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°t INBOUND NOTIFICATION : FAX RECEIVED SUCCESSFULLY un TIME RECEIVED REMOTE CSID DURATION PAGES STATUS July 14, 2025 at 7:18:24 AM CDT 7153724159 39 1 Received Jul 14 2025 22:38 HP Faxpolkosk Plumbing 7153724159 page 1 Request for Sanitary Inspection (24 lira. 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 Other fl on y �o j k o s k Phone Number Plumber: �o t J O5 u 5' wt n Fax Number _7 / 3-72--�J(5 Email Address Homeowner: 5 '7 1'okty & L as r7 u r e n c r 1A1 v Immediate Phone Number So Zoning Sanitary ZS— 9S Dept can call you right back (if needed) Permit#: ?,S—Z`3�—�lfSI Plumber's Choice g Dept Data: ' I^ v�r� Plumber's Choice Ing Dept Time: Township: o J I -.. Address #& & Road Name: w , f-. 1J -o.- u e r -Ta kt [ T f -1 .Q a v t 1-rfc . 3� , • i es —i--:, Lf e on ef T/f 13. eso ' '�i. (es r 2 or tz(- C El crJBe L,,,//e 6- r4 , J fcs Directions v✓n L{ ��� ��•�c "l• PG h•rt° �Yct( To Site: Comments: " Plumbers you must verify any change(s) by fax or email Notes from Zoning Dept: ulfonns/sanitarylrequestfodnspectlon Zoning Dept (04112104); 0 June 2023 POWTS HOLDING TANK INSPECTION REPORT (ATTACH TO PERMIT) RAY C EVERSON 76730 LOOP RD BRULE W1 54820 TANK INFORMATION I City 0 Village 0 Town of (%j�p £jSanitary Permit No. ix Parcel No.71 Sx „/ Property ddress if Av able f TYPE MAN FACTURER/MODEL # CAPACITY O G/ n SETBACKS Property Line Well Water Service Building All -Weather Road OHWM Swimming Pool O DEVIATIONS FROM APPROVED PLAN COMMENTS (Persons present, discrepancies, etc.) Tap dWNcR4C -'o s � r,�l /ocYS4C /s COMPONENTS NOT INSPECTED 4)v r, e t4Lv o f s e /f, Plan Revision Required ❑ Yes No D e Signature of Inspector: Cert. Number 5,Ke1C7 On other side 10 of 13 j BAYHELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Bayfield County Courthouse Fax: (715) 373-0114 Post Office Box 58 e-mail: zonina(a�bayfieldcountv.Wi.gov 117 East Fifth Street Web Site: www.bayfieldcountv.wi.gov1147 Washburn, WI 54891 Property Owner RAY C EVERSON Information 76730 LOOP RD BRULE W1 54820 As you know dhN /l/! �9 of ��L i was contracted by you to install a private onsite wastewater treat ent system on your property described as: Notes: A c /�c Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: on at AM/PM C. Tank was crushed / removed and pipes disconnected by: On at PM) the above -mentioned plumber contacted our office to conducta re-cover inspection as required under DSPS 383. One of the following applies: kwas 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. LIISystem 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. LISystem could not be inspected because County could not respond to plumber's time constraints. Comments: U/!arms/sanitaryproperryowner-input APri12019 „�ptuets:e ti � � Department of Safety County / / [ " & Professional Services, Industry Services.Division Sanitary Permit tuber (to be filled in by Co.) �6nrpr�Etr• �� �® Sanitary Permit Application 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-owned POWTS are submitted to Project Address (if different than mailing address) 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), Slats. ,, LL f/ I. Application'hffoliination -- Please -Print All Information T� 'e L r vt L. -. .- Property Owner's Name Parcel # RCkt leiV•e-tr s C> Z S 2 s' Property Own is Mailing Address Property Location 1!'73O Loo R� Govt. Lot City, State _ Zip Code Phone Number L) Ut Y 14J 1 ��� 2 O 'Z, l 8 .Lf cj I — b 4 S A,L'/,, Section jj II. Type of Buil ing (check all that apply) Lot # O' N R • .o VL I or 2 Family Dwelling —Number of Bedrooms Subdivision Name O Public/Commercial — Describe Use Block # Cl City of ❑ State Owned — Describe Use CSM Number O Village of Qg Town of O J t III. Type of POWTS Permit: (Check either "New" or "Replacelnelit" and other applicable on line A. Check one box on line B. Complete line C If a Ilcable. A. New System y 0 Replacement System 0 Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. Holding Tank ❑ In -Ground ❑ At -Grade 0 Mound 0 Individual Site Design 0 Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV.-Dispersal/Treatment Area and Tank Information: Design Flow (gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units New Tanks Existing Tanks Sapcia4r Holding Tank a U ca H iz C7 a Z ® o o Zo0O V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si atureP/MPRS Number I Phone Number AIleLti JTo l l�oS 4' aZoo7d71�2i _ (,c Plumber's Address (Street, City, State, Zip Code) 1" d• a coc S - z.- Z y Y©'.► VL County/Department Use Only Approved O Disapproved $ Pctmit Fee J Data Issued i L Issuing Age gn c ❑ Owner Given Reason for Denial 00 710 as 3T� Conditions of Approval/Reasons for Disapproval �!/• ��`'�! Ga'A► t/ ate' a'n e/ i f Yrs- .oa�is r cJt1-sLULD c(i'IC_i/ipe4 ('4'2121, L:.Hi. Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 Inches in size SBD-6398 (R. 03/22) - ,. r11/•1. 1I1N I? LVI 4IVU No. 9915 P. 2 Holding Tank Plan Index & Cover Sheet PAGE 10F8' Com onent Manuel Design Referancee: i rsiah.�Q j) Via. Pg I of Pg2of9 Pg3of9 Pg4of $ index & Cover Sheet Plot Plan Holding Tank Speclficati ns z s k ee 4' Management Plan Project Name I Description Owner Name(s): a.y' 7- '28 Phone: Owner Address: 7 (P 73o Lo • 3 vt.i l- L (-J r : �Ip: �( Project Address: o o J e, ✓ Li- jvc j * j S"`{t y'7 Govt. Lot: y 5 E1/4 of /J E ,114, Section U T -R Vij ._._..._._� �� '7 E D or HIV Township: 0 U t County: ;- -e IJL Y Project Parcel ID #: D 1a g z8' Designer Information 4 Designer Name: A 1 C L Fo / a s, Phone: 17/S' f S" Designer Address: 'PID. a)C S -z.. ,� �.� v •e W,. Zip: Yg V E-mail: a �L ' �.(� e 1 e. �-" � ` C b ,t.� Thispace reserved far approval stamp., License Number:r, a e 0 Remarks: 1?5 ;J ,Signature: Dat: ('_ z —2 ≤ Original aignature required on each submitted copy. I b ah cLn K BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) V Check List [�' Original Sanitary Application (Submitted in Deed Holders Name — no prospective buyers) (383.21(1)1.) i�1 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) fvJ' Original Plot Plan (383.22(2)2. 3. & 4.a) 'Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer Pump Tank Diagram, Alarm and Pump Curve (when applicable) ii7 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) 11 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) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) Fee (Make Check Payable to Bayfleld County Zoning) (383.21(2)(c)7) 1t 2 Complete 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)1.e.) ❑ State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) Gd I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) [0 Project Address or Road Name where driveway is/will come off of) 17 (Owners Phone Number) l6 II Type of Building 0 III Type of Permit i' IV Type of POWTS System ❑ V Dispersal / Treatment Area Information d VI Tank Information 96 VII Responsibility Statement (Plumber's Information) ❑ *Date Stamp* Plot Plan: (To Scale or To Dimension) tiZf Signature and Plumber Information E1'Surface Elevation of Body of Water ❑ Direction and Percent Land Slope .i Tank and Filter Information and Location 0 Wetlands / Navigable Bodies of Water ❑ Absorption Area (Proposed and Existing) 19 Bench Mark (Location, Elevation and Description) i Component Manual Version line,. but ESP Address Number and Road lt2i North Arrow 0 Contour Lines at Structures and Driveways J` 03 025 Ed Boring Location i Property Lines E Well Locations [11 Legal Descriptions -rte777T �—rte 7— =7 :kXiT : Turn Over ► L1 scrp+s gi. .V -so i4 Sec./ (a "r9 M W ~Tjp73o" L.o' R. g z o 1 w n& f a te' f - t4Y o yc'-tj �+. N c.o @.• 1 ' - Q't tvf 1e -s vl e N-.ct.r+ u: flobJev L; ia Z� ©O'et!lon LAJ: ser ranctre'k1 �k= rb1 "U • ,'4 i Vi-" .i b. j- i-o r.4 ec -3'eee� k to F jow Li&te i nl e+, 11 ft ye- 1 F42 0 •,��'. A i� 4C' ice. •4 �r lJo?01 S•e � %d<h'r' 0 J I' i) [ I 13ZD idi. :3 2025 1 d ;ply 1 o kote.ets c*Il , se- L?�.e.ks M o se trcz. C ;I,iti Elm"cn)Glt •C �', hE `. 001 f RP x le.uloo.o.' •5d&10 PAC ,/4? l a w / v�e�.. a 11 "A57'M D 1 z 1K u,i'v-E► v F•, vt.-{-t�, v -r Ct ( ; y,veaJc�. Mb /J (VAR 2 b oLyzLd-aO7) {� br& 3y a�oO Po l kes k1 f'lLt 'ran A've a w''8V7 PROPERTY OWNER: PLUMBER: Allan Polkoski/ Polkoski Plumbing SIGNATURE: ,-- •DATE: LICENSE # 220090 HOLDING TANK SPECIFICATIONS wa_• Number of bedrooms iNon-residential estimated flow (gpd) 2.08'0.0► Minimum holding tank volume required (gal) 2000A ;Proposed holding tank capacity (gal) Wieser Tank Manufacturer W2000 ;Tank model number �. . X'Y^'.u■.O5:.A:R.- �-. .LIS�:T«�.. •+,F......r!.:.'r[f7S:t� ;SJ Electro 4Alarm manufacturer 5T::.-=S.•►.IITROVaeiS=11.Rq 4*U!PAW.A-.Ivn t�r.7f7'+'^'SYl•N52Re!:�. .. -.H1N141 :Alarm model number :crrsr.,n.trRue;x,+. �..-••;=-. -*^ss�;,..rr • TankDimensions and Data ,..' ....:� IX for round tank 47.©'�Liquid depth below inlet invert (in) 8.0 :Maximum depth of soil cover (ft) 66.0 :Height (in) Outside 1 0 Length (in) Dimensions ;. 96.0,,.:. Width (in) Only. junction box conduit -9 blind plug •to.seai outlet Tank Anchor Calculations y 15370 ' Ibs Weight of tank and cover Safety factor :. a21:q.L"ptT.: J..=.Y 31055 Ibs Weight of anchor required 36.0 in Soil cover req. for anchor or 7.7 yds Concrete counterweight HOLDING TANK CROSS SECTION manhole cover with looking device and finished warning label grade 4"min. 24 In. - Manhole and vent locations may be reversed. service ,�, 12.0 in. alarm on Note: All tank joints, and joints between tank openings and piping are Electrical as per 35.0 in. sealed watertight. All NEC 300 pipe and vent rnmerials and Comm 16 comply with •5?5 3�; . vent cap 12" min. vent pipe T 18" min. -rH building sewer inlet JUL O3025 3 In. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: co 0) < w TOP VIEW INLET O N 3" 164" '1 co OUTLET to d' r M Q t� U M d a M D PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS WLP20O0-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 3" BOTTOM: SEP11C 3" HEAVY DUTY 5" (ADD 2.800 LBS.) COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 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 N 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 #8 (NO FIBER) TANK: MIX DESIGN #9 (SMALL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: O a _1 ('4 J3 Q N Q Z o a V o 0 V) W5 w It SHEET NO. OF/ J HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and , maintained according to ✓f 3$3 Wis. Admin. Code, the Holding Tank Component �ZJ) nual H 5,0 `'YA0.n v0l -t�YPA, 15R a VER 2do * and the -, e U & County Sanitary Ordinance. LWa. z©tLi 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 P5 383 and384 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 5PS p83.33 Wis. Adm. Code. 10. If there is a problem with, or question about this 'nstallation, the following persons should be contacted: a. Installer.............................Pad J fl1uez =r► .,JP.JS.VZZoogo Phone: 71 S' 372-- L114, b. Service Provider................... rovider...................R. t Z Phone: '1, 3a. - c. Co. Zoning or Health Dept. Phone: 7i 37.- 61,g 11. L_o_ss0 nm_��_ A ��-�. s - JIE.L, 14 /?AI R 9 �l Project <<uC C' 2015 Transaction Number: HOLDING TANK SERVICING CONTRACT Contract Date 1 "' Z ` This contract is made between the Holding Tank Owner(s) Name(s) - -- - - ------ --- 'F a, v Pumper's Name (Print) Pu . p is Signature Pumpers' Registration # We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PRWECT Legal crintlon•' 1 $ ?. s ..U� LOJCATiON < <1 {tlseTaxStatement) jp r• ( �4.,• ,EMI .. f.• Sctlon�� Tows of: = Lat Slie Acreage r ,Township 1'' N Range W ou I ]' ' Gov t Lat ; l lot U _ CSM #' Vol.: Page" CSM Dae qr, Lot(s) No:. B!oek(s) No. Subdlvlslan t 1. The owner agrees to file a copy of this contract with Bayfieid 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; The disposal sites to which the contents from the holding p 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) Owner's Sign ture(s) Subscribed andSworn to me: on this o2Q'th day of _ , aoas by: Notary Public c mission expires on: Revised: May 2016 (®May 2018) SANDRA _expires by E Personal Information you provide may be used for secondary purposes (PrIcy L w, e:76�(m) �FWts� Document Number/Plan I.D. No. HOLDING TANK AGREEMENT Owner Name (s) Owner(s) Mailing Address A art Parcel I entifier Number (PIN) Agreement Date (same as Notary•Date) , ck2 -Zlpg2g-70—Z0_ZV We acknowledge that application is being made for the installation of (a) holding tank(I 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. SP 1/4 of 1/4 Section _1 p Township ______N. Range 9W. Town of Additional Legal Description: $ Gov't Lot,,,_, Lot Block Subdivision CSM# Lot CSM # Vol Page _____CSM Doc# DOCUMENT NUMBER 2025R-608007 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED O6/25/2O25AT 1 1 :1 9 AM RECORDING FEE: $30.00 PAGES: 1 Return To: �hv/ r1kc.sk• As an inducement to Bayfield 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 falls 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. 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. Stalls., 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 onslte 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. Ow Name(s) — Please Print Subscribed and sworn to before me on this date: 1YO \ 41 2 aL?≤ Notarized Owner(s)— Sig ature(s) Notary Publ f* SANDRA (i ______ My Commission Expires: L /5 Drafted by: t0b% 77 d� Date:►'�� Personal information you pro a may be used for secondary purposes (Privacy Law, s.15.04 (I)(m)) ulforms/sanitaryIholdingtanksgreemanLdoo tune 2018 Soil Test # Bayfield County Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) I I c*.vi F / ko S /Z d 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. Property Owner 7- r Property Address +7 0 ° �'e-" L"& iL irate • J EV -J 17 Contractor Authorized Agent Agent's Telephone, Telephone '� i `i i ' 5° '_c Written Authorization Attached: Y or N Accurate Legal Description Is requested: 's -k.._5 114 of W r -1I4 Section Township N. Range 9 W. Town of L7.j 1' Additional Legal Description: Govt. Lot Lot Block Subdivision Lot CSM# Vol. Page CSM Doc # Volume Page of Deeds Tax I.D# 'Z4 24 Acreage Z - O z Indicate reasoning for -your determination: e-4 S Q a I h c be el 4 c fri € V1 ko Id ' ' Lc/ 0 1 1 Jo -/L tJ 3 £' r s44 Signature of Cou ty Official 7,%J/;zf Date 4'%"- 7 Signature of Certified Soil Tester L,_21 —ZS Date c,r ao'o Certification # (Submit a Plot Plan & Fee) u/forms/solltestwalver(KLK) JUL 0 3 ZO25 June 2018 4o L.00r R . cv4ye: yc-€i 1 7O jo (rare /d'j I 0pp0f40'T-i z3D w 0 ti a f 13thrms: I . 5oi 18c rse\ 1' N Scn k#.; 1 ' lia'u,� l ecs # a -fit 6 # o b ev Lr f -e C4 Z .zeasejO.!!oV esew f .�ncrre`+e- �a1k '1'&_y, k a irl ow L.f�•�, 011 tr-�-, I i cE1 jL d V,aue�0. Lr.e4gti^ Cc.v 13ZO ! ri -• �. JUL032025 3 2025 ` lc� A F.& = 4b-av� .�- Sm v RP = E1e.u/ao.o. I "AST O1 1) 17 19� "- fa? v-6 v ' � (1 • p �. 1�►. ieL� tr a ct l AQ He ld i 'icj T i k Camev+.�l .t 1 VE R aj) j c amyalzaa7) bruj& 3y: ? 1kesk, PLt,dti►dfmy f J /') v evv w' ≤ (7 BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): O Check List EEl Index Page / Title Sheet (Optional) EEl Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) A Original Plot Plan • Cross Section Soil Profile Sheet (optional) • Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) ® Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used 91 Property Owner's Information (aQt prospective buyer's name) m Property Location (Accurate Legal Description with Sec/Twp/Range) CE Road Name (where driveway is/will be coming off of) EEl Floodplain Elevation, Flow Rate, Comments and Recommendations l Complete Soil Boring / Pit Information EEl Date Soil Evaluation was conducted d CST Name, Signature, Number, Address and Phone Number 0 *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) EEl Bench Mark (Description, Elevation and Location) [J Contour Lines (Example = 98.0' /96.0' /94.0') EEl Property Location (Sec/Twp/Range/, Accurate Legal Description) EEl Borings (Locations and Elevations) Li Percent and Direction of Land Slope E�J Well Location (Including Neighboring Wells, if applicable) f6 Location of Wetland Areas, Floodplain and Navigable Waters lii Buildings, Driveways, and Structures (Location and Descriptions) U Location of Property Lines EE Existing System Location 0 Address Number and Road Name EEl Current Surface Elevation of Wetlands and Navigable Waters U CST, Owner and Property Information 5 North Arrow JUL032025 Fee: EEl Certified Soil Tests - Review & Filing Fee $ 50.00 u/farms/sanitary/checklist/checklistforests e Department of Safety County �` I CL d & Professional Services, Industry `e Sanitary Num�ber(to he filled in by Co.) ;,ASPS Services,Division Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adrn 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 maybe used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, a. lS.04(I)(nt), Stets. I. Application Information — Please Print All Information , I o O V •e. L r h CL.. Property Owner's Name Parcel Parcel U rt7 F0.t iC ✓'Q✓ S ovt /_ Z Ip g Zg Property Own is Mailing Address 773O Loo? k Property Location City, State Zip Code Phone Number 3 V J( Q Ii1J L S `f 2 O z i S '/91..fln.9 Govt. Lot :S 2_ ! y Section 1 5, II. Type of Buil ing (check all that apply) Lot a /C T T 8 7 I or 2 Family Dwelling — Number ofBedrooms N R x0 Subdivision Name - - ❑ Public/Commercial— Describe Use Block H ❑ State Owned — Describe Use ❑ City of CSM Number ❑ Village of 99 Town of O J t.l III. Type of PO�VTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if a Ilcable.) A. New System ❑ Replacement System y ❑ Oilier Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. ® Holding Tank ❑ In -Ground ❑ At -Grade 0 Mound ❑ Individual Site Design ❑ Ollter Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV. DispersauTreatment Area and Tank Information: Design Flow (gpd) Design Soil Application Ratc(gpd/sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf)5SYs1cmtion ISM _ —Capacity Tary Information in Gallons Total Gallons R of UnitsNew Manufacturer Tanks Existing Tanks eoO— Z000 W �tsav V. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si ature /MPRS Number Business Phone Number Ai/ !moo o5 %r 22009 d '�Szga-'��S% Plumber's Address (Street, City, State, Zip Code) VI. County/Department Use Only Approved ❑Disapproved Permit Fee Detc issued issuing Agc ❑ Owner Given Reason for Denial �� - gnant 710 as Conditions of Approval/Reasons for Disapproval (J'Qr ,u -r 70 A -'- f 4alti .Nt— oL S�.G4 r3 —n- -n-J7 �y . /%/ Gv4 ✓ ¢'ej. "ar / G/',rr. �` �.o �/ (� uJt. U J CUL5 Bayfield Co. Zoning Dept. Attach to conmiete Diana for the xvxren, and "Jm.rt,n n,. ('a/....... ^_,.. __ _..__.. __.._ _ .. .. _.. . _ .. . .3",. ,•.,p.. n.,. ,.+s "ran a vs x ii menee In sbe SBD-6398 (R. 03/22) PoWJ ________ `Z Soil Test # Bayfield County Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-1O(d)) II c .UI po / P�C> S k 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. Property Owner Ra' i1evS % ll Property Address ''�7 o a 1 e- v L"" -e i Telephone l 9 Accurate Legal Description is requested: Contractor Authorized Agent Agent's Telephone, Written Authorization Attached: Y or N S Z S 1/4 of t Y 1 /4 Section Township ? N. Range W. Town of t7u Additional Legal Description: Govt. Lot Lot Block Subdivision Lot CSM# Vol. Page CSM Doc # Volume Page of Deeds Tax l.D# Z4P 16 24 Acreage Z O Indicate reasoning for your determination: ia.4 S o < '1 e c k k Lac e / oh+1 fJo c,- L tJ13 x4,* 1k L l Signature of Cou ty Official Date Signature of Certified Soil Tester 4_z.i -z..s Date c X220090 Certification # .(Submit a Plot Plan & Fee) u/forms/soiltestwaiver(KLK) J U L 03 ? 015 June 2018 f &I A/e rsov� zs .I S .c_1( N2 N R j w 14,7 o Loon R pa.KTai 2i0��$� r a k CLr'lu ct. rrL l Pej cw, C -c' i V ©�f 6thr s: A N5. -.1e.0 1'� lia"lAv bass c I' ObJe, -c!. '. ZO ©o c GC J t oy► VJ .ce. r cv'Z'.'I'�;.. a k rb "L. g j'-Ftrin"I b6t'emQc 3'ccv� k to civ L.ni n1 e+. I 1320' JUL 032025 1d nkmfd oil 1L..k5 CP .31� ) �, C /�• a up -' i,,Lc►. I v�cz t ,� tiro os_ Bin 9 Of RP = Elew leo.o, h -•�1 Sick WO PvC w/4?l°w L .rec.4i a•h 11"ASTi9'1 D1z$5'ct,l>pv-dVt-� � .P ^tct,+ev-1cc tt Heldv'lj i MIc compemel , t mr'p. (VER h 2• ! yA& 2e zz ao 7 Y ) PP l ke s k, P1 L ,1P b � •1dY.S�:2 r J-rra•i P+vev w ≤'�'V7 BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): G6 Check List I6 Index Page / Title Sheet (Optional) 9 Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) l6 Original Plot Plan ❑ Cross Section Soil Profile Sheet (optional) ❑ Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) ® Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used C?1 Property Owner's Information (not prospective buyer's name) m Property Location (Accurate Legal Description with Sec/Twp/Range) t Road Name (where driveway is/will be coming off of) IZi Floodplain Elevation, Flow Rate, Comments and Recommendations LI Complete Soil Boring / Pit Information I l Date Soil Evaluation was conducted d CST Name, Signature, Number, Address and Phone Number O *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) l?i Bench Mark (Description, Elevation and Location) [J Contour Lines (Example = 98.0' /96.0' /94.0) L Property Location (Sec/Twp/Range/, Accurate Legal Description) 11 Borings (Locations and Elevations) Li Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) l! Location of Wetland Areas, Floodplain and Navigable Waters 0 Buildings, Driveways, and Structures (Location and Descriptions) Cf Location of Property Lines Existing System Location E Address Number and Road Name Cl Current Surface Elevation of Wetlands and Navigable Waters [11 CST, Owner and Property Information l' North Arrow JUL 032025 Fee: Certified Soil Tests - Review & Filing Fee $ 50.00 u/forms/sanitary/checklist/checklistforests U 4-M lth No, 9915 P. 2 PAGE 1 OF8 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Me it & -t V r-sDNI�a� C0.✓ �i�Z% —ZOl7) Pg 1 of Index & Cover Sheet ; - Pg 2 of 9 Plot Plan Pg 3 of 9 Holding Tank Specifications - Z s k ec r Pg 4 of 3 Management Plan Attachments: _- 8 Pa & 9 ' j r' g __7? Owner Name(s): jKtt Owner Address: 7 (p Project Address: Govt. Lot: yy SE 1/4 of tiE 1/4, Section _4 ,T N-R__jE ❑or W Township: o J I County: Y; Project Parcel ID #: xSD ¢ Z IC g 2. Soil Evaluation Project Name / Description d-eVsc,c, 0Lo<� 00 J't/ Le 54Ar Phone: 7-/g ..J91'.. 5C7S 7 a l -e W 1 Zip: ,clfgw ��o� l2 ✓ems .✓r s�/�Y'> Designer Information Designer Name: /< ?, //coslc,t Designer Address: T-- SThi y' cn /, ,,, w'_t Zip: S FRfl7 E-mail: jpL,' .(, c<, -a- u. de C. t[, - < Thiyspace reservecifox ypprovalscam License Number: z z Remarks; � t x)75 U Bayfiald Co, Zoning Dept. Signature: � Date: u— z I —ZS' Original signature required on each submitted copy. i j-[ 6 l , - c l cL rt K BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) 1 Check List GZ Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) Q Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) lac' Original Plot Plan (383.22(2)2. 3. & 4.a) Ed Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer 1P Pump Tank Diagram, Alarm and Pump Curve (when applicable) l3 Contingency Plan / Management Plan (383.22-3(2)(b)l.f.) ❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) ft? Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) 6Z1 Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) 0 ATU Servicing Agreement (Recorded at Reg. of Deeds) a Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) 10 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) m 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) RI I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) ® Project Address or Road Name where driveway is/will come off of) f$ (Owners Phone Number) l! II Type of Building ® III Type of Permit fd IV Type of POWTS System 0 V Dispersal / Treatment Area Information A VI Tank Information fd VII Responsibility Statement (Plumber's Information) 0 *Date Stamp* Plot Plan: (To Scale or To Dimension) 66 Signature and Plumber Information 11' Surface Elevation of Body of Water ❑ Direction and Percent Land Slope 19 Tank and Filter Information and Location 14 Wetlands / Navigable Bodies of Water 0 Absorption Area (Proposed and Existing) lib Bench Mark (Location, Elevation and Description) 66 Component Manual Version 19 Address Number and Road 10 North Arrow 0 Contour Lines .lr, InII l� Structures and Driv ysJUL 032025 IJ 2 Boring Location Gel Property Lines p Well Locations 0 Legal Descriptions 21 Piping Material Information (conveyance line, building sewer line, material type and diameter) Bayfield Co. Zoning Dept. Turn Over ► Property owner: Leal be.scr;p+Kent, 'g0. ,/t✓sovt s-Lsg 1�t4 Sec/(' 42N RI W 74r730 i.007'Zk B,✓�12� %AJ S}�Szo cwn f;Out t Ccwi y off; �ccy�/-elk Ir ' !v° Mire�E� l vlU&LOCy co^,nc OFF # ©9 fieArns:� St�.!e: 1'qo'e4ri/us ne4e.d NeAtrc5% goo TlobJev , Z-.zacc' ejc,/(on ul.eser cencre'k7anklt {v"V1Y q�y pvorr7 be.ttckfac Tank tO Flew Line. init-1; I :,) tJorkl,"t SRL , LEiTi prcrrsey 1&c6 v, U C L&) 0. 1310' rr ITh D j32025r�� Bayfield Co. Zoning Dept. ,'Pi 0.T' e I C Ua/cl ;n� lu.�kmee'ts a/( ..scl-Lc/Gs (SP5383) AFC- = ALave.-C;..e. ( cf v-tcje wtit Bfl1(f 1RPsEleu/oo•o.'' 2 J j'e5ckNopv .w/ -Flow c rec#'ta,n = !1 4 ASTni DIIQSctppreue_c(t�P-nut'+✓+«( r q) 0 1-1aldetyt<t.ike �cnipet r tvl `nu.41 us_Ck:m .n%La yP. lvER2j/; tW&y2eZL-Zo 7) brcuov, 13y n1,P(`.S', 22eo9® toollcc,sk.i f'lun-ti,;nej E?21.ISaK S 22 rron R tue.o wr $'YBY7 PROPERTY OWNER: 1 Ck/ 1 J e✓ s o' -I PLUMBER: Allan Polkoski/ Polkoski Plumbing SIGNATURE: �/%/ 1Th-X_* DATE:3- LICENSE # 220090 HOLDING TANK SPECIFICATIONS 1 Number of bedrooms Non-residential estimated flow (gpd) 2000.O Minimum holding tank volume required (gal) • 2000.0 Proposed holding tank capacity (gal) Wieser :Tank Manufacturer W2000 _Tank model number SJ Electro Alarm manufacturer •HW101 Alarm model number Tank Dimensions and Data X for round tank 47.0 " Liquid depth below inlet invert (in) 8.0 Maximum depth of soil cover (ft) 66.0 Height (in) Outside 14 0 Length (in) Dimensions 96.0 Width (in) ci,tly Tank Anchor Calculations 15370 'Ibs Weight of tank and cover 1.50 Safety factor 31055 ' ibs Weight of anchor required 36.0 in Soil cover req. for anchor or 7.7 yd' Concrete counterweight HOLDING TANK CROSS SECTION manhole cover with —— locking device and finished / vent cap junction warning label grade box —> 4" min. F-24 in. 12"min. Manhole and vent locations —4— conduit --j vent pipe t may be reversed, 1s" min. y blind plug to seal outlet service 1, 12.0 in. alarm on ,n Electrical as per NEC 300 and Comm 16 35.0 in. Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SP5 38:5. building sewer Inlet V JUL 032025 •:yfield Co. Zoning Dept. 3 In. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: WLP2000-MR TANK SPECIFICATIONS C INLET 164" 4" CAST -A -SEAL 4" CAST -A -SEAL DIMENSIONS: WALL: 3" BOTTOM: SEPTIC 3" HEAVY DUTY 5" (ADD 2,800 LBS.) COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 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. p?!1] n INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUALCO FILTER OR BAFFLE' INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 56.27 GAL/IN 0 LOADING DESIGN: 8' 0" UNSATURATED SOIL — TOP VIEW HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,138 GALLONS co TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #9 (SMALL FIBER) OUTLET CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE Li IIU 0 U 0 a a n 1 • PUMP PAD DRAWINGS SUBMITTED FOR APPROVAL SIDE VIEW APPROVED BY: APPROVAL DATE: TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS PRODUCTS NEEDED BY: HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to Sj 3$3 Wis. Admin. Code, the Holding Tank Component Manual t.tstJ "Ma.n v . ( 't ypt. VER 2vo and the ' Bu -f . 14 County Sanitary Ordinance. ` �R tll j tmc y ZoZa_Zv27) 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 SPS 383 and384 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 SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons should be contacted: a. Installer .............................}%/ �(as'IG P/Um �*y m.P,iZ.5.. ZZoo40 Phone:7iS 37z- Wt(o b. Service Provider ...................� � S :�• RPM n S1Z71 Phone:'7iy- 3-77,.- 4co c. Co. Zoning or Health Dept. &yCau Nip taner+v Phone: 7/.3 373__/7g' 11. Leon' nmc! ° SJy 5 i'1Ca- /ic TLl FAJ R 9 J •e Project Transaction Number: JL ( 2025 HOLDING TANK SERVICING CONTRACT Contract Date Lc —z° -ZS This contract is made between the We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION I Legal Description: (Use Tax Statement) Tax IDe // 2W ' 'Z(� 5 Z N _ X1/4, 1/4, ` Section ) i b Town of: Lot Size Acreage ,Township N, Range W DJIJ V- 'a C) Gov't Lot Lot# CSM N Vol. Page CSM Doc U Lot(s)No. alock(s)No. 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, 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; J t j L' L'J d. The sanitary permit number Issued for the holding tank; e. The dates on which the holding tank was serviced; o,1,,:' I'rl Co. Zoning Dapt. 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) Revised: May 2016 (®May 2018) Personal information you provide may be used for secondary purposes and•Sworn to me: on this dQ'" day of rr'' IIona __ by: �y`-- 11Iiu. Notary Public expires on: i_o 15 3V .1 tantd. * SANDRA)*1 Drafted by _ pe OF HOLDING TANK DOCUMENT NUMBER 2O25R-6O8OO7 Yarcel [Demeter Number tr1N) Agreement Uate (same as Notary -Date) 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 es permitted ceunder Ch. SPS 383, s W-5 m/Code or Ch. 1/4 Section I � Township 4d N. Range 9 w. Town of Q 1IO 1 J Additional Legal Description: $ Gov't Lot — Lot Black_Subdivision CSM# Lot_CSM # Vol _Page _CSM Doc# DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 06/25/2025 AT 1 1: 1 9 AM RECORDING FEE: $30.00 PAGES:1 Return To: 'fl h 'y 'fir / Ire • S `C (' ct_ fj c')< 5 L2 - As an inducement to Bayfield 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 Bayfield County or the Department of Commerce to prevent or abate a human health hazard as described In s. 254.59, Stets., 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. Bayfleld County shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as 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. Stets., 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 personlicensed pursuant to s.261.48 (3) Wis. Stets., 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. rt LU/S Drafted by: % o hh �o I iStSiCa Personal Infarmallon you provide may be used for secondary purposes (Privacy Law, s.15.04 (lm)7 sworn to Detore me on l✓ 15 -at) _2o_ZS ulformNaanllarymoldln0lankegraement.doc elune 2018 M C. - YFIELD 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: EVERSON, RAY C 76730 LOOP RD BRULE, WI 54820 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00281 Transaction Number: SR-00281-2F99A Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 6215 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 7/10/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. R YFIELD 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: EVERSON, RAY C 76730 LOOP RD BRULE, WI 54820 Description Private Sewage System (Holding Tanks) Submission Number: SS -00590 Transaction Number: SS-00590-2F99D Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 6215 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 7/10/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-25-69S STATE SANITARY PERMIT OWNER: RAY EVERSON G OV'T LOT: LOT: B LK: 1/4 1/4 SEC: 16, T 48 N, R 9 W TOWNSHIP: Oulu SOIL TEST: 63-25 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: ALLAN POLKOSKI TRACY POOLER Authorized Issuing Officer DATE: 7/10/2025 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: # 220090 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. Garage not to be used for habitation or sleeping without conversion permit from Zoning Department. THIS PERMIT EXPIRES 7/10/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION