HomeMy WebLinkAbout24-60S McCarver^n'^'- ?7">r-i1
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^M M/V'
Department of Safety
& Professional Services,
Industry Services Division^
County Bayfield
Sanitary Permit Number (to be filled in by Co.)'^6>G£
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)
45145 Sugar Bay Drive
Property Owner's Name
Thomas A & Jeannie L McCarver
Parcel#
Tax ID: 24324
Property Owner's Mailing Address
11443 Zachary Lane N
Property Location
4Govt. Lot
City, State
Maple Grove, MN
Zip Code
55369
H. Type of Building (check all that apply)
0 1 or 2 Family Dwelling-Number of Bedrooms
D Public/Commercial - Describe Use
D State Owned - Describe Use.
Phone Number
612-382-2026 _'/4,I4, Section 02
Lot #T 43 N R 06 EorW
1 Subdivision Name
Block #
CSM Number
723
D City of.
D Village of
0 Tcnvn of Namakagon
m. 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.)
New System Replacement System Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain)
B.D Holding Tank B 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 Owner List Previous Permit Number and Date Issued
IV. Dispersal/Treapnent Area and Tank Information:
Design Flow (gpd)^
600 ^
Design Soil Application/Rate(gpd/sf)
0.7 v^
Dispersal Area Required
857.1
Dispersal Area Proposgd^sf)
900 System Elevati(g^ ^^
A:88.45 B:87.6
Tank Information
Capacity in
Gallons
New Tanks Existing Tanks
Total
Gallons
# of
Units
Manufacturer si!&s Its
GO ~S -s sE 0
•G
Septic or Holding Tank 1000 & 800 1800 Andry Rasmussen
Dosing Chamber
V. Responsibility Statement- I, the undersigned, a^an\c responsibility forjnstallation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Douglas Manthey
Plumber MP/MPRS Number
MP 230722
Business Phone Number
715-739-6868
Plumber's Address (Street, City, State, Zip Code)
PO Box 196Drummonct,WI 54832
VI. County/Department Use Only
aApproved
^•5o-M
d Disapproved
D Owner Given Reason for Denial
Permjt Fee;rmjtFee \, f\ Rate Issued /| Issuing Agent Signature;^J ^K'^^IJFiy'/S^ 74^o?
conditions ofApproval/Reasons for Disapproval
'WN pia^ to ^w
fii^ Ca^i:JT~"w\KT^ Wpa^-
3>)^sm) ^w ^ ^ ^^^my
P^r ^PS 3^.
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. 03/22)
VV's^-f'i ')
Private Sewage System Maintenance Agreement
Owner(s) Name
Thomas A & Jeannie L McCarver
Owner(s) Mailing Address
11443 Zachary Lane N Maple Grove, MN 55369
Site Address
45145 Sugar Bay Drive Cable, Wl
Tax ID #24324
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 Legal is required)
JMof
Additional Legal Description:
Town of Namakagon
Lot _ Block.
.1/4 Section 02 Township 43N N. Range 06 W.
(Acreage) 2.07 Gov't Lot 4
Subdivision
Lot 1 ww-CSM # 723 Vol. 5 Page 98 CSM Doc # -8086^=589943
DOCUMENT NUMBER2024R-60337S
DANIEL. J. HEFFNER
REGISTER OF DEEOS
BAYFIELO COUNTY, Wl
RECORDED
05/28/2024 AT 1 1 :06 AM
RECORDING FEE: $30.00
PAGES: 1
Recording Area
Return To:
"^
Planning and Zoning Department
^ ,-.!/0^
J<| In-ground gravity
Mound
In-ground dosed D 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 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 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 ^of all cCHVWt^iWrMfnre own fs of such property." Notary" Public
Owner(s) Name(s) - Please Print
J(2^n^l<i ^lc CArv'e*
"n^ ^ M^ ^^^:.
Flhdwy?Jan 31, 2028
iQli thi^date: ('^5 ' 1-5^0^1
Nptarized Owner(s) - Signature(s)Notary Public\[^^£^{{c^
My Commission Expires: '
30L^_^1_W^
Drafted by: Douglas Manthey Date:05/10/24
Proofed by:
u/forms/sanitary/septicmaintenceagreementRevised July 2020
and frontage along either side of Washington Avenue South and Cedar Avenue South
between 14th Avenue South and 2 1/2 Street Southl
and on Interstate 35W/State Highway 62 west of Nicollet Avenue,
IMPORTANT:
PAGE 4 OF 4
In-ground Gravity Management Plan
j'''f;'i" ,' ,; ^
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wise. Admin. Code.
Maximum Dispersal Area Operatina Limits:
Design Flow = 60° gpd; BODg $ 220 mgL-1; TSS S 150 mgL-1; FOG <. 30 mgL-1
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (/.e. odors, user complaints, ete.)
o mechanical malfunction (/'.e., pumps, valves, switches, floats, etc.)
o material fatigue (/.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (/.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (/".e., pump re-cycling, float switch settings, ete.)
o electrical components - if applicable (/".e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or tateral orifice plugging (measure lateral distal pressure - compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats, when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wise. Admin. Code.
o Effluent filterfs) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wise. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: HK SeptlC _ phone: 715-798-3494
Local government unit: Bayfield County Zoning _ phone: 715-373-6138
Local government unit address: PO BOX 58 Washbum, Wl _ ZIP: 54891
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wise. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wise. 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, Wise. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wise. Admin. Code.
BAYFIELD COUNTS SANITARY PERMIT f#04)-24-60S
STATE SANITARY PERMIT
OWNER: THOMAS A & JEANNIE L MCCARVER
GOVTLOT: LOT: 1 BLK:
SUBDIVISION: Csm #723
1/4 1/4 SEC:2,T43N,R6W
TOWNSHIP: Namakagon
SOIL TEST: 48-24
REPLACEMENT SYSTEM
SYSTEM TYPE: Non-Pressurized In-Ground
PLUMBER: Douglas Manthey
MCKENZIE SLACK DATE: 5/31,2024
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 230722
Condition: System to meet all setbacks. Management plan to owner. Existing Field to be
abandoned per SPS 383. Properly maintain system per recorded agreement.
THIS PERMIT EXPIRES 5/31/2026
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION
^-^
Wisconsin Department of Safety & Professional Services
Division of Industry Services
;^|!;\t! j\^
! L,l!iii:'''r I'^'i^
'••^y LL li'_^-'i.;i'Z.3 Page./-of_
SOIL EVALUATION REPORT MAY
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,
seals 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)).
County ^y//^.^
Parcel l.D.T^j./>^ ^vs^y
Reviewed by Date
Property Owner
7'^.o^as 4 oLt^l ^d/i,
Property Owner's Mailing Address//^/3 2ea.c.^y ^<^ A/
Property Location
iivt. Lot VA
"D - W
% s <^» T y^ N R o <o E (or) W
I Site Address or CSM and Lot #: ^ 'S~/*^ S^ ^<A^r- &^Y D^.
iy e'SAtf^^ ^ ^ r A n(''^ j^ ^r ^
City, State, Zip
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Phone Number
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D City D Village
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Town
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Nearest Road^^^<}Y P<
Code derived designflow rate €*°C> GPD
Flood Plan elevation if applicable.
Q New Construction Use: B" Residential/ Numberof bedrooms
0 Replacement D Public or commercial - Describe:.
Parent material ^& e,^ I T^V/
ft.
General comments and recommendations:^-^>rr^t<^W/^/TY^^ ^ ^^^ /f f?'/-r^«=A /! ?t!' €>
Boring #a BoringBP't Ground surface ele'J?./^L Depth to limiting facto/^^ in. / e\w^¥Yf~
Horizon Depth
In.
Dominant Color
Munselt
2 y^ ^
Redox Description
Qu. Az. Cont. Color
Texture Structure
Or.Sz. Sh.
Consistence Boundary Roots
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0Pit Ground surface elev,^ft _in. / elev.S^.Cft.
Horizon
_/__^3_~SL
Depth
In.
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*Eff»1~^~
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CST Name (Please-SR o( Alfct^w^^^^CST Number7S'a Yo^c>
Address // 3 rl0 6e.H^c ^ Q.^ &<,C.ctf,/^ Wj: "s^f^'t "^Date Evaluation Conducted7,,^,.?^Telephone Number;^$--<-^7-//^
•' Effluent #1 = BOD > 30 S 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, & 30 mg/L and TSS £ 30 mg/L SBD-8330 (R03/22)
Boring #
D Boring0 Pit Ground surface elev.
Paae-o?. of 3
.%/'^ft. Depth to limiting factor/^Lln./elev.^![/$~-
Horizon
-/
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_i_
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Redox Description
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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
*Ef?1 *Eff#2
Boring #D BoringD Pit Ground surface elev..-ft.Depth lo limiting factor.Jn. / etev._Jt.
Horizon Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence Boundary Roots
Soil Application Rate
GPD/Ft"
*Eff»1_.*Ef»2
* Effluent #1 = BOD > 30 e. 220 mg/L and TSS > 30 & 150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS & 30 mg/L
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PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet M/i
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg1 of 4
Pg2of4
Pg3of4
Pg4of4
Index & Cover Sheet
Plot Plan
Dispersal Area Cross-Section & Plan View
Management Plan
Attachments:Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
McCarver Replacement Cells
Owner Name(s): Thomas & Jeannie McCarver _ Phone: 612 -382-2026
Owner Address: 11443 Zachary Lane N Maple Grove, MN _ Zip: 55369
Project Address: 45145 Sugar Bay Drive
Govt. Lot: _ 1/4 of
Township: Namakagon
1/4, Section_02_, T 43 N-R06 _E
. County: Bayfield
or W /
Project Parcel ID #: Tax ID:24324
Designer Information
Designer Name: Douglas Manthey _ Phone: 715 .739 -6868
Designer Address: PO Box 196 Drummond, Wl _ Zip: 54832
E-mail: norpines@cheqnet.net This space reserved for approval stamp.
License Number: MP230722
Remarks:
Signature:r^L^i f L^-^
Or^ir)$fl signature required on eacWTubmitted copy.
Date: 05/07/24
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IN-GROUND GRAVITY DISPERSAL AREA
Stepped Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
SOIL COVER
Septjc Tank(s) Manufacturer:
Andrv Rasmussen & Sons
1000 gal
Septic Tank(s) Volume(s):
800 gal _ gal
Effluent Filter Manufacturer:
gal
Orenco
Effluent Filter Model #: 14B
12°
min. trench
depth(typical)
Highest Trench
TYPICAL TRENCHCROSS SECTION VIEW
(No Scale)
Lowest Trench (as applicable)
System Elevations = 88.15 ft;87.6 ft;ft;ft;
Provide minimum 3 ft
separation between trenches.
OBSERVATION PIPE DETAIL
(No Scale)
Screw-Type orSlip Cap (loose)Finished Grade(mulched & seeded)
4"0 PVC Pipe
TYPICAL TRENCH
PLAN VIEW
(No Scale)
(Show location of inlet / outlet pipe connection on plan view.)
ff----f----m
4"0
Perforated Lateral
(typical)
-y/-
Observation pipe shall be Installed
at junction between two units.
Observation Pipe(typical)
10
J-
(typical)
J.
.ft
Top of pipe to terminate
at or above finished grade
(4)1/4"-1/2"X6"Slots
@ 90 apart
•
Anchoring Device
Topsoil Cover(min. 1 foot)
|L
h-
INSTALL PER TRENCH:
-//-
B= 90^
(typical)
ft
^ T
10-ft bundles @ 50 ff EISA/unit = 450
5-ft bundles @ 25 ff EISA/unit =,
ft2
ft2
h-A=3.0 ft
J_ (typical)
EZ1203H Bundle
(typical)
(mfd by Infiltrator Systems, Inc.)
Install pursuant to manufacturer's instructions.
-u>0m
000
= Proposed EISA per trench = 450 ft2 Required Infiltration Area = ^^-^ ft2
x trenches = Proposed Total EISA = 90° ft2
Distribution Method:
branched manifold
Bayfield County, Wl
5 PRPIO/Tax I&X LA KEFNttWWW
imw/jTw;i6y,if32yi•WonMsmffje'A?)ieiyHiiccAfi
5/30/2024,10:56:57 AM
::-iM.~- Wetlands — Town
pj Flood Plain Boundaries Active Dec 16th, 2011
^gg AE = Base floodplain where base flood elevations are provided.
-J Approximate Parcel Boundary Bu"din9 FootPrint 2015
0.01
1:1,313
0.03 0.06 mi
Road Type
~^~ County
Building
0.03 0.05 0.1 km
Bayfleld County Land Records Department
Bayfleld County Zoning ApplicationhUpsrf/maps.bayfleldcounty.wi.gov/ZoningWAB/
5/30/24, 10:56 AM Novus-Wisconsin Access rev. 12.0206
Real Estate Bayfield County Property Listing
Today's Date: 5/30/2024
m.Description
^
1
04
034
041491
001700
Updated: 2/8/2022
Tax ID: 24324
PIN: 04-034-2-43-06-02-3 05-004-30000
Legacy PIN: 034104010001
Map ID:
Municipality: (034) TOWN OF NAMAKAGON
STR: S02 T43N R06W
Description: LOT 1 CSM #723 IN V.5 P.98 (LOCATEDIN GOVT LOT 4) IN DOC 2020R-583043
Recorded Acres: 2.070
Calculated Acres: 1.963
Lottery Claims: 0
First Dollar: Yes
Zoning: (R-l) Residential-1
ESN: 123
Tax Districts Updated: 3/15/2006
STATE
COUNTY
TOWN OF NAMAKAGON
SCHL-DRUMMOND
TECHNICAL COLLEGE
m Ownership
Property Status: Current
Created On: 3/15/2006 1:15:47 PM
Updated: 2/8/2022
THOMAS A & JEANNIE L MCCARVER MAPLE GROVE MN
Billing Address:
THOMAS A &JEANNIEL
MCCARVER
11443 ZACHARY LANE N
MAPLE GROVE MN 55369
Mailing Address:
THOMAS A &JEANNIEL
MCCARVER
11443 ZACHARY LANE N
MAPLE GROVE MN 55369
y Site Address * indicates Private Road
45145 SUGAR BAY DR
Property Assessment
CABLE 54821
Updated: 3/25/2021
2024 Assessment Detail
Code Acres Land Imp.
Gl-RESIDENTIAL 2.070 330,800 276,100
2-Year Comparison 2023 2024 Change
Land: 330,800 330,800 0.0%
Improved: 276,100 276,100 0.0%
Total: 606,900 606,900 0.0%
« Recorded Documents Updated: 3/15/2006
S TRUSTEES DEED
Date Recorded: 7/9/2020
B CONVERSION
Date Recorded:
2020R-583043
565-274;603-101
Property History
N/A
https://novus.bayfieldcounty.wi.gov/access/master.asp?paprpid=24324 1/1
BAYFIELD COUNTS
CHECKLIST FOR SANITARY APPLICATONS ! I ' '• . • "I
Submit the R)llowina (Use Permanent Ink) (Title 15, Section 15-l-10(e)) p _ , ,;„ 1;;MA'. if •' ^'i/;i
'Check List
B'-Onginal Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.)
0'lndex Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
B^riginal Plot Plan (383.22(2)2. 3. & 4.a)
J3^Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer
D Pump Tank Diagram, Alarm and Pump Curve (when applicable)
B"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)
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)
(Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
^Comfi.tete Set» of Plans (383.22(2)(2.) (NoteLSanitary Application and Maintenance. Agreements are to be.attachect
to all copies')
B^oifand Site Evaluation Report (383.22-3(2)(b)l.e.)
D State Plan Review (when applicable)
D Copy of Warranty/Quit Claim Deed (Optional)
Sanitary Application: (Include the following Information)
I Application Information must include: d 23 digit Parcel ID# - fdo not use 12 digits anymore-obsolete)
B'Project Address or Road Name where driveway is/will come off of) ^(Owners Phone Number)
Q-TT Type of Building
arfn Type of Permit
B^fV Type of POWTS System
Dispersal / Treatment Area Information
D-VI Tank Information
Responsibility Statement (Plumber's Information)
D *Date Stamp*
Plot Plan: (To Scale or To Dimension)
&-5ignature and Plumber Information ZfAddress Number and Road
Q^Surface Elevation of Body of Water Q^North Arrow
C<M5irection and Percent Land Slope -flContour Lines
Tank and Filter Information and Location ET Structures and Driveways
/etlands / Navigable Bodies of Water Q^Boring Locations
[yAb§orption Area (Proposed and Existing) 0 Property Lines
C3^6ench Mark (Location, Elevation and Description) Q^Well Locations
Manual Version Ofcegal Descriptions
'iping Material Information (conveyance line, building sewer line, materia! type and diameter)
Turn Over >
Cross-Section and Over-Head Profile of the System:
^TSurface and System Elevation '
O^osition of Observation and Vent Pipes M,A
Q^imensions and Depths
B^Make, Model & Number of Chamber Units in each Cell
Property Information
How many systems will there be on this parcel of land? J_
D-tias this property been split? ^ (Property Statement shows Property History)
Fees:
'rivate 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
D Maintenance Agreements ^ $ 30.00
(checks made out to Reg of Deeds)
u/forms/checklists/checklistforsanitaryapps (10/2009);(®7/20ll);(®2/2012)(®5/2/2012-dc) Proofed by: