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HomeMy WebLinkAbout25-59S^\<ENTERB''^\^ Department of Safety & Professional, iSjer^ic^s, i i, ^ Industry Servic^.Divisioii iM 5$- ^05-7 ( \S>&Y -F/-€ tCounty iTrSanjll^y Permit Number (to be filled in by Co,)I 25-5(?S Sanitary Permit Application State Transaction Number [n accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate go^ernmentatnnit; 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 purposes ill accordance with the Privacy Law, s. 15.04(l)(m), Stats. I. Application Information - Please Print All Information Project Address (if different than mailing address) ^<ro B^^^F^^^ Property Owner's Name KiJiHt D&^liOiA)€. /^/,sq L^"Hy\ (-^y^-\^^^c-^\ P<nA. Pmnpi'fv Oumpr'c Mailtiiur A/irli'A^ Parcel#-T^ z^ri [^{^ Property Owner's Mailing Address z^c^ F<n^j^ff A</< Property Location ^ )i3 p^ ^' ^ ;ity, State S-h F^uf ^7 AY -^ Zip Code€€~i or II. Type of Building (check all that apply) I or2 Family Dwelling- Number ofBcdrooms D Public/Commcrcial -Describe Use D State Owned - Describe Use Govt. Lot. Phone Number 4?-S~/ 3-08 7^*7^-',4,-.'/<, Section 2^ Lot #T ^1 N R ^ ^o<^ Subdivision Name Block # CSM Number D City of_„ a Village of ^ Town of €^\y^^y HI. 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.D New System j2? Replacement System D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain) B.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 Owner,IList Previous Permit Number and Date Issued IV. Dispcrsal/Treatment Area and Tank Information: Design Flow (gpd)300 Design Soil Application Rate(gpd/sf)Dispersal Area Required (sf)Dispersal Area Proposed (sf)System Elevation Tank Information Capacity inGallons New Tanks Existing Tanks Total Gallons # of Units Manufacturer It W ~w So SeptWm-Holding Tank ^ C 0 o -z,coo T U) t^S-o-r (^.ortfi.•^ BuiiHETOIinwWr V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. natureM\^T^ ^s ^ I ^/^t^€y NP/MPRS Number 2.2-^o<? ^ Business Phone Number U7^S~2.<?S--^/^> Plumber's Address (Street, City, State, Zip Code) ~ ~ ^ ., n^ Bc,^ s-'^ '••^^^^^^ ^^ ^-^,7 VI. County/Department Use Only ^2. kpproved a Disapproved D Owner Given Reason for Denial Permit Fee ' 1-00 • Date Issued~rr\e'L- ((^^5 '^7,^^v Conditions ofApproval/Reasons for Disapproval ^fc^<^t ^A^ . Attach to complete plans fur the system and submit to the County only on paper not less than 8 1/2 x It Inches in size SBD-6398 (R. 03/22) Jij' 116 i I! I? I; ||)j /ENTERS $P-002^ Ill JUN 1 2 2025 ^ENTES?E?\-~^~ Bayfield County Soil Test # ?!cf i u Zoning DejWaiver of a Thorough Soil & Site Evaluation 30,1 ^ (subject to 15-1 -1 0(d)) fJ$S-*%" It /^ ^ ^-^ J€> I ^.OS ^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. £:(^l>^-'(^ ^^•s-/-*^5-^ i?°A. Property Owner '^ ^ ^ ^ <^^ U e> ^>-^- _ Contractor. Property Address ^^<?o ^v k P-f ^d Authorized Agent. t^-^-f^< 1^'J- ' Agent's Telephone. Telephone ^-$7 3cr^ '7^-7^ ______ written Authorization Attached: Y or N Accurate Legal Description is requested: J/4 of_1/4 Section ^ Township ^7 N. Range 7 W. Town of <^/arvk<-f< Additional Legal Description: A F^ " <--^-1 ' ^ > Govt. Lot \-^ 3 Lot Block Subdivision Lot _ CSM#_ Vol. _ Page _ CSM Doc #. Volume_Page_of Deeds Tax I.D# I ^ Dl _____________ Acreage. Indicate reasoning for your determination: U^^=~/~ ^/^ y -e-y S^ t ( / -i "t'^< ^ ^ <£ ^ €?ST nc-^i^.eii^^^j"^^ 1^ /^z^^c^-A/B p'f^-e<. p'ff^TS: ^^ fc><^ i^s^~^/^c{ . ••»T-^^i-^' Signature of Certified Soil Tester ^- -2. I - ^ 5" Date csnr ^ zzoo^o Certification # Signature of County Official (Submit a Plot Plan & Fee) Date u/forms/soiltestwaiver(KLK) June 2018 Jr^r+/0a^r: U.^ i ^cr< p-^n ^ l f"ff6c2r,ms!^• a <?c'< I Q ovi i'\«i}'..•Ku.+k ^ft^e^, _ ^^-^^5^c4:T^N ^7W S^J'/<^^^ ^a-/ej1^'1. s^L^ ^^t^:s'/''e'^^ypoK /^p^^^l^ z.z.c)g i^fvj&tl A^e T^un fi^:(lloy-^ ST. P^i, ^ ^ ^"l ^ t^n^ tf-F: B ^y^ e .-»•rb^l^l0! > ^y-h \^'^ ^14^y^ ^y&\''y^<^. ^ "^ f.^'^ VJ''(f". ^^^ N^r^5+ R^t ^^ T^^ ^ 'S-f-'^fi^ ^jA/lon aL'^s&r do^cr£^<e-~%,wfc=1^/<U%^ £ ^~f^m[^ir^msf'T^.^k i-6. Ficw'L'.^i^l^-h . ^'^~ ^y^5-.'^y.^y^./ // -^- I ^ IE N JUN 122025 ^ aavfteidCo.ZonitiuDept ..^01^..v^?.^c^^\«srv":^-.]^:;^^ Us." ^r ^^€/^-A'S-. •'•-,.</'r ^ /-" ^-^ r k.^ ^t^, .e[° , (..U* „/" ^/t^^f'T^i^Ou's.&^-s' <s-U ^-un. se,4l..ti.c^:.s Cs;PS3^s) A.F.6'. i- /Uo^<s- -f/'•>."./ ^ i^<:<L<je. -0" = uJeJl .. ,. ..'/ _ '&^S^S'^t^.r^ SEc-oK' ^ S8m& ^ KP ^ £:^fcJ'y/co.©/ -3-^7 3'^ 5ck «^o fvC wJ/-F^^ ci^e-"-^0:^ ^ . / ^ U " ASTW Q 1 ^^'S' ^pp v& y^,c4 p- p €. ^'Ki.+'a. i/'< c>~ I "" Hff /J< CICJ'TCT-M ^' Ce^ij'ys^ei' fV}Qi y\ n.% /, u $€.c( {M^n^ I Ty^/E R ^); (^m^Zfl •&2." Z^fc?) £W,jn ^y: mf^5.z2Goeio f<s /^:e.5 ^., f/a ^i !»' n^ P»©,S-s>i<; s'z'z. Tre^i /Z'^e-t/; 1^3: ^Y^^ ... mil i KM m ;.</!» tHU 3, yy/b p. 2 Holding Tank Plan Index & Cover Sheet :; V. W^f iHi .,[Ill \;UN A!/^ ^ Compwent S^Qnu^ Design RQfQrancex '/yWwA-i "t/f&"^V^rs?®^^i)J^,m^ Z.02-2--Z-OZ7'' Pg Pg: Pg; Pg^ 1 2 3 4 of^ of ^ of ^ of S Attachments: Index & Cover Sheet i Plot Plan ; Holding Tank Speclficatiqns Management Plan ! 2. S h.-e.-e.-/ £^<£i +iLjp^i 0 4i. Pc 7 o-^ ^ •^ s ^{- ^ Enelosures: [ POWT9 Appljcation for |RevjewC^^n' ^lri/ p^m' Soil Evaluation Report & Site Map (if applicable) Holding Tank Pumping Contract (if applicable) HoLding Tank Agreemerit (if applicable) Project Name / Description ^(7<^ fc>^-/-^^^i^-^te^5 0*n P.£?/V. Owner Name(s): jRi/t^^0^ _ phona: ^ -3^.-7^^<- Owner Address: ^Zc^ 1pc\^ U A >/€ ^4 7?,o ( ^i Ai Zjp: ^~^-/ ^^ Project Address: ^L(ct° '^av^- pe^-^/2-cL f-^rLs^^^t^r Govt Lot: [i3 ^ <fc-Q- { ' ^ Township: C\<^-f^-^ Project Parcel ID #: "T^)C X C) " l ^ ( <c? ( Section ^ . T-§~/ N-R '7 _E Q or W S County: ?A^j^^7 c1 Designer Information Designer Name: A //^^ Po / ^^^U, _ Phone: 7,^- -ja^2,- t// -S~^ DesignerAddress: R&-^c,^ ^"^-^T^on ^-<^^< WX :Zip: ^El.fjt^Z. E-mail: +'£•• ^.y (^.. ^> •e-«. 1^-^ t^ ? <^-e- ^ c!- y"~i~~^. •' <-' &> •*l-»^, Thi^ space reserved for approval stamp.1 —?'" ^ ' —" • i 'License Number; 2.2- oo'? o _ ; Remarks: Signature:/Date:5~~ Z / - 2 S- Original 5igna(ure required on aach submitted copy. Proj?^.r+^ Oi.o.'t&rJ •KtAL d>»^^c^ ^i .\., i^^i c^ ^ -^^r'^l"~' '*'" P,oA z.z-ctg F'clw&tl A^/e ST. P^[, ^\^ S-S-^o? r^'tt^w0^ ^L^c::^^... T:^y^.^ , u N»' •'(i^s^hf^c^T^N P.7W ^J^:7<ie'^J^'s^®^J1 ^ p^v^i ^ -r A^'-e-.s-f- R<|: ^^ ^k ?o^ <^ lz<i Tfftun fiKdloiX^ ^ " X»-*4ff,Oo^Jion ^^s&r (Lencr&4e-"%nk:=^ ^L~V/^ VK'^rf r^'Te -Yank i~e F<c(t>L^<£.Y^e:ht^Y ^-C-:~B ^y^ e (i w' ^ff^^i^^&K^6y c^ ^^\-^o ^^^V^^•^^.^%li 'D) !^ 1^ in ^ I Ini^\^^WAy>^^•^yy^ yTW .^;T^~W~.,^f^ ^. .^^^'^^y:—' 01 i-'""",. ^° r'h^' Na^<T<M.<:f"7^i^Ou<£e^5- <n// ^i'^'i, sa4l.,ac^".s ^^'P.S3^$) A.F.t". ^ A^ou'e. -f^*.o^ c} r-c<. J e. -Q~ = UJ@JI .. ,. .'/ B(54-(-<?^^.<J»»-t<i.<?i s£&cif-=- ^ @m &\} %p» £l^u/co.o.f -? ^ 3 3.' •= $ck ^0 /3vC ^.'/-F i0 ^ d ^e^4/ o-^ = ^ . V'ASTW »>i7^s" ^p,vv6 y&ci p-p<£- ^L<L+^y-'c'-l <- Hff Ul ^TCLH t^ Ce^ipes-nei' /v)a y\ ^L u S€.<^ ^7^nu&! T/r9&'(/£'R £,i) ; (; m^Zfl 2^ Z^Z7) t)r^^ ^y: wws.&e^iQ Fa Ikc'S ki f/a ^i i' n^ B©,6<»i<: ^z-z Tr^oi R'^e^; w3^ &'Y^7 PROPERTY OWNER: /?^+^ -^° ^^ ^'€.,^,.5^^^ d^'\^^^ "7 PLUMBER: Allan Polkoski/ Polkoski Plumbing _„ SIGNATURE: />L{A —Y DATE: <-^- ( .-^^ LICENSE # 220090 OT-1 ^A HOLDING TANK SPECIFICATIONS il ! UN 1 ''i 2- :• Number of bedrooms JNon-residential estimated flow (gpd) 2000.0 [Minimum holding tank volume required (gal) 2000.0 •iPrpposed ho^dmgtanl^capac[ty Wieser W2000 SJ Electro HWiOT ffi-"T^Tnrw*^T;;'T;"j-".-ztWt~^"w^^^--<-"".ffiw''s^?^^T;r;^ Tank Manufacturer •.Tank model number jAtarm manufacturer i:Alarm model number Tank Dimensions and Data 1;X for round tank 47.0 JLiquid depth below inlet invert (in) 8.0 sMaximum depth of soil cover(ft) 66.0 .Height (in) j OuTSide 151.0 ^Length (in) f Dimensions 86.0 ;Wictth(in) -' Only Tank Anchor Calculations 15370 jjlbs Weight of tank and coverr"""i:5o'"""i 31055 36.0 7.7 Safety factor Ibs Weight of anchor required in Soil cover req. for anchor or yet Concrete counter weight HOLDING TANK CROSS SECTION •-<• junction box conduit / blind plug to seal outlet ^—24 in. —>| ^\ -T» M/ manhole cover with locking device and warning label 4" min. finished grade1 /vent cap Manhole and vent locations may be reversed. 12"min. vent pipe service alarm on Electrical as per NEC 300 and Corn m 16 12.0 in. 35.0 in. Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent ma+?rials comply with ST? 3S'5. 3 In. bedding under tank.Tank Is anchored as necessary to negate buoyancy. Project: t 16" min.IJ3 building sewer inlet (001 •-1 t - 4" CAST-A-SEAL §^2^ > 164" FILTER 4" OR CAST-A-SEAL BAFFLE ^ ~\ _ TOP VIEW WLP2000-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 3" BOTTOM: SEPTIC 3"HEAVY DUTY 5" (ADD 2,800 LBS.)COVER: 6"MANHOLE: 24" I.D. PRECAST CONCRETE RISERHEIGHT: 53" O.D. LENGTH: 164" O.D. WIDTH: 96" O.D.BELOW INLET: 41" O.D.LIQUID LEVEL: 36" WEIGHT: BOTTOM 11,260 LBS.COVER 8.170 LBS. INLET 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: 56.27 GAL/IN LOADING DESIGN: 8' 0" UNSATURATED SOIL HOLDING TANK:OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,138 GALLONS TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN jj!8 (NO FIBER)TANK: MIX DESIGN jjf9 (SMALL FIBER) CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT WIESER CONCRETE I PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: OL\=>10]n-|I >i^'l g CD8 ml± ^t-iool0 Li ^>.\s CM10 0000 'I CM]s s\ 0I— a-^en <1 PlLJ|co I^iLLJIcn\ SHEET NO. 1 .OF 1 .\\'^ • ', /;;," HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and , », • maintained according toS>^3^3 Wis. Admin. Code, the Holding Tank Component jyi^nual^^^^^'"."^^ ^ 't"/f& ^ER 2.0 and the 'B<ty-pe U County Sanitary Ordinance. C^£'^ ^ ] L^ so 2^ -202.7} 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 foNowing persons should be contacted: a. Installer.............................Rg/^k; f/um^^f m.W*2.2.ffociO Phone: •7iS~ 372.- t/<'^~(o b. Service Provider.................^rts^^v^^'^>^;,. RQ^ ^ 8tZ7t Phone: '7,^ jty-A. - ^o&fo c. Co. Zoning or Health Dept. Ba.y^^.U C<s L> Vti^p "T^u^ _ Phone: 7/J 3-73. - ^tSS 11. L^J b^S€..f T^^^- ^ - n ^^ LA\^:^^^ -r^i ^ ^ 7t^ •T^^^: <^f-^C'Vof! ^y^€pc^Txbtt; -r^x r b * < z^l Project Transaction Number: HOLDING TANK SERVICING CONTRACT Contract Date $'--^-^.r This contract is made between the Holding Tank Owner(s) Name(s) \'Lu<^v\ T^WWC- -(^-A ^I^^^C^^s^K^ Pumper's Name (Print) . , -fl^oixvt.ta.j p&fl^&stCi •J^e.^ '^n/-(£.y $'<L.p-+(8^ Pumpers' Registration # ^IZ^! We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION Legal Description; (Use Tax Statement) Tax IDS i-^1 Section ^^ 1.1;1 lllii. Township S> I • '11:1\ N, Range... Gqrtt'otw lot«CSM#Vol. Page CSM Doc ff ±L w lot(s) No.Block(s»NO. ~WT^^ .1/4, ___1/4, Town of: cj.^^ ^-et ;^ lot Size Acreage?,<3> 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 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, Wls. 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) '|2^J^ 'Omlv-W 9bb ^\^i'^ CM ^w>ffi\ Owner's Signature(s) Wi^Apo/\ ">^A^.\AA^fl^vVkAAAAAAAAAAAAA\^^V^A tgQ^ LISA L. GRELL 1.5:.££:'"?E] Mnf-ir-, D.AA.^^^/.-x- Subscribed and'9<frecp to me: onthis33davlof /HlA^-3^r-^^^CP Notary Public My commission expires on: / • '01 'i ^ ^•:;»Ji^ MY Commission Expires Jan. 31 ^29: Revised: May 2016 (®May 2018) a^wv^^/ww^/^v—^.^^ Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (l)(m)] Drafted by Document Number/Plan I.D. No. |me (s)j^a^Vv ^^^W^poA" ~^ \ <rfc ^ ^d^^^\ ParceTldentifier Number (PIN) tU^\n->t>M-^ iic!>-c HOLDING TANK AGREEMENT Owner(s) Mailing Address^'^^^I.^IJ AV' ^P^\ MA;<5SK^ Agreement Date (same as Notary-Date) ^-/uu s-^-^r 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. Town of .1/4 of_J/4 DU -e-^- ^Section .^^..Jnifnship ^.N. Range _( Additional Legal Description:$<s>e A' * /-<' 1^* ^ f ,s ^-e.-e.'^r Gov'tLot. Lot. Lot__Block__Subdivision_.C8M#_ _CSM #_-Vol..Page._CSMDoc# DOCUMENT NUMBER2025R-6077 1 2 DANIEL J. HEF-F-NER REGISTER OF DEEDS BAYFIELD COUNTY, Wl RECORDED06/03/2025 AT 1 1:03 AM RECORDING FEE: $30.00 PAGES: 3 Return To: f^-. y "pc-.I.U.^Sk^ 3:'o>t- ,.&"' '_! 1^ i&'t^, f^_t ^ e.l^-/^ '^Wr 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. 2. 3. 4. 5. 6. 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 tho tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a speciai assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 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. 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. 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. 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. 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 (lv4-H • 'b- /M V' "^ ^-- ^A £/(^b4^ChH^SAi Subscribed and sworn to before me on this date; ^.D _2^2^1Notarized Owner(s) - Signature(s) '\A ,^^^.^uy/^^-A ^n t;omn;ilssior\ Expire;l_s^a@L Drafted by; Personal information you prout ,n<^t/ YQ i K^l€i ration you provfde msy hn *i<;ed ^r pc""ln;-i:s."y p'jrpsscs ;";•;»(;-/ \-^., •-;. ;u.04 ;;/imij Date;<-^^-^^ u/forms/sanltary/holdingtankagreement.doc ©June 201 u/^./'/uwvia K 6 1.3 a S^€^ } £L U K J '" .. i.'; '!. ;.: . - .: BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS ;u nv Submit the Following (Use Permanent Ink) (Title 15, Section 15-l-10(e)) 0 Check List C5T Original Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.) 0 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 12T Original Plot Plan (383.22(2)2. 3. & 4.a) @f Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer ^ Pump Tank Diagram, Alarm and Pump Curve (when applicable) ET 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) 0' Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) 0 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) 0' 2 CQmElete Sets of Plans (383,22(2)(2.) (Note: Sanitary Application and Majntenance_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) 10 Project Address or Road Name where driveway is/will come off of) \SS (Owners Phone Number) ri II Type of Building 0 III Type of Permit St IV Type of POWTS System D V Dispersal / Treatment Area Information 121 VI Tank Information 3 VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan: (To Scale or To Dimension) Bf Signature and Plumber Information \M Address Number and Road ST Surface Elevation of Body of Water . ^ North Arrow D Direction and Percent Land Slope D Contour Lines El Tank and Filter Information and Location 5f Structures and Driveways 0 Wetlands / Navigable Bodies of Water 0 Boring Location D Absorption Area (Proposed and Existing) Ef Property Lines 13 Bench Mark (Location, Elevation and Description) 0 Well Locations Ef Component Manual Version El Legal Descriptions 0 |iipJh9N^ri^l^lnf61^ati6n;i[con^e^^ Turn Over > BAYFIELD COUNTY !,;i ;:' ;i:: y ii ';1;1 V 1, CHECKLIST FOR CERTIFIED SOIL TESTS i ,an^ ; /_ /';/" Submit the Following (Use Permanent Ink): 0 Check List 10 Index Page / Title Sheet (Optional) ^ El Original Soil Evaluation Report (Submitted in Deed Holders Name - riot prospective buyers) Sl 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) El Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used 0 Property Owner's Information (not prospective buyer's name) E Property Location (Accurate Legal Description with Sec/Twp/Range) [0 Road Name (where driveway is/will be coming off of) 13 Floodplain Elevation, Flow Rate, Comments and Recommendations ^ Complete Soil Boring / Pit Information G2 Date Soil Evaluation was conducted 13 CST Name, Signature, Number, Address and Phone Number D *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) Si Bench Mark (Description, Elevation and Location) Q Contour Lines (Example = 98.0' ,96.0' ,94.0') E] Pioperty Location (Sec/Twp/Range/, Accurate Legal Description) 0 Borings (Locations and Elevations) C Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) 1/1 Location of Wetland Areas, Floodplain and Navigable Waters Wl Buildings, Driveways, and Structures (Location and Descriptions) ^ Location of Property Lines Existing System Location [Zl Address Number and Road Name [3 Current Surface Elevation of Wetlands and Navigable Waters El CST, Owner and Property Information North Arrow Fee: E3 Certified Soil Tests - Review & Filing Fee . $ 50.00 . u/forms/sanitary/checklist/checklistforcsts H.C.MUIer Company [pjq] DOCUMENT NO. 344347 Charles W. Egstad conveys and warrants to Gordon Donhowe and Ruth Donhowe, his wife, as -ioint tenants. the following described real estate in State of Wisconsin: Bavfield County, STATE BAR OF WISCONSIN — FORM 2 WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATAREGISTER'S OFFICE ^ g^g^ Bayfield County, Wis. ^ RECORDED AT 5^0/PM. ON ' AUG 2 - 1982 IN V°l- 3^?<7 of ^. Pagep?//-<2/<2 RCGtSTER OF DEEDS RETURNTO^:^^ DO^^OIO^ ^13^ K^cipp 6t.^? s+, p^,'MN5|r-^^, crt ?^ Tax Key No. A parcel of land ip. Government Lot 3, Section 26,'^and Government Lot "I ^Section 25, Township 51 North, Range 7 West, described on the Schedule attached hereto. Mr.' This deed is given in performance of that certain Land Cpntract between the parties dated May 6, 1978, and recorded in Volume 315 of Records, at Pages 449-451; inclusive. This IS nothomestead property. (is) (is not) Exception to warranties: TRANSFER S^ODTEE Dated this day of ,ia82 . * * TITLE: (If AUTHENTICATION Signatures authenticated this , 19 MEMBER STATE BAR OF WISCONSIN not, (SEAL) (SEAL) day of ^^' &^SL^ * Charles W. Eqstad ACKNOWLEDGEMENT STATE OF WISCONSIN ss. Bayfield county ) ^^ Personally came before me, this "? !=? (SEAL) (SEAL) ^ -^ )Jt- authorized by § 706.06, Wis. Stats.) This instrument was drafted by Atty. R. W. Norlin Washburn, Wt (Signatures may be authenticated or acknowledged. Both are not necessary.) •Names ot persons signing In any capacity must be typed or printed below their signatures. Charles W. Eastad. :,19_8^ the above named day of to me known to be the person _ who executed the foregoing in- strument and acknowledged the same. /^''-cs-z^^-^, 6^ ^ (^-^-<»--A-3--a_<^ * J^-hU^., '•>.(. ) cf Sd Notary Public Bayfield _ County, Wis. C,p<nmission^is p^rmar|ent. (if_not, state expiration date: /-X<. ,19 ^.i.) -5lhocrTro~T3Q02- ^a~&Kr;7D.""0': 'IsaKss&'ri'"" "7':xT7i9"^Z) 1C =WARFCSNW'DEED-STAfrB?fl"0^^ A parcel of land loca-bed in Gov't Lot 5, Section 26, and Gov't. Lot 1 Section 25, T. 51 N., R, 7 W., Bayfield County, Wisconsin, describedas follows: To locate the Point of Beginning, commence at; the South % corner of saidSection 26 and run N. 01° 01' 00" W, along the North - South % line of Section 26, 197/i-*61 feet to an iron pipe on the Southerly R. 0. W. line of a Town Road; Thence N 4.7° 4^-' 00" E, along said Southerly R. O.W. line, 865.21 feet to an iron pipe on the East-West % line of Section26; Thence N. 89° 05' 00" E, along the East-West % line (parallel to the South line of Section 26), 11^-^.25 feet, (passing thru an iron pipe at 1105.79 feet) to a 1" iron pipe, which is the Point of Beginning. Tfaence from said Point of Beginning by metes and bounds. N 89° 05' 00" E, along the East - Vest % lin<? 619.5^ feet (passing into Section 25 at 568.55 feet) to an iron pipe near the shore of Lake Sup- erior? Thence along a meandej? line near the shore of Lake Superior, N00° 01' 58" W, 100.02 feet to a 1" iron pipe; Thence leaving said meander line, S 89° 03' 00" V, 621.15 feet, (passing into Section 26 at 51<?6 feet), to a 1" iron pipe $ Thence S 00° 57' 00" E, 100.00 feet t3 the Point of Beginning. Intending to include that land lying between the meander line and the shore of Lake Supetior and the extensions of the North and South lot lines to the shore of Lake Superior. •'ii/'1 B-^FIELD Pl Property Owner: DONHOWE/ RUTH S 2298 FOLWELL AVE ST PAUL/ MN 55108 Description Certified Soil Tests - Review & Filing Total: Payment Amount: Bayfield County Planning & Zoning Department 117 E 5th Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-0114 Fee Submission Number: SR-00264 Transaction Number: SR-00264-2E329 Amount $50.00 $50.00 $50.00 Reference: 6200 Paid by: Polkoski Plumbing/ PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 6/20/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit B-^yFIELD Pl Property Owner: DONHOWE, RUTH S 2298 FOLWELL AVE ST PAUL/ MN 55108 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 (Septic Tanks) Total: Payment Amount: Submission Number: SS-00571 Transaction Number: SS-00571-2E32A Amount $400.00 $400.00 $400.00 Reference: 6200 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 6/20/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit BAYFIELD COUNTS SANITARY PERMIT (#04)-25^9S STATE SANITARY PERMIT OWNER: RUTH S DONHOWE GOVTLOT: LOT: BLK: 1/4 1/4 SEC: 26, T 51 N,R7W TOWNSHIP: Clover SOIL TEST: 55-25 REPLACEMENT SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: ALLAN POLKOSKI 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. 1 68; 1979 c. 34,221 ;1981C.314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. PREVIOUS PERMIT #: LICENSE: # MPRS 220090 TRACY POOLER Authorized Issuing Officer DATE: 6/20/2025 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 6/20/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION