HomeMy WebLinkAbout25-91SRequest for Sanitary Inspection (24 Hrs. in Advance)
Fax or email this form to Zoning Dept (24 Hrs.) prior to when you want an inspection
Fax (715) 373-0114 or Email zoninp(g bayfieldcounty.wi.gov
Note
Time Change fl Discrepancy
Other
Phone Number
Plumber:
- f W
Fax Number
Homeowner:
Q
Email Address
Immediate Phone Number So Zoning
Sanitary
Permit M
[
S
Dept can call you right back (if needed)
I
Plumber's Choice
Zoning Dept
■
No Inspection(s) during this time
Date:
l 30
a y�
Tuesday (9:30 am - 12:15 pm) (Tracy)
Plumber's Choice
ng Dept
Time:
C Y(
Township:
c 1,
Address # &
Road Name:
_ l
/3 54gg
or
Directions
Lo►- uoq , w41 -
To Site:
RECEIVED
SEP 297025
Comments:
Bayfield Co.
Planning and Zoning Agei
**
Plumbers you must verify any change(s) by fax or email **
Notes from Zoni
July 2025
T n(X e -s J
A) -"c l c. TAI
(ATTACH TO PE fi a we 11 /per
LEONARD & KA
ZEELAND
10114 W HIGHWI
WAUWATOSA W
TANK INFORMATION
TYPE MANUFACTURER/MODEL# CAPACITY
TANK INSPECTION REPORT
SETBACKS
Property Line
Well
Water Service
Building
All -Weather
Road
OHWM
Swimming Pool
fl/Of.
DEVIATIONS FROM APPROVED PLAN
COMMENTS (Persons present, discrepancies, etc.) ; jtgrrgl{
✓
1)C46 r . — rnsU to d 5twcr 1u.c t
&ttd lxdd ��uktCk - )(«.SI Ch\Ut'ns
H`
ofiarrvv ekIS A-" erf ltj% hs -aU cA '
COMPONENTS NOT INSPECTED
Plan Revislo equlred
❑ Yes o
I De:
Signature f Inspecto
ryl
(
C oUyrpr
aKetcn on omer sloe Dq/3d/qr
10 of 13
Property Owner
Information
As you know
onsite wastewater treatment system on your property described as:
BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT
Telephone: (715) 373-6138 Bayfield County Courthouse
Fax: (715) 373-0114 Post Office Box 58
e-mail: 117 East Fifth Street
Web Site: www.bayfieldeounty.wi.gov/147 Washburn, WI 54891
LEONARD & KATHLEEN VAN
ZEELAND
10114 W HIGH WOOD AVE
WAUWATOSA WI -53222
Notes:
was contracted by you to install a private
Abandonment of Old System to meet all applicable code requirements:
:• Tank was pumped by:
C. Tank was crushed I removed and pipes disconnected by:
on
at AM/PM
On at (AM / PM) the above -mentioned plumber contacted our office to
conduct a pre -cover inspection as required under DSPS 383. One of the following applies:
System was inspected and appears to meet all applicable code requirements.
❑ System was inspected and appears to meet all applicable code requirements; however, a plan revision
is necessary because the installation was substantially different than the original approval.
❑ System could not be inspected because plumber covered prior to scheduled time of inspection.
❑ System could not be inspected because plumber was not ready at scheduled time of inspection.
County was unable to return to complete inspection.
System could not be inspected because plumber was not ready at scheduled time of inspection.
A re -inspection and $50 fee are required.
System could not be inspected because County could not respond to plumber's time constraints.
Comments: kktA) 5eWQ Qa M L4ST4L(€4A ¶2ifljK 4UU o❑L(('\ G
Ulformslsanitaryprapertyowner-Input
April20'19
s- 0bci
Safety and Buildings Division
County /t ,
JT'
f- d
201 W. Washington Ave., P.O. Box 7162
f
Sanitary Perini in
PS Zt
Madison.
umber (to be filled by Co.)
��t
WI 53707-7162
�5-q IS
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. Notc Application forms for slabowned POWTS are submitted to
Project Address (ifdifferent than mailing address)
the ➢epamoca.of Safety and Professional Sarvics. Personal information you provide maybe used for secondary
Purposes in accordance with the Priva Law. s. 15.09 1 (m). Sims.
��.
Zit V V `1 13
!! n 1
L Application lmformatlon—Please Print Alt lnfoemaHon.
Property Owner's Name
Parcel #
(,tty k(6omg 4L,trvx VcmItt(4tnd
I�C 5y1�
Property Owner's Mailingf A'ddress
Property Location
LOCI Jl W limn,, tnweOA 0<
out. Lot
F.. v. v., Section19
City, Sam
Zip Code
5312 Z
Phone Nrmiber
t-(f�(-y5
j
ti JAN: R TickeEorW
11. Type -of Bulding(check a6 that apply)
Lot#
VIor2Family Dwelling —Number ofBedrooms
Subdivision Name
Block #
0 Publie/Commercial — Describe Use
'L
F] Stare Owned —Describe Use
❑Villageof
CSM Number
Town of
Ili. Type -of Permit: (Checkoniy-ant boy amine A. Completeime Bif applicable)
A.
.')4ev System
Tank,' Replacement Only
Modification to Existing System (explain)
B.
❑Pemdt Renewal
_0ReplacementSystem
❑ Pamil Rcvis)on
_0Trealanent/ilolding
OChange ofPlnmiser ❑ Permit Ttansfm toNen•
_0Other
LisLPreviousPermil NtunbermullnuclsmW
Defoe Dzpimlion
Owner
W. Type orPOWTSS stem/Coin onent7Device: (Check all that apply)
❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ AI -Grade ❑ Mound ≥ 24 in. of suitable soil ❑ Mound <24 in. of suitable soil
'Holding Tank Mother Dispersal Component (explain)_________________________ ❑ Pretreatment Device (explain)
V. Dix salffrcatment Area Information:
Design plow (gpd) Design Soil Application Rate(gpds0
Dispersal Area Required (at)
Dispersal Areatem
Elevation
Vt. Tank Info
Capacity in
Total
#of
ManufnGallons
Gallons
- Units
u
•• 2
8
iz
a
rn
ii. O
a
Scp&ur HokingTmk
c
.2. 00 '
toot
IAi lrv7,!/.-.,
Dosing Oumbcr
VIL Responsibility Statement- I. the undersigned, assume responsibility for installation of thePOWTS shown an the attached Tans
Plwabm's Name (Pilot)
Plu m en's Si
MP/MPRS Number
Business Phone Number
• (fir raw •A
oti P-Gct43.7
71s.2aq—o(
PlumbWs Address (Sh,c4City, State, Zip Code)
13�GOr H HT P01V PT-L/e9
e w' l
'/. County/De ent Use dniy
Approved ❑ Disapproved
Scn)nitPee
`IOO
'Date lssued�6 (—
4��
i A Si ��
❑ Owner Given Reason for Denial
/L/� /
IR. Condtdo s of A pmv a ons for Dis pp oval
Ve. y l/I lank,, / y 1 1�f1 .ek (�"s 'oz8/lf i xi
�4r7 J a(ar �t
AnucblpeamplmepraatfodhcarstemanJ mbnu4ip46cGnwU• enb.an-papmpol.lessihvv BNz.Minchesimslze
SBD-6378 (R. frill)
ll JUL 2.9 2025
Baylleld Co. Zoning Dept.
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Holding Tank Owner(s) Name(s)
1vk '±McO
i(tlz.hLIc
JUL 182025
Ba}afield Co. Zoning Dept.
Pumper's Name (Print)
t�o Sw�p��i.r�c�kCc.r�+►
Pumper's Signa re Pumpers' Registration #
.._. --
ass a
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROJECT
Legal Description:
I Tax IDS!
/L/ff1/4,
LOCATION
(Use Tax Statement)
196
1.x.1/40 ry
Section .township N, Range w
Town of:
*Sublkion:
I LotSize >
.BfqQa a-,
Acreage
ts_c
Gov't Lot
Lot #
CSM #
Vol. Page
CSM Doc #
Lot(s) No.
Block(s) No.
1. The owner agrees to file a copy of this contract with Bayfield Co unto 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 b.
g. The disposal sites to which the contents from the holding tank were le�yo 6d.
4. This agreement will remain in effect until the owner or pumper termine
contract, the owner agrees to file a copy of any changes to this sen
with the local government unit and the County named above within (1
service contract.
(Print)
is 1
GARY
c. In tie egent of a change in this
ract o Cop! eel new service contract
ies 'Y l�s fro date of change to this
SubS(�iloeAsO l'Swom to me:
on this ,day of , �....
by: 1 frUtt
Notary Public
My commission expires on: J
Revised: May 2016 (®May 2018) Drafted by
Personal Information you provide may be used for secondary purposes [Privacy Law. s.15.04 (I)(m))
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JUL 2.92025
Bayfield Co. Zoning Dept.
• CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
E SOIL EVALUATION Scale: �" -4a' 80 ❑ SYSTEM PAGE 2 OF
0 4o 60
SITE MAP PLOT PLAN
PROJECT NAME: (to ft od) 102 DESIGN FLOW: GPO
\j
0A .�., 0J Attach design flow calculations for commercial plans.
PROJECT ADDRESS NPipe Material I ASTM St ndard (Tables 384.30-3 & 384.30-5)
O N Sanitary Sewer. /______
IP VG
BM Symbol: • BM Elevallon: FT Force Maur / A ii BM Descdptlon: _r1k
rnct to rearm by IMPORTANT:
Slope Gradient(%) Well Symbol (If applicable): Q drawing an arra+u Show ground elevation contours at suitable Intervals.
of Tested Area: on the approprite tine.
I ' i t l ' s I I i I 1 J .i - — /__/7
....................................
1.1 ; .
........j.\... .
:
I H.
['!� a '- � � _3_�_ it � .`_ i ! •!
--• JUL... 292025 .._-.. ----
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g
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Et cm�t = - y :car
71FL�7t¢u�e l
I�ta[ic3u c >i_€t3ua 4 I L
-,--t 11
@ Inlet
Appm ed F%pa3 ftomtG
Saud tra!md
TANK
(—W `LT',»`mss"--_x au=.
7-u is list armor fli
1JDJNGTAIt<
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3' ac��Q3edo5rgl..t-�Uf�J.=��'�-s;
4 nwtlorZ-4jtijova
EsbBW4ad Road Elavak
/ (typ4cnl)
e r
Plug
JUL 292025 L
hayfield Co Zoning Dept
HOLDING TANK — MANAGEMENT PLAN
The Private Onsite Waste Treatment System (POWTS) has been designed and is to be
installed and maintained according to SPS 383, Wisconsin Administrative Code,
Holding Tank Component Manual for Private Onsite Waste Treatment Systems
(SBD-10571-P)(R.6199) and the Bayfield County Zoning Department Sanitary and Private
Sewage Ordinance.
1. This POWTS has been designed to accommodate a maximum daily flow of
gallons of domestic wastewater per day.
2. The owner of this POWTS is responsible for system operation and
maintenance, locking device, alarm and access.
3. The owner or owner's agent is required to submit reports as required by SPS
383.55(1), Wis. Adm. Code, to the Bayfield County Zoning Department.
4. Design approval and site inspections before, during and after the construction
are accomplished by the county or other appropriate jurisdictions in
accordance with SPS 383 of the Wis. Adm. Code.
5. Maintenance Cycle. The holding tank must be serviced by licensed pumpers.
An alarm system is to be installed to activate when the tank is < 90% full.
6. Performance monitoring. At the time of servicing, the service provider files a
report with the department of designated agent.
7. A User's Manual will accompany the component. It will include the names
and phone numbers of local health authorities, component manufacturer or
POWTS service provider to be contacted in the event of component
malfunction or failure.
8. In the event that this POWTS or a component of this POWTS fails and cannot
be repaired the owner will find in the User's Manual the names and telephone
numbers of property licensed individuals to contact for such repairs.
This agreement shall be binding on all assignees and heirs
NE 1/4 of SE 1/4
Section 19 Township 51 N. Range 05 W. Town of Bayfield
Govt.
Lot Lot Block Subdivision
Additiqnal Legal
72 C
Property Owners Signature ij 1 (f 1 I1 Date
ii
ulforms/managementplan ,J U L 29 2025
Bayfieiu Go. Zoning Dept
Revised: July 2013
CSM#
HOLDING TANK SERVICING CONTRACT
Contract Date
2:- d c This contract is made between the
Holding Tank Owner(s) Name(s)
Pumper's Name (Print)
IvU tPh` U►���� 4 L-XCcucY�
—�C
Pumper's I nature
f
Pumpers' Registration #
2,
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROJECT Legal Description: Tax 100 , y� 1/4� ,5s� 1/4,
LOCATION (Use Tax Statement) �-V75-
/V
/ To n of: Lot Size Acreage
Section ! 9 .Township S / N, Range L' .69'/'e J q.
GoVt Lot J Lot R CSM Vol. Page �SNl,pp p Lot(s) No. Block(s) No. Subdivision:
I I 3 if i_3o3 r-/'� O91_Yw
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; MADISON BRINI
I N
d. The sanitary permit number issued for the holding tank; 1 Notary Public
e. The dates on which the holding tank was serviced; State of Wiseon;
f. The volumes in gallons of the contents pumped from the holding tank for each servicin
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)
Owner's Signatures
/ee /i,i
Subscribed and Sworn to me:
on this 25 day of ,
by:
17a
Notary Public
If
in
Revised: May 2016 (@May 2018)
Personal information you provide may be used for secondary purposes [Privacy Law, s.1
UL 29 2025 P ftedby
Bavfiek i Co. Zani►ig Dept.
• -0i9213
Soil Test #
Bayfield County `� ~
Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1-10(d))
ITf ykkot. 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 &Alld A" V n 2eel4# cI Contractor
Property Address ,�<?' g S1- Y 13 Authorized Agent
ILL( ¶ Lr S/' /tf Agent's Telephone
Telephone /- Y/y- ?/S♦ ff5 C Written Authorization Attached: Y or N
Accurate Legal Description is requested: 1) 5i,
114 of 114 Section 1/ Township Si N. Range DS W. Town of J,e.lJ
Additional Legal Description:
Govt. Lot Lot Block Subdivision
Lot 3 CSM# )303 Vol. g Page 66 CSM Doc # ROAI P -18876 7
Volume Page of Deeds Tax I.D# Sy%5- Acreage y 96
Indicate reasoning for your determination: Si' . l t,1d�;n�eS did Nor mu.f jf4 f'Y
I 0?fJ
1111 JUL 18 2025
Bayffeld Co. Zoning Dept.
•
Signature of County Official
g- /�
7 a
Date
Signature of certified Soil Tester
Date
l� t 38 ss
Certification #
(Submit a Plot Plan & Fee)
ulformslsoiltestwaiver(KLK)
June 2018
Wisconsin �tY ART►f�
• X `li Department of Safety and Professional Services
-1 \ Division of Industry Services
Page oft
6fii
;=P= , SOIL EVALUATION REPORT
rL'"•raw�! In accordance with SPS 385. Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches In size. Plan must include.
Baytild
but not limited to: vertical and horizontal reference point (BM), direction and percent slope.
Parcel I.D.
scale or dimensions, north arrow, and location and distance to nearest road.
04-006-2-51-05-19-4 01-000-40000
Please print all Information.
Reviewed by
Date
Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)).
I
Property Owner
Property Location
❑
Lenny+Kathleen Van Zeeland
Govt. Lot r
TrS 19 T 51
N R 05 E (or) W
Property Owner's Mailing Address
Site Address or CSM and Lot#:
10114 W Highwood Ave
25758 St Hwy 13 Bayfield WI 54814
City
State
Zip Code
Phone Number
0 City ❑ Village
9 Town
Nearest Road
Wauwatosa
WI
53222
141491595&
Bayfield
St Hwy 13
=.l NewConstruction Use: 0 Residential/Numberof bedrooms#• Code derived designflow rate 1 GPD
Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft.
'arent material
general comments and recommendations: Site Does not meet A+4. Holding tank required
❑Boring 97.5
Boring # Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft.
Seel Annftinn Rate I
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft2
'Eff#1
'Eff#2
O
0-1
5YR 4/2
SC
1-gr-vf
ds
as
2f 2m
0.0
0.0
A
1-10
2.5YR .513
o -2-d 5YR 6/8
C
3-m-vc
dvh
-
if
0.0
0.0
Boring # ❑Boring
EJP€t Ground surface eiev. ft. Depth to limiting factor in. / elev. ft.
Soil Anolicatinn Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft2
'Eff#1
'Eff#2
_______
___
_____
v
____
____
______
_____
Dept.
CST Name (Please Print)
Signature
CST Number
Tim Dykstra
1213855
Address
Date Evaluation Conducted
Telephone Number
10620 Eagle Lake Rd Iron River WI
7/28/2023
715-209-5748
• Effluent #1 = BOO > 30 S 220 mg/L and TSS > 30 S 150 mglL ' Effluent #2 = BOO, 5 30 mglL and TSS 530 mg/L
SBD-8330 (R04/21)
1 ♦
Boring #
Page 2 of 2
❑ Boring
Pit Ground surface etev. ft. Depth to limiting factor In. /elev. ft.
Snit Anniicatinn Rata
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft2
*Eff#1
*Eff#2
F-1 Boring #
❑ Boring
❑ Pit Ground surface elev. ft.
Depth to limiting factor In. / eteevv.--- ft.
Snl it Anniiratin
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDJFt2
*Eff#1
*Eff#2
[1111
Boring #
❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.! elev. ft.
I Snil Annlirtinn Rata
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDJFt2
'Eff#1
*Etf#2
* Effluent #1= BOD > 30 5 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L
1111 JUL 1 8 zoZ5
Bayfleld Co. Zoning Dept.
t
o iao
-7�r•-.-
L40 h ctr� t /Ca4-h len flan Zee (av►c�
a2T?S'S ST Kwy r3 Q�y e%f W1 -Wel
1cit ≤97s
-own p -f $ iy/?e/d
N
NN
!erg y Ate. soy / 1Gstj
106.)0 Ie, Lake £d
iof% p Cfir- All Toy?
C5i" I2I3Sss
7/1:11.25-
,'JL 1 02025
Bayfield Co. Zoning Dept.
5- 6H
+x'aFy�,
�'t'-i -' zfhts
Safety and Buildings Division
County
(Z f (•/
p"'B ,.
•PS:a 14
201 W. Washington Ave., P.O. Box 7162
Madison. WI 53707-7162
Sanitary Permi umber (b be filled in by Co.)
y
5q Is
Sanitary Permit Application
Slate Transaction Number
In accordance with SPS 353.21(2), Wis. Adm. Cade, rubmission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application fours for statavwned POWTS are submitted to
Project Address (if different than mailing address)
the Department of Safety and Professional Scivies. Personal information you provide may be used for secondary
u ses in accordance with the Privacy Law. S. 15.04 1 m). Slats.
q� �-,r�.
1 ..v yC 1 `� 11
v v R
L fnfarrnatlon-Please
Applicailon Print Altlaforamdon
V
Property Owner's Name
Parcel
(, tomct(6cMJ 4Lke JDAAZCt(At&ti
_ 697_
Property (Tuner's Mailing Address
Property Location
(oily W E{: to wood m)
aw.Lar
p
�'/.. L'/.. on 1
City. Slate tl
Zip Code 'Ph1one
532 z Z
Nu bar
rr;; G
-l'
V A o l/` ) s
% l SCE
n�� - l5
(circle
(eirek one)
T �( N'RV E orW \Y
U. Type of Building (check all that apply)
Lot tt
1<I or 2 Family Dwelling -Number of Bedrooms (
Subdivision Name
Black f!
❑ Publi✓Commercial - Describe Use
City of BCtf.L[C-
❑Stale Owned -Describe Use
❑ Village of
CSM Number
XTawo of
Ill. Type of Permit. (Check only one box on fine A. Complete line B If applicable)
A.
1cw System
❑ Replacement System
0 Tromtent/lfolding Tank Replacement Only
0 Other Modificatimt to Existing System (explain)
B.
0 Pemdt Retrmvel
0 Permit Raeiaoo
❑ @ange of PkrnW ❑ Permit Trarsfcno Nmv
List Previous Permit Number audDatclsmed
Before Expiration
f
j Owner
IV. Tv to of POWTS System/Component/Device: (Check all that apply)
Non -Pressurised In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound ≥ 24 is of suitable soil 0 Mound < 24 in. of suitable soil
�❑y
Y.e.HUhiiag Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. DispersalfFreatment Area Information:
Design Flow (gpd) Design Soil Application Rete(gpdsfl
Dispersal Area Required (s0
Dispersal Area Pronoted (s0
Sys0.at Elevation
VI. Tank Into
Capacity in
Total
#of
Manufuaurer
Gallons
Gallons
Units
�
-
u
co
U
X
-
New Tanks
Existing Tanks
&pticorll_Wing Tack
ZOO
'toot
(A1tA.7.ie.
Doting Oaurdwr
VII. Responsibility Statement- I. the mudenigned, assume responsibility far Installation of the POWTS shown an the attached plans.
Plumber's Name (Print)
Piu s tt s Sig
MP/MI'RS Number
Business Phone Number
bf hj(ov) n
ra P—G443�
71S.2a[—o(6
Plumber's Mctress (Street C/Iit;;, State. Zip Code)
l3FGor IRON ktu SK tt11
cf Hw w+,
V$I. Ceunty/Depa,tent Use Only
A roved ❑ Disa roved
nn en
Permit Fee
s —
Date Issued Ib L
1 A Si
❑ Owner Given Reason for Denial
4°O
,, rrr"
8 Q rages
G Z
M Coatditiop of A rnv Re sons for Dis pgrovnI P Z
is ,l4 4- 44rM
nuacnm compterepmns.lor me nyatam and saumtbioaaceouaty ampompapernotiess than a laa tHnchn In Are
SBD-6398 (R. I1/II)
[i5 flUV
liii JUL 292025
Bayfield Co. Zoning Dept.
S IZ - OOza3
7l a31z5
Soil Test # `35
Bayfield County
Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1-10(d))
I I Fw byksk'. oi. 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 Lenny fk4MIcen PL 2ee(ca'c, Contractor
Property Address 2c%C8 SFM4 /3 Authorized Agent
awpwA WI 9/2/y Agent's Telephone
Telephone yry- 9is- ?cc Written Authorization Attached: Y or N
Accurate Legal Description is requested: T yii 54/75
1/4 of 1/4 Section1? Township S/ N. Range OS W. Town of 6 _lI
Additional Legal Description:
Govt. Lot Lot Y Block Subdivision
Lot 3
CSM# )303voi. R
Page 66
CSMDoc# # 9.Ca(
- J8&767
Volume
Page of Deeds
Tax I.D#
Acreage y 96
Indicate reasoning for your determination: 5 ke F vn tk5S did NOT ,s&af A f7
liii IDS ESEE VED
JUL 18 2025
Bayfield Co. Zoning Dept.
/�a3�i3
Signature of County Official
71 g/o2
Date
zvfr
Signature of Certified Soil Tester
?j'/I/2'C
Date
(38 Ss
Certification #
(Submit a Plot Plan & Fee)
ulforms/soi Itestwaiver(KLK)
June 2018
' Wisconsin Department of Safety and Professional Services
l;7. ' Division of IndustryServices
SOIL EVALUATION REPORT
t
%r._. % In accordance with SPS 385. Wis. Adm. Code
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include,
but not limited to: vertical and horizontal reference point (BM), direction and percent slope.
scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. I
Personal information you provide may be used for secondary purposes (Priu
Property Owner
Lenny+Kathleen Van Zeeland
Property Owner's Mailing Address
10114 W Highwood Ave
City State Zip Code Phone Number
Wauwatosa WI 53222 4149j1595€
12
Page of
Parcel I.D.
04-006-2-51-05-19-0 01-000-40000
Reviewed by , Date
Property Location Li L
Govt. Lot Y. V. 519 T 51 N R 05 E (or) W
iite Address or CSM and Lot #:
?5758 St Hwy 13 Bayfield WI 54814
❑ City ❑ Village 111 Town Nearest Road
3ayfield St Hwy 13
NewConstruction Use: ❑� Residential/Numberof bedrooms 4. Code derived designflow rate I b GPD
Replacement ❑ Public or commercial —Describe: Flood Plan elevation if applicable ft.
'arent material
3eneral comments and recommendations: Site Does not meet A+4. Holding tank required
Boring# ❑Boring
ppn
97.5
Ground surface elev. ft. Depth to limiting factor in./ elev. ft.
Soil Anolication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Cu. Az. Cont. Color
Texture
Structure
Cr. Sz. Sh.
Consistence
Boundary
Roots
GPD/FP
•Eff#1
Eff#2
O
0-1
5YR 4/2
SC
1-gr-vf
ds
as
2f 2m
0.0
0.0
A
1-10
2.5YR 5/3
c -2-d 5YR 618
C
3-m-vc
dvh
-
If
0.0
0.0
W Boring # ❑Boring
ltPit Ground surface elev. ft. Depth to limiting factor in. I elev._ft.
SoilAnolication
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Cu. Az. Cont. Color
Texture
Structure
Cr. Sz. Sh.
Consistence
Boundary
Roots
GPO/Pt'
•Eff#1
Eff#2
Dept
CST Name (Please Print)
Signature
CST Number
Tim Dykstra
1213855
Address
Date Evaluation Conducted
Telephone Number
10620 Eagle Lake Rd Iron River WI
7/28/2023
715-209-5748
' Effluent #1 = BOD > 305 220 mg/L and TSS' 30 5150 mg/L ' Effluent #2 = BOD, 530 mg/L and TSS 5 30 mg/L
SBD-8330 (R04/21)
Page 2 of 2
7 Boring #
❑ Boring
M Pit Ground surface elev.ft.
Depth to limiting factor in. / elev._ft.
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft2
•Eff#1
Eff#2
❑ Boring #
❑ Boring
❑ Pit Ground surface elev.ft. Depth to limiting factor In. / elev.ft.
s.m e.,,.rraun.. Data
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Cr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Flr
•Eff#1
Eff#2
❑ Boring #
❑ Boring
❑ Pit Ground surface elev.It. Depth to limiting factor In. / elev._ft.
c..0 e....r....r...,
Horizon
Depth
In,
Dominant Color
Munsell
Redox Description
Du. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ftr
•Eff#1
Eff#2
' Effluent Si = BOO > 30 s 220 mg/L and TSS > 30 5150 mg/L ' Effluent #2 = SOD, 5 30 mg/L and TSS 5 30 mg/L
JUL 182025
D
Bayfleld Co. Zoning Dept.
L-eoha.cA i Zee( 4
aS?Y8 St Hwy 1) &y/'eld wI ''t/y
-rcx 20 ! S5'7S
Twn en
N.
Qtly Are,. S0;/ Tat.%y
/06.,)0 {.9le Lake BEd
Von eCver hiI Sv'8v)
csr # iai38ss
7//,42s
JL 182025
Bayfield Co. Zoning Dept.
HOLDING TANK SERVICING CONTRACT
Contract Date
I i 1 `1 1ao a s
Pumper's Name
o Iw,. &1�.J
This contract is made between the
Pumper's
1111 JUL 16 2025
Bayfield Co. Zoning Dept.
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROJECT
Legal Description:
Tax 101�
rt P\ '. )
1/4, 3/4,
LOCATION
(Use Tax Statement)
3 O
v
S.
Section Township 4') N, Range O6
Town of:
Lot Size I Acreage
W
3L>7rC `� syff8, p�—
oI
Gov't Lot
Lot If
CSM#
Vol. Page
CSM Doc#
Lot(s)No.
Block(s) No.
Suh ivislon:
19R• 37
qy8
1. The owner agrees to file a copy of this contract with Bavfield Counts, 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 , h setwlfj' J+,
g. The disposal sites to which the contents from the holding tank were;47*,Lr'e_d. p :;
�f '(AR?
4. This agreement will remain in effect until the owner or pumper terminate ijs ct rggL In tt%e etent of a change in this
contract, the owner agrees to file a copy of any changes to this services cdntraqt o CoA new service contract
with the local government unit and the County named above within (10 b�q).es apt frof i date of change to this
service contract. 'c. A".. _0 _4
(• z/ t t. fJrr(�
to me:
on this _______day of
by:
My commission expires on:
Revised: May 2016 (®May 2018) Drafted by
Personal Information you provide may be used for secondary purposes [Privacy Law, s.15.04 (n(m)]
s
V 1A
- .r===. .r
�
PVI-_
C:LaaS//ir.�-. aPlot
Viscr 2i3.
FAGEI OF4
,tr,_fw;a,5• ;c sv^'YSu:_4f8Vicu'c Qa (hp \tcn VZtCIKNd g'�2e ^` 1ilLI V{ J
w€aa€r Ad to II 9 W L 1�p0 d v t � sa 3z1Z
ll' s 2S 7 Rtsy 13
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= H: t\!ta r6 Wv (tiWy l GC3 %&'J I • C)Lv- This,g ersrses�c rappvvaIsrr�»p_
&e: PMZ/Ftii1
A " _
Zoao Oc(.4-15 naL(tA✓cam kscr
�09���✓r5 D [�6�od� D
JUL 2g25 2025
Bayfield Co. Zoning Dept.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
SOIL EVALUATION Scale: t"=ao ❑ SYSTEM PAGE 2 OF
SITE MAP p 4D A PLOT PLAN
PROJECT NAME: (10 ft grid) ID? DESIGN FLOW: GPO
i aY\ Z t L 1 q 1 Attach design flow calculations for commercial plans.
PROJECT ADDRESS: NO Pipe Material / ASTM St ndard (Tables 384.30-3 & 384.30-5)
N Santtary Sewer. /_i✓c
BM Symbol: BM Elevation: to O FT
Force Main: /
BM Description: L Pr
Indicate noon by IMPORTANT:
Slope Gradient (l Well Symbol (if applicable): Q drawing an anon Show ground elevation contours at suitable Intervals.
of Tested Area: on the eppropdto One
N
Q
(
s - I
II
n
(3 JUL 292025 LI
"a5fiel i Op. Dept.
PAGE 3 o
HOLM ` G TANK SPEC0FQCATOMQ
(No S'
Etecuicai must complytr-S
8Pa sit; atd MEG as
Ia,MimV
(it) I
mist
Appmrad.b tsuM j
Appmt'ed PipaS uocdc
Safld Gmurd :: Q
u3Read Efvitm
?mata th2n ara fR iz
Vl..'JJM
�.....e_= — '--'-r-' i`._ fat
S'Acp,�rcd2eddmgtl9.=e1 2thTap.T
MK. -i G ; :`:.�Ii JUL 292025
ay field Co. Zoning Dept.
u athnr Sarin as .''t aro
HOLDING TANK — MANAGEMENT PLAN
The Private Onsite Waste Treatment System (POWTS) has been designed and is to be
installed and maintained according to SPS 383, Wisconsin Administrative Code,
Holding Tank Component Manual for Private Onsite Waste Treatment Systems
(SBD-10571-P)(R.D/99) and the Bayfield County Zoning Department Sanitary and Private
Sewage Ordinance.
This POWTS has been designed to accommodate a maximum daily flow of
55 ?` gallons of domestic wastewater per day.
2. The owner of this POWTS is responsible for system operation and
maintenance, locking device, alarm and access.
3. The owner or owner's agent is required to submit reports as required by SPS
383.55(1), Wis. Adm. Code, to the Bayfield County Zoning Department.
4. Design approval and site inspections before, during and after the construction
are accomplished by the county or other appropriate jurisdictions in
accordance with SPS 383 of the Wis. Adm. Code.
5. Maintenance Cycle. The holding tank must be serviced by licensed pumpers.
An alarm system is to be installed to activate when the tank is < 90% full.
6. Performance monitoring. At the time of servicing, the service provider files a
report with the department of designated agent.
7. A User's Manual will accompany the component. It will include the names
and phone numbers of local health authorities, component manufacturer or
POWTS service provider to be contacted in the event of component
malfunction or failure.
In the event that this POWTS or a component of this POWTS fails and cannot
be repaired the owner will find in the User's Manual the names and telephone
numbers of property licensed individuals to contact for such repairs.
This agreement shall be binding on all assignees and heirs
NE 1/4 of SE 1/4
Section 19 Township 51 N. Range 05 W. Town of Bayfield
Govt.
Lot Lot Block Subdivision CSM#
Additional Legal Description
Property Owners Signature Date
u/forms/managementplan ,JUL 29 2025
Bayfield Co. Zoning Dept.
Revised: July 2013
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Holding Tank
Pumper's Name (Print)
flu lllnra�'ph� 7uwy 4 C-xaLcr9
Pumpers, 1 nature
Pumpers' Registration #
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROJECT Legal Description:
LOCATION (Use Tax Statement) //+. 3/a,
To n of: I LotSlu
Section ,Township � N, Range W I
\ Acreage
Gov't Lot
O
Vol. Page
Block(s)
1. The owner agrees to file a copy of this contract with Bavfield County as required in SPS 383.55, Wis. Adm. Code.
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have
access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain
the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by
the owner and pumper.
3. The pumper agrees to submit to the local government unit which has signed the pumping agreement required by SPS
383.55, Wis. Adm. Code, and the County, a report for the servicing of the holding tank(s) on a semiannual basis. The
pumper further agrees to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed; I MADISON BRINI R
d. The sanitary permit number issued for the holding tank; 1 Notary Public
e. The dates on which the holding tank was serviced; I State of Wiscoru in
f. The volumes in gallons of the contents pumped from the holding tank for each servicin
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.
�••=•... ^a,,=ter t.-„iw owners algnaturetsI Subscribed and Sworn to me:
on this 25 day of__
Notary Public
Revised: rMay2016
you p 2018) [Privacy Ojjq (mQJ L 292025
Personal information provide may be used for secondary purposes Privac Law, s.15.
Bayfield Co. Zoning Dept.
3 `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: Submission Number:
VAN ZEELAND, LEONARD & KATHLEEN SR -00293
10114 W HIGHWOOD AVE
WAUWATOSA, WI 53222 Transaction Number:
SR -00293-313D5
Description Amount
Certified Soil Tests - Review & Filing Fee $50.00
Total: $50.00
Payment Amount: $50.00
Reference: 3365
Paid by: Timothy Dykstra, 10620 Eagle Lake Rd, Iron River WI 54847
Payment Type: Check
Transaction Date: 7/29/2025
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
13-_ 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:
VAN ZEELAND, LEONARD & KATHLEEN
10114 W HIGHWOOD AVE
WAUWATOSA, WI 53222
Description
Private Sewage System (Holding Tanks)
Submission Number:
:X.w1i11.111
Transaction Number:
SS -00611-313C7
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 3865
Paid by: Greg's Plumbing, 13660 County Hwy H, Iron River WI 54847
Payment Type: Check
Transaction Date: 8/8/2025
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-25-91 S
STATE SANITARY PERMIT
OWNER: LEONARD & KATHLEEN VAN ZEELAND
GOVT LOT: LOT: BLK:
1/4 1/4 SEC: 19, T 51 N, R 5 W
TOWNSHIP: Bayfield
SOIL TEST: 83-25
NEW SYSTEM
SYSTEM TYPE: Holding Tank
PLUMBER: GREG BROWN
TRACY POOLER
Authorized Issuing Officer
DATE: 8/8/2025
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: # MP699374
Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all-
weather road. Verify that the tank Is properly watertight w/lock and chains end plug and alarm.
THIS PERMIT EXPIRES 8/8/2027
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION