HomeMy WebLinkAbout24-65S Hrdlicka,<,J-)•!!KJ55,.V ,/'._yl~/
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Department of Safety
& Professional Sfinlces^;;
Industry Services Division
County
'f:)K2J>
Sanitary Permit Number (to be filled in by Co.)•^^
Sanitary Permit Application
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this fonn to the appropriate governmental unit
is required prior to obtaining a sanitary pennit. 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 wife the Privacy Law, s. 15.04(l)(m), Stats.
State Transaction Number
I. Application Information - Please Print All Information
:t Address (if different than mailing address)^lP-^0\JEftfi^ev do
^?x0&70e.u^ s^8^
Property Owner's Name
fe^-DT;) ^02.1/-K^
Parcel #///^
Property Owner's Mailing Address^^ 1& A^E Property Location
Govt.Lot.
City, State
C-HET-^, ^-T
Zip Code^neII. Type of Building (check all that apply)
1 or 2 Family Dwelling - Number ofBedrooms
0 Public/Commercial-Describe Use
a State Owned - Describe Use.
Phone Number
W-^'o^^o
Lot #
'f'/<. <SA</ '/^ Section
T_<2(to»R_SLjgo,
Subdivision Name
Block*
CSM Number
D City of _
a ViUageof
Town of ^^Ot)E^)^°
m. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on Bne A. Cheek one box on line B. Complete line C If
applicable.)
A.New System D Replacement System D Otfaer Modification to Existing System (explain)D Additional Pretreatment Unit (explain)
B.Holding Tank D to-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 OwnerlList Previous Pennit Number and Date Issued
IV. DisperssI/Treatment Area and Tank Information:
Design Flow (gpd)Design Soil Application Rate(gpd/sf)Dispersal Area Required (sf)Dispersal Area Proposed (st)System Elevation
Tank Information
Capacity inGallons
New Tanks Existing Tanks
Total
Gallons
# of
Units
Manufacturer
.11^li
M &fe Ss siS 0
t«ptir4>r Holding Tank ^<W)a^M?^))£%Kf^^3Dosing Chamber
V. Responsibility Statement- I, the undersigned, assume respomibfllty for InstaBatton ef die POWTS ahown on the attached plans.
Plumber's Name (Print) ] Plpnljer's Signature
DET^AHS L Sfl&^tjo I VA^L^v^L
MP/MPRS Number^w^Business Phone NumberI^W^G^Plumber's Address (Street, City, State, Zip Code) ~
PO^y ^_^/te/^^ ^ ^<3ci\
VI. County/Department Use Only
ennitFeei^^T,D Disapproved
D Owner Given Reason for Denial
Rate Issued
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"^^^ j}l<y\ ^ o^^r
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Attach to complete plans for the system and submit to tfac County only on paper not less than 81/2x11 iaches in size
SBD-6398 (R. 03/22)
<"L?-W^i. / ^ '..,' "/ !^-;.' ^.'/^u^;
Bayfield County
Soil Test # tj-j ^^i//Q
Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1-10(d))
I 'B^UCT^ \J I^LW^/W a certified soil tester determine that in my pfofesSibffail
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.
Property Owner W-^^W /T^LIC«^ Contractor.
Property Address Sic^ i^fi-iV-c.'L ^ Authorized Agent.
\\i^S^r^ i^ ^S^ _ Agent's Telephone_
Telephone.7,^- -2^ - ^°^Written Authorization Attached: Y or N
Accurate Legal Description is requested:
J[E_1/4 of ^ 1/4 Section V Township ^^ N. Range ^ W. Town of CLu^^
GovtLot Lot_ Block_Subdivision_CSM#
Volume_Page_of Deeds Parcel I.D# //^^_Acreage.
Additional Legal Description:.
Indicate reasoning for your determination:CLA-/ ^TiL. LW /^^
((/f ^6R3/-^A/>> /)/-U$ /// 77 S^f^^^ ^ft'Tu^T^o^.
(^UAC^-e^yx<si^
Signature of County Official
Date
Signature ofCeftified Soil Tester
^//^/.2^/
Date
yo8/</€
Certification #
(Submit a Plot Plan & Fee)
u/forms/soiltestwaiver(KLK)
February 2005
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Page 1 of 4
PRIVATE ON-SFTE WASTEWATER TREATMENT SYSTEM (POWTS)
INDEX AND TITLE SHEET
OWNER:I=?^:D£TA) D/?DLi ^\<LA
PROJECT NAME AND SYSTEM T^PE: _ ^ U/_/ C^L/\ - ^ffl^pf. A? ^-"T^io<
COMPONENT MANUAL. VER 2.0; SBD-I0855-P (N. 03/07, R. 1/12)
LOCATION: ^ 10 ^0 L^iOft-^E^- H P
Street Address
^^,s^^-^-7c<3
Legal Description
(^UVf^ / 13^^/^j^
Township/Counl^
CONTENTS: Page I: Index and Title Sheet
Pa9® 2: Plot Plan with Contingency Plan
Page 3: Holding Tank Cross Secti'on
fage 4: Management Plan
Phunbci/DcsigncT Dennis t. Bachand Signed: /^^^^Li^ A ^6ld<<Wi\
Credential Number. 221446 . Date : /S'-^?^?.-^^
Ogjo^v > ^ 84^ ^^° .BAGHAMmUMBING & HEKSTIKG
P, 0. BOX 56WASHBURN. WSCONSIN 54881
fi^Er5^
^^ne- ^,1
CONTINGENCY PLAN:
In the event of system failure
the owner could replace the
holding tank with another
holding tank or check additional
soil for a possible alternate
system.^
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t^'f^ol$^ no ?^
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fa)-!r0fl\6f-Sl»ii36-
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N^D^r^/h' /<. 4^-^S^ ^^t:?
Driveway is. all weather
road to within 25' of
holding tank manhole
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Page 3 of t^
HOLDING TANK CROSS SECTION
GRADE
u
HIGH WATER WARNING DEVICEON 8* POLE OR IN/ONBUILDING SERVED
12" MINIMUM
\\^ /co
WEATHERPROOF JUNCTION BOX
4" SCH 40 PVC WITH
APPROVED VENT CAP. 10* HIM.FROM DOOR, WINDOW OR FRESHAIR INLET
CONDUIT
/LOCKING DEVICE AND
WARNING LABEL AT COVER
1
MANHOLE -
MiN.24" ID
"^
^" MINIMUM
^1\
LEAD JOINT
BLIND PVC OR CI PLUG
AIRTI6HT SEAL
HIGH MATERALARM SWITCH
OEPARTMENT APPROVED
JOINT
WATERTI6HT JOINTS ARE INDICATEDBY UNLABELED ARROWS
"PROVIDE APPROVED PIPE FROM INLET TO 3'BEYOND EDGE W UNDISTURBED SOIL
40 PVC
5" SAND BEDDING
SPECIFICATIONS
TANK MANUFACTURER: Wieser
TANK CAPACITY: 2,000 GALLONS
ALARM MANUFACTURER:SJ Rhombus
MODEL NUMBER:101-HW
NUMBER OF BEDROOMS: 3
(OVER)
i;EEaastti38;)0aiB3QQS3SGS33S3S3&
Bayfield County, Wl
E8SS0SSSB10SSES(Mcasoaasisoa
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CESBSff&QSEiOQSSGGKEBOTigQSKQS
m8S03338SOaSEQ'QSSSESESOQSSSSS 1 :": ffigRffiEoasoaiaiCei3!a3i7C>@ii32ERS •2i ssas^^osse)"^ - iBBsSfssaaT
6/11/2024, 12:06:50 PM
Approximate Parcel Boundary
Road Type
Town
Building Footprint 2015
'* Building
0.01
1:1,310
0.03 0.06 mi
0.03 0.05 0.1 km
Bayfietd County Land Records Department
Bayfleld County Zoning Applicationhllps:tfmaps.bayneldcounly.wi.gov/ZoningWAB/
6/11/24,12:06 PM Novus-Wisconsin Access rev. 12.0206
Real Estate Bayfield County Property Listing
Today's Date: 6/11/2024
\m.Description Updated: 6/28/2022 w Ownership
Property Status: Current
Created On: 3/15/2006 1:15:11 PM
Updated: 6/28/2022
Tax ID:
PIN:
Legacy PIN:
Map ID:
Municipality:
STR:
Description:
Recorded Acres:
Calculated Acres:
Lottery Claims:
First Dollar:
Zoning:
ESN:
^ Tax Districts
1
04
014
044522
001700
11153
04-014-2-49-07-04-3 04-000-10000
014100401000
(014) TOWN OF CLOVER
504 T49N R07W
SE SW LYING E OF
2022R-595122
6.000
5.746
0
Yes
(F-l) Forestry-1
109
^ Recorded Documents
:LENAWEE RD IN
Updated: 3/15/2006
STATE
COUNTS
TOWN OF CLOVER
SCHL-SOUTHSHORE
TECHNICAL COLLEGE
Updated: 8/22/2008
BRANDEN L HRDLICKA
Billing Address:
BRANDEN L HRDLICKA
2474 4 1/2 AVE
CHETEK WI 54728
Site Address * indicates
81030 LENAWEE RD
t«a Property Assessment
2024 Assessment Detail
Code
Gl-RESIDENTIAL
Land:
Improved:
Total:
B2B1 Property History
Mailing Address:
BRANDEN
2474 4 1/2
CHETEK WI
Private Road
Acres
6.000
25,000
40,100
65,100
CHETEK WI
L HRDLICKA
AVE
54728
HERBSTER 54844
Updated:
Land
25,000
25,000
40,100
65,100
: 7/30/2018
Imp.
40,100
Change
0.0%
0.0%
0.0%
B QUIT CLAIM DEED
Date Recorded: 6/17/2022
83 WARRANTY DEED
Date Recorded: 7/15/2008
a ORDER
Date Recorded: 7/15/2008
B DOMICILIARY LETTERS
Date Recorded: 7/15/2008
B PERSONAL REPRESENTATIVES DEED
Date Recorded: 7/15/2008
2022R-595122
2008R-521858 999-490
2008R-521857 999-487
2008R-521856 999-485
2008R-521855 999-484
https://novus.bayfieldcounty.wi.gov/access/master.asp?paprpid=11153 1/1
Document Number/Plan 1.0. No-HOLDING TANK
AGREEMENT
Owner Name (s)
f^^^A- ^A^,./ •<.r/
Owner(s) Mailing Address
-3-n^ "4'^/i^
c^ i^-r-c.^, [.cj^ ^ ln^
Parcel Identifier Number (PIN)
m.^3
Agreement Date (same as Notary Date)
^- ^-.^y
We acknowledge that application is being made for the installation of (a) holding tank(s)
on the foliowing property or that continued use of the existing premises requires that a
tiolding 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 una'er Ch. SPS 383.
Wis. Adm. Code or Ch. 145, Wis Stats.
w-
DOCUMENT NUMBER2024R-603374
DANIEL J. HEF-F-NER
REGISTER OF DEEDS
BAYFIELD COUNTY. Wl
RECOROED
05/28/202--1. AT 9:59 AM
RECORDING FEE: $30.00
PAGES: 1
Additional Legal Description: t—yrlt)6-k: G f= /-^.ZTsU/^-E^ ^-V^!
Return TDENN^S L BAGHAND
^O.i@OX?6i ^ ^Wasri^um, Wr54891JUN 05202^
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.
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 ta?; 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 otheroise 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 ttie 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. 281.46 (3) Wis. Stats., and Ch. NR 114, Wl's Adm. Code who shall
submit 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 Bayfietd 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) Name(s) - Please Print
^fOt^A^ /JfJttc.^
Subscribed and sworn to before me on this date:
.^-;^-^^HllltlU^
;?^ .' <-<t~VAA '"->" ^KROra
<i^tn ^.~. i -!i((
Notan'zed Owner(s) - Signature(s)
^ ^.^
Notary Publii
^2//i/^/
My Commissiqp Expires^ ^ • ^ S'^SwfW^^
Drafted by: Dennis L. Bachand Date:
Personal intomiadon you prouide may be used far secondary purposes jPrivacy Law. s 15.04 (])(m)!u/forms/sanitafyftoldingtankagreement doc ^w'(fmini
Page 4 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to Comm 83, Wis. Admin. Code, ths Holding Tank Component Manual (SBD-10571-P
6/11/1999), and the BAYFIELD__ County Sanitary Ordinance.
1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 300 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 will 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 venfy 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 Comm 83 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 tho 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 sen/ices 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 Comm 83.33 Wis. Adm. Code.
10. If there is a problem with. or question about this installation, the following persons should be contacted:
a. Installer............................Bac ha nd Plumbine _ Phone: 715-373-2070
b. Service Provider................. Birch Street Septic ^ Phone: 715 -373-568 3
c. Co. Zoning or Health Dept. Bayfield County Zoning Phone: 715-373-6138
11. OWNER: ^^LJC-)sfA
LOCATION: ^f^oL^^Au^e^ ^
LEGAL: S^ 31^ f-^'^l^
TA( .• flL^OKR. C.-^ \ ^VF/&L^>
HOLDING TANK SERVICING CONTRACT JUN 0 52024
Contract Date
^'^-^This contract is made between the
Holding Tank Owner(s) Name{s)
(3^/Co^AJ ^RP^ICK^
Pumper's Name (Print)
DOUG BELANGER
Pumper's Signature^A/——Pumpers' Registration #
01203
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROJECTLOCOTON Legal Description: (Use Tax Statement)
PIN:M_lLi^S
^ \£^. 1/4. .6 K/ 1/9, of Section ti~ , Township <~J 7 N, Range __J_ W
Gov'tLot Lot»CSM«Vol. Page Lot(s) No.Block(s) No.
Town of:
C-^^^7^
Lot Size Acreage
(o
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 purnptflg equipment. The owner
further agrees to pay the pumper for ail 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.
1111111
Owner(s) Name(s) (Print)
7)^hM^ //r^.-^-c^
Owner's Signature(s)
^
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im to me:ribel^^^S^ /^4y . s^
,.U ^S inject ^by:.\^'^^'.'u^oi\0 .'.^U&tary Public^' v.t"'^''J^/^'^W^f^^on: ^-^-^
Revised: May 2016 (Bayfield County Zoning)
Personal information you provide may be used for secondary purposes [Privacy Law, s-15.04 (l)(m)]
Drafted by D/^^
BAYFIELD COUNTS SANITARY PERMIT (#04)-24^5S
STATE SANITARY PERMIT
OWNER: BRANDEN L HRDLICKA
GOV'TLOT: LOT: BLK:
SE 1/4 SW 1/4 SEC: 4, T 49 N, R 7 W
TOWNSHIP: Clover
SOIL TEST: 72-24
NEW SYSTEM
SYSTEM P^PE: Holding Tank
PLUMBER: Dennis Bachand
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: #221446
ALESSANDRO HALL
Authorized Issuing Officer
DATE: 6/12/2024 Condition: Tank to meet setbacks. Management plan to owner. Properly maintain system per
recorded agreement. To be located within 25' of all weather road.
THIS PERMIT EXPIRES 6/12/2026
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION