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HomeMy WebLinkAbout25-35S<S5-00537 •• foma^Department of Safety & Professional Services, Industry Services .Division County 'B- G-Y f''^^ Sanitary Permit Number (to be filled in by Co.) 55-35 S 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 sanitary 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 secondary puiposes in accordance with the Privacy Law, s, I5.04(l)(m), Stats. State Transaction Number Project Address (if different than mailing address) I. Application Information - Please Print All Information Property Owner's Name " ^n-t-ll^^-i^ s- C)^^>«^ ^i^^l-C^d^ Parcel # •-Tc^ Z & ^ -^ <, 7 <ecf iress -73<P^O A< <p<&^^ /^ City, State -^^ok,^.^^^ '-<j-T Zip Code^V5^ II. Type of Building (check all that apply) JS 1 or2 Family Dwelling-Number of Bedrooms a Public/Commercial - Describe Use D State Owned - Describe Use -2- Property Location Govt. Lot TZ.<L$S ^-5.,^'^ Phone Number -7< 5^V< ?- OS-«/7 Lot # ^'A. 5^ ./, Section <3 T tt^ N R _l__J<o<® Subdivision Name Block# CSM Number a City of. a Village of I? Town of_0 ^ ( ^ III. 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.D New System ^Q Replacement System D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain) B.[^Holding Tank D In-Ground (conventional) D At-Grade D Mound D Individual Site Design D Other Type (explain) c.D Renewal Before Expiration D Revision D Change of Plumber D Transfer to New OwnerIList Previous Permit Number and Date Issued IV. DispersaVTrcatment Area and Tank Information: Design Flow (gpd) 3c>o Design Soil Application Ratc(gpd/sf) | Dispersal Area Required (sf)Dispersal Area Proposed (sf)System Elevation Tank Information Capacity in Gallons New Tanks Existing Tanks Total Gallons # of Units Manufacturer IIIQ 0sW u tfl .0 .2E U Septiu as Holding Tank ZS~00 ZjfOO LOt'e-S-e.K C.c.^C..^ -liuuui-OuunlurD«siuji£l V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print)All^ To\^s^ Plumber's Address (Street, City, State, Zip Code) " v ,'PM B^ s-'^ ' ^^^ <?< ^ _^j ^ ^^y7 •WP/MPRS Number~ 2,2. ooct 0 Business Phone Number -7tS~ ^^.-^/^ VI^County/Department Use Only Approved D Disapproved D Owner Given Reason for Denial Permit Fee Date Issued"l^i—5/30/.25 Issuing Agen(<8%haturc,^^-.Y^Jpy^^ Conditions ofApproval/Reasons for Disapproval S^ a.'V'^oh^d (L^e{,t ISilti 81 MAY > 9,OZ5 fi'S^fl.r.h.S .- Attach to complete plans for the system and submit to the County only on paper not less than 81/2x11 lncil'es'fii'slzir'y /-i-'i tfj fg UQpt. SBD-6398 (R, 03/22) S^- OOiqi Bayfield County Soil Test # Waiver of a Thorough Soil & Site Evaluation ^^^ (subject"to 15-1-10(d)) t-^3 ^.lA T€> I Ko S l^.i_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. \AA \ i 1 (^A -.'t-110^ Property Owner be ^>^^ -e i^ ti ^" 'i. VI.' iJ ^ '^^c tl Contractor Property Address_"7^_°^0 -^-•- 0 ^ < r p^ ^t R<1 Authorized Agent. Agent's Telephone. Written Authorization Attached: Y or N ^ < u ^-^ ^U I: ^~ ^ <?Y^ Telephone "? l ^ ^3 o^^~7 Accurate Legal Description is requested: '$ '^ 1/4 of 5L^1/4 Section ^ Township ^ S' N. Range 7 W. Town of_E^_ Additional Legal Description:, IL-^SJ; tJ-^ ;\/L^-^ Govt. Lot Lot_CSM#_ Volume_Page Lot Block _Subdivision . Vol. _ Page _ CSM Doc # _of Deeds Tax I.D# ^-i?~7^cj Acreage ^ 0 Indicate reasoning for your determination: ^\)-^'t c /^y •e-iy jS&i ( •s^ '-" ^0 'ot 2->- ^D L-jT S> ^_c< ^ i-e /~ ^ ^ / ^^ ypf Signature of Certified Soil Tester ^/ ^-^~ Date Mv/^'s-v, I, ^oct o Signature of County Official^/>^/^^ Date Certification # [S fl *^ 1^ Fn\ (Submit a Plot Plan & Fee)i^ ^ l[i [I ^ Ib u/forms/soiltestwaiver(KLK) June 2018 NAY 1 9 Z025 Bayridd Go, Zonini, 0°pfc ^& r - •S - ^ ( S - ^ <( - . " ' o' r * . - ^ - i (5 \ ^ . 4i p ^ y^ . Q . s ^A .? 2 SE ?~ 9 - . „ ^ S r ° ? c . 0- - ^ ^Q . ' • , - _ 1 i- ' s f* I t ^ft -j - ft"i 'p \f tHi f\ .0 ?f6 ^n li -^ . - '2 — 3 ^ • if .p.+.r- ?•f^?T - Vs r\ 'u t . -'U u" . £A » <» a^ ^ & H-Hi ? ? ^H ^K i S ^ ^ " S a (S t " t ~ 0 ~ t ) s " £^1 (A•<CS-c "N f N p~ . 3 s ^ L ? ° o~ - y -M t pyn0 -. 8© ^? &m? ? . - ^) ? ^ ' ' Pf t l - 5 . :^ ~ ^ -. s p °% i So L . ^ S. a ^ T \ ^ ^ y t^ ^ " $ ^ ? 6 S' P r* j -00 rt »-^ 3 '- A -^ 1^ft t<1' b ^/ / ^ k & ^, V j s e s - ^ - { ~ '• 1 •* 5 - A. ? T ^ T - f ; i r ^ ^3 Z o Q; ^ w & ' ^ \ ^ ^ + ^ • ^ T O 0 ^ o . rf c P * . r > ) . ' , - , , , _ ? ^r ? ^ co 0111 , fBQ:00N03 IQaco -a ^= = ) -73>_\co r~ < ? c= > r~ < ; en -Q j FG = 3 <S = 2 ) fr u ^ <3 S g [n F O imu W ^.l»IIUHU NO, yy/1) ?. 2 ^ ni v.n ^ 11 ^} Bayi'ield ^o'Zor?9c3ePL Pgl Pg2of^ Pg 3 of @ Pg 4 of S Attachments: Holding Tank Plan Index & Cover Sheet | i Component Manual Design RQfQrencex \ * /ywwsJ '-t /f&'^V^rs?®^ ^j.)j ^ m<^ PAGE 1 OF^ Index & Cover Sheet Plot Plan Holding Tank Speclficatiojns - 2- 7^^<^ Management Plan Z.02-Z.-Z-OZ7•). ^££>^ _P<-i_4! ^4-^? c£_^_ r<.i 8 ^{- ^ I-._ ;POWT8AppHcation for |Review C^7f^t/ p^tr^ ' Soil Evaluation Report & Site Map (|f applicable) Holding Tank Pumping Contract (if applicable) Holding Tank Agreemetft (if applicable) Project Name / Description ^ n 4" ^ •° (<f^ ^ ,• ^- ?l ^ <A*-CV ^ :~Owner Name(s): i>€-^ ^ ^ ^'~ ^ i ^ '^^ ^ _ Phons: :^5~-'//3_._^^~ Owner Address: '7^£>8'o A- ^p^^/~ /^i/:T^-z ^'^^r^Zip: s~^^«^ Project Address: ^-^.<e ^-r - ^^< _^ L^5 ^4- ^^-^ Township: 0^\ u 5 uJ 1/4 of 5 ^ 1/4, Section ^3 . T L/^N-R Project Parcel ID #: "^T^K rTZ>^^-7^^ County: B^y\-F^ or wixl Designer Name: A CL ^ / £5 Designer Information / A:oj-^-,Phone: J7/J~-J>^2.- l// ^ Designer Address:'P-£>. Bo^ ^~^-^Z^^^ ^-^'^ '^JX :Zip:_QX^2_ E-mail: +i?. ^y CKL. ^ •e-^ i^-^ um d.e~ ^ & i^-'t-U - c & ^'^^ Thf^ space reserved for approval stamp.1 ~ y ^ \ License Number: 2-2- &o<y o _ i Remarks; Signature:Date:JS>( (p-^r Original 5ignature required on aach submitted copy. Pr,\"sj» € r +^ Orj ^i & rB L&.^ 0. ^ D @,£<L ir' p +' < e"^ ^ j\lt^~k o.^ ^ U 4 •^5^ su^7 $<Lci3 T^M p.c| w^^^l:i<l^^ -^ L^S^4^W-V 73'oSD H^'-rDf^i-T-....'~\^^.\ . T •^'^ ^l:'.^T^^7re^ir\ &sr: ° ^ i -3, / d.e^i^y <?-?.'' '73 «.y^\e( -2Jo-7 tec/ ' \ ^ ^lfe ^ N1wH^.0M ^. Kl Q -^1 •-a sk ^7 re^i-73D<SQ A'rp^^" (N/© +^ ^ ^ I ^ -^ ' /! < '- ^ 5 < r -h£ < ^ •I'"' < Tc t-» K ^< /i'/t t.' i-t k. € ^-' (-' ^•l ^"(; q i>^/i ^ c,.., & e p<g.^ $ far ?(?X:iJ 7 v <e '.»• i<n c. lc eL i^-;/ n- e i^j "/ \0 •^t;•c (A,. i^J/ n.eia ^^T<?(£>S v <e "f i (ft C lc eL i^-V >i-e <AJ '^^T<?(£> if/e-iii fy\ 1-J'^S-e.i/ 1-; » /^ «i^- T^.n^ ^ ^° ^'^0' •*»- o-{- y^sr^tsf • '!-4>CI\B<3VI\Oj1'- ,|| N f^J<L: / "^ l-/Q{^ {^S ^<s-/ei»' /\^<.r<L5+ ^.t A<vpc^ ^<L ?'-s-%s"0<? a{0.\\ay\ U^Y<i€.r cenctC^C^.nk-i i6'^L-W//uj s ^yi fv'6m. fc&ftoMof ~T<v.^k i-e. ^c'tuL^e'inlt:t-. mi MAY 1 9 2025 Bayfieid Co, Zoning Dept £50 ^^"s^o 2-B'e.Z^' i?.€C:^-Ct'^'t;- d^'i ^ •€ t^)^'./ > '^^ ^ /«. «-/^ & fct "<i CL<;< •'r r ^.P'^J^-M 'i'{Z-ct"A^'& - i/" S^Wo i/^i ^' <z.'''A F-'.S-. ^>tt^ S&f ^/3<^0/" ^A^.^FL 2-^^ ?-r \0^NA ^ 1 ^B^ifnq'T^rtl^/H&e'^S'<X//Al.l/^-l, S.oA'^ii.C.ic.S 0"F,S3i A.F.6-. ^ A^o'Jf&. -f/^&/ cjye<.J<£ -<?.- s:_u.f&.H , . ^ a/ „ '8 C-(-+'•" .-». ^' r <^ < ,/•» ^ £? M S^ ^~ 0 •- ^ •<-•'''•• ^ = g»1g\/%p » £/fcu/'co.o./ -3- J 3 »"= Sck l/o PVC ^/-fl6^ cl^e-t-~('' e<n "= V'ASTW 0»-7^S~ ^pfJve'u'eA p-p^ ^ittt^.v'^-1 s.s Hfi /J< ci^'Tn.^ ifc C®^(j-?<S<»t.€.>' fV}Cf. r\ K.<t /,. t-t S'<9-cl l/fl^n li-Sl. i[V£ R £.4); ^'m^Zfi ^2-- ZQ'Z'J) Dr^Jn ]Sy: WJ?K^2Z<c<??0 •,Pe Ikc-S k"i f/a ^-n fc' ^<5 B&S.91C S-Z-2. :TY.^ ^u€^ua3-&'VW7 \ ''" , II'PROPERTY OWNER: A^^°^ ^ '!>^ ^ W, 111 ^^^^ ! PLUMBER: Allan Polkoski/ Polkoski PIumh|nq SIGNATURE:. •DATE: _5-^-^ ^ LICENSE # 220090 HOLDING TANK SPECIFICATIONS Number of bedrooms Non-residentlal estimated flow (gpd) Minimum holding tank volume'required (gal) 2500.0 proposed holding tank capacity (gat«iteserSm—lUmHuwntuiMiimiirof*wnwuvuwuttfur^ mm itwuuwuiwwunt?arm mod Tank Manufacturer ITank model number [Alarm manufacturer el number '-,• f ^ K € Hi Ji ?! Ib- v.- 1.3 *^ y M/vf 'i y ^025 BayTi&ic- C ^Oiiiisy^'. Tank Dimensions and Data i —jx for round tank 5^y^JLiquid depth below Inlet Invert (in)f^Mt^trtM^tMSMaximum depth of soil cover (ft) i;aHei9ht('") L outeide 189.5 jLength (in) F Dimensions"93TB1Width (in) ^ Only Tank Anchor Calculations tilAWMDi/ttWH rronr'-tsnt^'drdTl -46.8 9.9 Ibs Weight of tank and cover Safety factor Ibs Weight of anchor required |in Soil cover req. for anchor or |yd Concrete counter weight HOLDING TANK CROSS SECTION Junction box $ 4"mln. mannole cover with locking device and warning label finished gradev /vent cap / blind plug to seal outlet Manhole and vent locations may be reversed. $ 12"min. vent pipe aeivlce alarm on Electrical as perNEC 300 and 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 complywithW.g?85 J~ 18"mln, -!.3) building sewer Intel 3 In. bedding under tank.Tank Is anchored as naceasaryto negate buoyancy. ••^-i LT-) C^l^.S C=>C^l 05 FU-L", — jT^U'] •a..aj,0 ;.-Ti 183^ 4" CAST-A-SEAL 4" CAST-A-SEAL FILTER ORBAFFLE TOP VIEW WLP2500 TANK SPECIFICATIONS DIMENSIONS:WALL: 3"BOTTOM: 3"HEAVY - 5"COVER: 6" MANHOLE: 24" .1.0. PRECAST CONCRETE RISERHEIGHT: 52-3/4" O.D. LENGTH: 183-1/4" O.D. WIDTH: 101-1/4" O.D.BELOW INLET: 41" 0.0.LIQUID LEVEL: 36"WEIGHT: TANK - 3" BOTTOM TANK - 5" BOTTOM WEIGHT: COVER 9,300 LBS. 12,560 LBS.15,527 LBS. 1NLET AND OUTLET:4" CAST-A-SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER:WISCONSIN, SEE DETAIL #10(OTHER STATES SEE CHART) LIQUID CAPACITY: 69.44 GAL/IN HOLDING TANK:OUTLET HOLE PLUGGEDACTUAL CAPACITl': 2,639 GALLONS LOADING DESIGN: 8' 0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #S (NO FIBER)TANK: MIX DESIGN jji9 (SMALL FIBER) CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT WIESER CONCRETE SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS DRAWINGS SUBMITTEDFOR APPROVAL APPROVED BY: APPROVAL DATE; PRODUCTS NEEDED BY: 0:13101n-1 >-1u:l<13| ^'l<1 (08 ml^ ^00 I17s ins CM I1^> 0 I >- 0|s Qlx do 'I CM I 0|IN I 00u->CM <=>I ?12 ^| y pl OLu-iw w\>:!UJ|0:1 SHEET NO. 1 .OF 1 ^ ^ ^ II ^ ^^ iS H ?' £ IP HOLDING TANK MANAGEMENT PLAN uu '1AI '025 ' bayfieiu Co. Zoninc. DeDt.This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be Installed and ' ':'" 7" t< maintained according toSaf^3^3 Wis. Admin. Code, the Holding Tank Component ^l?nualjA?«-^ ^f^a.nu& I -t"y<f& ^ER 2.0 and the 'B<ty-p€. U County Sanitary Ordinance. (.^£1R &i) J <iM<<-/ so2&-2oz.7^ 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 S'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 installation, the fojjowing persons should be contacted: a. Installer.............................Pal^^ fia.m^^ /71RAA2.2.e>c>c{0 Phone: 7^ 37%- ^i^~<e b. Service Provider.......^..........^rts^^v^ 6^-fie_ R&g tt ^277 Phone: ---us- S7^- ^essfy c. Co. Zoning or Health Dept. Sw/fj &.U C&^ wj;^ "t^^^i _ Phone: 7/J' 3'73-MM_ n. L^J i^^ ^\ ^^ ^c ^ -7-^|^<? ^ ^^ <j4 ^^Jy To um 6-f ^ o u 1 ^ CflLm-^ of ^^y^'-~~^ ( <L P&^l J& " ; -T-^ k 2: -0 -"- •^4' 7^ ^ Project Transaction Number: HOLDING TANK SERVICING CONTRACT Contract Date^b - ^ ^This contract is made between the R !S li'fl ijL,. ... :.. •, . • -.. ,,^ •Ill MAY 1 92U25 ^ Kayfi&JL;^ Zonir'fi Cfci^". Holding Tank Owner(s) Name(s) I AtWtDN^ k ^£B(£A H\^0(jrM^ Pumper's Name (Print) , . , -f j/i.&- t^.a.s" ^'po'fl^.&Sfc' ^t^e.^ ^(.rf-e.^ $'<e-p4-«,.> Purpp,6r's Signatun f-^1,-1^^- —' ^ Pumpers' Registration # ^IZ7! We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT IOCATION Section I 3 Gov'tLot Lot ft Leeal Description: (Use Tax Statement) , Township CSM#Vol. P! Tax IDS^e-7^<7 N,Range, age CSMDocff w lot(s) No.Block(s) No. <$-tJ Town of: OU .1/4, ^^ /^ Subdivisions 1/4,u^_ lot Size UJ.^ /JUJ- Acreage s<r 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 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: 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,^^ jor each servicing; g. The disposal sites to which the contents from the holding t^fiK^^ ^^(%ed. 4. This agreement will remain in effect until the owner or pump^J^m1r}^§ithi6<<gyi^act. In the event of a change in this contract, the owner agrees to file a copy of any changes ® ^\s 9^rVice~'<SftQtr^tSr a copy of a new service contract with the local government unit and the County named aboffi^a/fthin (l^t'busine® Says from the date of change to this service contract.0\ • "^> -("> • 5V^•y\'. ^/o> \u •'^.'^.. Owner(s) Name(s) (Print) f\W40M^ ^UtCXLWA^ tea^ ^uic€)LmuJ led and'Sworn to me: -day< by: _;1^/y^^A / Not'ary Public My commission expires on: -/y-Y'^As/ IID-ilh Revised: May 2016 (®May 2018)Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (l)(m)] Drafted by ^w Document Number/Plan I.D. No. Owner Name (s)^mo^ M-t^xau^OEBRA^LlCX^CJ^ Parcel Identifier Number (PIN) "I^Kl:^** 2.lfi~7 ^ HOLDING TANKAGREEMENT Owner(s) Majling Address-73(5&?A«:WPT^ >(<OH ^?iV>\-SW-7 Agreement Date (sameas Notary Date) 5--^.-^ 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 onslte wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code or Ch. 145, Wis Stats. _^J_1/4 of J^<^j/4 Section ^ ^ Township _^N. Range *7 W. Town of C>^> 1. ^ Additional Legal Description: L-^S$ l-J ^ /\) ^ ^ Gov't Lot_ Lot_Block_Subdivision. Loi_C3M #_ Voi _Page i_CSM#_ _CSiVi Does. DOCUMENT NUMBER2025R-607442 DANIEL J. HEF-F-NER REGISTER OF DEEDS BAYFIELD COUNTY, Wl RECORDED05, 1 2/2025 AT 8:00 AM RECORDING FEE: $30.00 PAGES: 1 Return To: 'fo -z y 'J:=5£- / 1^- ^J Al. f^-.- 3'oy ^'^-^- "jVo'tr. S-\ ^ e ^- ^i)J- S'~'i'^y"7 / As an inducement to Bayfleld 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 Bayfleld 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 uponthe 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 specia! assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 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. 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. 4. 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. 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 wastewstsr trsatmsnt system that ccmpHss with Ch. SPS 3S3, Wl's Adm. Cads. in addition, this agrc-emsnt may bs cancoHsd by executing and recording said certification with reference ^^Ijijp agreement in such manner which will permit the existence of thecertification to be determined by reference to the prope^f^ ' '^^ ,. //// 6. This agreement shall be binding upon the owner^^eirsopHe.^gg^and assignees of the owner. The owner shall submit thisagreement to the register of deeds, and the agr^^pt ^1 ()4j®cor<^d^y the register of deeds in a manner which will permit the existence of the agreement to be determined by rSw^nce to the^prbi&U^iftfie the holding tank is installed."• 5(" ' ".^S Owner(s) Name(s) - Please Print ^(^. <,1.^'. </'fiL\° I*^ H^^^u^p^.^SEA C^C ^^nLS-'lUA^^!sc0^TTIT L^^' id and sworn to before me on this date; ^ ^ 2025 is:~^~— - -^" to/^-/^/1 2^ZJ Drafted by:"to ^ I/ -T?c:> / k'<?$ k.' Personal Information you provFde may be used for secondary purposes [Privacy Law, s.15.04 (l}(m)] Date:ST-^-^S'10 mi i w i ufformsfeaniiary/holdingtankaSM^menl.doc®June2018 iIJU MAY 1 9? !L Saynsid ^o. ^lumny Oepi.- H& Id ^< BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-l-10(e)) |)) | 'p1^ f) |^ f? l,^L—i Li i^ jL ^ | i0 Check List (i )j ;; jiili MA'/ '! U ')mi: .'i.a Original Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.)' " ' ^ L ui-J 0 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) Bayffefj ^ ^^ ^^ •^ ^.- ^-r^.,, ET Original Plot Plan (383.22(2)2. 3. &4.a) Ef Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer I? Pump Tank Diagram, Alarm and Pump Curve (when applicable) 0" 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) 13' 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) S? 2 Com.Blete 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.) D State Plan Review (when applicable) D Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) El I Application Information must include: D 23 diait Parcel ID# - (do not use 12 digits anymore-obsolete) S Project Address or Road Name where driveway is/will come off of) Ef (Owners Phone Number) Ei II Type of Building 0 III Type of Permit 0" IV Type of POWTS System D V Dispersal / Treatment Area Information 0 VI Tank Information 31 VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan; (To Scale or To Dimension) Bf Signature and Plumber Information ^ Address Number and Road ST Surface Elevation of Body of Water [p North Arrow D Direction and Percent Land Slope D Contour Lines El Tank and Filter Information and Location Ef Structures and Driveways 0 Wetlands / Navigable Bodies of Water 0 Boring Location D Absorption Area (Proposed and Existing) 13 Property Lines Bl Bench Mark (Location, Elevation and Description) 0 Well Locations 53 Component Manual Version El Legal Descriptions 0 }3i^ing;;^ateriei|: Information (e6 Turn Over > BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): Q |S (g ]j ir0 Check List iili MAY 192025 10 Index Page / Title Sheet (Optional) feayfieid Co. Zoning Depf • 0 Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers) EZ? Original Plot Plan D Cross Section Soil Profile Sheet (optional) D Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) S Parcel Identification Number (must be Zldigrt Tax ID#) DO NOT USE 12 digit, they are no longer being used S Property Owner's Information (not prospective buyer's name) [3 Property Location (Accurate Legal Description with Sec/Twp/Range) El Road Name (where driveway is/will be coming off of) IZ1 Floodplain Elevation, Flow Rate, Comments and Recommendations 0 Complete Soil Boring / Pit Information El Date Soil Evaluation was conducted [3 CST Name, Signature, Number, Address and Phone Number a *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) ^ Bench Mark (Description, Elevation and Location) E3 Contour Lines (Example = 98.0796.0794.0') 13 Pioperty Location (Sec/Twp/Range/, Accurate Legal Description) El Borings (Locations and Elevations) ^ Percent and Direction of Land Slope 13 Well Location (Including Neighboring Wells, if applicable) [/1 Location of Wetland Areas, Floodplain and Navigable Waters [3 Buildings, Driveways, and Structures (Location and Descriptions) El Location of Property Lines Ef Existing System Location 1ZI Address Number and Road Name 0 Current Surface Elevation of Wetlands and Navigable Waters ^ CST, Owner and Property Information Bi North Arrow Fee: E3 Certified Soil Tests - Review & Filing Fee , $ 50.00 . u/forms/sanitary/checklist/checklistforcsts BAYFIELD COUNTS SANITARY PERMIT f#04)-25-35S STATE SANITARY PERMIT OWNER: ANTHONY JOHN & DEBRA ANN MIDDLEMAN GOV'TLOT: LOT: BLK: SW1/4 SW1/4 SEC:13,T48N,R9W TOWNSHIP: Oulu SOIL TEST: 33-25 REPLACEMENT SYSTEM SYSTEM T^PE: Holding Tank PLUMBER: ALLAN POLKOSKI TRACY POOLER Authorized Issuing Officer DATE: 5/30/2025 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 PERMITS LICENSE: # 220090 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 5/30/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION