HomeMy WebLinkAbout25-44Si^W?
S,^ K fifl '
1; [I MAY .1
I !F
QmOZ5
lustry Services Division
'2 Madison Yards Way
ladison, WI 53705
F P.O. Box 7302
Madison, WI 53707
CountyBayfield
Sanitary Permit Number (to be filled in by Co.)
^5- HHS
SanitetyfPermi^AppHcation State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-cnvned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats.
Project Address (if different than mailing address)
86020 Buckley Rd, Herbster, W
I. Application Information - Please Print All Information
Property Owner's Name
Molly B Larson Parcel # ^^ fftf^
04-014-2-50-07-07-4 03-000-20000
Property Owner's Mailing Address315WillisAve Property Location
Govt. Lot
City, StateAshland, WI Zip Code54806
II. Type of Building (check all that apply)
•|l or2 Family Dwelling-Number ofBedrooms^_
D''ublic/Commercial - Describe Use
IState Owned - Describe Use
Phone Number218-730-7828 SW ,/,SE ',4, Section 07
Lot #50 _N R 07 _Eor®
Subdivision Name
Block #
|Cityof_
CSM Number Qvillage of
r^lTown of Clover
III. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i
applicable.)
A.• p^Tew System Leplacement System ther Modification to Existing System (explain)(Additional Pretreatment Unit (explain)
B.!• [Holding Tank DIn-Ground
(conventional)
I[At-Grade DMound Individual Site Design I Other Type (explain)
c.Renewal Before
Expiration
[Revision 'hange of Plumber 'ransfer to New Ownerl ,ist Previous Permit Number and Date Issued
IV. DispersaI/TreatmentArea and Tank Information:
Design Flow (gpd)Design Soil Application Rate(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
^ g£ S& u
0 ys g rS cd£ U
Septic or Holding Tank 2500 2500 Weiser
Dosing Chamber a en
V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Dean Blakeman
Plumber's Signature-^•:'s^ —MP/MPRS Number1092768 Business Phone Number
715-682-6050
Plumber's Address (Street, City, State, Zip Code)44941 State Hwy 13, Ashland, Wl54806
VI. County/Department Use Only //^a_
,0 Approved D Disapproved
D Owner Given Reason for Denial
Permit Fee$w-Date Issued
(el^ ^
Issuing Agent^Sign^tiin ^^]rfwl\1
Conditions ofApproval/Reasons for Disapproval
^d2- ^AiC^4 ^(^-^
Attach to complete plans for the system and submit to the County only on paper not less than 81/2x11 inches in size
SBD-6398 (R. 02/22)
o^m^ ^-QQWQ
\[i ..„ ,^.,.,.; Ill/ ^^7/X^ I SoilTest#IJU MAY^DZUZb 1^ Bayfield Coun^
Bayfjeia Co Zoning Depi Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1-10(d)) t^£-lT_
1 tWn Vfiy\ /Am<^
tent the followina site (se<
a certified soil tester determine that in my professional
judgrrient 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 JV\OJ\\/ l^^v^c'A/ _ Contractor.
Property Address ^09-0 (b\JLcLi^/ /^P Authorized Agent.~T
Utrlo&kv. m jy^w _ Agent's Telephone_/
Telephone f^iif) 7 ^0 - 7^^ _ Written Authorization Attached: Y or N
Accurate Legal Description is requested:
1/4of_^_1/4 Section 7 Township 5^:) N. Range/^ W. Town of_^^^^_
Govt.Lot Lot Block_Subdivision_ CSM#
Volume_Page_of Deeds Parcel I.D# // '-\^>^> _Acreage.
Additional Legal Description:.
Indicate reasoning for your determination: <C/<4|/ ^i'f-^ /^-S-S ^^^ ^ ^'
SUU^^Ie- ^/7 . ^<^5^^/ 5^-kt^^^^ W/^^ ^/f ^^ S^-^'t^t^
^ /^-/^~
Signature of Certified Soil Tester
5'/n/^^
Date
/^/i
Certification #/^?7/J
Signature of County Official
^ (Submit a Plot Plan & Fee)
Date
u/forms/soiltestwaiver(KLK)
February 2005i^O ch^ ^^ <^^5 m^
1^^
^_tis
t*^M^^
^in ^
^^j^&t2 /^^'^!0
H^
^^^L<f i u1A^iCl/A ^Q_^layfj M.Wi Ce^1 \Y^^k\M L e^\^0 (t&
^:^^
M u/H 1}06 M^<vc
^
m^jy^^(^\^ft^^
•^
^\[N /i frte^b^
4(1 //_
Vf
7^5'
A^•^^
^4 N ^•AI
r
i
CDg
!ljiH^1
3I
CASHRECEIPT nt ^j^OA^
Received From
Date:inl^n^^nu^
Address ^p^'o^ Jo/m^^/
rt^ir^^ ^r ^^sc>
\Fo.^t^cm SoV^ ^-00 We
ACCOUNT HOW PAID
AMT. OFACCOUNT
BALANCEDUE IMONEV ORDER UCREDIT CARD D By.Wi-.
015891
Dollars $50
Pg
Pg:
Pg;
Pg-
1
2
3
4
of 4
of 4
of 4
of 4
Attachments:
PAGE 1 OF 4Holding Tank Plan
Index & Cover Sheet I ' ; I ^ ^ I ^
H^i ^.. ... ^ liiiMAV '• '"' ',:' ^' ''•'
Component Manual Design References: ' '•"
Holding Tank Version 2.1 (May 2022-2027) , ,
Index & Cover Sheet
Plot Plan
Holding Tank Specifications
Management Plan
Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicable)
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, Wl _ zip: 54806
Project Address: 86020 Buckley Rd, Herbster, Wl54844
or WGovt. Lot: _ sw 1/4 ofSE 1/4, Section 07 , T 50 N-R 07 E |
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, Wl zip: 54806
E-mail: dean@blakemanplumbing.com _ This space reserved for approval stamp.
License Number: 1092768
Remarks:
L>- 3^—-—" Date: S/3o/2oZ^Signature:
Original signature required on each submitted copy.
CHECK BOX AS APPLICABLE.
SOIL EVALUATION
SITE MAP
PROJECT NAME:
Molly Larson Holding Tank
CHECK BOX AS APPLICAgLB.
Scale: 1"= 40'
40 60 80 Q SYSTEM,,, PAGE20F4
/////////77^^/////
(10 ft grid)
~7ZZ
102
V7,
/
PLOT PLAN
DESIGN FLOW:300 GPD
PROJECT ADDRESS: 86020 Buckley Rd, Herbster, Wl 54844
BM Symbol: -^- BM Elevation: _100 FT
BM Description;Top of well casing
Attach design flow calculations for commercial plans.
Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5)
Sanitary Sewer.
Force Main:
4"./_SDR35
Slope Gradient(%)of Tested Area:Well Symbol (if applicable); Q Indicate north by
drawing an arrowon the approprite line.
IMPORTANT:
Show ground elevation contours at suitable inten/als.
T3±
^
Wooded Site
Over 300' to N lot line
(line not to scale)
328' to Buckley Rd
(line not to scale)Proposed
House
28'x26'
^)
Over 1,000'to E lot line
(line not to scale)
20' 4" SDR 35 Pipe
Proposed 2500-gal
Holding Tank
116'to Slot line
PAGE 3 OF 4|^ ^ ^ K fi ^ ^ ^
MAY '-, ' '-ir'"1- u''
HOLDING TANK SPECIFICATIONS
(No Scale)
Electrical must comply with
SPS 316 and NEC 300
\1/ \L/
tO Weatherproof
-Junction and
Alarm Box
Conduit
12"Min. or 2.Oft above
Established Flood Elevation
Ve'ntCap / ^P1031)
Approved Locking Manhole
4"0 Vent Pipe ^ / with Warning Label Attached
>10 ft from —\ T—TT
Building
18"Min.
(typical)
^ Inlet
N
•AirtightSeal
Approved Joints with
Approved Pipe 3 ft onto
Solid Ground
(typical)
Inlet Invert
^-
— Max. 12" or 90% of total volume
if more than one tank
Alarm-On
HOLDING TANK
VOLUME = 2500 gal
3" Approved Bedding Material Beneath Tank
1^
4" Min. or 2.0 ft above
Established Flood Elevation
(typical)
\^ \/
Finished Grade
J~1
1—Watertight
Plug
TANK MANUFACTURER:Weiser
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight = [(cu.ft.tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt] x 1.5
Ballast Weight = \( 495.99 cu.ft. x 62.4 Ibs/cu.ft) - 16,840 |bs1x1.5= 21,164.66 Ibs
PAGE 4 OF 4
Holding Tank Management Plan [( ^
IMPORTANT: ;;ll MA ^ '" l
The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance [>ui;suarrt to , ;; ^, -..
requirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, this holding tank(s)
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wise. Admin. Code.
Estimated Daily Wastewater Flow = _^ju\j _ gp<j
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (/.e. odors, user complaints, etc.)
o mechanical malfunction (/.e., pumps, valves, switches, floats, etc.)
o material fatigue (/'.e., leaks, breaks, corrosion, etc.}
o neglect or improper use (/'.e., exceeding design capacities, prohibited activities, etc.)
o electrical components (/.e., wiring, connections, switches, controls, timers, alarms, ete.)
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 Wise. 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, Wise. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company: Blakeman Plumbing & Heating, Inc. p^e: 715-682-6050
Local government unit: Bayfield County Zoning Administration phone: 715-373-6138
Local government unit address: 1 1 7E 5th St, Washbum, Wl ZIP: 54891
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wise. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wise. 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, Wise. 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, Wise. Admin. Code.
ii-i
nA'^
TOP VIEW
W2500-MRTANK SPECIFICATIONS
DIMENSIONS:WALL: 2 1/2"BOTTOM: SEPTIC 4"
COVER: 6"MANHOLE: 24" I.D. PRECAST CONCRETE RISERHEIGHT: 71" O.D.LENGTH: 159 1/2" O.D.
WIDTti: 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 EQUALGASKET, CAST-A-SEAL BOOT OR EQUAL
LIQUID CAPACirr: 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 #8 (NO RBER)TANK: MIX DESIGN j?9 (SMALL RBER)
CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT VWESER CONCRETE
SIDE VIEW
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
DRAWINGS SUBMITTEDFOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
>lril
< U3LOl^t-z 00a I§m|3 CMnS IPlo|1 001
<=)
0Fa.
SHEET NO.^
BAYFIELD COUNTS ;| ^ i|;CHECKLIST FOR SANITARY APPLICATONS ! HA? u^
Submit the Following (Use Permanent Ink) CTitle 15, Section 15-l-10(e)) f;:.; ,::': ' ,,,,,: ^ ^
H Check List
Kl Original Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.)
Kl Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
K Original Plot Plan (383.22(2)2. 3. & 4.a)
K] Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer
D Pump Tank Diagram, Alarm and Pump Curve (when applicable)
a 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)
Kl Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds)
B 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)
Kl Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
D 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached
to all copies)
K] Soil and Site Evaluation Report (383.22-3(2)(b)l.e.)
D State Plan Review (when applicable)
D Copy ofWarranty/Quit Claim Deed (Optional)
Sanitary Application: (Include the following Information)
K] I Application Information must include: S 23 digit Parcel ID# - (do not use 12 digits anymore-obsolete)
B Project Address or Road Name where driveway is/will come off of) S (Owners Phone Number)
K] II Type of Building
Kl HI Type of Permit
KI IV Type of POWTS System
D V Dispersal / Treatment Area Information
El VI Tank Information
Kl VII Responsibility Statement (Plumber's Information)
H *Date Stamp*
Plot Plan: (To Scale or To Dimension)
K] Signature and Plumber Information B Address Number and Road
B Surface Elevation of Body of Water IS North Arrow
K] Direction and Percent Land Slope B Contour Lines
KI Tank and Filter Information and Location K Structures and Driveways
El Wetlands / Navigable Bodies of Water Kl Boring Locations
Kl Absorption Area (Proposed and Existing) B Property Lines
El Bench Mark (Location, Elevation and Description) Kl Well Locations
B3 Component Manual Version S Legal Descriptions
B Piping Material Information (conveyance line, building sewer line, material type and diameter)
Turn Over >
^ !!' 1;:J II I lc iruCross-Section and Over-Head Profile of the System: lU; " !1|;
AY '^ '" ! !;'/•• IL'
D Surface and System Elevation '•••"' tlw! -' '
D Position of Observation and Vent Pipes ^.^e';: i^;;.—:-.
D Dimensions and Depths
D Make, Model & Number of Chamber Units in each Cell
Property Information
K] How many systems will there be on this parcel of land? 1
Kl Has this property been split? No (Property Statement shows Property History)
Fees:
D Private Sewage System (Septic Tanks) $ 400.00
K] Private Sewage System (Holding Tanks) $ 400.00
D Mounds or Systems requiring Pre-Treatment $ 500.00
D Sanitary Revisions $ 25.00
D Private Sewage System Reconnection $ 50.00
and Private Interceptor
D Return Inspection $ 50.00
Kl 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:
$y-oo%?
HOLDING TANK SERVICING CONTRACT ID) ^ ^ ^ ^ ^
MAY 2 9 Z025 ^
Contract Date
/Y)^ 2^) 20^5 Bgytieid Go. lofing DeptThis contract is made between the
Holding Tank Owner(s) Name(s)/HO /ty ^
Pumper's Name (Print)
h-^T^^+i^ ^v^i'^ f^fc^i^Jj
Pumper's Signaturerwm^Jm Pumpers' Registration #5^
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PKOJECT
LOCATION
Leeal Description:
(Usetax Statement)
Tax 100
Section / .Township '^^ _ N,Range.
Gov'tlOt 1.018 CSM«Vol. Pagft CSIVJDplSjff
lliia>a>
w
Lot(s)Np.Block(s)No.
^ IV 1/4. S£r 1/4.
Town of:
<l/Ot/€T"
Lot Size Atreage^0
Subdivision;
1. The owner agrees to file a copy of this contract with Bayfield County as required in SPS 383.55, Wis. Adm. Code.
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have
access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain
the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper for ail 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)
fY\olly5 L<^TSO(^
Owner's Signature(s)
^..
MADISO
Notar
Subscribed and Sworn to me:
on this c^ v day of
by.^&A^^JLU^-
f,M BRI^ER
/ rf^Ufatoission exfj
^lotao?~Public
ires on: ^lOll^O^S
jiaio ui vviso'unsiii
Revised: May 2016 (®May 2018)Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (l)(m)]
Drafted by fr}^i^
Document Number/Plan I.D. No.
Owner Name (s)
IV\o^ ft Larso^
Parcel Identifier Number (PIN)[\H^'b
HOLDING TANK
AGREEMENT
Owner(s) Mailing Address
5/5 Witlis /Yv-e//hhl^hd l^-T £^^0 I/toAgreement Date (same as Notary Date)
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 onsite wastewater treatment system as permitted under Ch. SPS 383,
Wis. Adm. Code or Ch. 145, Wis Stats.
1/4ofs-'t- 1/4 Section Township _N. Range w.
Town of ^V^l^
Additional Legal Description: .^0
Gov't Lot ^Lot ,BIock__Subdivision__CSM#
Lot_CSM#Vol .Page CSM Doc#
DOCUMENT NUMBER2025R-607651
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED05/29/2025 AT 1 0:02 AM
RECORDING FEE: $30.00
PAGES: 1
Return To:'^^^'^Mn ,^.
1AY !U!
As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above describ(ga';'gr|3perty,.-^,ag^e to do thefollowing: -- ....„ u.;^ ,.,yi;.
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. 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 wastewater treatment system that complies with Ch. SPS 383, Wl'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.
BRINERiSubscribed and sworn to beforefne on|WI*Ua<A?"55/^//^^5 I ' Notary PublicOwner(s) Name(s) - Please Print
fW(?/(y6- LffX^'/'State of Wiscoft^
/Uy/i &^rNotarized Owner(s) - Signature(s)Notary Public
- ^^9^-^My Commission Expires:K/O'il^W
Drafted by: ^0 1^7 ^ L^CSD ^
Personal information you provifle may be used for secondary purposes [Privacy Law, s.15.04 (l)(m)]
Date: /^ 2^ ^^i ^^-
u/forms/sanitary/holdingtankagreement.doc@June 2018
B'YFIELD
[3
Property Owner:
LARSON/ MOLLY B
315 WILLIS AVE
ASHLAND, WI 54806
Description
Bayfield County
Planning & Zoning Department
117 E 5th Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-0114
Private Sewage System (Holding Tanks)
Total:
Payment Amount:
Submission Number:
SS-00557
Transaction Number:
SS-00557-2C8E5
Amount
$400.00
$400.00
$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 COUNTS SANITARY PERMIT f#04)-25-44S
STATE SANITARY PERMIT
OWNER: MOLLY B LARSON
60VTLOT: LOT: BLK:
SW 1/4 SE 1/4 SEC: 7, T 50 N, R 7 W
TOWNSHIP: Clover
SOIL TEST: 35-25
NEW SYSTEM
SYSTEM T^PE: Holding Tank
PLUMBER: DEAN BLAKEMAN
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
TRACY POOLER
Authorized Issuing Officer
DATE: 6/4/2025 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