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1° INBOUND NOTIFICATION : FAX RECEIVED SUCCESSFULLY -- TIME RECEIVED REMOTE CSID DURATION PAGES STATUS September 4, 2025 at 3:36:31 aM CDT 7153724159 37 1 Received Sep 05 2025 06:57 HP Faxpolkosld Plumbing 7153724159 page 1 Request for Sanitary Inspection (24 firs. 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. Time Change flj Discrepancy fl Other Plumber: Ohl c /kor Fax Number Homeowner: I Email T� ✓1� S!e f-f�-� mnnnwaaa rnone Number So Zoning Sanitary Dept can call you right back (if needed) Permit #: Z — S Choice Date: I I- I Z— Z≤- (l:ooAwl I ownship: y✓ort Address # & Road Name: �` �� Z✓a� R' ✓er Tc,L--C GT(-t 4{ ,5o,tt1 or o✓ G �y �..._ t>°_ Directions [i✓. Q Jay, �/oiQ� Lih -{ uv n. KS c1 . ��lT r✓Cee ToSite: IL.kc Dr $4c, to x114 rr k� �t��.1 r tout �_ �r✓t ` r (. g z r 5- /{ an�h L kK a Comments: Plumbers you must verify any changes) by fax or email ek Notes from uMormslsan Itery/requestrorinspectlon Zoning Dept (04)12104); ® June 2023 �rp Industry Services Division General Information Pen Private Onsite Wastewater Treatment Systems ( POWTS) Inspection Report (Attach to Permit) TIM J & JANE M SLETTEN ET AL 7803 ST CROIX TR NORTH BRANCH MN 55056 Information City I I Village I I Town of: Xlc4, / ( /4 setback to: County] (�6kL /''� 11 Sanitary ermltNo: State Plan Transaction ID#: Parcel Tax No: 11 . y4; TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road Se tc 79 30 7 N/A Dosing N/A Aeration N/A Holding Pump! Siphon Information Pump Manufacturer Pump Model Demand GPM Filter Manufacturer Filter Model TDH Lift Friction Loss Head Total Forcemain Length Dia Dist To Well Dispersal Cell Information DIMENSIONS I Width I Length I # of Cells 9 1q31 SETBACK FROM I Prop. Line I Building I Well OHW Qj itv Type of Cell I Manufacturer: Model Number. Pretreatment Unit Die Dia Elevation Data STATION BS HI FS ELEV Benchmark 3 c3,c/ Bldg. Sewer Tank Inlet 90 Tank Outlet 9 cc 3_ t3 Dose Tank Inlet ________ ________________ Dose Tank Bottom Inst. Contour Header / Manifold Distribution Pipe Infiltrative Surface iag Final Grade S & X Pressure ❑ Yes ❑ Depth Over Depth Over I Depth of I Seeded I Sodded I Mulched Cell Center Cell Edces Topsoil ❑ Yes ❑ No 0 Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 1On y Grtw'%lIo t,ne4 0- .W / �oc(�C.sd���,h5. 'Ian revision required? ❑ Yes4"No n y Jse other side for additional information. /� � 3 Date POWTS Inspector's Signature cans71n «z mr7I\ License Number Property Owner BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Bayfield County Courthouse Fax: (715) 373-0114 Post Office Box 58 e-mail: zoning(ahbavfieldcountv.org 117 East Fifth Street Web Site: www.bavfieldcounty.org/147 Washburn, WI 54891 Information TIM J & JANE M SLETTEN ET AL 7803 ST CROIX TR NORTH BRANCH MN 55056 As you know was contracted by you to install a private onsite wastewater treatcnent system on your property (Tax ID# above). To know when your system will be due for servicing please go to www.septicsearch.com Notes: Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: Tank was crushed I removed and pipes disconnected by: on at AM/PM On at ________ (9l k l PM) the above -mentioned plumber contacted our office to conduct a pre -cover inspection as required under DSPS 383. One of the following applies: System 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. System could not be inspected because County could not respond to plumber's time constraints Comments: URorms/sanitarypropertyowner4nput April 2019 ,�� Atari, 1t •'I , R R Department of Safety County �S a S S_©Q 5?X & Profess n S V PS's- Industry S r g� SOsI Sanitary Permit Number (to be filled in by Co.) ________________ i)) c2s—pg8 Sanitary Permit Applicati Stat0TransactionNumber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to lb Is required prior to obtaining a sanitary permit. Note: Application forms for state- {� 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(1)(m), Stats. Project Address Of different than mailing address) c/,,f f f #vl Lm k -e I. Application Information — Please Print All Information 000 vI cl)l 9 � Property Owner's Name '-r';fl4Property ...• ,._ Parcel!! petty Owner's Mailing Address O3 57'` tc Property Location City, State c A P1'/ M Zip Code b Phone Number c fp ! Z 'z �'c�--�P g' GovLot____• ' Govt. , '/, / ..___-.�'�� Section II. Type of Building (check all that apply) Lot!! L/IN N R '• IF1 I or 2 Family Dwelling — Number ofBedrooms 9 Subdivision Name O Public/Commercial — Describe Use Wc, I'-( `Il a�z t' c k s f r,1iP Block! O State Owned — Describe Use O City of O Village of CSM Number Q1Townof PVC n• TII. Type of POWTS Permit; (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line Cif a liable. I A. 0 New System 0 Replacement System ❑ Other Modification to Existing System (explain) 0 Additional Pretreatment Unit (explain) B' 0 Holding Tank 1W In -Ground 0 At -Grade ❑ Mound ❑ Individual Site Design I 0 Other Type (explain) (conventional) C. 0 Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration O — •-r-•-.... Ya/ Nyai sit D5 ViRi n / Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units New Tams Existing Tanks aI W W wt7 Srptic u• -Balcittg Tank V. ResponsibilityStatement- 1, the undersigned, assume responsibility for install don of the POWTS shown on the attached plans. Plumber's Name (Print) t Plumber's Si tut n)MP/MFRS Number Business Phone Number AilPlumber's Address (Street, City, State, Zip Code) c ,5- Z y tit < <! �e. v , ` `{d Y VI. County/Department Use Only Approved ❑ Disapproved O Owner Given Reason for Denial Conditions of Approval/Reasons for Disapproval Etoo ,ob J 5/2i/ 'T7i 5ec71. Attach to complete plans for the system and submit to the County only on papanot less than $ 112 x II Inches In size 2 SBD-6398 (R. 03/22) E II Wisconsin Department of Safety and Professional ServiL,, Page!_. • . Division of IndustryServices MAY 13 2025 Scl! TEST SOIL EVALUATION REPORT a9 - 25 6a urz In accordance with SPS 385, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, CLY l but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. Z K 1 D 3 I 6 Please print all information. e 1 Date _ Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). /q' / Property Owner I Property Location EJ Q %V f 'e_ T T 'e in Govt. Lot '/< % S / 7 T 417 N R _E (or) 1� Property Owner's LMailiinng Address Site Addjess or SM and Lot #r• f yQ!f_1 �° 1 ..L,, q 7� 3 s'f 6wc, l X v ttCj 1- i'V1 ors..1 Lc k� 5T4 S La 1 1 CI y State I Zip Code Phone Number ❑ City ❑ Villagq �I Town Neares Road o ✓ -t1v r-�C ( ,z-)t1a ~ ' - 1, 1461 I�w� Dv _ LQ 1c6e d- NewConstruction Use:ER Residential/Number of bedrooms Z+ Code derived designflow rate 300 GPD Replacement . ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft. Parent material 4 ke- g. t ' a d 9 General comments and recommendations: a Boring # ❑Boring �Plt Ground surface elev.-199y.O ft. Depth to limiting factor' "/Tin. / elev. ft. Q..11 A ....11...,is.... n..+.. Horizon Depth In. Dominant Color Munseli Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots •rr• GPD/Ft2 *Eff#1 *Eff#2 © i O i23 o &) ✓ 4 3 4, . b - T-IO4R54 ant P Ls O k4 ,/ (_S 3 .1 /7- Boring c/ IPit Ground surface elev.cl `7.0 ft. Depth to limiting factor 7ll I in. / eiev. ft. Qni1 e...,1:...�+1w.. bw+w Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cant. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 o-5 'o'z.3 oMe SL- k ivt✓ ✓ C,5 3 2 c -z4 s≥ -7 .-(f ° e k t/ r a s 3h ? t 2-1 —I i s U b X11{ / (% 1. , r v c .7 CS d Name (Pleasse,�Print) . � I 4'1. l m Pl l k -d Signatur t CST Number 2-2. d O 9O Address 'P C). Be, f. S&2.. Date Evaluation Conducted Telephone Number * Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 5150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS s 30 mg/L SBD-8330 (R04/21) I -4 50 -- 5o i 1 s V -Q cr 4r- (x �q 1.3 Boring # Page ❑ Boring Pit Ground surface elev. 97.0 ft. Depth to limiting factor ?'8rin. / elev. ft: Q..it A....G....it..., o_•.. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 2 ,-≤' /op fl'e sL (-Lk v- aS 3 •L( Z -17 c -'a- a' P LS O 14'lZ cc. .7 1/ j2. U U , ` :� Z 025 L ❑ ❑ Boring Boring # ❑ Pit Ground surface elev.BafieId c `[ @Jing factor in. ! elev. ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Eff#1 *Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. c..tt w_..ts__•t__ d_a_ Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2= BOD, <_ 30 mg/L and TSS 5 30 mglL r y s c+s 6©; J Goo, p,r yo aJG:QNt�; '11�, fo;.� s I ° I��W�lo'&Anfez s�� �� v ,4.I ��'/ JI. s �rp�;' 1 '' %✓c✓ w� .:� ' Mb f JetP EIev,,�m,�( 1Z' 6S3D ®; DI /�oJia) II y� e L 5 T 7► : s p+ t."�'ei ,k 0 7 ,�c+ /!s n FIJI eser tA:,0NGv'e�-��`; . 9 It `.` fig'j2, H�°g l��"w G� vt�ta►jt� �o + ;v Iq x;1'l � I �YG i• , �'1,•��k x{75' ut iles. I.°A;& & 16 i ,6. s Q.si3+G'&/444 ` .p •s itIC, - 1��.t : /.:.' a.. �O.ew-e. fie0 rj�o/1'm%r d /H p`'�. a.Ed pp Arm i"- a.c& t /C. A5'p'ivv IiiI.. L �� MAY 132025 Joo AL;... b ✓��a Ion 9t' �' _ e `'.�. Alms a y ,o��-�'- ' .v 1b 411 :. ,7� p lira ti 2. Getty L x A�''-/ Pr 'r r/u r� � �y OL_1 5GlI`ck mN a i 5 t 5'ee:-� 7" 7N �, '' W _ `7 8 v 3 6✓ - cv' ; K rE! ". )4c /T l/V1a c� .-) t-4 k E 5-IcdeS .Z.c* �•1 r �` ✓'ci yc `1 /74/..) 'Foos rn o¢ .L K was � "/'Va.►+ C4 p BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): d Check List 1111 MAY 1 31025 E Index Page / Title Sheet (Optional) Bayfield Co. Zoning Dept. ' El Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) 171 Original Plot Plan ❑ Cross Section Soil Profile Sheet (optional) ❑ Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) m Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used l?1 Property Owner's Information not prospective buyer's name) m Property Location (Accurate Legal Description with Sec/Twp/Range) tJ Road Name (where driveway is/will be coming off of) d Floodplain Elevation, Flow Rate, Comments and Recommendations El Complete Soil Boring / Pit Information 171 Date Soil Evaluation was conducted Cl CST Name, Signature, Number, Address and Phone Number 0 *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) IYi Bench Mark (Description, Elevation and Location) [in Contour Lines (Example = 98.0' /96.0' /94.0') m Property Location (Sec/Twp/Range/, Accurate Legal Description) 56 Borings (Locations and Elevations) U Percent and Direction of Land Slope Li Well Location (Including Neighboring Wells, if applicable) L] Location of Wetland Areas, Floodplain and Navigable Waters m Buildings, Driveways, and Structures (Location and Descriptions) 9 Location of Property Lines C1 Existing System Location l21 Address Number and Road Name d Current Surface Elevation of Wetlands and Navigable Waters A CST, Owner and Property Information 0 North Arrow Fee: 66 Certified Soil Tests - Review & Filing Fee $ 50.00 u/forms/sanitary/checkiist/checklistforcsts May. 5. 2017 •10:41AM BAYFIELD CO PLANNING & ZONING No. 9975 P. 3 PAGE 1 OF "7 In -Ground Gravity Plan Index & Cover Sheet Component Manuel Design References: Version 2.0, SBD-1 0705-P (N.01101, R. 10/12) Pg1 of7 Pg2of7 Pg3ofI Pg4of7 Attachments: 0 a Index & -Cover Sheet Plot Plan 5.phTu4 6 c'ss Section & Plan View Management Plan tnciosures: POWTS Application for Review ( San; Soil. Evaluation Report & Site Map fti Ii c.. A j r Project Name .1 Description MAY 1 32025 Zoning Dept Owner Names) fy► S 1 Phone: l'/Z -4b- 3 Owner Address: 7g 3 a r4 3 ra ,lYll(l Zi p: :ssb' Project Address: L41) ) y,- ¢ P_ . U.-- w -C ' 7 l cc I I o" Section 1.`7 T ? N -R ifE w _ - 1 ....-.�T� pf JC�I Township: ,- Y County: Y Project Parcel ID #: 74 Y c �/ L D 4 '.l Designer Information Designer Name; A 1!' 7© I ko s k - Phone: 7 'f- 7Z - V / �P Designer Address: P a. )(S7- pro 2 v'eZip; _ , ?`(-7 J E-mail: "'o n .b ems. r- j u)% 'k n e_ © m This space reserved for approval stamp, License Number: Zz o d g C Remarks: Signature: - `' Date: 3 0 odg!Ral signature required on each submitted copy. P ik, : Pi i' :� p j' /0' j �I� less �� �._ �- d����s�� d �tcUQ e'%f"j A i► giIY'.wlga,.�ii '�Y•y 7 am ' V A PEr1 v� �l. .A ' '"' ® oV d"' ` // �io �a�/ j I •1 f �� Vii. E6 Q aJ 6c� �9 c�W6''�/' Sys 1.eu: q W d Z: Slzp fe.T'c k + 75D idI%A wJeseto t dHG.V�.-�'e.. T a �r �ae�', ah �t `�D #a 3V�/ 6 Z-' e b / �_y ' ., » • ptiw e; �� � J P ✓ °e 3''�'' tad t 8 id ��1 J � J�i��'q 1 • � % G. tNta+t i •O1 - to `f'v aizc. 1 .. ti;I . p s/ c'�, 1« w; �11- SPS 3S 3 �p ®� a'. ! dt .t �. fJ Q"9 fir',' rev► 1.� 5 pr' Gi �A `� Y f' a �. bo ''c ` -; ►a "• 'Pc/f' iG i�+Q.J+2, `�" Lh LbF VC. A rin ptic Pp' 's ASi vi 311 st. . - I l\I MAY 1 3 2025 ( 300 ("TI tP 70 � r V See 2 r��, � �� , • ' - �g "s-.- 'lO. 4L\0 , 3o 1Ii + /V `-r�c.�c. L.•e. ;4i : Zz-G1i K'l /c1+ -' .�.+%CKacc j'5 9 t i ► l -`�.' "e hk SCJ7TVTN Rf t 7 9 a 3 t Gve. X •rr. i 1 1-4 ke s•�G • mss ��G�� 1 -ti 13 r-ci vL d1 nn4 nJ .•� f % Y=om �� L./ L �.�4 3cg r'" I cL el Vo•n+ Cop ear •rj r.. Oa ...........,.,.q.,,,w.». Q s4 I4 „s� 08 nwa p, fir. • Mqq t� I : ' andtc4/P lr�� o 0 N 0) O CN O flnfl '— ci U � Q v ca a TOP VIEW PUMP PAD SIDE VIEW 4" CAST -A -SEAL WLP750-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1/2" BOTTOM: 3" COVER: 4" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: DOME COVER 61" O.D. FLAT COVER 53 1/4" O.D. OUTSIDE DIAMETER: 84" O.D. BELOW INLET: 42" O.D. LIQUID LEVEL: 37" WEIGHT: 6,150 LBS. 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: 20.28 GAL/IN HOLDING TANK: ACTUAL CAPACITY: 790 GALLONS OUTLET HOLE PLUGGED LOADING DESIGN: 8' 0" UNSATURATED SOIL OPTIONAL FLAT COVER TANK CAN BE USED AS: IS AVAILABLE FOR EXCHANGE SEPTIC/ HOLDING/ PUMP OR SIPHON FOR DOME COVER. COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) OUTLET CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 0 m m a �z III c W c m U m u) Q oI N Luo I �S0 Wm� N J3 0 < N Q 0 Q U c 0N DRAWINGS SUBMITTED N w FOR APPROVAL APPROVED BY: SHEET NO. APPROVAL DATE: 1 PRODUCTS NEEDED BY: ,.OF . E p D Department of Safety County g ,[ PS & Profess n $ V C s Industry Sanitary Permit Number (to be filled in by Co.) S _____________________________s- 02 b J Sanitary Permit Applicati MAY 13 WZ5 State Transaction Number In accordance with SPS 383.21(2), Wia. Adm. Code, submission of this form to th��yygg�p�+�jp�,g is required prior to obtaining a sanitary permit, Note: Application forms for state-dd<dd't�nk`f(rEYfbYtbfFtH the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Low, s. 15.04(1)(m), Stats. L f1c !.� /YIG� �,e DrI. Application Information — Please Print All Information T[ Property Owner's Name I i'vi Parcel I/ Property Owner's Mailing Address iat.kZ� 344I Property Locution 7 g u3 5-1 C b o; �c I City, State Zip Code Phone Number Jor+lI Ci ✓4.nc L( fl///U SS 65 0 /r z Apo\ -10 3o? Govt. Lot /<, I !-7 // , swoon II. Type of Building (check all that apply) Lot k tf' I or 2 Family Dwelling — Number ofBedrooms Z 9 T N R o o Sub/divisions Name C Public/Commereinl — Describe Use Block# / /,, _ 1 J jYCc �7 {'j'/buy `[L T-c(c rc ❑ State Owned — Describe Use 0 City of CSM Number ❑ Village of X Town of 1✓c n /Z• ✓�.r III. Type of PO\VTS Permit; (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C If njpplicablej A. New System ❑ Replacement System 0 Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) Holdin Tank8 ❑ At -Grade ❑ Mound qC13 ❑ Individual Sire Design ❑ Other Type (explain) (convents (conventional) Renewal Before ❑ Revision 0 Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV. Dis ersal/TreatlnentAlea and Tank Information: Design Plow (gpd) Design Soil Application Ratc(gpd/50 Dispersal Area Required (sf) Dispersal A a Proposed (at) I System Elevation .3t7 0 .' �z jJ S f Capacity in Total //of Manufacturer - Tank information Gallons Gallons Units New Tanks Existing Tanks a E .� E 9 to .bo _ rn y ii t7 SepIkur.7ialdmgTank K S O — `'?.5"O /. nC'ehmn6n• W 4'C.S •L l/ 6...G KC, ✓ V. Responsibility Statement- 1, the undersigned, assume responsibility for Install don of the POWT9 shown on the attached plans. Plumber's Name (Print) '/ Plumber's Si mr Ailea $ lC �'XP/MFRS Number Business Phone Number oIL=o t ,_ ( vY 22oo9d Plumber's Address (Street, City, State, Zip Code) -ncn-s{lS-(o ! - b Bess s - z- z y vo -t g t n/ e.✓4L:S yes Y7 VI. County/Department Use Only Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent SI am L ❑ $ �(oo DO Owner Given Reason for Denial , I5/j 2J Conditions of Approval/Reasons for Disapproval 5e,, ,, c / _ Attach to complete plans for tae sysren, and sahmrt Irvin ra,,n, .a., .... ......... , r ••�. pass umn o u• x i1 incur, In sin SBD-6398 (R. 03/22) yAAf1Ilfi�,r o Wisconsin Department of Safety and Professional ServiL,.. ,sF Division of Industry Services SOIL EVALUATION REF In accordance with SPS 385, Wis. Adm. C Attach complete site plan on paper not less than 81/2 x 11 inches In size. Plan must €nclude, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. I15) OUi) __ __ ml liii Page .of.. 3 U Ii MAY 132025 so l TEST ) RT #9,- aS IParcel I.D. K T D'- q '` / Personal information you provide maybe used for secondary purposes (Privacy Law. s. 15.04(1)(m)). 1 /4'J Property Owner Property Location _-._•I 'e.T Govt. Lot 14 '/a S 7 T 417 N R T E (or) Property Owner's Mailing inAddress Site Add ess /or SM and Lot #: 7 b �� a fr c / X C( l` o L-4 � � 574 'es Li- 1 1C€ `` State Zip Code Phone Number ❑ City ❑ Village- �I Town Nearest Road o r f�t � r-' .� -1)1� S �d 3�p ( �1z ), $? r G .--� `lam -�� I/44/f oo -i L 4 keL - NewConstruction Use: ER Residential/Number of bedrooms Code derived designflow rate 300 GPD Replacement I ❑ Public or jornmercial — Describe: Flood Plan elevation €f applicable ft. Parent material & lk e i. t '1 Q General comments and recommendations: Li I Boring # ❑Boring Pit Ground surface elev. 9 /. °. Depth to limiting factor'"/in. / elev. ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr, Si. Sh. Consistence Boundary Roots GPD/Ft2 Eff#1 *Eff#2 o— awe Z _ o / r ezt 't5 S 3 r ,to l..3 (-7-0 4 R S Yf—s7f ,4/ 5' C) vv ___ ),')r , I2.. I Boring # ❑Boring IPit Ground surface elev.?9.0 ft. Depth to limiting factor //rf €n. / elev. f.. 0-11 A ....li....it.... d..t.. I Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 I t? --S ,DVS2/ /\J9/(.),. iC "4✓ r ctS 3/14 S'- sY7Z (f o".e L- ,pck771v1cr Q .S 3 ; 7 t 2 24 -I s• a iv- S v 1 ACSTd �ame�.(Please Print) .�� � � � �� 0vi a S€gnatur � .. CST Number �� ® � 9 Address R 0. B� k. g'1Z- j r S'�' t'7 Date Evaluation Conducted ' - 3 0 - z I Telephone Number 1 l 4 Effluent #1 = BOO > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOO, s 30 mg/L and TSS s 30 mg/i. 4 SBD-8330 (R04/21) _t1 p 50 Sal ) '�"S+ �?� c GY X0 C� b o s1 212S ❑ Boring j Boring # Pit Ground surface eiev. 0710 ft. Pageof J rr Depth to limiting factor �" in. I elev. ft. A e..11 A....tt....at.... o...,. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#�1 *Eff#2 Z. C).-≤ ,D(g-3 cL ( c cc≤ 3, .'-( . Z Ste' -17 SY t2 a/ J( LS O L44L- 4 S Z\ .7 1 Z 1T- ))0U< -� #7 f 2- UU i: ' :i 1025 U Boring # ❑ Boring ❑ Pit Ground surface elev. a1etd Co. `png factor in. / elev. ft. C..tl A.....t=....at..., d.... Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots -rr^ GPD/Ft2 *Eff#1 *Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. / elev. ft. I Cnil A Horizon Depth In. Dominant Color Munseli Redox Description Qu. Az. Cont. Color Texture Structure ' Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 5 220 mg1L and TSS > 30 s 150 mg/L • * Effluent #2 = BOD, 5 30 mglL and TSS s 30 mg/L r y s o+,3 d 60 I +atD�,4 t yo aJ obt• `PtO1"4,,� �'cWctE+�° 1<<waIo'rti� �-�. 'd1u.er -� �e� end p� }� r �' ... I i + , t . P trJ • o ?wrf... . o I. .w �yyy! ` Y hr , ► !`f" i/ ` ),AC`1 _ b�,O+a,�1��y�% 1L� �J � e -a s ►JQ i/i� nal 'Y!f .' ` �jII10 V Pw Iri�. F�4v1'�G���zAM'S8 �'� ®`y 05dr ,�tf a!!i�N"A0Gi► y;. �" �z��q c, 5Sys4•. 14 eA� o 1 S�g +k..'���'�"ex�y,k % �R� itO J'l W1 P.Sr' �diH�{P�.-�� «I✓S ',.i�, �,, V 0 �•/ / / y� `. l (Z—" � � �! 6ni L,A.- on - �. 1��'^ . �y'• •eM'Y� ¢�iTrp f d�I r� y • '+ •wbi a d 11 G� {oY}0 �7 ti'if1; Gi°�" 1�1 a' � GIf�Ih�% � i G �/g 7 "'� 1r. �i�:ant �C1. i %d► �V'Cra�n�il /1 r IYs����'I'fld��t °'�'';� Le•., !`�c.. Gir� h I�aG.� t+� • Y ' •�•ar.p T4.1 k..a, tr A' � fir, " `y► c+ s r- vr .�; /-..p1q,k d+e. ! ep'2 � . J3 &f® PNX •P:pt-sQo ASrn'1 DJ'- aa.h S0 R3 ' P11C s ASTIveD 3 Y 'P" Ws. /,-J JJ4 r 'r r1 La r. 1111 MAY 132025 2 '/2 c+i;;* W 6e, Y1r Gel 11 Z2 C. �► X 'z c. "�G� + i Wa•1•av �sa�� Cap , L.•e.sf44 : ZZc1► C`��, 4 3,1 p5 q 1 ....•..,..� obs�aru��ia��pe5 __ J Ip©rey y Laid bas6rc Ia mti a '�.. w: r7Ina! g G'4a -A u 7 O - C. v' X L ti''. If 1 -1 e T c, i S LG• * � v1 � — v ' p. 1 ®!� YL s�T .� I'" m r,-� - V �., v' d.�i+o'� �1 Q" dal a�+ P • r• 6 . I:ku , 1• BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): D E 11 W E Z Check List 1111 MAY .1 32025 i6 Index Page / Title Sheet (Optional) Bayfield Co. Zoning Dept. ' . m Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) 66 Original Plot Plan ❑ Cross Section Soil Profile Sheet (optional) ❑ Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report (Include the following Information) ® Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used L?J Property Owner's Information (nQt prospective buyer's name) 121 Property Location (Accurate Legal Description with Sec/Twp/Range) C6 Road Name (where driveway is/will be coming off of) d Floodplain Elevation, Flow Rate, Comments and Recommendations 9 Complete Soil Boring / Pit Information Ql Date Soil Evaluation was conducted d CST Name, Signature, Number, Address and Phone Number ❑ *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) C6 Bench Mark (Description, Elevation and Location) li Contour Lines (Example = 98.0' /96.0' /94.0') m -Property Location (Sec/Twp/Range/, Accurate Legal Description) t Borings (Locations and Elevations) E1 Percent and Direction of Land Slope Ed Well Location (Including Neighboring Wells, if applicable) El Location of Wetland Areas, Floodplain and Navigable Waters I Buildings, Driveways, and Structures (Location and Descriptions) Ei Location of Property Lines C( Existing System Location IZI Address Number and Road Name L?J Current Surface Elevation of Wetlands and Navigable Waters l?i CST, Owner and Property Information E6 North Arrow Fee: l Certified Soil Tests - Review & Filing Fee , $ 50.00 u/farms/sanitary/checklist/checkllstforests May 5. 2017 10:41AM BAYFIELD CO PLANNING & ZONING No. 9975 P. 3 PAGE 1 OF7 In -Ground Gravity Plan Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10705-P (N.01/01, R. 10/12) Pg1ofi Pg2of-7 Pg3of7 Pg4of7 Attachments: O Index & Cover Sheet Plot Plan r.i>> Ic: Lro$sSection & Plan View Management Plan POINTS Applic Soil Evaluation 4. n." ("2� G N e -e Project Name I Description Owner Name(s): f r1 /tii S I e 4-fe vj Owner Address: 7 `; c 3 SficrcA x "( r Project Address: Z 9 s/ l �lYIo� n KII4 A�Y11oon"keGs 4eS Lc+C 1 Township: y v t r R: ✓-€ for Review(Sunf4 rr berm Air) )rt & Site Map c rew en MAY 132025 inning Dept. Phone: /F/Z -Z4b - (, 3 e `( 1Jor441 rq.4CI1bt/AZip: S.Sb≤% ! G {tee DV yr o : v -e - w Z r 4r k'F 7 Section 17 , T 47 N -R if E❑or w County: Ba Y ,c -c id Project Parcel ID #: Z D d 3 -(q/ t9 Designer Information Designer Name: Ai/4 r ?'o //C0 s /C Phone: 71C - 7y - V / S(P Designer Address. fPLo. 23 ©/c cn ::Cy-_ r `Z , ver '-j±L Zip; S`f RV7 E-mail: o n / hy u-' ci eyt o v h - C v ivy This space reserved for approval stamp. License Number: Z2-ED0 90 Remarks: Signature: __ bate:— 3 z S Original Signature requIred on each submitted copy. � �ryj !/,� 6 Z Sai { �or sae �f / Dvn.+n/nBy o �❑"olkpove! PIrin4'A1 /1 • S, a.CNVfn 111417 Jctla�46sorpPt 1 •O. tar w 7...'�,.. �•{L7 l' c n ('M y W "v ! uYY1.QLr1.P.rAT /'vlltK lSG11 �%S K.C�Q �� 2r a i�:r� ✓ w rW din; 7 ' gm. ¢ ditP%191ev. D®dlds(-/z'.4Mis ab—/D ®5. 9�.Bfl/4fr 8®QB ) / 3.6 se 4-lankb y5V jalfonwiesa'c.oncvve.•5e-gK"Lr 'a4, wneJ /4; �'y Z f✓oY�1 b.44..., 4 t.ar-M lew. finei.4 �G"!' I i$• Cp,.olie• pc: f S'4°b+alcdh•. i , f2'!{!s1 h1•• '�L Ywni..el� l�bp� { Gmng 4 � f Id. 'to 5� aF'icTan(ct Znifvc�°y:cou7ik'1 ) °' 'I /t y'f�oN�lss.vav/sl»co.�1 /'d w; -A 5P53oy 41 !/I f �49r Df. fereeB In � .5cp/.c /n•,/L oui'4@"P'"rm n4 £e ta.c ,c/ wppr."c L .cfy,:,.-psriekm Je.i pt_-eac 5J%go pJL Arr,n DP796-_ SLk S0R3a PJC. Pitt {S Asi-ni Dbe 3Y appv�adc. . y. r .»Lt�&Iroee'�tl I4IF%vtionn Lakr r�r. 7%1ve 'g�KlsTDIa14 i,W-^�-, Lk MAY 1 3 2025 !.o Set 7S, nlc;. 300 d / ,7qP ,e.t.a :. q25 4'i'ad.e5 ,f 2 •2.�,�y� c 0 t2 -C- Lell.f. _Z2 eL KZefi'/G r1 -h E. $'-Ff Z/�G. 1 o+cI La *c4A _ ZZcf Xtv/Gt.-� ',1cnrd.cc T+5 t 91 300 - Cf-yV 4.v, t✓ Properly ®Wer Lgcd OQsc.&;P am/1 a j 1rYt ctei 7[en I +se-c./flh/7NR`tW y '70 o3 CJI Cvc rCl? I"'�a'(IT emce%-ti BCE .C's4 c.7 eS 1„G*/ Lz c, 1 i lr /74/U ( _ c19#: -®.V1 (Zt VE.v o{ 3c. r1" 3 I WI t aMe y - C �Y'ryt4 F. t+B ��8. owapp y• uwn, fr s rth G+ an, 6cwa Wv A4 - V 0 Li M Rye4-#ea. .t R04b-0 WLP750- MR a TANK SPECIFICATIONS LC)o a N o Cl c DIMENSIONS: o a WALL: 2 1/2" BOTTOM: 3" COVER: 4" o MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: COVER 61COVERO I FFOMELAT O.D. m OUTSIDE DIAMETER: 84" O.D. BELOW INLET: 42" 4" CAST -A -SEAL\ 4" CAST -A -SEAL O.D. LIQUID LEVEL: 37" WEIGHT: 6,150 LBS. o24" INLET AND OUTLET: m TV 4" CAST -A -SEAL BOOT OR EQUAL GASKET. CAST -A -SEAL BOOT OR EQUAL FILTER OR INLET AND OUTLET BAFFLE AND FILTER: BAFFLE WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 20.28 GAL/IN HOLDING TANK: ACTUAL CAPACITY: 790 GALLONS TOP VIEW OUTLET HOLE PLUGGED LOADING DESIGN: 8' 0" UNSATURATED SOIL OPTIONAL FLAT COVER TANK CAN BE USED AS: IS AVAILABLE FOR EXCHANGE SEPTIC/ HOLDING/ PUMP OR SIPHON FOR DOME COVER. COVER: MIX DESIGN #8 NO FIBER) TANK: MIX DESIGN #10 STRUCTURAL FIBER) irv�u - -- OUTLET N N m a ¢ m < U M UEli' 22 ro C' a in PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: N .43 Q N II Q Q n U O O W5 N w o' SHEET NO. ,OF POWTS OWNER'S MANUAL & FILE INFORMATION Owner _j') Jf F v1 Permit # DESIGN PARAMETERS Number of Bedrooms 2, 0 NA Number of Public Facility Units NA Estimated (average) flow ZCC gal/day Design (peak) flow = (Estimated x 1.5) 3 gal/day In Situ Soil Application Rate % al/da /ff2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) ≤30 mg/L Biochemical Oxygen Demand (BOD5) ≤220 mg/L 61 NA Total Suspended Solids (TSS) ≤150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L lI NA Fecal Coliform (geometric mean) 510° cfu/10oml Maximum Effluent Particle Size %in die. 91 NA Other: NA 'Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ;3 mear (Maximum 3 years) 0 NA ss) Pump out contents of tank(s) 651 When combined sludge and scum equals one-third ('A) of tank volume ❑ NA 69 When the high water alarm is activated Inspect dispersal cell(s) At least once every: ® y ear(s)((Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) ® year(s)) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month((s) ®year(s) ❑ NA Flush laterals and pressure test At least once every: ❑ month(s) ❑ year(s) ® NA Other: At least once every: ❑ m ) ❑ year(s) ) X NA Other: I)6 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank Inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may Indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third ('/6) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. MANAGEMEND AN Uli MAY SYSTEM SPECIFICATIONS Tank Manufacturer ai kltC0, jept. ❑ NA ll Septic 0 Dose 0 Holding vol. 750 gal Tank Manufacturer NA ❑ Septic 0 Dose 0 Holding vol. gal Effluent Filter Manufacturer PC I y 10G 0 NA Effluent Filter Model P L 52 ≤ Pump Manufacturer 05 NA Pump Model Pretreatment Unit 69 NA ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration 0 Wetland ❑ Disinfection 0 Other: Manufacturer Dispersal Cell(s) 0 NA 69In-Ground (gravity) 0 In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip-Une ❑ Other: Other: NA Other: ys1 NA Page of 1 3 2025 A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (12/02) Page Z of I START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged ,to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist In manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify -a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be Installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name A 114h lea I `LAS k t�v f!i eG ?Ib; ) Name `(4 -L 01kos k (�o� k SG?L'. .'S� Phone 7 / L- bf l S Phone 1/ S Z ? Z - / ��► SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name " r o f cs ? I k os k( re"n'x•tter �,4) Name i s -R t I L.o tjvZ a n r on Phone 115 3"7 2— ft00 (p Phone -7/ g 37 3'— (p132' This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Private Sewage System Maintenance Agreement T,m SIe1-- '$03 Sf Gvc t'i. /JerHn f3ravic1 WIN cSos- Site Address SZcc bIct(f Moon Lje for fro t`/',J�v t.dLSr/F' Tax ID# 3L1'2 I /_ As owner, I (we) do hereby certify the private sewage system will be Installed In accordance with the certified soil tester's report and approved plans and specifications on file with Bayfleld County Planning and Zoning Department. The system will be operated in such a manner as to meet the designed plans. I (we) agree to maintain sold private system at the below listed location in accordance with rules established in the WI Adm. Code, as from time to time amended. (COMPLETE Legal is required) 1/4 of 114 ,,SectiionGG 17 Townshipi['7 'C 7 N. Range Q w. Additional Legal Description: ck I T M oar f.*_rce Es4s I -e S Town of ✓i) i ? , J2 {^ (Acreage) _ Gov't Lot Lot 9 Block Subdivision Az rAOOt-r La'LQ i s -M *cc Lot_CSM#_ Vol._Page_ CSMDoc# DOCUMENT NUMBER 2025R-607375 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 05/05/2025 AT 1 1 :20 AM RECORDING FEE: $30.00 PAGES: 1 Return To: D f2 (I� lyl D n,/ rC ( �S15/L`uJ/` ©. ( `3 0)c S MAY 132025 yl-c" (j. Jt t( grf1 `inquept- ® In -ground gravity ❑ in -ground dosed ❑ in -ground pressure distribution Sewage System: ❑ Mound O At -grade Sewage System ❑ Other Septic Tank (system types A through E): The septic tank shell be pumped by a certified septage servicing operator within three (3) years of the date of installation and at least once every three (3) years thereafter unless, upon inspection by a licensed master plumber or other person authorized to make such Inspection, the tank is found to have less than one-third (1/3) of the volume occupied by sludge and scum. Pump Chamber (system types B, C, D. and E): The pump chamber shall also be rinsed and pumped out when the septic tank is serviced as provided above. The switches and pump controls shall also be inspected and maintained to ensure operability of said components. Septic Tank Effluent Filter (system types A through E): The septic tank effluent filter shall be Inspected and maintained as necessary end in accordance with manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin. Code, Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually Inspected by a certified septage servicing operator, POWTS Inspector, or licensed master plumber within three (3) years of the date of installation and at least once every three (3) years thereafter to determine whether wastewater or effluent from the system Is ponding on the ground surface. Mounds At grade end In around Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbed if needed when the wastewater distribution call component is Inspected as provided above. Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs Incurred by Bayge/d County for inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate any human health hazard caused by the system. 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 especial assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. The terms and conditions of the agreement shall be binding upon and inure to the benefit of ell current and future owners of such property. Owner(s) Name(s) — Please Print y `rrvA S L� Trz N Subscribed and sworn to before me on this date: ktLVp, 7l5 Notarize wner(s)-Slgnature(s) Not.ary P^ublic My Commission Expires: urarrea Dy: r on f Date: _l (_ _ S 44 r HEATHER GILLETTE SLETTEN Proofed by: t�. r jtyy NOTARY PUBLIC MINNESOiorme/sanit /sepdcmaintenceagreement My Revised 2020 . j C0.Z:r�I�{ Jan 31,2026 July Lot' �J�nT10Vtci( BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) MAY 132075 uzl Check List Bayfield Co. Zoning Dept d Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) d Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 1' Original Plot Plan (383.22(2)2. 3. & 4.a) M Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) d Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) Gd Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(S),(6) (Recorded at Reg. of Deeds) ❑ Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) ❑ Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) 121 Fee (Make Check Payable to Bayfeld County Zoning) (383.21(2)(c)7) d . Comolete Set of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all conies) Ct'Soll 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) d I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) ® Project Address s Road Name where driveway is/will come off of) d II Type of Building ® III Type of Permit d IV Type of POWTS System d V Dispersal / Treatment Area Information d VI Tank Information d VII Responsibility Statement (Plumber's Information) 0 *Date Stamp* Plot Plan: (To Scale or To Dimension) RfSignature and Plumber Information i21 Surface Elevation of Body of Water Di Direction and Percent Land Slope 9Tank and Filter Information and Location t-rf Wetlands / Navigable Bodies of Water d Absorption Area (Proposed and Existing) Ef Bench Mark (Location, Elevation and Description) ® (Owners Phone Number) d Address Number and Road 56 North Arrow d Contour Lines 12' Structures and Driveways Cv3 Boring Locations tI Property Lines tii Well Locations g Component Manual Version El Legal Descriptions 3 Piping Material Information (conveyance line building sewer line, material type and diameter) Turn Over ► Cross -Section and Over Head Profile of the System: Surface and System Elevation UI Position of Observation and Vent Pipes E'Dimensions and Depths GA Make, Model & Number of Chamber Units in each Cell Property Information 1111 NAY 132u: ) Bayfield Co. Zoning Dept ❑ How many systems will there be on this parcel of land? 1 O Has this property been split? rsa (Property Statement shows Property History) Fees; 0 Private Sewage System (Septic Tanks) $ 400.00 ❑ 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 E Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) u/forms/checklists/checklistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012•dc) Proofed by: 5/21/25, 3:38 PM CarmodyT*' BAYFIELD COUNTY SANITARY PERMIT (#04)-25-28S STATE SANITARY PERMIT OWNER: TIM J & JANE M SLETTEN ET AL GOVT LOT: LOT: 9 BLK: SUBDIVISION: Half Moon Lake Estates 1/4 1/4 SEC:17, T 47 N, R 8 W TOWNSHIP: Iron River SOIL TEST: 29-25 NEW SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: Allan Polkoski TRACY POOLER DATE: 5/21/2025 Authorized Issuing Officer CHAPTER 145.135(2) WISCONSIN STATUTES a. The purpose of the sanitary permit Is to allow installation of the private sewage system described In the permit. b. The approval of the sanitary permit is based on regulations in force on the date of approval. c. The sanitary permit Is valid and may be renewed for specified period. d. Changed regulations will not impair the validity of a sanitary permit. e. Renewal of the sanitary permit will be based on regulations In force at the time renewal is sought, and that changed regulations may Impede renewal. f. The sanitary permit is transferable. History: 1977 c. 168;1979 c. 34,221; 1981 C. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. PREVIOUS PERMIT #: LICENSE: # 220090 Condition: Properly Maintain System Per Recorded Agreement THIS PERMIT EXPIRES 5/21/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION https://www.carmodyinc.com/PermitApp/Permit Sign.aspx?Print=l &permitappid=7473 1/2