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Home My WebLink About25-44SRequest 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: Molly Larson steven.waby@blakemanplumbing.com Immediate Phone Number So Zoning Sanitary Dept can call you right back (if needed) Permit #: 25-44S 715-685-4128 Plumber's Choice ing Dept No Inspection(s) during this time Date: 10/16/2025 Tuesday (9:30 am - 12:15 pm) (Tracy) Plumber's Choice Zo Dept Time: u1I11 1r1 • ill am r Township: Clover Address # & 86020 Buckley Rd Road Name: Herbster, WI 54844 or 12 J Directions \` To Site: Comments: Holding Tank Inspection ** Plumbers you must verify any change(s) by fax or email ** Notes from W forms/sanitary/req uestforinspection Zoning Dept (cc34/12/04); ® June 2023 POWTS HOLDING TANK INSPECTION REPORT /ATTAr+u T!l UI=PRAIT1 MOLLY B LARSON 315 WILLIS AVE ASHLAND WI 54806 TANK INFORMATION TYPE MANUFACTURER/MODEL# CAPACITY uitctr �Cfr�O SETBACKS Property Line Well Water Service Building All -Weather oad OHWM Swimming Pool —• DEVIATIONS FROM APPROVED PLAN COMMENTS (Persons present, discrepancies, etc.) %1O Weser` (scon4t rater -kun aal e� ea�VL ivy . _f15t(S,CWiijloLakCKat'`s on &dde Ut hr Qa OA COMPONENTS NOT INSPECTIZD Plan Revlslon qulred ❑ Yes o a Signature of Inspector: Cent. Number 4 3 SKetch on other side 10 of 13 .J - J Property Owner Information As you know onsite wastewater treatment system on your property described as: BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Fax: (715) 373-0114 e-mail: zoninaatabayfieldcountv.wi.gov Web Site: www bayfieldcountv.wi.aov1147 MOLLY 0 LARSON 315 WILLIS AVE ASHLAND WI 54806 Notes: Bayfield County Courthouse Post Office Box 58 117 East Fifth Street Washburn, WI 54891 was contracted by you to install a private Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: Tank was crushed / removed and pipes disconnected by: on at AM/PM On at (AM I PM) the above -mentioned plumber contacted our office to conduct pre -cover inspection as required under DSPS 383. One of the following applies: stem 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 $50 fee are required. System could not be inspected because County could not `erre�spond to plumber's time constraints. III ? Comments: btw �/�iLwl (yj U/forms/sanilarypropertyowner-input April2019 t ( LJ, n ustry Services Division \,'422 Madison Yards Way Madison, WI 53705 County Bayfield Sanitary Permit Number(to be filled in by Co.) \/ lii MAY , , , - P.O. Box 7302 0 LU/b Madison, WI 53707 AS'- L/l7/$ Sansen i1 ii lcation State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Project Address (if different than mailing address) 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 86020 Buckley Rd, Herbster, Wl purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. I. Application .Information -Please Print All Information :: Property Owner's Name Parcel # ,t47% //Sj Molly B Larson 04-014-2-50-07-07-4 03-000-20000 Property Owner's Mailing Address Property Location 315 Willis Ave Govt. Lot SW ,,SE ,,,, Section 07 City, State Ashland, WI Zip Code 54806 Phone Number 218-730-7828 T50 N R 07 E or ti Type of Building (checkall that apply) Lot # Subdivision Name lI1 or 2 Family Dwelling — Number ofBedrooms 2 [) ublic/Commercial — Describe Use Block # City of ❑State Owned — Describe Use Village of CSM Number Town of Clover IIL Type of POWTS Permit' (Check either„ New or Replacement and pile on hne4. Check one box oil hne B Complete hne-C x ` A. ❑✓ New System IliReplacement System ❑Other Modification to Existing System (explain) Additional Pretreatment Unit (explain) B. Holding Tank ❑In -Ground ❑At -Grade ❑Mound llndividual Site Design Other Type (explain) (conventional) C. ❑ Renewal Before ❑Revision Change of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued Expiration ;.IV DlspersalTreatment'Area and; Tank Information Design Flow (gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units Uo New Tanks Existing Tanks c o; Septic or Holding Tank 2500 2500 1 Weiser L.J✓ Dosing Chamber ❑ V Responsib ty;Statement I, the undersigned, assume responsibility; for installation of the POWTS shoyn on the attached plans. Plumber's Name (Print) Plumber's Signature MP/11PRS 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 VL'.Coutityepairtmenf<Use:Oply Approved 0 Disapproved $Permit Fee Date Issued 4 Issu' g Agent ign 0 Owner Given Reason for Denial TO (e Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x ti inches in size SBD-6398 (R 02/22) PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Holding Tank Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan 15) t [ \# 1 fl liii MAY .c.: ,... 1 Fayfieki C } %0nirig Dept Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map (if ap Holding Tank Pumping Contract (if appl Holding Tank Agreement (if applicable) Project Name / Description Molly Larson Holding Tank Owner Name(s): Molly B Larson Owner Address: 315 Willis Ave, Ashland, WI plicable) cable) Phone: 218 -730 -7828 Zip: 54806 Project Address: 86020 Buckley Rd, Herbster, WI 54844 Govt. Lot: SW 1/4 of SE .1/4, Section 07 , T 50 N -R 07 E ❑ or W ❑✓ Township: Clover County: Bayfield Project Parcel ID #: 04-014-2-50-07-07-4 03-000-20000 Designer Information Designer Name: Dean Blakeman Phone: 715 -682 -6050 Designer Address: 44941 State Hwy 13, Ashland, WI Zip: 54806 E-mail: dean@blakemanplumbing.com This space reserved for approval stamp. License Number: 1092768 Remarks: Signature: �— Date: 5/3p 1202 Original signature required on each submitted copy. FE II \'ll CHECK BOX AS APPLICABLE. CHECK BOX AS APPLIC ,L MAY 3 0 202 ._! SOIL EVALUATION Scale: 1"=40' a SYSTEM PAGE 2 OF 4 Co. Zoning Dept 0 40 60 80 SITE MAP PLOT PLAN PROJECT NAME: (10 ft grid) 10 DESIGN FLOW: 300 GPD Molly Larson Holding Tank Attach design flow calculations for commercial plans. PROJECT ADDRESS: 86020 Buckley Rd, Herbster, WI 54844 Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) BM Symbol: - BM Elevation: 100 FT N Sanitary Sewer. 4 / SDR 35 Force Main: BM Description: Top of well casing ________________/________________ Slope Gradient (%) Well Symbol (if applicable): Q Indicate north by IMPORTANT: drawing an arrow Show ground elevation contours at suitable intervals. of Tested Area: on the approprite Line. i 1 ._.. _ Wooded Site Over 300' to N lot line (line not to scale)- Over 1,000' to E lot line -� line- not to scale --- ' I OC i 328 to Buckley Rd Proposed (line not to scale) _ 86020 g - Y _i t u�7cley Rd DriVew 'House - 28'x26' 20' 4' SDR 35 Pipe o Proposed 2500 -gal.-_.__ Holding Tank 1 116' to S lot line PAGE 3 OF 4 r C F El # MAY 330 ?OZ 5avelcj C, %onirg Dept. HOLDING TANK SPECIFICATIONS (No Scale) Weatherproof 12" Min. or 2.0 ft above Junction and Approved Established Flood Elevation Alarm Box Vent Cap Alarm Box Vent Ca1 (typical) Electrical must comply with Approved Locking Manhole SPS 316 and NEC 300 4"Q Vent Pipe with Warning Label Attached Conduit >10 ft from (typical) 4" Min. or 2.0 ft above Building Established Flood Elevation (typical) Airti ht Seal g fFinished I '• Grade 18" Min. (typical) • : d . v V ti 8 Inlet Approved Joints J Inlet Invert --Watertight Plug with Approved Pipe 3 ft onto Max. 12" or 90% of total volume Solid Ground if more than one tank Alarm -On Q e HOLDING TANK VOLUME = 2500 gal 4 3" Approved Bedding Material Beneath Tank TANK MANUFACTURER: Weiser Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight = [(cu.ft.tank.vol x 62.4 lbs/cu.ft) - lbs.tank.wt] x 1.5 Ballast Weight = [( 495.99 cu.ft. x 62.4 lbs/cu.ft) - 16,840 Ibs] x 1.5 = 21.164.66 lbs cS-0c67 C!:;: V }nustry Services Division i{2 Madison Yards Way �iUtadison,WI53705 County Bayfield SanitasyPennitNumber(tobefiilledinbyCo.) pED MAY 0 2025 Madissonn,,oWI53707 as- £711713 SaniftvelFCciIdthir4pqkication State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Project Address (if different than mailing address) 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 86020 Buckley Rd, Herbster, WI purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. I. Application Information — Please Print All Information Property Owner's Name Parcel # 33 Molly B Larson 04-014-2-50-07-07-4 03-000-20000 Property Owner's Mailing Address Property Location 315 Willis Ave Govt. Lot SW 'A SE 'A, Section 07 City, State Ashland, WI I Zip Code 54806 Phone Number 218-730-7828 T50 N R 07 E or II.'I'ype of Building (check all that apply) Lot # -- Subdivision Name I or 2 Family Dwelling — Number ofBedrooms 2 LiPublic/Commercial—Describe Use Block # -. Cityof State Owned— Describe Use Village of CSM Number y❑'fown of Clover 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 i a licable. A. New System ❑Replacement System Other Modification to Existing System (explain) ❑Additional Pretreatment Unit (explain) B. Holding Tank jln-Ground 114t -Grade ❑Mound Individual Site Design Other Type (explain) (conventional) C. ❑ Renewal Before ❑Revision JChange of Plumber f Cransfer to New Owner List Previous Permit Number and Date Issued Expiration IV. Dispersal/freatment Area and Tank Information: Design Flow (gpd) Design Soil Application liate(gpd/st) Dispersal Area Required (st) Dispersal Area Proposed (sf) System Elevation Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units V ° o New Tanks Existing Tanks y o d its 1n Yn '�'� ii Q 5, o U Septic or Holding Tank 2500 2500 1 Weiser ✓II C Dosing Chamber = O EJ V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Dean Blakeman I Plumber's Signature TT— I MP/MPRS Number 1O92768 I Business Phone Number -- 715-682-6050 Plumber's Address (Street, City, State, Zip Code) 44941 State Hwy 13, Ashland, WI 548O6 VI. County/Department Use Only I'crn it Pee I Date Issued L Issu're Agent ien ur Approved ❑ Disapproved $ /TIB O Owner Given Reason for Denial Conditions of Approval/Reasons for Disapproval cL ri Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x It inches in size SBD-6398 (R. 02/22) PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Holding Tank Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan MAY 302025 Bayfield Co. Zoning Dept. Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map (if applicabl Holding Tank Pumping Contract (if applicable) Holding Tank Agreement (if applicable) Project Name / Description Molly Larson Holding Tank Owner Name(s): Molly B Larson Phone: 218 730 _7828 Owner Address: 315 Willis Ave, Ashland, WI Zip: 54806 Project Address: 86020 Buckley Rd, Herbster, WI 54844 Govt. Lot: SW 1/4 of SE 1/4, Section 07 , T 50 N -R 07 E ❑ or W ❑✓ Township: Clover County: Bayfield Project Parcel ID #: 04-014-2-50-07-07-4 03-000-20000 Designer Information Designer Name: Dean Blakeman Phone: 715 £82 -6050 Designer Address: 44941 State Hwy 13, Ashland, WI Zip: 54806 E-mail: dean@blakemanplumbing.comThis space reserved for approval stamp. License Number: 1092768 Remarks: Signature: Date: S�3o /Zo2� Original signature required on each submitted copy. CHECK BOX ASAPPLICABLE. CHECK BOX ASAPPLICAIILII. MAY 3 0 2025 L ❑ SOIL EVALUATION 0 Scale: 40 40 60 6D ❑✓ SYSTEI�ayfield Co. Zoning Dept SITE MAPPAGE 2 OF4 PLOT PLAN PROJECT NAME: Molly Larson Holding Tank (0Hjjjsnd) 'D PROJECTADDRESS: 86020 Buckley Rd, Herbster, WI 54844 BM Symbol: 4 BM Elevation: 100 FT N BM Descrlptlon: Top of well casing Slope Gradient (%) Indicate north by Ma: Well Symbol (if applicable): $ drawing an amrw Sf on the appmprite line. Wooded Site 0< z 328'to Buckley Rd (line not to scale) 86 U 020 Buckley Rd Drive ay DESIGN FLOW: 300 GPO Attach design flow calculations for commercial plans. Pipe Material I ASTM Standard (Tables 384.30-3 & 384.30-5) Sanitary Sewer 4" / SDR 35 Force Main: / IMPORTANT: Show ground elevation contours at suitable intervals. Over 300' to N lot line (line not to scale) Over 1,000' to E lot line (line not to scale) Proposed House 28'x26' 204" SDR 35 Pipe • o Proposed 2500 -gal Holding Tank 116' to S lot line PAGE 3 OF 4 DII MAY 3 C 2025 Bayfield Co. Zoning Dept. HOLDING TANK SPECIFICATIONS (No Scale) Electrical must comply with SPS 316 and NEC 300 18" Min. (typical) Approved Joints with - Approved Pipe 3 it onto Solid Ground A P m Weatherproof 12" Min. or 2.0 ft above —Junction and Approved Established Flood Elevation AlarmBox Vent Cap (typical) Approved Locking Manhole 4"0 Vent Pipe with Warning Label Attached Conduit >10itfrom a (typical) 4" Mm. or Elevation e Building I Established Flood Elevation / (typical) Seal 9 Max. 12" or 90% of total volume if more than one tank Alarm -On HOLDING TANK VOLUME = 2500 gal a ' 3" Approved Bedding Material Beneath Tank TANK MANUFACTURER: Weiser Finished Grade Plug Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight = [(cu.ft.tank.vol x 62.4 lbs/cu.ft) - lbs.tank.wt] x 1.5 Ballast Weight = [( 495.99 cu.ft. x 62.4 lbs/cu.ft) - 16,840 Ibs] x 1.5 = 21.164.66 lbs O32.LSIn U 2 r, Soil Test # ii i MAY 2 U 1UL5 Bayfield Count Bayfield Co. Zoning Dept. Waiver of a Thorough Soil & Site Evaluation Sl TEST (subject to 15-1-10(d)) I f<'1')i4fl '1/1 YV)(V✓1 a certified soil tester determine that in my professional judgnlent 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 oL$9ylsy Property Address O a -O 13w..LI,, L ]?1Vb51CV, kt Telephone73o-79-,;�8- %� 7,9 Accurate Legal Description is requested: Contractor Authorized Agent Agent's Telephone, Written Authorization Attached: Y or N J) 1/4 of 114 Section 7 Township 5° N. Range 7 W. Town of `a ve,r Govt. Lot Lot Block Subdivision CSM# Volume Page of Deeds Parcel I.D# /1 y33 Acreage 20 Additional Legal Description: Indicate reasoning for your determination: 3 D/ I. 5Csort #94l J�i�7�t.�v�a- ti '("%M ,A 5" a, N237/3 Signature of County Official Date d.e.ck(- ,2o3 �d X 50 /L 4 - Si nature of Certified Soil Tester Date /jsjj Certification # (Submit a Plot Plan & Fee) as u/forms/soiltestwaiver(KLK) �Z- February 2005 PAGE 4 OF 4 Holding Tank Management Plan n E C E 0 d t p IMPORTANT: MAY 307075 U The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenanc1Jmarf&o7onino Dept. requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, t is of ing t nk(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= 300 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 acc Admin. Code. Report any component failure or malfunction to: Name of individual or company: Blakeman Plumbing & Heating, Inc. Phone, Local government unit: Bayfield County Zoning Administration Phone, Local government unit address: 117E 5th St, Washburn, WI ordance with SPS 383.55 Wis 715-682-6050 715-373-6138 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. EcfoU MAY 30'10? Baeld Co. Zoning Dept. n C, 159j" 4" CAST -A -SEAL 4" CAST -A -SEAL FILTER OR BAFFLE •" I TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS W2500 -MR TANK SPECIFICATIONS DIMENSIONS: WALL 2 1/2" BOTTOM: SEPTIC 4" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 71" O.D. LENGTH: 159 1/2" O.D. WIDTH: 93" O.D. BELOW INLET: 57" O.D. LIQUID LEVEL: 50" WEIGHT: 10,500 LBS. COVER 6.340 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET, CAST -A -SEAL BOOT OR EQUAL UQUID CAPACITY: 49.46 GAL/IN LOADING DESIGN: 8' 0" UNSATURATED SOIL HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2.621 GALLONS TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN 68 (NO FIBER) TANK: MIX DESIGN /9 (SMALL FIBER) CUSTOMIZED TANKS FOR CUSTOM TANKS CONTACT WIESER CONCRETE FOR APPROVAL APPROVED BY: PROVAL DATE: D UCTS NEEDED BY: 1 DI ECHHfl BAYFIELD COUNTY liiiMAY 3 G 2025 U CHECKLIST FOR SANITARY APPLICATONS ii H Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Elayfield Co. Zoning Dept. KI Check Ust KI Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) N Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 151 Original Plot Plan (383.22(2)2. 3. & 4.a) KI 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.) ❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) ® 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) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) N Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) ❑ 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) N 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) N I Application Information must include: IKI 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) Project Address or Road Name where driveway is/will come off of) IK (Owners Phone Number) N II Type of Building N III Type of Permit N IV Type of POWTS System ❑ V Dispersal / Treatment Area Information N VI Tank Information N VII Responsibility Statement (Plumber's Information) N *Date Stamp* Plot Plan: (To Scale or To Dimension) N Signature and Plumber Information IO Address Number and Road N Surface Elevation of Body of Water ® North Arrow N Direction and Percent Land Slope ® Contour Lines N Tank and Filter Information and Location 1 Structures and Driveways ® Wetlands / Navigable Bodies of Water N Boring Locations N Absorption Area (Proposed and Existing) KJ Property Unes N Bench Mark (Location, Elevation and Description) N Well Locations N Component Manual Version IN Legal Descriptions N Piping Material Information (conveyance line, building sewer line, material type and diameter) Turn Over ► 'Cross -Section and Over -Head Profile of the System: U I D ❑ Surface and System Elevation 1111 MAY 30 2015 ❑ Position of Observation and Vent Pipes Bayfield Co. Zoning Dept. ❑ Dimensions and Depths ❑ Make, Model & Number of Chamber Units in each Cell Property Information KI How many systems will there be on this parcel of land? 1 ® Has this property been split? No (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 131 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 ZI Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) u/forms/checklists/checklistfo,sanitaryapps (10/2009);(®7/2011);(®2/2012)(®512/2012 -dc) Proofed by: SS-oo7 HOLDING TANK SERVICING CONTRACT 0 ipjjp) MAY 292025 Contract Date 2°f 2°S Bayfieid Co. Zoning Dept a^J I This contract is made between the II Holding Tank Owner(s) Name(s) We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT Legal Description: I Tax ID# I �w 1/4, SC (Use Tax Statement) / S> 3' ySC 1/4, Section , Township57 N, Range W Town of: Lot Size I Acreage 0 Ve' AO Gov't Lot Lot 41 CSM # Vol. Page CSM Doc# Lot(s)No. elock(s)No. Subdivision: 1. The owner agrees to file a copy of this contract with Bavfield 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 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) I Owner's moll g L so v'\ Subscribed and Sworn to me: on this t day of tkcu\ , by: Sa MADISON BRII4ER Notar4 rRttiaMetissh on: IJV VIIJ111 ` Revised: May 2016 (®May 2018) Drafted by Personal information you provide maybe used for secondary purposes (Privacy Law, s.15.04 (I)(m)) Document Number/Plan I.D. No. HOLDING TANK AGREEMENT Mo W11 8 Lcvso IQ L I L1 Owner(s) Mailing Add 315 Mills Agreement Date (same as Notary on the following property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. CodeorCh. 145, Wis Scats. �-f Stn/ 1/4 of 5e 1/4 Section T TownshipS.9' Range 7 W. Town of 210 V{2 Additional Legal Description: .co ft4'\ hR 1 T GoVt Lot _ Lot_ Block_ Subdivision CSM# Lot_CSM # Vol _Page _CSM Doc# DOCUMENT NUMBER 2025R-607651 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFtELD COUNTY. WI RECORDED O5/29/2O25 AT 1O:O2 AM RECORDING FEE: $30.00 PAGES: 1 Return To: r lgg A V I? MAY 3 As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above descrSiayfgtpto do the following: ''ff``JJ f[ 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, 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. 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. Scats., 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. Owner(s) Name(s) —Please Print AA0 l'% LC�it'�� Subscribed -and sworn to before eon OS-191/ada5 Notary Public ,State of WiscOnii NotarizedSignature(s) //l�� / Notary Public,(/,, ¼_41air WcNJvt My Commission Expires: l�/Dy a bag Drafted by: r' 1w It %% LA"reD j Date: �� /� 1 a Z.CC Personal information you pro4e a may be used for secondary purposes [Privacy Law, s.15.04 (1(m)] u/farms/sanhlryoholdingtankagreemenldoc €June 2018 p Y FT E L D Bayfield County Planning & Zoning Department 117 E 5th Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-0114 Property Owner: LARSON, MOLLY B 315 WILLIS AVE ASHLAND, WI 54806 Description Private Sewage System (Holding Tanks) Submission Number: SS -00557 Transaction Number: SS-00557-2C8E5 Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 33996 - sanitary Paid by: Blakeman Plumbing & Heating, 44941 State Hwy 13, Ashland WI 54806 Payment Type: Check Transaction Date: 6/4/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-25-44S STATE SANITARY PERMIT OWNER: MOLLY B LARSON GOVT LOT: LOT: BLK: SW 1/4 SE 1/4 SEC: 7, T 50 N, R 7 W TOWNSHIP: Clover SOIL TEST: 3 5-25 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: DEAN BLAKEMAN TRACY POOLER Authorized Issuing Officer DATE: 6/4/2025 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 PERMIT #: LICENSE: # 1092768 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 6/4/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION