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HomeMy WebLinkAbout25-139SRequest 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 zoning bavfieldcounty.wi.gov Note fl Time Change fl Discrepancy fl Other Phone Number Plumber: \c \ \eWSlC� I�� .� Fax Number Homeowner: Tv� � ��! A & t-un Vaimen* ; (' Email Address Immediate Phone Number So Zoning Sanitary Permit #: -s— \ S Dept can call you right back (if needed) I -7IS-amt- Plumber's Choice Zoning Dept No Inspection(s) during this time Date: I a a 5 Tuesday (9:30 am - 12:15 pm) (Tracy) Plumber's Choice Zoning Dept Time: � ' 0O p w\ Township: Address # & Road Name: aQ 36 L cc I c l�J\ or `S UacLl'J�nr1\ WZ Directions To Site: Comments: Plumbers you must verify any change(s) by fax or email ** Notes from Zoning Dept: July 2025 LAURA PARMENTIER ET AL 35 W LIBERTY ST EVANSVILLE WI 53536 ( GENERAL INFORMATION )ING TANK INSPECTION REPORT Permit Holder's Name ❑ City ❑ Village ❑ Town of Sanitary Permit No. Plan ID No. Tax Parcel No. Property ddress if Avai able TANK INFORMATION TYPE MANUFA TURER/MODEL # CAPACITY r 1 SETBACKS Property Line Well Water Service Building All -Weather Road OHWM Swimming Pool ,rJ0 3 FA DEVIATIONS FROM APPROVED PLAN k,t ,VO ,' 9 c-izeA, COMMENTS (Persons present, discrepancies, etc.) e A? � 69 - (in TP✓ A A11 12 4i t� COMPONENTS NOT INSPECTED Plan Revisio Required ❑ Yes No 2 Signature Insp Cert. Number aneu:u lOil uuIer slue 10 of 13 v f Property Owner Information BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Fax: (715) 373-0114 e-mail: zoning(aWbayfieldcounty wi gov Web Site: www.bavfieldcountv.wi.govl147 — LAURA PARMENTIER ET AL 35 W LIBERTY ST — EVANSVILLE WI 53536 Bayfield County Courthouse Post Office Box 58 117 East Fifth Street Washburn, WI 54891 As you know �jX€- "v CUB✓/P Af was contracted by you to install a private onsite wastewater treatment system on your property described as: Notes Abandonment of Old System to meet all applicable code requirements: C' Tank was pumped by: C. Tank was crushed / removed and pipes disconnected by: on at AM/PM On / ✓I at / (AM I he above -mentioned plumber contacted our office to conduc a pre -cover inspection as required under DSPS 383. One of the following applies: ,S s t t�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: ❑lformsfsanilaryproperlyowner-input April 2019 5 Department of Safety & Professional Services, County SaniNumber(to be filled in by Co.)((') Industry Service' %D S -/3 S Sanitary Permit Application OCT 022025 State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Project Address (if different_ than mailing address) L ic1�. is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PO Biatd eubmitted to the Department of Safety and Professional Services. Personal information you provi 'e s d'for:secQgdai , purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. L sox ,.rte l,-3 J ..-t 8 I. Application Information —Please Print All Information Property Owner's Name Parcel # To L c G 30 S C a Property Owner's Mailing Address Property Location 0 5 W L. -.;b P (`� c �� • Govt. Lot _ N%.,— '/,, Section a J City, State W -T EUOrs Vt \€ Zip Code 553 36 Phone Number 602-05--3-�LEN T 1R N R E or IL Type of Building (check all that apply) Lot # Subdivision Name I or2 Family Dwelling —Number ofBedrooms 0 Public/Commercial — Describe Use Blocks 0 Cityof 0 State Owned— Describe Use 0 Village of CSM Number 1,kTownof- 11L Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C il a licable. A. ,1 New System ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. Holding Tank ❑ In -Ground ❑ At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) ' (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner st Previous Permit Number and Date Issued Expiration IV. Dispersal/Treatment Area and Tank In€ormation: Design Flow (gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required (s fl Dispersal Area Proposed (so System Elevation yso Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units o '$ o New Tanks Existing Tanks a O w C7 Q. Septic or Holding Tank a DO p1©ocI t e so r 0 cccrk / Dosing Chamber V. Responsibility. Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signs MP/MPRS Number Business Phone Number 1a885o3 71S-adg-iSi Plumber's Address (Street, City, State, Zip Code) °1 O L \kw C o\k\oc L) S'-i VI. County/Departm nt Use Only /Approved I 0 Disapproved Permit Fee Date Issued mob, Issuing Age ign 0 Owner Given Reason for Denial lb 3� 3 &ZI Conditions of Approval/Reasons for Disapproval OaAcP.. anew to complete puns ror tae system ana submit to the County only on paper not less than S Ills II inches in size SBD-6398 (R. 03/22) RECEIVED CONCRETE HOLDING TANK DESIGN OCT 02 2025 Single Tank Option Bayfie►d Co. INDEX AND TITLE SHEET Pinning a; d Z0n;;-, Agency Project Tom Blain & Laura Parmentier - Holding Tank Owner Tom Blain & Laura Parmentier Address 28365 Lucia Road Washburn, WI 54891 (608) 695-3284 Legal Description NE NW 803 T48 R05W Township Washbum Subdivision Name Parcel ID Number 30592 Plan Transaction ID Number Designer Michael Wroblewski Signature License Number County Bayfield Index and title sheet Holding tank specifications Site plan Maintenance and contingency plan Soil test Soil test plot plan Holding tank agreement holding serviicing contract Holding tank specifications 1288503 Lot No. Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Phone No. (715) 209-7521 Date 10/02/25 Designed pursuantto: Holding Tank Component Manual For POWTS (Version 2.0) SBD-10855-P (N. 03/07, R. 01/12) version 7.0 (11/12) Page 1 of 9 HOLDING TANK SPECIFICATIONS RECEIVED 3 Number of bedrooms Non-residential estimated flow (gpd) 2000.0 IMinimum holding tank volume required (gal) 200o.0j Proposed hold inq. tank capacityal) Wieser concrete Tank Manufacturer WLP2000-MR jTank model number SJ Electro s stems J Alarm manufacturer 101 JAlarm model number OCT 02202bi saynt'-d co. Planning and :7c ,,s An r,r_j Tank Dimensions and Data Tank Anchor Calculations I! X for round tank 22230 lbs Weight of tank and cover 43.0 Liquid depth below inlet invert (in) 1.10 Safety factor 8.0 Maximum de th of soil cover (ft) 12166 lbs Weight of anchor required 55.0 Height (in) Outside 13.4 in Soil cover req. for anchor or 164.0 Length (in) Dimensions 3.0 yd3 Concrete counter weight 96.0 Width (in) junction boot . condtit btu outlet HOLDING TANK CROSS SECTION manhole cover with locking device and finished warning label grade 4" min. ,r 23 in. Manhole and vent locations may be reversed. tether weight service alarm on Electrical as per NEC 300 and SPS 316 3 in. bedding under tank. 12.0 in. 31.0 in. Not: All tank joints and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SPS 384. Tank is anchored as necessary to negate buoyancy. vent cap 12' min. vent pipe 18" min. building sewer Inlet Project: Tom Blain & Laura Parmentier - Holding Tank Transaction Number Page 2 of 9 0 w Or w ft::::il INLET T fl - - 1- - - - - Lilt (o I Li I I 2j" I TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS OUTLET :D O to W2000 -MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1/2" BOTTOM: 4" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" O.D. LENGTH: 12'-7" O.D. WIDTH: 7-2" O.D. BELOW INLET: 53" O.D. LIQUID LEVEL: 46" WEIGHT: BOTTOM 9,430 LBS. COVER 5,940 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 42.92 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,126 GALLONS LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE o a a _ I w �0 a a 0 w I O II 3E 01 "00 \ m O N Q < F- (U) 00 W to N LU �' 0OO0 a`n N WO 1 o C1im0OO0 WM a IIr Ix REVIEWED BY REVIEW DATE J a U £1- w U) SHEET NO. 17 OF 1 ❑EXISTING PRIW BARN 1U 20 30 AO 5D 80PT SHEET3 of9 RF.C.E�VED OCT 022025 HOLDING TANK MANAGEMENT PLAN a°Yf Rio Co. Planning and LOr:inG Agency. This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P N. 03/07, R. 01112), and the Bayfield County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow of 60.0 to 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 Service 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 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 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 may be contacted: a. Installer ......................... Big Lake Plumbing Phone: 715-209-7521 b. Service Provider ............... Birch Street Sepiic Service Phone: 715-373-5683 c. Co. Zoning or Health Dept. Bayfield County Planning & Zoning Phone: 715-373-6138 11 Project: Tom Blain & Laura Parmentier - Holding Tank Transaction Number Page 4 019 HOLDING TANK AGREEMENT DOCUMENT NUMBER 2025R-609260 Document Number Document Title DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 09/ 19/2025 AT 8:20 AM RECORDING FEE: $30.00 PAGES: 2 Recording Area Name and Return Address BIG LAKE PLUMBING 1491 COUNTY HIGHWAY C WASHBURN WI 54891 Parcel Identification Number (PIN) RECEIVED OCT 022025 Bav1i ki Co. Planning 2nd Zc.r r•g; Agency THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE. This information must be completed by submitter: document title. name & return address, and PIN (if required). Other information such as the granting clause, legal description, etc., may be placed on this first page of the document or may be placed on additional pages of the document. WRDA Rev. 12/22/2010 a%1:" £tit't h .! s'� iE;^ :i'ii{! {�,,r ,: !l t _.. 1.r'' { :° ,• ! a . .. ' 1 on : p,Gp; : Of (ft. CQii!!u , L< . Or 1« OXt, '. ? a Cc pu i. 4' Cis)l .. of R s .- p' G r:- E ttCt ht: by c.. type to �. , t :EJ71t .. .•. -. :. V.�i .r, re?il iT as ir> :(.... .' .. •. t+. l :is Cod:' or C..' , 1', ..t:, <.�1, 5 t'il•. 0 Tnv:: ;i.;r; ::t+;r: ''-... -ii i.::c:!! G..:... i;Y:".;I -1 (_f%Q Goo i at t. ol_ _....._=3ioc!t_._ St hd' '\:# _ �►•``'' B U�q 9114IR •_•su t % • • PUB'Y . • •OF AI' - I BIG LAK7 PLMBINGJ 1491 County Highway C Washburn, WI 54891 -. rllri:(-..• : to :-i �f :J 1. , il1' tCi :�i.i� ;.r ' �!i .. i t i3 iti. cl i £? _.:t_; tc:l, o t:':'' CCcve det; d`-,e'J nrC_•periy, Wa agree to do 'he act `.O G£'?,s,,,•;; to ::i! 1�! ii;- i t ;i;i;:r:a:!. £3 (;n. S P .+'•w W:', Adr r ;f;d eta+i;Itr to hoi£5stw u ntc ir.t teUIatiof'' and rf•tc li,ilt f r ;" :" ownef fain; C f.? t 1 ti=ham;. n' c" i e : r•" :'.rvlc'e:: Ifl !`: t;/c'..� to illi r ° t;'-• 1; s r.. 1 f1r tatJt"'.C' ••. ttl ?; �Y ,�G d by �s'uyfl..11. County or the the < i{ , 1: i'; ttt i { t t ?. c:. �3'G'S r ) a £' t t 't4 6ay' ek1 County may enter or � G 1 �. .�e,.�e.J� 1 � s � �� f prop:3! i t e.' �, sc . ,..: the to ti' or c . •c. .. .- '. ,.? .. r.. f Y `t:F•c ch c!. - t. h ' ,•. owner � r :�:::,'.:;! ti2,� chars on tt,:.• ,c;: �iF' toh'1'1 e ?�` p .7. Vri .r LL•� ^; -:r• �` G . ' r ice C wr, t :!t 1''_cr to cc; as c71't atn ' costs t:'r :!''. .'! "r•r • toe ti" J tank .'} <;t; ;; a fC;.;.,");. 35 :r 'tt J: +. !! ,IGf. tf! t''-+!p,t+� tic3ll;tli.3, or &their i,i}yfl `'JIt':t any;.:. �e&tt haz:ci causer: by the hoiaing tort;. Bavtieicl k1'cunti,' shat not owrl f of r w cost., w-' } Isht, `: oe ;?it .;L' s1.i tat , ;301 days fro;;^ :, t o h p t ,t. v'L^Ji3(i does not ?Itl t.£i��Z1111i•'t•I, is , lJl UC i� l+E:. i�t... [3: Si,rC't:i.ty '� i('.l:i date 4'i 11�S!(.•t. In the event the G „ Gt3 t ,Et CI7 ;yas may ie paced or tha f«,r, roi; ac ei Sp.__( u.. _ d`<;rme ti E w ', Y:ti:ti ..;' h,... t. ' t t ._ ta.....ir:Fl r` coII clot'�'•'d by {a � as �JrClyit,,.t, law t • V au to cont;.' •_,. t; .i{1': pc t r� 0 1R. = « N• ' i l; n.C s 2£i :. 3`, ! ; rr Jtct ,.. LF:) Cf%Ei ,tai' iati '! jci Wis. ACiti't. GC+2_ fl*, toil{,l' ,:. f>�l,,:i:.�t7 i�, i�t. �i {...J ••..- L+.III: i-.�f. e. 3.� W;s Ac: 1. ,", •♦ tl' i;'' (•'a t + , a The owner S:.if tip ' r3 I't sto> ,• T{: a Gat,y C1' the coritr;<1 withBa d Couni fill; a copy 01 any t ! icsi('lt ' the 5' G:.>I� r or a "r'' t'now L �E.i 30 days tn,m iti, Ct/lie of change to t({: serf+;.._ Coi?ti-:iC. `''•) of a rtt,11. S :Itli<;` contract. with ti?:n county 1+Vt`.�i . 4. ov'EiCe!crses to contract with crt person �tce 1 �• } 43 Ws. c pe -- 7 of-; -t.. :1 2t• (5 t „r ,� ,, at; :t �Ii:. �7. a : 1 '1 t�'rt'r . Code who shalt SU iti In Ere Coi!ilr'y tiihin 30 thiy=_: a rei-Xii t: •!t: ;} rvr of I'f '�'• t tc. 1^ _ S C- i' Gl.�eCl'1 t%',� FI+ s '.., .1BVfi {r,i Cot;r i• born enter 1 pop the property to E)Cl£ ;Io! of t:"r `t +''. Ct ? .1 ,k t'V fit; ii'il iCi'� r='s:')' : ,):T rfit3T t iP.:�:l!?t:S me j 1nd3Ci^Ii? It z~i tt1 hot ,•?i::r� tank :S no tS !rl�t ';. This a=-reerm,t : win ir, rot ) e 0 { 12' B ,�, t�r,,.r, ,, • t. _. �- .. ,: ,t. 1 is: 5e".:)'y.;"d by either a iC?Li 1[; ti%'! �r» oP SIi':= `/t�c ii . ..,, rr; i co ,y, 1 ti Ot c 't. Ltiti ' Ch i . W' i 1 tr _�. sewer or a i3riV,�t.. d ./83. Vt Aci ! Coot.. In addition this 1M apreerne, J. �ewL[v,a execu:. ,Y at rec r'.= c' c it, c' t t. c%? I u£) ti ?tn, �5 l r 1 i RT g t} t: ` such: t1'I<ri{l/'{' #l!f! ^. wilt pe Tt7! 16 ( the 4 Ttn. reelrc''. stir {t e o n ' upon the ovvnt::r the heirs o: ;,;,-: i QCT 0 2% 20 t :d; _ !�. rltvr. . aand�; ,tis,il1eEls of the owner. Inc owner shall-stsbr s this G•i 1ll•it to irn. r::J ::t..t of (+ c:l+y at.r—J ti,� "!, : y: r th:', ,t ,.. r♦ �: L i t of deeds in e manner ��ah'^h i i�oerfni t the Ur it"; .jyet fl :rJ i; , tcCt .. +. _ �YnE1� • £, ,f h' t l. t. ti �h)� tank is instaikid• Planning Non. _......__ _ _ .. ...._ ... _.. _._....._...... and Zu;li;l� Agency i'•, ,•,`2,t r'`r .'"i Y"IY ,t�1.! � Si.1 ....... .. ... __ _. ,. .. ' _ _. .. _' .«..r. -.r. .-.....-.._...,_..___�_ �...-....-._..-._._.._-....___.._._.__. .,_... .'t .....,t. - son :>i'.'rm'Ci to before .me oil this date -: per 11\O i/I—Q U / s3 i� t .: .L Qb .....- -. .... . ;:.c. ::iN)1Risr. ,,,. , , t= .•. ,_ '+;.: , CiC,( C'C.Ic,i:9ri aC58 HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(s) Name(s) Pumper's Name (Print) Pumper's Signature I Pumpers' Registration # We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION I Legs! Description: (Use Tax Statement) Tax fort :3 �.� S r ;- 1/4, 1/4, L" C� ... Section 0) ,Township N, Range OS �W Town of: Lot Size i_ Acreage Gov't Lot Lot # CSM # Vol. Page CSM Doc # Lot(s) No. Blocks) No. Subdivision: 1. The owner agrees to file a copy of this contract with Bavfield County as required in SPS 383.55, Wis. Adm. Code. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local government unit which has signed the pumping agreement required by SPS 383.55, Wis. Adm. Code, and the County, a report for the servicing of the holding tank(s) on a semiannual basis, The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; RECEIVED b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; OCT 02 2025 d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; Bay i&. Co. f. The volumes in gallons of the contents pumped from the holding tank for each servicing; Planning and Zcng Agency 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) Nam(s) (Print) ti •'�G� �` G. i ry O s Sign (s Subscribed and Sworn to me: on this day of , by: __ Nota Public ry My commission expires on: • 2_ ' • 29 Revised: May 2016 (®May 2018) Drafted by JI V Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (i)(m)j RECEIVED BAYFIELD COUNTY OCT 0 2 2025 CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Check List Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 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) } Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) \❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) O ATU Servicing Agreement (Recorded at Reg. of Deeds) Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) t Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) 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 ADDlication: (Include the following Information) ,j Application Information must include: V 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) Project Address or Road Name where driveway is/will come off of) (Owners Phone Number) II \Type of Building III Type of Permit IV Type of POWTS System V Dispersal / Treatment Area Information VI Tank Information 1k4in Responsibility Statement (Plumber's Information) *Date Stamp* Plot Plan: (To Scale or To Dimension) Signature and Plumber Information Address Number and Road ❑\ Surface Elevation of Body of Water North Arrow O Direction and Percent Land Slope P Contour Lines kTank and Filter Information and Location Structures and Driveways O Wetlands / Navigable Bodies of Water Boring Locations El Absorption Area (Proposed and Existing) Property Lines ❑ Bench Mark (Location, Elevation and Description) IJ Well Locations Component Manual Version Legal Descriptions Turn Over ► • RECEIVED Cross -Section and Over -Head Profile of the System: OCT 022025 ❑ Surface and System Elevation e. ❑ Position of Observation and Vent Pipes 6ay�eio in Planning and Zoning Agency ❑ Dimensions and Depths ❑ Make, Model & Number of Chamber Units in each Cell Property Information How many systems will there be on this parcel of land? I Has this property been split? Ca (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 k Private Sewage System (Holding Tanks) $ 400.00 ❑ Mounds or Systems requiring Pre -Treatment $ 500.00 ❑ Sanitary Revisions $ 25.00 ❑ Private Sewage System Reconnection $ 50.00 and Private Interceptor ❑ Return Inspection $ 50.00 ❑ Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) u/forms/checklists/checklistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: 10 Bayfield Soli Test#/3325 /3RCVED County R Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) OCT 0 2 2025 EDWARD J WROBLEWSKi a certified soil tester determine that i saxr Co. j 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 LAURA PARMENTIER ET AL Property Address s 28365 LUCIA RD Telephone, WASHBURN, WI 54891 608-695-3284 ccurate'Legal Description is requested: NE 1I4 of NW 1/4 Contractor ED'S MECHANICAL LLC Authorized Agent EDWARD J WROBLEWSKI Agent's Telephone 715-209-4055 Written Authorization Attached: V or N Section 03 Township 48 N. Range 05 W. Town of Additional Legal Description: NE NW IN V.636 P.11839 Govt. Lot lot Block Subdivision Lot____ CSI'# Vol. Page CSM Doc # WASHBURN Volume Page of Deeds Tax l.D# 30592 Acreage 46.32 Indicate reasoning for your determination: CLAY SOILS AND EVIDENCE OF SEASONAL HIGH GROUNDWATER /V277/ Signature of County Official Date Signature of Certified Soil Tester g 17/7 5 Date SP -72000013 Certification # (Submit a Plot Plan & Fee) u/forms/s o i ltestwa iver(KLK) June 2018 EDWARD J. WROBLEWSKI, CST #SP -72000013 RECEIVED SOIL TEST PLOT PLAN r� LAURA P.4RMENT I4R ET AL 28365 LUCIA RD -;u OCT 02 2025 NE NW IN V.636 P. 118 39 S03 T48N R05W TOWN OF WASHBURN WI Bayfield Co. SCALE 1" = 60 Planning and Zoning Agency LUCIA RD NORTH LOT LINE yi IM r m Oi z m BUNKHOUSE EXISTING PRIVY SOIL BORING BARN O FAILING SEPTIC SYSTEM HOUSE WELL O APPROX 1200' TO SOUTH LOT LINE APPROX 800' TO EAST LOT LINE 0 f0 -j00 t0 50 60•FT SHEET 2 OF 2 BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS RECEWED Submit the Following (Use Permanent Ink): Check List O Index Page / Title Sheet (Optional) OCT 02201 Bayfseid Co. Planning and Zoning Agency Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) Original Plot Plan Cross Section Soil Profile Sheet (optional) O Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) )if Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used X❑ Property Owner's Information (not prospective buyer's name) Property Location (Accurate Legal Description with Sec/Twp/Range) Road Name (where driveway is/will be coming off of) O Floodplain Elevation, Flow Rate, Comments and Recommendations 1J Complete Soil Boring / Pit Information ate Soil Evaluation was conducted CST Name, Signature, Number,.Address and Phone Number Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) Bench Mark (Description, Elevation and Location) O Contour Lines (Example = 98.0' /96.0' /94.0') ❑ Property Location (Sec/Twp/Range/, Accurate Legal Description) Borings (Locations and Elevations) ❑ Percent and Direction of Land Slope Well Location (Including Neighboring Wells, if applicable) ❑ Location of Wetland Areas, Floodplain and Navigable Waters Buildings, Driveways, and Structures (Location and Descriptions) Location of Property Lines Existing System Location Address Number and Road Name Current Surface Elevation of Wetlands and Navigable Waters CST, Owner and Property Information .North Arrow Fee: Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checklist/checkiistforests BAYFIELD COUNTY SANITARY PERMIT (#04)-25-139S STATE SANITARY PERMIT OWNER: LAURA PARMENTIER ET AL GOVT LOT: LOT: BLK: NE 1/4 NW 1/4 SEC: 3, T 48 N, R 5 W TOWNSHIP: Washburn SOIL TEST: 133-25 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: MICHAEL WROBLEWSKI TRACY POOLER Authorized Issuing Officer DATE: 10/3/2025 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: # MP 1288503 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 10/3/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION