HomeMy WebLinkAbout25-153S�tI
Department of Safety
County
NOV 14 2025
& Professional Services,
Sanitary Permit Number
Industry Services.Division
(to be filled in by Co.)
Bayfield C I
Ss-oo 6
Sanitary ermit 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 fortes for state-owned POWTS are submitted to
the Department
Project Address (if different than mailing address)
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), Stats.
I G I _�
4
I. Application Information — Please Print All Information
o c` v
rP U KiZcl
Property Owner's Name (ENTERED')
Z/ �I�t
Parcel
dam � ✓ wt a h ,i iy
z a� -, C>
Property Owner's Mailing Address
'Coo
Property Location
b fl -t S £ ✓t z/ .e S
Govt. Lot
City, Stale
Zip Cod.
Phone Number
o 1 to 6- ✓ o V -cn#J
/
cro W
4 / 2- C/ 4 3 — 0p 0p /dp
'/, '/, Section Zz
T tf 1 2' • 'o
II. Type of Building (check all that apply)
Lot #
SA I or 2 Family Dwelling — Number of Bedrooms
3
N R
Subdivision Name ,,/
re c —r
❑Public/Commercial
Block #
Ua)r �. E I �-o. ) S
— Describe Use
ht,r) oo�
O City of
❑Blatt Owned — Describe Use
CSM Number
❑ Village of
P Town of.ir'E'1 R-ty-e .�
III. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if
a Iicabie.
A. '® New System y ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain)
❑ Holding Tank In -Ground 0 At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued
Expiration
IV. Dis ersal/Treatment Area and Tank Information:
Design Flow (gpd) Design Soil Application Ratc&Dispersal I Required (af) Dispersal Arca Proposed (sl) Sysem Elevation
30o
a7Capacity
in #of Manufacturer
Tank Information Gallans Unitsa
d 8New Tanks Exist
%USepticeeift
ding Tank7O
i
W;e5ev Cr,nC,
✓
V. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's mName (Print) Plumber's Si re fiP/MPRS Number Business Phone Number
Ail j o (�OSICI r
,te L2ooy n h'SLa_4/c6
Plumber's Address (Street, City, State, Zip Code)
Bs ,S? -2 5voriVI.
County/Department Use Only
Approved
0 Disapproved
Permit Fec
$
Date Issued L
1
Iss ' gran ate
/,7
❑ Owner Given Reason for Denial
--
Conditions of Approval/Reasons for Disapproval
SP0
Attach Mennnratnmans r,.,n.a...m...,,a....'....n...,._n_.._.___.___ .. .. .. _
...y ..., nape. uu, ,use Ia Ina 1/2 x I /
SBD-6398 (R. 03/22)
SOIL TEST#/VS-)5
Wisconsin Department of Safety & Professional Services
Di dTojIWjV&rvices ≤ R.- 0 0363
SOIL EVALUATION REPORT
' w Bay''i Co.In accordance with SPS 385, Wis. Adm. Code County
PIannir, -,d zcrling Agency •�
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include,
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. Q 0
Please print all information. Revi e y
Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04(1)(m)).
Property Owner kr3cF � 1eld
Zunrr 4 Qi X41 N,
Properly Owners Mailing Address Site Address or CSM and Lot #:
U490Lcke
Pagejof2
City, State, Zip * `t Phone Number Q /�j ❑i City ❑ Village Town jN�earest Road
�r� .A d �w Jew • J _AA J/ <<A� 1 Inl �_ q [OZ +4J 1� YS i -A—w_ w l i .i, �J,2. ,. I
)Q New Construction Use: I&I Residential/ Number of bedrooms _dam
❑ Replacement ❑ Public or commercial — escribe:
Parent material [J tt� `i 1A,i O SL SOI V .5
General comments and recommendations:
[]][) Boring
Boring # � Pit Ground surface elev. ft.
I/
[j;7/2s
erWa
Code derived designflow rate3PD
Flood Plan elevation if applicable ft.
Depth to limiting facin. I eleS ft.
Snil Annhrafinn Raio I
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Cr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft'
'Eff#1
'Eff#2
i
-G,
Iv r
1
1
3
t''_31
�'
_q__
t j
isyg 6/3
______
________
-
J
___7_
LII Boring
rr
Boring # Pit Ground surface elev `ft. Depth to limiting fact) O_in. / el�
Snit Annlir-atinn Rate I
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft= '
'Eff#1
Eff#2
--
5
�s 6K
.7
!.6
14
--
s
i
J
I S
_
S
0
m I
J uc
7
CST Name (Please Tint Signature
CST Number i Q
Address Jam: $ C %( r%W I B Date Evaluation Conducted
Si — Z.. ≤
Telephone Number
21 ~ "70
W= -
-__I
Effluent #1 = BOD > 30 ≤ 220 mg/L and TSS > 30 ≤ 150 mg/L ' Effluent #2 = B0D. ≤ 30 mg/L and TSS ≤ 30 mg/L
SBD-8330 (R03122)
NOV 14 2025 w Boring
EI1 Boring # Pit
BayfW Co.
Planning and Zcnir`, Agency
Page of
Ground surface elel ft. Depth to limiting iactI in./ ele913 ( ft.
Soil Aoolication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary Roots
GPD/Ft'
'Eff#1
' Eff#2
O-6
—'
!
t
L u& 3cr>
• 1
14
j1(
k
CS rt'
•'7
i
--
l
t ,
S
❑ Boring
Boring # O Pit Ground surface elev. ft. Depth to limiting factor
in./elev. ft.
Soil l Aonlicalinn Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary Roots
GPD/FP
•Eff#1
Eff#2
Boring
Boring # Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft.
Soil Aoolication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary Roots
GPO/Ft'
•Eff#1
Eff#2
_ J
r ' Effluent #1 = BOD > 30 ≤ 220 mg/L and TSS > 30 ≤ 150 mg/L ' Effluent #2 = SOD, ≤ 30 mg/L and TSS ≤ 30 mg/L
i %)
Soil Evaluation Site Map - System Plot Plan
In Ground Soil Absorption for POWTS
Component Manual V_2.1
Site Owner: Kevin Zimmerman
Site Address: 66680 Hart Lake
Legal Description:
Map Coordinate Reference System:
NAD83(2011) I WISCRS Bayfield (ftUS) EPSG:7590
Rd, Iron River, WI 54847
Lot Three (3) Bavfield County Plat of Ellenwood
; Town of Iron River, Bayfiel
d
r ASO *SB1
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k tTo I
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� Q
b O gyp, 94 °o
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4" Pipe Material / ASTM Standard';
(Tables 384 30-3 & 384.30-5)
' No Well on Property Sanitary Sewer ASTM F789
O No Wetlands, Floodplains or Navigable Waters
L Approximate Property Line
-- BM - Screw in Poplar Tree - Elevation 100.00'
/ A SBI - Elevation 96.50
A SB2 - Elevation 96.81
C
A SB3 - Elevation 96.64
y ;
CST Name & License #: Ton Polkoski 11068 - ST
CST Signature: r .. a
r I
Plumber Name & Licens : Allan Polkoski PMRS 220090
Plumber Signature: z r 1 l-
I ,
r ,
---------------------------------------------------------------------------------------------------
Nov 1.4 2025 BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
pao,,a' i Co.
Submit�the=Fo1rovii�9 (Use Permanent Ink):
Check List
,l Index Page / Title Sheet (Optional)
)1 Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers)
J Original Plot Plan
U Cross Section Soil Profile Sheet (optional)
U Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Report: (Include the following Information)
l Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
d9 Property Owner's Information (not prospective buyer's name)
1i Property Location (Accurate Legal Description with Sec/Twp/Range)
f Road Name (where driveway is/will be coming off of)
11 Floodplain Elevation, Flow Rate, Comments and Recommendations
f0 Complete Soil Boring / Pit Information
Date Soil Evaluation was conducted
1 CST Name, Signature, Number, Address and Phone Number
F *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
Bench Mark (Description, Elevation and Location)
IF Contour Lines (Example = 98.0' /96.0' /94.0')
X Property Location (Sec/Twp/Range/, Accurate Legal Description)
X Borings (Locations and Elevations)
'I l Percent and Direction of Land Slope
)f Well Location (Including Neighboring Wells, if applicable)
E Location of Wetland Areas, Floodplain and Navigable Waters
11 Buildings, Driveways, and Structures (Location and Descriptions)
IV Location of Property Lines
11 Existing System Location 9— /U/A
[Address Number and Road Name
❑ Current Surface Elevation of Wetlands and Navigable Waters — 4)/A
1 CST, Owner and Property Information
A North Arrow
Fee:
iI Certified Soil Tests - Review & Filing Fee $ 50.00 u/forms/sanitary/checklist/checklistforests
PAGE 1 OF 4
N0V 142025 In -Ground Gravity Plan
F3aY`iel5 co. Index & Cover Sheet
Punning and Zoning AgenCY
Component Manual Design References:
In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan — Sot\ lEvol A\O— Site Ma�
Pg 3 of 4 Dispersal Area Cross -Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
Serve i MpfP POWTS Application for Review - a 904€S
rusk„ 9v\exnca A5rtevtea-7. Soil Evaluation Report p-apagc5
?rope.r-+'4 aced Sots SMy4kor r�. G�+eC-kliS-r,5 0.9es
- WflflRToh k Specs — 1 pa5t
Project Name / Description
Owner Name(s): kauir Ziyv\rneg-nna h Phone: (4I. -S63-881918
Project Address.
1/4 of 1/4, Sec
13o'y$it1p1 Cov+nty Plw't•
U or vv V\
'on River C
*,SCa'\sir
Project Parcel ID #: y o ay e'L- cW - op aa-aO0 —3a3 - 030 oe
TciKITJ ft
�C��/
Designer Information
Designer Name: A I 14 ✓1 fo I ko Sk 4 Phone:
Designer Address: 7b. $'oK SZz Tj7ati ve ✓ W_l
E-mail: to nye
License Number: FkM t25 1Z..Z oo ¶0
Remarks:
7/S Z9z y/s%
zip: s t'fy7 -
Signature: Date:
Original -signature required on each submitted copy.
Soil Evaluation Site Map - System Plot Plan
In Ground Soil Absorption for POWTS
Component Manual V_2.1 Map Coordinate Reference System:
Site Owner: Kevin Zimmerman NAD83(2011) / WISCRS Bayfield (ftUS) EPSG:7590
Site Address: 66680 Hart Lake Rd, Iron River, WI 54847
Legal Description: Lot Three (3), Bayfield County Plat of Ellenwood,
Town of Iron River, Bayfield County, Wisconsin 0 50 100 ft
PIN: 04-024-2-47-08-22-2 00-323.03000
--------------------------------I N
.�,Ci\/�i) Sanitary Permit Dimentions List (applicable).::- -
NOV 14 2025 Proposed 2 bedrom home: 30' x 40'
Building to lot lines: ≥145'
Bayfield Co. ,, Building to road centerline: 192'
Planning and Zoning Agency ' Septic tank to closest lot line: 134'
Septic tank to building: 15'
Drain field to closest lot line: 90'
Drain field to building: 25'
Tank- Wieser WLP750-MR
Filter- PolyLoc
4" Pipe Material /ASTM Stan
(Tables 384 30-3 & 384.30-5)
No Well on Property Sanitary Sewer ASTM F789
No Wetlands, Floodplains or Navigable Waters
L; Approximate Property Line
BM - Screw in Poplar Tree - Elevation 100.00'
A SB1 - Elevation 96.50
% A SB2 - Elevation 96.81
A SB3 - Elevation 96.64
CST Name & License #: Tony Poll5oski 11068 - ST
CST Signature: /� Y L^ - 2C
Plumber Name & Licens : Allan Poi PMRS 220090
Plumber Signature: w __%L-g_z5-
IN -GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard -W Chambers
3 -ft Trench (down -sizing credit)
SOIL COVER
m:i 12'
(tycica!)
Septic Tanks) Manufacturer
W1PSe�
COSeptic Tank(s) Volume(s):
iO 7 . cal gal gal gal
Effluent Filter Manufacturer
iP4yLoc }� �1r
Effluent Filter Model: PL — 5 a s
2"
m 9 trench
dour:
rya, TYPICAL TRENCH
a CROSS SECTION VIEW
3c
(typical) (No Scale)
System Elevation = 9U ft
(typical)
Quick4 Standard -W
w/ End Cap (Show location of inlet / outlet pipe connection on plan view.)
(typical)
eee_
B=T,oeasch��
(typical)
INSTALL PER TRENCH:
Provide minimum 3 ft
separation between trenches.
Observation Pipe
(typical)
Install per manufacturers
/ instructions.
IA = 3.0 ft
(typical)
TYPICAL TRENCH
PLAN VIEW
(No Scale)
"—Quick4 Standard -W Chamber
(typical)
(mfd by Infiltrator Systems. Inc.)
-TI— tt �� ft Install JuIsu an: n rlanufac:urers sisuuctlons
•7'`�¢ Quick4 Std -W @ 20 ft` EISA/chamber =
+ ________ Pairs of end caps @ 6 ft= EISA/pair = ___a ft` u
= Proposed EISA per trench = ' ft` Required Infiltration Area = 4 A ft'
®TI __ trenches = Proposed Total EISA = 43 . r
Distribution Method:
G u�
V)
m
U)
O
m
a
PAGE 4 OF 4
In -ground Gravity Management Plan
IMPORT:) 4 2025
The owner &q l ,g(*�g)*jravily system shall be responsible for its perpetual operation and maintenance pursuant to
requir ii'�`tS'f8 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow = 300 gpd; BOD5 ≤ 220 mgL-'; TSS ≤ 150 mgL'; FOG 5 30 mgL'
Inspection Checklist INSPECT EVERY 3 YEARS
type of use
x age of system
nuisance factors (i.e. odors, user complaints, etc.)
' mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
material fatigue (i.e., leaks, breaks, corrosion, etc.)
y solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
extent of pending in distribution cell prior to dosing
j dosing irregularities - if applicable (i.e., pump re -cycling, float switch settings, etc.)
I electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
I distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
-4 surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
16 Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
iQ Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. • A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: J-Yt n V e SQL C Phone:
Local government unit: �a1� F 2 I A e o, Z® fl r^ C Phone:
Local government unit address: W a 5 ✓ rvt \�
71 5 3 —7 z_— V( "S 4
-7 !S 373- (013(F
ZIP: 5 �g
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in -ground dispersal component may be
abandoned and replaced by a code -complying dispersal component in a pre -determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
�ai.�`,s iyG lwU
NOV 14 2025
aayfietdCo. BAYFIELD COUNTY
planning and zoning Agency 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)
49 Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer
I I Pump Tank Diagram, Alarm and Pump Curve (when applicable)
Contingency Plan / Management Plan (383.22-3(2)(b)1.f.)
Ff 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)
I_I Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5)
I I ATU Servicing Agreement (Recorded at Reg. of Deeds)
)(Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
LComplete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached
to all co ies
Soil and Site Evaluation Report (383.22-3(2)(b)1.e.)
Li State Plan Review (when applicable)
I? Copy of Warranty/Quit Claim Deed (Optional)
Sanitary ADDlication: (Include the following Information)
I Application Information must include: ❑ 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete)
9f Project Address or Road Name where driveway is/will come off of)
J1 I1 Type of Building
p'. III Type of Permit
10 IV Type of POWTS System
10 V Dispersal / Treatment Area Information
V VI Tank Information
'VII Responsibility Statement (Plumber's Information)
I) *Date Stamp*
Plot Plan: (To Scale or To Dimension)
Xt Signature and Plumber Information
Surface Elevation of Body of Water - NA
)(, Direction and Percent Land Slope
X' lank and Filter Information and Location
Wetlands / Navigable Bodies of Water — NSA
DC Absorption Area (Proposed and Existing)
,)( Bench Mark (Location, Elevation and Description)
MComponent Manual Version
;( Piping Material Information (conveyance line, building sewer line, material type and diameter)
Turn Over ►
[ I (Owners Phone Number)
'gyp Address Number and Road
10 North Arrow
N Contour Lines
p( Structures and Driveways
% Boring Locations
XProperty Lines
)4 Well Locations
( Legal Descriptions
Cross -Section and Over -Head Profile of the System:
I� Surface and System Elevation liu j 1 4 an
4 Position of Observation and Vent Pipes
eayaeid co.
1PDimensions and Depths Planning and Zoning Agency
t� Make, Model & Number of Chamber Units in each Cell
Property Information
TX How many systems will there be on this parcel of land? J-
Has this property been split? JJ 0 (Property Statement shows Property History)
Fees:
)SI Private Sewage System (Septic Tanks)
$ 400.00
_1 Private Sewage System (Holding Tanks)
$ 400.00
Mounds or Systems requiring Pre -Treatment
$ 500.00
• Sanitary Revisions
$ 25.00
1 Private Sewage System Reconnection
$ 50.00
and Private Interceptor
Li Return Inspection
$ 50.00
Li Maintenance Agreements +
$ 30.00
(checks made out to Reg of Deeds)
u/forms/checklists/checklistforsanrtaryapps (10/2009);(®712011);(®d/J012)(®R S/2/7D12-dc) Proofed by:
TA
TOP VIEW
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C-
ARE
MANUFACTURED TO MEET OR
_ . . A- SEAS:
1
WLP750- MR
TANK SPECIFICATIONS
DIMENSIONS:
WALL: 2 1/2"
BOTTOM: 3"
COVER: 5'
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 54"
OUTSIDE DIAMETER: 7'-0"
BELOW INLET: 42"
LIQUID LEVEL: 37"
WEIGHT: 6,150 LBS.
INLET AND OUTLET:
4" CAST -A -SEAL BOOT OR EQUAL GASKET
INLET AND OUTLET BAFFLE AND FILTER:
WISCONSIN, SEE DETAIL µ10
(OTHER STATES SEE CHART)
LIQUID CAPACITY: 20.28 GAL/IN
W
HOLDING TANK:
W
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 790 GALLONS
LOADING DESIGN: 8'-0" UNSATURATED SOIL
TANK CAN BE USED AS:
SEPTIC / HOLDING / PUMP OR SIPHON
.i
COVER: MIX DESIGN #8 (NO FIBER)
of
TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
W
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
SIDE VIEW [B�y
PPROVED
Glen Schlueter at 8:19 pm, May 30, 2022
:EED ASTM C-1227 REQUIREMENTS
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REVIEWED BY
REVIEW DATE
3
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DRAWINGS SUBMITTED
FOR APPROVAL
A-PRCVED BY:
,.
APPROVAL SATE:
PRODLC"F %FEDE'�
Private Sewage System Maintenance Agreement
Kevin Zimmerman
Owner(s) Mailing Address pl O\/ 14 2025
8500 Jensen Ave S. Cottage Grove, MN 55016
Planning and Zoning Agency
66680 Hart Lake Road, Iron River, WI 54847
20809
As owner, I (we) do hereby certify the private sewage system will be installed in
accordance with the certified soil tester's report and approved plans and specifications
on file with Bayfield County Planning and Zoning Department. The system will be
operated in such a manner as to meet the designed plans. I (we) agree to maintain said
private system at the below listed location in accordance with rules established in the WI
Adm. Code, as from time to time amended. (COMPLETE Legal Is required)
1/4 of 1/4 Section tiZ.Z.Township T2' N. Range 8 W.
Additional Legal Description: L o�-#3 $ay f i e Iii Lo P!a l Df EI/e i iu000
T c ,r
Town of Y r ° 'n R' J €-r (Acreage) _ 7 •7 � Gov't Lot
Lot_ Block Subdivision
Lot _ CSM # Vol. _ Page _ CSM Doc #
DOCUMENT NUMBER
20258-609682
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
1O/23/2O25 AT 1 1:O2 AM
RECORDING FEE: $30.00
PAGES:3
Return To:
te. ref lcs�
10, �X SZz
y✓Ovt �,Jer W� e-LI
Area
N
In -ground gravity
❑
In -ground dosed
❑
In -ground pressure distribution Sewage System:
❑
Mound
❑
At -grade Sewage System
❑
Other
Septic Tank (system types A through E): The septic tank shall be pumped by a certified septage servicing operator within three (3) years of the date of
installation and at least once every three (3) years thereafter unless, upon inspection by a licensed master plumber or other person authorized to make
such inspection, the tank is found to have less than one-third (1/3) of the volume occupied by sludge and scum.
Pump Chamber (system types B, C, D, and E): The pump chamber shall also bejlnsed and pumped out when the septic tank is serviced as provided
above. The switches and pump controls shall also be inspected and maintained to ensure operability of said components.
Septic Tank Effluent Filter (system types A through E): The septic tank effluent filter shall be inspected and maintained as necessary and in accordance
with manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin. Code.
Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually inspected by a certified
septage servicing operator, POWTS inspector, or licensed master plumber within three (3) years of the date of installation and at least once every three
(3) years thereafter to determine whether wastewater or effluent from the system is ponding on the ground surface.
Mounds. At -grade, and In -ground Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbed if needed when
the wastewater distribution cell component is inspected as provided above.
Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs incurred by Bayfield County for
inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate any
human health hazard caused by the system. Bayfield County shall notify the owner of any costs which shall be paid by the owner within thi ( O)
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 a s
maybe placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as pr i _ tijqa 6
The terms and conditions of the agreement shall be binding upon and inure to the benefit of all current and future owners of such
Owner(s) Name(s) — Please Print
Subscribed and sworn to before me on this date:
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Notarized Owner(s)—Signatures)
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wformslsanitary/septicmaintenceagmement
State Bar of Wisconsin Form 1-2003
WARRANTY DEED
Document Number 11 Document Name
THIS DEED, made between Sharon M. Alit
("Grantor," whether one or more),
and Kevin K, Zimmerman
("Gututge," whethet one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real
estate, together with the rents, profits, fixtures and other appurtenant interests, in
BAYFIELD County, State of Wisconsin ("Property'.') (if more space is
needed, please attach addendum):
Lot Three (3), Bayfield County Plat !l, Town of Iron River,
Bayfield County, Wisconsin.
NOV 14 2025
Bayfield Co.
Planning and Zoning Agency
Recording Area
Name and Return Address
Kevin K. Zimmerman
8500 Jensen Ave S
Cottage Grove, MN 55016
18847-24
04-024-2-47-08-22-2 00-323-03000
Parcel Identification Number (PIN)
This IS NOT homestead property
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of en
EASEMENTS, RESERVATIONS AND RESTRICTIONS OF RECORD. IEFENDERFER
Dated Merck 2Ca`j 20214. •Mlnnesota
M,=NICOLEMARIE
lrae Jan 3t, 2o2a
" Sharon M. Ahl
(SEAL) (SEAL)
* *
AUTHENTICATION
Signature(s)
authenticated on
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by Wis. Stat. § 706.06)
THIS INSTRUMENT DRAFTED BY:
ATTORNEY MATTHEW F. ANICH, SB#1017169
Anich, Wickman & Lindsey, S.C., Ashland, WI 54806
ACKNOWLEDGMENT
STATEOF µtneto}w
) ss.
__________________COUNTY )
Personally came before me on t/14YLh Belo
the above -named Sharon M. Ahl
to me known to be the person(s) who executed the foregoing
i s t and acknowledge the sam
* 'n i P.014 AA - LJ Iej-P k ,jciei—
Nofary Public, State of
My Commission (is permanent) (expires: SA�t�'2uZlP
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED O 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003
• Type name below signatures.
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NOV 14 2025 '
Bayfield Co.
Planning and Zoning Agency
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jr 3 13AFIELD 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:
ZIMMERMAN, KEVIN K
8500 JENSEN AVE S
COTTAGE GROVE, MN 55016
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00363
Transaction Number:
SR -00363-3881E
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
Reference: 6274
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 11/17/2025
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
_ 'FIELD 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:
ZIMMERMAN, KEVIN K
8500 JENSEN AVE S
COTTAGE GROVE , MN 55016
Description
Private Sewage System (Septic Tanks)
Submission Number:
SS -00681
Transaction Number:
SS-00681-388CE
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 6274
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 11/17/2025
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-25-153S
STATE SANITARY PERMIT
OWNER: KEVIN K ZIMMERMAN
GOVT LOT: LOT: 3 BLK:
1/4 1/4 SEC: 22, T 47 N, R 8 W
TOWNSHIP: Iron River
SOIL TEST: 145-25
NEW SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: ALLAN POLKOSKI
TRACY POOLER DATE: 1/1/2000
Authorized Issuing Officer
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
THIS PERMIT EXPIRES 1/1/2002
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION