locking device andwarning label 4" mln. flntBhad grade'1 /vent cap C=3 '^ 12"mln. / blind plug to seal outlet Electrical as perNEC 300 and Comm 16 Manhole and vent locations may be reversed.vent pipe 98(VlC® alarm on ^,1 12.0 In. 39.0 In. Note: All tank Joints, and' joints between tank openings and piping areseated watertlght. All pipe and vent materials comply T18" mln, A_3) building sewerIntet 3 In. bedding under tank.Tank Is anchored as necosaaiyto nsgate buoyancy. |Wy>IE»7jax;IbT#j2yA35 ty:A!6ENJAMINRlWOOtaHULU l^ ^^ -1"*-:. PRPI&7iTdx1'IC»^T26"63Z ROeERlK'ATJOrtANMATMyjOHNSON -.^aji.ix,.. SM,,-.,-*!.? /.,,. ;^j8;-«;.U»^S®»&;^•y^'- %!{SSK*'1-; %Ste>MSit.,a(.3t^ ^^ssK'ff ^...ifra&i.VS5''"ff^aS*"':' 'B:S.A.''.-"i«S St;: -flptt^' •»''"«» ..,,..^,^.. •.:.-{&..,.., 1. ;^" * ''" '*%.. -& "^'^ ^^Ny'^ 0" ^?S.ytt^ ?^.^"•"'7^ ft '!f''^ ^ ( <l,^^ ,< BAYRELD COUNTY CHECKLIST FOR SANITARY APPLICATONS !vlAY ?QW^Submit the Following (Use Permanent Ink) (Title 15, Section 15-l-10(e)) 0 Check List Q Original Sanitary Application (Submitted in Deed Holders Name - flgt prospective buyers) (383.21(1)1.) 0 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) ET Original Plot Plan (383.22(2)2. 3. & 4.a) Ef Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer I? Pump Tank Diagram, Alarm and Pump Curve (when applicable) 0' Contingency Plan / Management Plan (383.22-3(2)(b)l.f.) D Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) ET Holding Tank Agreement (383.21(2)(c)(5) (Recorded aii: Reg. of Deeds) 0 Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) D ATU Servicing Agreement (Recorded at teg. ®f 10<@@ds) 0 Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) 0' 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanifcar^ppljcation and Maintenance Agreements are to be attached. to all copies') 0 Soil and Site Evaluation Report (383.22"3(2)(b)l.e.) D State Plan Review (when applicable) a Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application; (Include the foBlowang Information) 0 I Application Information must include: D 23 diait Parcel ID# " (do not use 12 digits anymore-obsolete) (s3 Project Address or Road Name where driveway is/will come off of) &! (Owners Phone Number) ^ 11 Type of Building E3 III Type of Permit Type of POWTS System D V Dispersal / Treatment Area Information 0 VI Tank Information Ef VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan: (To Scale or To Dimension) @T Signature and Plumber Information H/ Address Number and Road 6T Surface Elevation of Body of Water 13 North Arrow D Direction and Percent Land Slope D Contour Lines E? Tank and Filter Information and Location [gf Structures and Driveways S Wetlands / Navigable Bodies of Water 3 Boring Location D Absorption Area (Proposed and Existing) 0 Property Lines El Bench Mark (Location, Elevation and Description) @ Well Locations [3 Component Manual Version El Legal Descriptions Eli Piping Material Information (conveyance line, building sewer line, matsrial type and diameter) Turn Over > Cross-Section and Over-Head Profile of the System: a Surface and System Elevation Bl Position of Observation and Vent Pipes D Dimensions and Depths D Make, Model & Number of Chamber Units In each Cell Property Information D How many systems will there be on this parcel of land? D Has this property been split? _ (Property Statement shows Property History) D Private Sewage System (Septic Tanks) $ 400.00 0 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 D Maintenance Agreements ^ $ 30.00 (checks made out to Reg of Deeds) u,'foms/checkHsts/checklistforsanltaryapps(10/2009};(®7/201l);(®Z/2012)(®5/2/2012-dc) Proofed by: 5/28/24, 1:27 PM Real Estate Bayfield County Property Listing Today's Date: 5/28/2024 Novus-Wisconsin Access rev. 12.0206 Property Status: Current Created On: 3/15/2006 1:15:53 PM 1^ Description Tax ID: PIN: Legacy PIN: Map ID: Municipality: STR: Description: Recorded Acres: Calculated Acres: Lottery Claims: First Dollar: Zoning: ESN: Tax Districts 1 04 038 044522 001700 Updated: 4/24/2006 26625 04-038-2-48-09-07-1 01-000-10000 038101108000 (038) TOWN OF OULU S07 T48N R09W NE NE IN V.774 P.885 98 40.000 40.152 0 Yes (AG-1) Agricultural-1 Updated: 3/15/2006 STATE COUNTf TOWN OF OULU SCHL-SOUTHSHORE TECHNICAL COLLEGE -*' Recorded Documents Updated: 3/15/2006 Q CONVERSION Date Recorded:568-248;774-885 Ownership JONATHAN F & JENNY SHAMLA Billing Address: JONATHAN F & JENNY SHAMLA 2939 S ENGDAHL RD SOUTH RANGE WI 54874 Site Address * indicates 1755 PUDAS RD Property Assessment 2024 Assessment Detail Code Sm-AGRICULTURAL FOREST Gl-RESIDENTIAL G4-AGRICULTURAL 2-Year Comparison Land: Improved: Total: i3& property History Updated: SOUTH Mailing Address: 3/15/2006 RANGE WI JONATHAN F & JENNY SHAMLA 2939 S ENGDAHL RD SOUTH RANGE WI 54874 Private Road Acres 18.000 2.000 20.000 2023 26,500 19,400 45,900 BRULE 54820 Updated: Land 8,100 16,000 2,400 2024 26,500 19,400 45,900 9/22/2022 Imp. 0 19,400 0 Change 0.0% 0.0% 0.0% N/A https://novus.bayfieldcounty.wi.gov/access/master.asp?paprpid=26625 1/1