Loading...
HomeMy WebLinkAbout24-173SRequest for Sanitary Inspection (24 Hrs. in Advance) Fax this form to Zoning Dept (24 Hrs.) prior to when you want an inspection — (715) 373-0114 If you do not have a fax and must email the inspection; you must email all staff members. Note fl Time Change fl Discrepancy fl Other Phone Number 715-682-6050 Plumber: Blakeman Plumbing & Heating Inc. Fax Number -Email Address Homeowner: Dale & Savannah Jolma steven.waby@blakemanplumbing.com Immediate Phone Number So Zoning Sanitary Dept can call you right back (if needed) Permit #: 24-173S 715-685-4128 Plumber's Choice Z Ing Dept No Inspection(s) during this time Date: 9/05/2025 Y� Tuesday (9:30 am - 12:15 pm) (Tracy) Plumber's Choice Z ng Dept Time: 10:00am `.� � Y Township: Kelly Address # & 60620 Argo Rd Road Name: Mason, WI 54856 or Directions To Site: Comments: Holding Tank Install Inspection ** Plumbers you must verify any change(s) by fax or email *` Notes from Zoning Dept: u/forms/sanitary/requestforinspection Zoning Dept (©4/12/04); ® June 2023 Lift nIRIn rnnirr'wtSPECTION REPORT (ATTACH TO PER DALE & SAVANNAH JOLMA 65352 ADLER RD TANK INFORMATION TYPE MANUFACTURER/MODEL# CAPACItY /s cA At I OALIr\J Property Line Well Water Service Building All -Weather Road OHWM Swimming Pool DEVIATIONS FROM APPROVED PLAN COMMENT $ (Persons �(pLLres t, di repancies, etc.) 'pil frt/ ,w8J COMPONENTS NOT INSPECTED P'an Rev i Required 1 Yes No Date: Signatur Ce m r / S.ketchW other side " w / tU' 10 of 13 Property Owner Information BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Bayfield County Courthouse Fax: (715) 373-0114 Post Office Box 58 e-mail: zoning(a bayfieldcountv.wi.uov 117 East Fifth Street Web Site: www.bayfieldcountv.wi.nov/147 Washburn, WI 54891 DALE & SAVANNAH JOLMA 65352 ADLER RD MARENGO WI 54855 As you know ,56/,tai.. I/U✓ w was contracted by you to install a private onsite wastewater treatment system on you property described as: Notes: Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: C. Tank was crushed / removed and pipes disconnected by: on at AM/PM On _✓� at /2 (�I PM) the above -mentioned plumber contacted our office to onduct a pre -cover inspection as required under DSPS 383. One of the following applies: SjSystem was inspected and appears to meet all applicable code requirements. ❑ System was inspected and appears to meet all applicable code requirements; however, a plan revision is necessary because the installation was substantially different than the original approval. System could not be inspected because plumber covered prior to scheduled time of inspection. ❑ System could not be inspected because plumber was not ready at scheduled time of inspection. County was unable to return to complete inspection. System could not be inspected because plumber was not ready at scheduled time of inspection. A re -inspection and $50 fee are required. P1System could not be inspected because County could not respond to plumber's time constraints. Comments: Ulformslsanilaryproperlyowner-input Apri12019 Department of Safety c•nlllny Bayfield e , = & Professional Semi - :f0 - S:uon Permit Number Iluhe Olld u, 1w Kn1 ., gP5 ` 01. :. Industry Services Division st:ne'I mnsacuoa Number Sanitary Permit Application � In nCCnrdallet' Nilll til'K ;%;._ 112 t. \1'is Mm time sotnmr imt o(tins fonu to the appu+prlate gin Cr will __-_ Is required poor to ohl:nnmg a sari per limit Note Application limns tar scne-rimed PC AV IS arc suhmlttcd to Pronto AJdlcm ul'Jif1'crcm iGun mailing addrewl the Dep:nbnent of Sniaty and I'rolessional Senores. lirw,mi udhnw,nlon you provide may be used li+r secondary purposes in accordance with the Privacy l nw. g 15.IW I Noy Stars. 60620 Argo Rd. Mason, WI L Application Information— Please Print All Information _ _ - I'ropeny Owner's N:uc Parcel a 04-026.2-46-05-24-203-000-100�/00 Dale & Savannah Jolma - — --- -- I'ropcnr Danwr's Sladntg Addle Property Location 65352 Adler Rd. J Goa Lnl.__ City, Suns Zip Code Phone Number SW NW 24 Marengo, WI 54855 715-681-1008 1.. s,. section _ 11. Type of Building (check nit that apply) Lot a 17— -- N R OS -_ 5 L• or W R I or'- Earn Dnelbng - Nw iher o(Rttlr,s'ins — _ ir —J Black a --- - - O I'ubltc/C ommcrcwl . Uascnhe t 0a- . . _ . - ❑ Olt' of ❑ 51.1c"nned Describe t'v _ ._ CS\I \wnhcr ❑ villaee at O'I'nort of Kelly _ III. Type of POWTS Permit: (Check either •'New" or "Replacement" and other applicable on line A. Check one hoc on line H. Complete line C it n , Iicable.) A ❑'' New System ❑ Iteplocement System 9 Other hloditicauon to 8slattng System (explu ni ❑ Additional lheueatmem 11,111 (explaml ❑ At -tirade ❑ Nitala l ❑ Indrcldual Site Dell It. ❑r tIolding'1'ank ❑ In -Ground tcons•entiannll C. - Ids"ilreyious Permit Number and Date Issued lWage ofPlunder ❑ Oran":, to New ow er ❑ I l ❑ Iictesyal liclare ❑ Ras•isinn f%piratiun IV. Dig ersallTreittment Area and tank Information: Design Soil Application Kateigp&Usl) Dispersal Area Required Igll Dispersal Area I'ngnad (at) I Sysdnn Elevation Design Fiu\\ (gpd) 450 N/A N/A N/A ('alxtnq'm l owl aui hlanuliwturel lank Inlimnnuw, l'ndluns Gallons Units 7 _3 Csuarink. � j 9 NmrI':mi,. ill 1250/750 Combi elxiew lh.hhnr,a^A 1250 750 - —J-- 1250 750 1 Wieser 1 Wieser IN'taat,mn,+r, V. Responsibility Statement- 4 the undenigned. assume responsibility for imultation or the PGWTS shown on the attached plans. I'Itimber's Name (Trott I' other's Signature MP/MPItS Number liusb,ess Phone Ntanber 715-682-6050 Dean Blakeman 1092768 Plumber s Address IStreet. City. Sane. Zip Codcl 44941 State Hwy 13; Ashland, WI 54806 VI. County/Oeportmcnt 1'sc Ooly Ctl ill fl'C JtaC Issued lagllllg Approved ❑ Disapptnyad S n y; '�F'C 1l n l h.ne, 61".. Reason n., Mri,m -" ('ondttiu : orAppmral/Rcisons for Disapproval bUeaifr (a I Sktll be- wi44,;r, Z5' of -iGtnk (Access cci a -d si,an .n tl.i Oaf it nl., I r au• ...loll aNl ,pinnn In mr (null, nni.. nun ,uai.er Oar M.. iiiYO n l t \ .l tntnl. ,n."f Seib -6398 (R. 03/22) Soil Test # Bayfield County Waiver of a Thorough Soil & Site Evaluation D E c E v E D (subject to 15-1-10(d)) '`'s'NZ4 I '-LCt (1f rT.) t.AKf olt qAl 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 h -A L T-" L r'l A- Contracto Property Address (o0(9& ARCAuthorized Agent M- SOA/ / L✓=L Agent's Telephone Telephone 7,/ST 6 '/ /o0S' Written Authorization Attached: Y or N Accurate Legal Description is requested: Sl✓ 1/4 of NIJ1/4 SectionZY Township N. Range 5 W. Town of_________ Govt. Lot Lot Block Subdivision CSM# Volume Page of Deeds Parcel I.D# Acreage G' Additional Legal Description: Indicate reasoning for your determination: rr A foRxzaN,r LC IS ?44, SAC lSo,tt (, 2ctfl47Zcv/ Signature O/Certified Soil Tester Date Certification # Signature of County Official (Submit a Plot Plan & Fee) Date u/forms/soi Itestwa iver(K L K) February 2005 • SLV\4 S �,//Ji✓52y7—V6 AIA5" r-,/ TOWN cc KCLLY, Bfly.cLLLD c_i_v y0 f9CR.E5 9of 1111 0CT L o -UL4 Bayfield Co. Zoning Depi SCRl / =1 fU / N° W' LL cR scPTic- A -Y TH cc rz6ME UVt0 ,5ac' T N'RT-' PkoP LZNi, PRoPost6 Nom t CLCARfb 1R�Pr 4PPea)(, .3.s/ #P3 j PAGE 1 OF 4 Pg 1 of 4 Pg 2 of 4 Pg 3 of 4 Pg 4 of 4 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Holding Tank Version 2.1 (May 2022-2027) Index & Cover Sheet Plot Plan Holding Tank Specifications Management Plan EGEoVE 0 0CT 2.82024 Bayfield Co. Zoning Dept. Attachments: Enclosures: Filter Detail POWTS Application for Review Alarm Detail Soil Evaluation Report & Site Map (if ap Tank Specs Holding Tank Pumping Contract (if app! Holding Tank Agreement (if a plicable) Project Name / Description Dale & Savannah Jolma Holding Tank Owner Name(s): Dale & Savannah Jolma Owner Address: 65352 Adler Rd. Marengo, WI Zip: 54855 Project Address: 60620 Argo Rd. Mason, WI Govt. Lot: SW 1/4 of NW 1/4, Section 24 ,T 46 N -R 05 E ❑ or W C Township: Kelly County: Bayfield Project Parcel ID #: 04-026-2-46-05-24-2 03-000-10000 Legacy PIN: 026104910000 plicable) cable) Phone: 715 -681 -1008 Designer Information Designer Name: Dean Blakeman Designer Address: 44941 State Hwy 13, Ashland, WI Zip: 54806 E-mail: dean@blakemanplumbing.com This space reserved for approval stamp. License Number: 1092768 Phone: 715 £82 _6050 Remarks: Signature: Date: 10/24/2024 9 Original slg ure required on each submitted copy. CHECK BOX AS APPLICABLE. 0CT 28202 HEQC9BOX AS APPLICABLE. ❑ SOIL EVALUATION uU Scale: 1"=40' ® SYSTEM PAGE 2 OF4 SITE MAP ° 40 g ng DepOLOT PLAN PROJECT NAME 10, DESIGN FLOW: 450 GPO Dale & Savannah Holding Tank Attach design flow calculations for commercial plans. .lolma PROJECT ADDRESS: Bna7n Argn Rd Mason WI Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) BM Symbol: h BM Elevation: 100 00' FT sanitary Sewer: 4" PVC / SDR 35 Y Force Main: I BM Description: eGradient(% Slope ) Well Symbol (If applicable): 0 Indicate north by drawing an arrow IMPORTANT: Show ground elevation contours at suitable intervals. of Tested Area: on the approprue line. No Well Present at this time 40 Acre Parcel (Proposed 1250/750 Hold 355' 16 60620 Driveway Wooded Area 0 Proposed 30' 4" SDR 35 Pipe Protected From Frost if Necessary Proposed 3 Bed Home Cleared Area Bi 0 B2 0 PAGE 3 OF 4 HOLDING TANK SPECIFICATIONS (No Scale) 4"9 Vent Pipe Weatherproof >10 ft from Junction and AlarmBox Building Approved Electrical must comply with Approved Locking Manhole 12" Min. or 2.0 ft above Vent Cap Established Flood Elevation 4" Min, or 2.0 ft above SPS 316 and NEC 300 with Warning Label Attached (typinl) t ( YPi�I) Established Flood Elevation - (typical) Conduit I [L Airtight Seal - Finished Grade 18' Min. (typical) • . .•• •Inlet Inlet Invert H I atertight ApproveT Jointswint Plug Approved Pipe 3 ft ontho Max. 12" or 90% of total volume Solid Ground If more then one tank (typical) Alarm -On a. Compartment 1 Vol = 1250 gal Compartment 2 Vol = 750 gal TOTAL HOLDING TANK • VOLUME= 2000 gal • e• ar 3" Approved Bedding Material Beneath Tank TANK MANUFACTURER: Weser Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight = [(cu.ft.tank.vol x 62.4 lbs/cu.ft) - Ibs.tank.wt] x 1.5 Ballast Weight = [( 280 cu.ft. x 62.4 lbs/cu.ft) - 14,680 lbs] x 1.5 = 3,918 lbs W1250/750 -MR I RS" u 0 TOP VIEW or SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1/2" BOTTOM: 3" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" O.D. LENGTH: 155" O.D. WIDTH: 86" O.D. BELOW INLET: 53" O.D. LIQUID LEVEL: 48" 4" CAST -A -SEAL WEIGHT: 14,860 LBS. SEP11C INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET, CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.66 GALAN (SEPTIC) 16.12 GAL/IN (PUMP) LOADING DESIGN: 8' 0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC/SEPTIC, SEPTIC/PUMP OR SEPTIC/SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) v CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER UONCIgE n P N O Cp � � r` G � a Rf II DRAWINGS TED APPROVAL FOR APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: Q C Z 4 U F 0 W PDL PA Inc. Innovations in Precast Drainage C Zabel= & Wastewater Products A Division of Polylok Inc. PL -525 Filter The PL -525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL -122, the Polylok PL -525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. i Af 1111 ECEoVE 0 OCT 2 8 zu14 Bayfield Co. Zoning Dept. PL -525 Effluent Filter Features: • Rated for 10,000 GPD (gallons per day). • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. • Accepts PVC extension handle. PL -525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL -525 filter into its housing. 5. Replace and secure the septic tank cover. PL -525 Maintenance: The PL -525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL -525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filth .10,000 Accepts 4" & 6" SCHD 40 pipe v�. Outdoor SmartFiltex Alarm Polylok, Zabel & Best filters accept the SmartFilter@ switch and alarm. Extend & LokTa' Easily installs into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com PS Patrol® System with 120V Alarm Installation Instructions ELECTRICAL SHOCK HAZARD Disconnect all power sources before servicing. Failure to do so could result in serious injury or death. This control panel must be installed and serviced by a licensed electri- cian in accordance with the National Electric Code NFPA-70, state and local electrical codes. Figure 1 3.5 inch (9 cm) minimum tether length Install alarm float and pump float. (Mounting Clamp detail) Figure 2 Figure 3 OCT 282024 Bayfield Co. Zoning Dept. Wide angle* float system. SJE Double Float` Master and Double *SJEPumpMastel°, SJEPumpMastef° Plus, Float® pump switches orSuperSing/e® pump switches DETERMINING PUMPING RANGE (IN INCHES) Super Single® pumping range I tether length 3.5 5 7 9 11 13 15 pumping range 6.5 7.5 8.5 10 11(12.5 13.5 SJE PumpMaster® & SJE PumpMaster Plus® pumping range tether length 3.5 6 10 9 14 18 22 pumping range 7 10 16 22 28 33 36 Use only as a guide. Pumping ranges are based on testing in non -turbulent conditions. Range may vary due to water temperature and cord shape. Note: As the tetherlength increases, so does the variance of the pumping range. Sjltjlhombus 22650 County Highway 6 N P.O. Box 1708 / Detroit Lakes, Minnesota 56502 USA 1-888-DIAL-SJE (1-888-342-5753) / Phone: 218-847-1317 / Fax: 218-847-4617 E—mail: customer.service@sjerhombus.com AF Websile: www.sjerhombus.com ®SJE-Rhombus PN1039317A • Rev 10/14 Figure 4 Pump power cord, alarm float cable, �y )� Riser mounting kit and pump float c L U �9 (optional) OCT 282024 power, and optional Pump power, alarmrA. RiBayfield Co. Zoning De pi p auxiliary alalm cable Run cables through optional riser mounting kit and post. Figure 6 cable cable PSP Punch out power cable knock outs as shown. Note: Only remove knock outs for number of cables used. Figure 7 Post (optional) Holding base, run cables through cord seal holes. ure 0 PVC pipe stomer supplied) Mount PS Patrol® to post. Note: PS Patrol® can be mounted to optional square plastic post as shown in Figure 7 or 4 inch conduit / PVC Pipe (customer supplied) as shown in Figure 8. Use #8 x 1" screws only. Figure 9 Incoming alarm power Incoming pump II I power L1 Alarm float switch I Connect alarm power, pump power and alarm float switch as shown. PSP ug Plug pump switch piggy -back plug into PSP cord receptacle. If using optional ETM plug this into back of pump switch piggy -back plug. Plug pump in last. If ETM is used, snap into location as shown. Arrange cords as WARNING: Failure to have the plugs in order descr bed shown. Receptacle is inserted into pocket. Push excess cord back as shown will effect proper operation of system. through cord seal. Install PVC dowels into unused holes of cord seal. Duct / seal Use electrical duct seal to fill around incoming power cords. Ensure pocket is filled completely and the gaps filled around each cable. WARNING: Failure to do so will allow sewer gases to enter control panel causing corrosion and failure of electrical components. Figure 12 ETM (optional) snaps into base r - li Fill unused holes in cord PSP receptacle with-�_�_ fits into pocket PVC ,. dowels Cord seal, nut 14 Firmly tighten cord seal nut so that cables do not move and cord seal is held in place. Install cover on base and screw into place. Figure 16 ELECTRICAL SHOCK HAZARD Disconnect all power sources before servicing. Failure to do so could result in serious injury or death. Figure 15 Power 0 Indicator Push to test Turn on power and test alarm by pressing the test silence switch. Horn will sound and alarm light will illuminate. SJE-RHOMBUS® warrants to the original consumer that this product shall be free of manufacturing defects for five years after the date of consumer purchase. During that time period and subject to the conditions set forth below, SJE- RHOMBUS® will repair or replace, forthe original consumer, any component which proves to be defective due to defective materials or workmanship of SJE-RHOMBUS®. ELECTRICAL WIRING AND SERVICING OF THIS PRODUCT MUST BE PERFORMED BY A LICENSED ELECTRICIAN. THIS WARRANTY DOES NOT APPLY: (A) to damage due to lightning or conditions beyond the control of SJE- RHOMBUS®; (B) to defects or malfunctions resulting from failure to properly install, operate or maintain the unit in accordance with printed instructions provided; (C) to failures resulting from abuse, misuse, accident, or negligence; (D) to units which are not installed in accordance with applicable local codes, ordinances, or accepted trade practices, and (E) to units repaired and/or modified without prior authorization from SJE-RHOMBUS®. will turn on. When alarm float is lifted, the alarm horn will sound and alarm light will illuminate. Dept. Some states do not allow limitations on how long an implied warranty lasts, so the above limitation may not apply to you. Some states do not allow the exclusion or limitation of incidental orconsequential damages, so the above limitation or exclusion may not apply to you. This warranty gives you specific legal rights, and you may also have other rights which vary from state to state. TO OBTAIN WARRANTY SERVICE: The consumer shall assume all responsibility and expense for removal, reinstallation, and freight. Any item to be repaired or replaced under this warranty must be returned to SJE-RHOMBUS®, or such place as designated by SJE-RHOMBUS®. ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS ARE LIMITED TO THE DURATION OF THIS WRITTEN WARRANTY. SJE-RHOMBUS® SHALL NOT, IN ANY MANNER, BE LIABLE FOR ANY INCIDENTAL OR CONSEQUENTIAL DAMAGES AS A RESULT OF A BREACH OF THIS WRITTEN WARRANTY OR ANY IMPLIED WARRANTY. NOTICE! Products returned must be cleaned, sanitized, or decontaminated as necessary prior to shipment to ensure that employees *" will not be exposed to health hazards in handling said material. All applicable laws and regulations shall apply. BAYFIELD COUNTY OCT 2 8 CUZ�i CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Bayfield Co. Zoning Dept. '1st, Check List %Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) I) Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) , Original Plot Plan (383.22(2)2. 3. &4.a) Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer Pump Tank Diagram, Alarm and Pump Curve (when applicable) Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) am ds) Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) N Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) -H-Am Servicing Agreement (Reeardad at Reg. of Deeds) [\Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) LN2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) State Plan Review (when applicable) Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) I Application Information must include: .,23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) Project Address or Road Name where driveway is/will come off of) II Type of Building Nk III Type of Permit LNIV Type of POWTS System NV Dispersal / Treatment Area Information VI Tank Information VII Responsibility Statement (Plumber's Information) lSi\ *Date Stamp* Plot Plan: (To Scale or To Dimension) Signature and Plumber Information Surface Elevation of Body of Water l Direction and Percent Land Slope Tank and Filter Information and Location l Wetlands / Navigable Bodies of Water Absorption Area (Proposed and Existing) Bench Mark (Location, Elevation and Description) N, Component Manual Version IN\ Piping Material Information (conveyance line, building sewer line, material type and diameter) Turn Over ► (,(Owners Phone Number) Address Number and Road S! North Arrow Contour Lines Structures and Driveways Boring Locations Property Lines Well Locations Legal Descriptions Cross -Section and Over -Head Profile of the System: OCT 282024 U Surface and System Elevation Bayfield Co. Zoning Dept. Position of Observation and Vent Pipes l Dimensions and Depths Lh. Make, Model & Number of Chamber Units in each Cell Property Information How many systems will there be on this parcel of land? __ - NHas this property been split? 1___p__ (Property Statement shows Property History) Fees: Private Sewage System (Septic Tanks) 00.0 ❑ Private Sewage System (Holding Tanks) $ 400.00 ❑ Mounds or Systems requiring Pre -Treatment $ 500.00 ❑ Sanitary Revisions $ 25.00 ❑ Private Sewage System Reconnection $ 50.00 and Private Interceptor ❑ Return Inspection $ 50.00 am anc Ants + c ec E.C1? S) u/forms/checklists/checklistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: Department of Safety Bayfield rr &Professional Services, i•0 <0 ;nir ,Pumil St ether iii, K111W w h, C.l 'lr\ P1 I : �l. Industry Services Division —'_Y•• _____ • IranAKtlnll NuIIIIA'I Sanitary Permit Application In accordance N,m MS .53 2n'). Wis Ado ('ode.,uhml6ion or lhi, than lU Cite :plprnpolte(!ii cc InnMi:d Lino _ -- . b required poor to uln.anmg a .:mitan pcuun Note Appiicathw hums tie nuitc-od t PC )WI S we suhmincd iii Prniect Addles I I F dill'erenl Own mailing address) the Dep:ulntenl of Sality and 1'n'kssional San ices. I'elsonal voli.nnahon you provide may be used fir sccwalary purposes in tegndai , wllh the Privacy Law. s I S.ii(I Nm), Sorts � 60620 Argo Rd. Mason, WI 1.:\pplicntion Information — Please Prior All Information _ _ Prapcn) (Tines s Name I',uccl n Dale & Savannah Jolma 04.026-2-46-05-24-203-000-10000 I'roperu t inners \laillug ,ddiess _— _- — Progeny Location 65352 Adler Rd. Cott 1.01- .._ - [it. Staic -- Zip Code Phone Number SW NW 24 Marengo, WI 54855 715-681-1008 s'-_ ',- Secm,n - 146 R 05 L• or W II. Type of Buildin>; (check all that apply) Lot a N �� _ ___ _ C l or d Painily Duelling- Number of0edris,ms ? _ allele a O I'ubhr/Cmnmcreial. Describe 11se. .— _. — _ — O lilt iii ❑Staten rimed-- Dewnl'e UM ' -- . ('$\I\mnher ❑Villace of _ e'fnttn of Kelly _ -- Ill. Type of PONES Permit: (Check either •'New" or"RReplacentent" and other applicable on line A. Check one has ml line B. Complete line C f a licahle. A 0 New System ❑ Replacement Svsem El)alien \lodilicauml to Gsbutsa Sysleui (explain) Additional IhetreJ neat Unit (cspland ❑ At -de D Mound I❑ individual Site Design ❑omer'IYpe (explain) 11. El IloldingTank Din -Ground i eonvernmmll l C. ❑ Renewal 11ctnrr ❑ Revision ❑ Change ul'Plunder D Transfer to New uttner l.ist I'rueioar I'emm NumhJ ',d Date Issued Expiration i Dispersal/Treatment Area and Tank Inrormation: Flory (gpd) Design Suil Applicatum Rate(gpd/sl) Dispersal Area Required (sf) Dispersal Amu Proposed (st) System Elevation N/A N/A N/A Capacity in llual h of Manulmrcl S a 7 lankIIIIrIIIflIiWI [L1250/750 l iallons Calkins Umt - `' y y I B Combs Nan ,iNb j irs14,1,1!,gni:a L `"r —lildlkagT'^t 1250_ -- 1250 1 _ Wieser ✓ _ IMninp (Lamtte, — 0 ! 750 1 Wieser V. Responsibility Statement- 1, the undersigned, assume responalhility for installation or the POUTS shown on the attached plans. - Plumber's Name (Print P nnber's Slannulrc MPIMPItS Number liusincss Phone Nunber Dean Blakeman 1092768 715-682-6050 _ Plumbers AJdrcss tstrtat. City. State. Zip ('tale) -- 44941 State Hwy 13; Ashland, WI 54806 \'I. Cuunly/Depnrtment Use Onl ' Pen^1Ili Per fY,ne Issued Issuing Approved O Ilisnppnn•nl S 'z4. 111-1 p <I,,nel 6n cn Rcmcn l:n lxnial I N' C,indilioi ' of Appmtul/keasuns for Disappmenl LIrCUfr rofttd .S4taL( be, Wi4th ZS' OE -lank <,(C(e ADeal),Inoell1aflr nl4ns ear derail,., nnil YUIIIYI. in Inw e -...n .,n .„ I"tiprr n.. In nraa a i 1♦.1,n[nar .a:,rr Si1D-63t)N (It. 03/22) :Y-177 n p Department of Safe County & Professional Servic Iui2q Bayfield Sanitary Permit Number (to be filled in by Co.) OCT 28 l / Industry Services Div isi 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(l)(m), Stats. 60620 Argo Rd. Mason, WI I. Application Information — Please Print All Information Property Owner's Name Parcel # Dale & Savannah Jolma 04-026-2-46-05-24-203-000-10000 Property Owner's Mailing Address Property Location 65352 Adler Rd. Govt. Lot SW NW 24 City, State I Zip Code Phone Number Marengo, WI 54855 715-681-1008 u, Y., Section T46 05 N R E or W H. Type of Building (check all that apply) Lot # a I or2 Family Dwelling —Number of Bedrooms 3 Block # ❑ Public/Commercial — Describe Use ❑Cityof ❑ State Owned — Describe Use ❑ Village of CSM Number S Town of Kelly III. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i a licable.) A. ❑ New ✓System❑Replacement System ❑✓Existing System (explain) Other Modification to ❑ Additional Pretreatment Unit (explain) B. ❑✓ Holding Tank ❑ In -Ground At -Grade I❑ Mound ❑ Individual Site Design Other Type (explain) (conventional)I C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV. Dispersal/freatment Area and Tank Information: Design flow (gpd) Design Soil Application Rate(gpd/st) I Dispersal Area Required (st) I Dispersal Area Proposed (sf) I System Elevation 450 N/A N/A N/A Capacity in Total H of Manufacturer Tank Information Gallons Gallons Units , e U'$ New Tanks Existing Tanks 1250/750 Combi I w r y ti w a Septic or Holding Taok 1250 1250 1 Wieser ✓ ❑ Dosing Chamber 750 750 1 Wieser ❑ ❑ V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POW'I'S shown on the attached plans. Plumber's Name (Print) P tuber's Signature MPMPRS Number Business Phone Number Dean Blakeman 1092768 715-682-6050 Plumber's Address (Street, City, State, Zip Code) 44941 State Hwy 13; Ashland, WI 54806 VI. County/Department Use Only ❑ Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature 0 Owner Given Reason for Denial Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than a in x 11 inches in size SBD-6398 (IL 03/22) Contract Date / o/zq/Zozy HOLDING TANK SERVICING CONTRACT This contract is made between the flu kill OCT 282024 Li Bayfield Co. Zoning Dept. HoldingTaTanker(s) Name(s) Pumper's Name ^� 4. (/ 1 J orfiwA a Sy-a'I+c Y.�,�ny f�K C, -t i.. , �,, c D. Savan 4 F0-i Sb1�1 �kc (A.113 Fl7t`l�Jt LN......b......,l...l.... tl.., i...-Inlhtinr. of M\ hnlrlinn ton4/el nn tho fnhInulinn nrnnarty' (Prnvidp IAnnl desnrintions ') PROJECT PIN Legal Description: (UseTaxstatement) 04-026-2-y6-Ds-2y-203-000-ICoo& LOCATION Town of: Lot Size Acreage ,t�'-' S Lt( 1/4, /VW 1/4, of Section 2d ,Township -/ O N,Range CC W y 0 Gov't Lot Lot 44 CSMN Vol. Page Lot(s) No. Block(s)No. Subdivision: 1. The owner agrees to file a copy of this contract with Bayfield 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 t 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) Ow s ature(s) Subscribed and sworn to me on this date: [j„l e To!,}to &I,, �Ooday' atePumpers O�P Name (Print) Pumper's Signature �`?"•.•�la Public Signature s mj .• AUBt\CJ ` 2-at?Pumper's Registration Number 9 Of 5G`` com4iission Expiration a. �.�a— ll/rnittt Revised: November2012 (Bayfield County Zoning) Drafted by u0..: 'SoIf A Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (I)(m)j E0 t�4 Holding Tank Management Plan OCT 2 8 2014 IMPORTANT: Bayfield Co Zoning Dept. The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s) 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), Wisc. Admin. Code. Estimated Daily Wastewater Flow = 450 Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o surface discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats. when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s). Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Blakeman Plumbing & Heating Phone: 715-682-6050 Local government unit: Bayfield County Zoning Phone: 715-373-6138 Local government unit address: 117 E 5th St. WaShbuf n, WI ZIP: 54891 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. 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, Wisc. Admin. Code. Contingency Plan In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agecy for review and approval. System Abandonment If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. Document Number/Plan I.D. No. ar Name (s) Dale & Savannah Jolma 04-026-2-46-05-24-2 03-000-10000 HOLDING TANK AGREEMENT Owner(s) Mailing Address 352 Adler Rd. Marengo, WI Agreement Date (same as Notary on the following property or that continued use of the existing premises requires that 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. SW 1/4 of NW 1/4 Section 24 Township 46 N. Range 05 W Town of Kelly Return To: Additional Legal Description: Gov't Lot Lot Block_ Subdivision CSM#_ Lot CSM # Vol _Page CSM Doc# DOCUMENT NUMBER 2O24R-6O5275 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 10/28/2024 AT 10:50 AM RECORDING FEE: $30.00 PAGES: 1 rr 292024 D As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property�lw8 eQdAll4 �t following: dYY�I e� 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., 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, Scats. 2. 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. 3. The owner agrees to contract with a person who is licensed pursuant to s.281.17 (3) Wis. Scats., and chapter NR 114 Wis. Adm. Code, to have the holding tank serviced in accordance with Ch. NR1 13, 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. 4. The owner agrees to contract with a person licensed pursuant to s. 281.48 (3) Wis. Stalls,, and Ch. NR 114, WI'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. 5. 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, WI'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. 6. 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. vnerLs) Naame(s)` Please Print %anru/ of rna Subscribed and sworn to before me on this date: 21 2 ;. (J•\'� ri d Owners) Slgnature(s) Notary Public My Commission Expires: 03 - 2 -202 '° s - Drafted by: Dale Jolma le I if 11111 Date: 10/24/2024 Personal Information you provide may be used forsecondary puryoses [Privacy Law, s.15.04 (I)(m)l ulformslsanilarylnoldngtankegreement.doc ®June 2018 11/8/24, 9:45 AM CarmodyTm BAYFIELD COUNTY SANITARY PERMIT (#04)-24173S STATE SANITARY PERMIT OWNER: DALE E & SAVANNAH N JOLMA GOVT LOT: LOT: BLK: SW1/4 /4 NW1/4 /4 SEC: 24, T 46 N, R 5 W TOWNSHIP: Kelly SOIL TEST: 151-24 (waiver) NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: Dean Blakeman CECE RUDNICKI Authorized Issuing Officer DATE: 11/8/2024 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 #: 06-0356 (County) LICENSE: # 1092768 Condition: Management plan to owners. Properly maintain system per recorded agreement. Tank to meet all setbacks and to be within 25' of an all-weather road. THIS PERMIT EXPIRES 11/8/2026 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION https:llwww.carmodyinc.com/PermitApp/Permit_Sign.aspx?Print=l &permitappid=7411 1/2