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HomeMy WebLinkAbout24-70S Polifka^T^Department of Safety & Professional Services, Industry Services .Division Countyf?>^Y-i-^ i^cL Sanitary Permit Number (to be filled in by Co.)2^-70S 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 to the Department of Safety and Professional Services. Personal information you provide may be used for secondaiy 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) ^ (^cj .S"S~ T^ivn^€r ^^ ^ Property Owner's Name w^l^^l ?c\\^\^ + if\^ f>^'fkA Parcel #8/o7 Property Owner's Mailing Address 34- / ^ ^ ^ f^ ( i_ A ^ ^ s City, State n) ^ ^- ^ ^ ^ I ~^ /^ fJ Zip Code S-^WO^ II. Type of Building (check all that apply) ^i 1 or 2 Family Dwelling - Number ofBcdrooms D Public/Commercial - Describe Use D State Owned - Describe Use Phone Number ^/^3cj(^ /£/ ^ Lot # Property Location Oovt.Lot 2. '^^ ^-^1-^ ^Ja/,/, ^lE: ^ s^ 3^ T_$jL_N _R _A—-Xo<® ^-Subdivision Nai Blocks '"T'^'^L ^-e../- ^>c<_i CSM Number D City of__ 0 Village of I? Town of_@Le_ HI. Type of POWTS Permit; (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if| applicable.) A.^ New System D Replacement System D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain) B.8'Holding Tank D In-Ground (conventional) D At-Grade D Mound a Individual Site Design D Other Type (explain) c.D Renewal Before Expiration D Revision D Change of Plumber D Transfer to New OwnerlList Previous Permit Number and Date Issued IV. DispersaI/Treatmeiit Area and Tank Information: Design Flow (gpd)^ SQ Design Soil Application Ratc(gpd/sf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System Elevation Tank Information Capacity inGallons New Tanks Existing Tanks Total Gallons # ofUnits Manufacturer iisu5 'S EO Saptio-w Holding Tank •£.TOO 2^~DO j-LO t'c-S^K- (^.onfi,^ Dosm^ehen*<r V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print)Alt^b T^^^^t Plumber's Sisiiature^'^•NP/MPRS Number 2.Z.<30C? 0 Business Phone Number -7tS~ ^-^-^l^~(ft Plumber's Address (Street, City, State, Zip Code)Ha B^ s-'^ ' ^^^ <?^^ ^1. ^^7 VI. County/Department Use Only Permit Fee•Hoc'Approved a Disapproved D Owner Given Reason for Denial Date Issuedtolziw } fc3S-2-^ ^/^Pli!stof;s~ Conditions ofApproval/Reasons for Disapproval:fH VW^ ^ -,^^^»r^c^f-rnt^ ^n ^ <^^)^, p<^;/); ) pe^/f/ pc^a/^ .9'^^^ c^(^ci ^a?/w^ Attach to complete plans for the system and submit to the County only on paper not less than 81/2x11 Inches in size SBD-6398 (R. 03/22) <$-UUU/3 '\J / •'^ -^ /.^&. \W^nw Bayfield County Soil Test #7b-2t/ Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) JUN U OZUZ4 I, ^ / I. a^l F£) / ^-O S /<• ^ 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. Property Owner ^.c^^t fJ;-F^Contractor e.^Authorized Agent_Property Address <g ? <7 ^ 'TA v^ < S ^./ /^ d /^ ^ J>s -fce ^ \^T s~^^ agent's Telephone. Telephone U? I -?_ ^ CJ (^ /?^/Written Authorization Attached: Y or N Accurate Legal Description is requested: _1/4 of _1/4 Section ~§ 7- Township -5~/ N. Range ^ W. Town of ^ ription: r^^o-^-f^ /U^^^^^Additional Legal Descripti -^ Govt. Lot _^_Lot 2.Block Lot_CSM#. Volume Vol. Subdivision -T^ ^ ^-- ^^>^ Page _ CSM Doc # Page_of Deeds Tax I.D# <L I D 7 Indicate reasoning for your determination: W e" ~^v-y< ^ T E> i^-T^ ^^ -^ */^^^/A_, Acreage / • C [t^tf €. t/- SO ' f— /^° ^ ^-^l- / Signature of Certified Soil Tester ^-^o-^Y Date Signature of County Official ^//A /LH ZZQO^O Certification # (Submit a Plot Plan & Fee) Date ^Oi) ^y ^^6 ,5W//^/vt u/forms/soiltestwaiver(KLK) June 2018 ,^y ^^6 .5W/ ^/vt > ^? fc(^(2-4 ^ ^CJ rm?t ^L ^M^ a.t 1^ ^ 2^;?%?^^^.jte^^^S^^<% ^fo ^ ^ . - ^ . > ^ ~ - _ i ^ " ? ^ ^' F - " J ; . 4»4>K L. C t v ^ ^ •t h ^i i " ^ ^ ? 1 >j s L ^ ' ? \ ; 0 - ^ - If t < I * ^° i ? ? i p ^ •s ^ ? ~ ] * ^ - h , S < c f 8 ' - * < a . ^0 ^ . ^ > - ? ' . - + - o ^ ^ , 5 ^ ^i l ' ^ ^ — f t v^ - ° . f - a ^ ? F ^ J s ^~c^ ^ ^ " 6 £ < o ' & ' > , ! 'l \ r : f [ f i Q I ^ € ^. f 3>1^ , ^ ^ $ ( s ft ^ ft - ' ^ ^. a . -y ' - s fi 1 \ H: 0 ^ 5 t 7 yo i t t ~ ? "~ ~ - ^ ^ C a ? ^ ? s. s & ? 5 \ f l . ^ t » -^£^1 BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS „, n Submit the Following (Use Permanent Ink): 12 Check List 10 Index Page / Title Sheet (Optional) 03 Original Soil Evaluation Report (Submitted in Deed Holders Name - ngt prospective buyers) \^ Original Plot Plan a Cross Section Soil Profile Sheet (optional) D Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) 13 Parcel Identification Number (must be 23_diait Tax ID#) DO NOT USE 12 digit, they are no longer being used IZ3 Property Owner's Information (not prospective buyer's name) El Property Location (Accurate Legal Description with Sec/Twp/Range) El Road Name (where driveway is/will be coming off of) 0 Floodplain Elevation, Flow Rate, Comments and Recommendations El Complete Soil Boring / Pit Information 13 Date Soil Evaluation was conducted [2 CST Name, Signature, Number, Address and Phone Number D *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) E3 Bench Mark (Description, Elevation and Location) •A Contour Lines (Example = 98.0',96.0',94.0') 13 Pioperty Location (Sec/Twp/Range/, Accurate Legal Description) El Borings (Locations and Elevations) u Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) 1/1 Location of Wetland Areas, Floodplain and Navigable Waters 0 Buildings, Driveways, and Structures (Location and Descriptions) El Location of Property Lines El Existing System Location IZI Address Number and Road Name 13 Current Surface Elevation of Wetlands and Navigable Waters £1 CST, Owner and Property Information North Arrow Fee: E^ Certified Soil Tests - Review & Filing Fee . $ 50.00 . u/forms/sanitar//checklist/chec.klistforcsts -wy vu i Lnnmnu O! ^.ytU'HU No.9975 P. 2 Pgl Pg 2 of ^ Pg3of^ Pg 4 of S Attachments: Holding Tank Plan Index & Cover Sheet Component Manual Design RQferences:"W<MmoJ -t/fe<^V€4-5^^^i);^,my Index & Cover Sheet Plot Plan Holding Tank Speclficatio;ns Management Plan i PAGE 1 OF 5> 2-02-^-^02.7•). € ^S» ift ^ s Pq 7 ^ ]^r4 s ^{~ ^ Enclosures: _L POWTS Application forJReviewC^7^/p^m< Soil Evaluation Report & Site Map (lif applicable) Holding Tank Pumping pontract (if applicable) Holding Tank Agreement (if applicable) Project Name / Description Owner Name(s)..ft\: d.^/ T^//-?^Phone::i^/2L- 3^. /9^-/ Owner Address: ^^IL/^^^ I i^S.^-^ ^^-^ Zip: <S-<rVo^ Project Address: ^g75-^T^^-^- ^y ^^ ft^r^s^ ^X ^r?t^^_ Govt Lot ^ U ^ Az ^u\ /4 of ^ ^ .1/4, Section ^^. T 3-/ N-R ^ E Township: '^e-1 (_ County: B^'/-f~'-^ or W Proiect Parcel ID #: ^7^x ^ !> ^ ^ / °7 '^Ti.u^.^-e^^'^ <^o^l-^''Si = All G.^ I C3 Designer Information I / A:oj• l^\ Phone: 7^T-Ja-72. - {// ^Designer Name: Designer Address:'P-&. BQ^C ^~^-^-'£/~ on ^.'^ ••?-»; '^UZ' izip: _^X^2- E-mail: ~l~"cs ^ -/ e^.. t> • e-cs. ^ ^ m d^- ^<a s^~'~t~^" <-' &> *t^-. Thi^ space reserved for approval stamp.7—7- " !License Number; 2-2. oo<? o _ | I Remarks; Signature:^^.Date: /-^-^ Original signature requhwl on each submitted copy. ^. - 0 - > ". . 1 ^ ^ . ^\ t t : ^ ^ L. < s . f c g . - S i ^ r ' £= : { • < S L k / - c ^ a ^? , ? i ^ ^ - ^ 2 c ! t o ^ a . t 3 S c d Sc i ; : . •^ ^ ' ; ( ? ri ^ ^ a' r - - . ^ ( & t< ' 4 - f t ' ^ If t ^ ^ ^ ' in ^ S : ^y ? : - ' - ^? & r - ? . ^ ^ ^ - 1 ' c o x < ^ c & S T{ e ; ^ c t ~ < 3 ^ *' J ° . : L 3 ' ? r^ S i£ ^ ^ t ^ f ^ U S V ^F i -i i £ 3 £^ u &^' i^ ^31! § •' & - ?^f^ ' f i^ a a s JN ? ~ \ J p 7? ^ ^T f t l , PROPERTY OWNER: /7l -< ^ i i c,€_/^_//-f:^ " PLUMBER: Allan Polkoski/ Polkoski Plumhjnq SIGNATURE: ^7Y/ ^l^^-^ DAT& .-^-^°'^^ LICENSE # 220090 '•/• •*' HOLDING TANK SPECIFICATIONS .^iWtMlfMMWWWMW^<s ^MfWMdhtI?i.iu'rtn Number of bedrooms Non-resldentiat estimated flow (gpd) Minimum holding tank volume required (gal) r^®^pro£^?di!°^n9^iLro^^ fjTank Manufacturer jTank model number SAterm manufacturer eser ^ESectroWST aslarm model number Tank Dimensions and Data 8X for round tank 5liT"n'|Liquid depth below intet Invert (in) t^uu.tnwi/'wi'utawumi?.c|u»B"yyk^ B.U.UHU.W.UUBU.VUUIU169.6l-'aww SLWU'iWtlAWMBiWW Maximum de Height (in) [Length (in)iWldth (In) 3|=of soil cover (ft) Outside DimensionsOnly Tank Anchor Calculations |lbs Weight of tank and cover Safety factor I Ibs Weight of anchor required (in Soil cover req, for anchor or40.8 9.9 yd3 Concrete counter weight HOLDING TANK CROSS SECTION junction box . / blind plugto sea) outlet <—24 In. -^ mannolBCovarwIth locking device and warning label finlshsd grade /vent cap $4"mln.1 R Manhote and vent locations may be reversed. 12"min. ventplps service alarm on Electrical as perNEC 300and Comm 16 12.0 In. 39.0 in. Note: All tank Joints, and joints between tank openings and piping are sealed watertlght. All pipe and vent materials complywlth^piS^S T18" mln,A .D building sewer Intel 3 In. bedding undor tank.Tank Is anchored as neceaaatyto negate buoyancy. HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and . i, • maintained according toS»^3g3 Wis. Admin. Code, the Holding Tank Component ^?nualjA$^^ ">^a.ny& I 't"/f& ^E-R 2.0 and the 'B^4^€. U County Sanitary Ordinance. C^ &J) J ^^/ zo^^zo^ 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 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 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 363.33 Wis. Adm. Code. 10. If there is a problem with, or question about this jnstallation, the fojjowing persons should be contacted: a. Installer.............................Ro/^k* ^/awL'^S m.HR5. 2.2.0oci0 Phone: -71^ 372--t//^6> b. Service Provider... ...... ....^c^^v^. S-ep^^ R&g J* 8tZ7t Phone: '7,^- 37^ - ^o&tp c. Co. Zoning or Health Dept. Ba.</fns^A C.^ys^ti :~Z^^/J>»4?___ _ _,_ _ Phone: 7/j- 3-73, - ^/^ n. L^aJ b^s^. f. %^-P t^/J ^-L/ ^^ ^ <^ ^z-'Ts-/ ^ ^ ^ ^ ^ , •Tot^n^y^e-/^ ^-oj-f ^tcr^-2_e-/-ffZ. -r^^^-^^^o^ ^-^^^-5<o^iC^un-^of BG^-T'^^ _'_-/u of-: Ba^-(-^ aJL£fi-^__^L^P^c^TD^: «'/'?7 Project Transaction Number: f-t6 16 i t^<\ ^ j <xn K BAYFIELD COUNTYCHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-l-10(e)) 0 Check List 3 Original Sanitary Application (Submitted in Deed Holders Name - nfit prospective buyers) (383.21(1)1.) 0 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 63'Original Plot Plan (383.22(2)2. 3. & 4.a) @f Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer Ip Pump Tank Diagram, Alarm and Pump Curve (when applicable) ET 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 at Reg. of Deeds) ET 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) 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: Sanitary Application and Maintenance Agreements are to be attached to all copies! 0 Soil and Site Evaluation Report (383.22-3(2)(b)l.e.) a State Plan Review (when applicable) D Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) B I Application Information must include: D 23 diait Parcel ID# - fdo not use 12 digits anymore-obsolete) B Project Address or Road Name where driveway is/will come off of) 0' (Owners Phone Number) ri 11 Type of Building 0 III Type of Permit S IV Type of POWTS System D V Dispersal / Treatment Area Information B! VI Tank Information Ef VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan; (To Scale or To Dimension) ET Signature and Plumber Information \M Address Number and Road Sf Surface Elevation of Body of Water ly! North Arrow D Direction and Percent Land Slope D Contour Lines d Tank and Filter Information and Location \^ Structures and Driveways 0 Wetlands / Navigable Bodies of Water 0 Boring Location D Absorption Area (Proposed and Existing) 51' Property Lines El Bench Mark (Location, Elevation and Description) 0 Well Locations Sf Component Manual Version 53 Legal Descriptions Turn Over > Cross-Section and Over-Head Profile of the System: D Surface and System Elevation S Position of Observation and Vent Pipes D Dimensions and Depths D Make, Model & Number of Chamber Units in each Cell Property Information a How many systems will there be on this parcel of land? D Has this property been split? _ (Property Statement shows Property History) Fees: 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/forms/checkllsts/checklistforsanltaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012-dc) Proofed by: Bayfield County, Wl 6/19/2024, 8:15:32 AM Rivers L.........J Approximate Parcel Boundary Road Type ~—" Town Lake Superior Shoreline Recession Segments The average annual rate of bluff recession in this reach of shoreline is approximately 1 .0 feet. Flood Plain Boundaries Active Dec 16th, 2011 0 AE = Base floodplain where base flood elevations are provided. o Lake Superior Proposed Setback Line Building Footprint 2015 * Building 0.01 1:653 0.01 0.03 mi 0.01 0.03 0.05 km Bayfiefd County Land Records Department Bayfield County Zoning Application https://maps.bayfieldcounty.wi.gov/ZoningWAB/ 5/30/24. 11:08 AM Novus-Wisconsin Access rev. 12.0206 Real Estate Bayfield County Property Listing Today's Date: 5/30/2024 Description Tax ID: PIN: Legacy PIN: Map ID: Municipality: STR: Description: Recorded Acres; Calculated Acres: Lottery Claims: First Dollar: Zoning: ESN: v Tax Districts 1 04 010 044522 001700 Updated: 5/20/2024 8107 04-010-2-51-06-32-2 00-299-02000 010109501000 (010) TOWN OF BELL S32 T51N R06W THUNDER BAY SUB-DIV LOCATED INGOVT LOT 2 & PART OF NW NE LOT 2 IN DOC 2024R-603126 468A 1.800 1.807 0 Yes (R-l) Residential-1 107 Updated: 3/15/2006 STATE COUNTY TOWN OF BELL SCHL-SOUTHSHORE TECHNICAL COLLEGE a Ownership Property Status: Current Created On: 3/15/2006 1:15:03 PM Updated: 5/20/2024. MICHAEL T & LAURA J POUFKA MINNEAPOLIS MM Billing Address:MICHAEL T & LAURA ]POLIFKA3614 GARFIELD AVE SOUTHMINNEAPOLIS MM 55409 Mailing Address: MICHAEL T& LAURA J POLIFKA3614 GARFIELD AVE SOUTHMINNEAPOUS MN 55409 V Site Address * indicates Private Road 88955 THUNDERBAY RD Property Assessment HERBSTER 54844 Updated: 10/19/2015 * Recorded Documents Updated: 3/15/2006 2024 Assessment Detail Code Gl-RESIDENTIAL 2-Year Comparison Land: Improved: Total; Property History Acres 1.800 Land 138,300 Imp. 33,000 2023 2024 Change 138,300 138,300 0.0% 33,000 33,000 0.0% 171,300 171,300 0.0% Q WARRANTTDEED Date Recorded: 5/3/2024 2024R-603126 a PERSONAL REPRESENTATIVES DEED Date Recorded: 10/27/2017 2017R-570610 B CONVERSION N/A Date Recorded:482-299;511-30;736-263 https://novus.bayfieldcounty.wi.gov/access/master.asp 1/1 HOLDING TANK SERVICING CONTRACT Contract Date^^'^JUN (HjZm This contract is made between the Holding Tank Owner(s) Name(s) f^^ti/^L T. Po/i^lto. ^^t/e^ J'. ftli^K^ Pumper's Name (Print) , , [ ^ —T^<? ^^s T'e' I l^e.s-K' '^i^o '1 "p?.l i/^ ^-e f^, <_- Pumper^s Signature Pumpers' Registration # ^ / 2-"7 f We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION Legal Description: (Use Tax Statement) Tax IDS S I c/7- Section 0 t- .Township 3 ( __ N, Range _^_W____ w Gov't Lot •2- Lot»z CSM#Vol. Page CSM Doc ff Lot(s) No.Block(s) No. .1/4, _ 1/4, TownCT' 6eH Lot Size \,^c.<-^5 Acreage77 Subdivision: Tl^u^^lo^ 1. The owner agrees to file a copy of this contract with BayfJeld 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: JACOB R BUESGENSNotary PublicMinnesota My Commission ExpiresJan 31, 2027 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 fiie 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) ^l^k^f t. Pol,fK^\ l^M^A ^ ^l.fk^\ Owner's Signature(s) ^J^r,/jc^ Subscribed and Sworn to me: +vnon this J^__day of Apr ^ I , t^>^ by: ^<Sco6 ^u^^£) Notary Public My commission expires on: Revised: May 2016 (®May 2018) Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (l)(m)] Drafted by-^fL Document Number/Plan I.D. No. Owner Name (s)^h^ ^ /A^a-P^Li^l^A Parcel Identifier Number (PIN) -r'^Y.'!^ ^ g / 07 HOLDING TANKAGREEMENT Owner(s) Mailing Address^?$"f f^^b^^J. /-^e/^<-.- ^ 7: ^-V^// Agreement Date (same as NotaryDate) ^- / 0 - ^-</ We 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 a holding 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. -1/4of__1/4 Section..Township S-l .N. Range ^-w. 6t^L.Town of. Additional Legal Description: bc-'C ^ ^t/ 'R - ^^ '2- <<° Gov't Lot_2L Lot Z- Block _Subdivision T^-^ ^ <^ ^-^ Lot_CSM #„ Vol ., Page _CSM Doc#. ^?/\ "-/ CSM#T DOCUMENT NUMBER2024R-603412 DANSEL. J. HEF^NER Rh'GiSTER OF OKfciUS BAYFIELD COUNTY. Wi RECORDED 05.-'.30 ,'2024 AT i 1:00 AM RECORDING FEE: $30.00 PAGES' 2 Return To: 7"&»-». <y 'J^i- / k- <r'i5" ,fe. • r^-.- ^oy ^" 'TKO'<T. l^..^e»--^d.^•^8Y'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. 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., Bayfleld 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. 2. 3. 4. 5. 6. 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. Bayfleld 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 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 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 subr agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will per( existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Please Print/^W fi/.-P^ ^cWli^ /^///7/<<:<<- Subscribed and sworn to before me on this date; ^/f*l^0^<-( Notarized Owner(s) - Signature(s)^^/r/^^ Notary Public My Commission Expires:€>(.( ^ <f(^W r Drafted by:^To ci I/ 'f?c» / k'OS k' 'ormatlon you provfde may be used for secondary purposet Date;^/^--z-/ Personal Information you is [Privacy Law, s.15.04 (l)(m)]u/forms/sanltary/holdingtankagreement.doc ©June 201 BAYFIELD COUNTY SANITARY PERMIT # 24-70S STATE SANITARY PERMIT D TRANSFER/RENEWAL PREVIOUS NO. OWNER: Michael & Laura Polifka PROPERTY LOCATION: Town of Bell Lot 2, Thunder Bay Sub-Div SEC 32, T51N, R6W PLUMBER: Allan Polkoski LIC. #: 220090 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 a 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. Alessandro Hall AUTHORIZED ISSUING OFFICER 6/27/2024 DATE Condition: System to meet all setbacks. Management plan to owner. Properly maintain per recorded agreement. Properly abandon existing/old system per SPS 383. THIS PERMIT EXPIRES 6/27/2026 UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R. 06/23)