HomeMy WebLinkAbout24-95SRflit,,
Department of Safety
County
Q°' �'e 1 A-
& Professional Services,
Sanitary Permit Number (to be filled in by Co.)
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SS OO376
Industry Services Division
1 - 5 Sic
Sanitary Permit Application
State Transaction Number
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
Project Address (if different than mailing address)
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(I)(m), Slats.
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J 331 O Fa: I'� rr...l7 2
1. Application Information —Please Print All Information
Property Owner's Name ERTEREU
Parcel # TAX 1(i 3 S S9 8
Sandia Favll4ner 3//>/a6
0y-031 •t•p . I3
Property Owner's Mailing Address
Property Location
/q
l9 a70 Cc-Iiiin perison iR
Govt. Lot
City, State
I Zip Code
Phone Number
lx'�a5av+ , W I
SYSS(e
7,s---,t.lY
5E /,, N W '/4, Section � 3_
T y (, N R L L -o
II. Type of Building (check all that apply)
Lot #
�1 or 2 Family Dwelling — Number ofBedrooms 3
Subdivision Name
Block #
❑ Public/Commercial — Describe Use
0 City of
❑ State Owned — Describe Use
0 Village of
CSM Number
%Town of M`san
111. Type of P0WTS 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
❑ Replacement System
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatment Unit (explain)
B.
❑ Holding Tank
�In-Ground
❑ At -Grade
❑ Mound
❑ Individual Site Design
❑ Other Type (explain)
yp ( p
(conventional)
C.
❑ Renewal Before
Revision
❑ Change of PlumberList
❑ Transfer to New Owner
Previous Permit Number and Date Issued
Expiration
rank O%4n qe,
aLl- gss CFA) v9/as/LI
IV.
Dispersal/Treatment Area and Tank Information: �,K P h b e rb a 5 e fs o F e .-, d
Design Flow (gpd)
Design Soil Application Rate(gpd/sf)
I Dispersal Area Required (st)
Dispersal Area Proposed (st)
System Elevation
0.7
_ 3
Gsa A
4a. 1/7
Capacity in
Total
# of
Manufacturer
Tank Information
Gallons
Gallons
Units
a
I
V v
—
v
New Tanks I
Existing Tanks
c
a
,
A
U
rn
i% 0
Septic or Holding Tank
p
'!
—
Cl o
i
S e O r C63 F
Dosing Chamber
V. Responsibility Statement- I, the undersigned,
assume responsibility r installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Plu r s Signature
MP/MPRS Number I
Business Phone Number
-r�pxrls 13L,+FCr4:e1
G 7
715-6311-9
Plumber's Address (Street, City, State, Zip Code)
!W3fl) Ska Road 77 IdaGoX 99 q3
VI. County/Department Use Only
�Js
``pproved
0 Disapproved
Permit Fee
$
Date Issued ��r
�T
I sui g A Si mre
Z/�
II
0 Owner Given Reason for Denial
p25
3 2'Ij •�I
y
/
Conditions of Approval/Reasons for Disapproval
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-
RECEIVED
MAR 16 2026
Attach to complete plans for the system and submit to the County only on paper not less than a ii, x O inches in size Bayfield Co.
Planning act Z_;,'n9 Agency
SBD-6398 (R. 03/22)
PLo SCLC= I /O
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F) L do Do
334O Fe' %t 4 cl4vacN RO
(rev:sed� sel/v, n w /ti
Se C, a3, T4(, N, R06W
Towi op MRSOtJ , Q/aYFIELDCO,
Pc.\. 04-O -a•` -ct. •a3•a 04-DUU-13v0O
(3M= Nail t..t1 R:)oloU n I(s'IMofle
Properly Owner;
Sandca Lynn FA IKncr
RECEIVED
3 sar...
Dwo); ng
patvewnY
sv' c4oya). pr-ck. co. credo Sep I.c +cnli
Me -dc by .See or Pre•s+ Co w/
Lfc'c} mt LT-t/c;%-cr
P= Abserp} on kt¢- cv s;s+;-n5 of �wb
c..fln space d >_3 f t apa.r4 ,
c 1-o Fca 1 cE 3a Gj c K 1
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97-S& iE
133
9c..00 Ft
R,o.L , 1=(>,1TH Cl1iRGN RI).
MAR 16 2026
Bayfield Co.
Planning :riri'7 Agency
Page 3 of L
B^YFIELD Bayfield County
Planning & Zoning Department
117 E 5th Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-4010
Property Owner:
Submission Number:
FAULKNER, SANDRA LYNN
SS -00376R
19270 CALVIN BENSON RD
MASON, WI 54856
Transaction Number:
SS-00376R-1AEE7
Description
Amount
Sanitary Revisions
$25.00
Total:
$25.00
Payment Amount:
$25.00
Reference: 5137
Paid by: Butterfield, 14346W State Rd 77, Hayward WI 54843
Payment Type: Check
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-2495SR
STATE SANITARY PERMIT
OWNER: SANDRA LYNN FAULKNER
GOVT LOT: LOT: BLK:
SE 1/4 NW 1/4 SEC: 23, T 46 N, R 06 W
TOWNSHIP: Mason
SOIL TEST: 88-24
TREATMENT/HOLDING TANK
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: TRAVIS BUTTERFIELD
TRACY POOLER
Authorized Issuing Officer
DATE: 3/23/2026
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 #: 24-95S
LICENSE: # 652879
Condition: Properly Maintain System Per Recorded Agreement
THIS PERMIT EXPIRES 3/23/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION