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RECtIWED QENTERED S IZ- oo3s 7 Soil Test # tjp
NOV 03M5 Bayfield County
planning"ard Zomn9l'��� Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1 -1 0(d))
I. A l / a111 'Fo / Y,..®S i/C G 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 set 1� fie/ Oe h e ✓± Contractor
Property Address
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Agent's Telep
Telephone 12 i/ 7 7 9 1- 2-9' 30 Written Authorization Attached: Y or N
Accurate Legal Description is requested:
6k) 1/4 of i-1w114 1/4 Section 3 Township ≤ O N. Range 7 W. Town of C t c V 2 r
Additional Legal Description: I I) ii 5
Govt. Lot Lot Block Subdivision
Lot CSM# Vol. Page CSM Doc #
Volume Page of Deeds Tax I.D# / 1 3 2 S Acreage qy
Indicate reasoning for your determination: C I c<i/ &- 9 , ,l 4 /' ,i y S
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Signature of Certified Soil Tester
Date
C. JT 2 Z & o o
Certification #
Sig
Date
of County
(Submit a Plot Plan & Fee)
u/forms/soiltestwaiver(KLK)
iver(KLK )
June 2018
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RECEIVED ~ \\ 3
NOV 032025
Bayfielo Co. h„ `�}
Planning and Zoning Agency
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BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS RECEIVED
Submit the Following (Use Permanent Ink): NOV 03 2025
Bayfieid Co.
Check List
Planning and Zoning Agency
m Index Page / Title Sheet (Optional)
fd Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers)
It 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
d Property Owner's Information ( ltot prospective buyer's name)
10 Property Location (Accurate Legal Description with Sec/Twp/Range)
m Road Name (where driveway Is/will be coming off of)
d Floodplain Elevation, Flow Rate, Comments and Recommendations
LS Complete Soil Boring / Pit Information
Gd Date Soil Evaluation was conducted
ICST Name, Signature, Number, Address and Phone Number
❑ *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
d Bench Mark (Description, Elevation and Location)
71 Contour Lines (Example = 98.0' /96.0' /94.0')
m Property Location (Sec/Twp/Range/, Accurate Legal Description)
m Borings (Locations and Elevations)
Li Percent and Direction of Land Slope
C✓I Well Location (Including Neighboring Wells, If applicable)
16J Location of Wetland Areas, Floodplain and Navigable Waters
m Buildings, Driveways, and Structures (Location and Descriptions)
2�J Location of Property Lines
L( Existing System Location
121 Address Number and Road Name
d Current Surface Elevation of Wetlands and Navigable Waters
RI CST, Owner and Property Information
16 North Arrow
Fee:
0 Certified Soil Tests - Review & Filing Fee $ 50.00
u/forms/sanitary/checklist/checklistforests
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:
OEHLERT, SAMUEL
SR -00357
16190 NICOLETTI RD
Herbster, WI 54844
Transaction Number:
SR -00357-37D74
Description
Amount
Certified Soil Tests - Review & Filing Fee
$50.00
Total:
$50.00
Payment Amount:
$50.00
Reference: 6269
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 11/3/2025
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.