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HomeMy WebLinkAbout25-162SRequest 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(�bavfieldcountv.wi.gov Note Time Change fl Discrepancy fl Other Phone Number Plumber: ' 0` Ml1 \eW `��`�' � 7/ 6`30c - 7Sd-1 Fax Number Homeowner: S�& p k r Email Address I met Immediate Ph a Number So Zbhing Sanitary 1 Is — 16 Dept can call you right back (if needed) Permit #: �( d s- Plumber's Choice Zoning Dept No Inspection(s) during this time Date: Tuesday (9:30 am - 12:15 pm) (Tracy) Plumber's Choice Zoning Dept Time: cJj) Township: 1 1 ____ __ Address # & Road Name: S lS1� -Z b3`- or Co wrISa� � ( Directions To Site: Comments: ** Plumbers you must verify any change(s) by fax or email ** Notes from Zoning Dept: July 2025 MATTHEW J & JODY HIPSHER 22450 SISKIWIT LAKERD DING TANK INSPECTION REPORT CORNUCOPIA WI 54827 GENERAL INFORMATION Permit Holder's Name ❑ City ❑ Village D Town of Sanitary Permit No. Plan ID No. Tax Parcel No. Properly ddress If Av able TANK INFORMATION TYPE MANUFACTURER/MODEL# CAPACITY IaCco SETBACKS Property Line Well Water Service Building All -Weather Road OHWM Swimming Pool DEVIATIONS FROM APPROVED PLAN COMMENTS (Persons present, discrepancies, etc.) ulna 6�r.bwl �gece�(t 2Ykd' r ISR � ply \ham 1 I�strk afar (hoOKa 14 e) � old tQumo b P� {Yl0rvtnt j d Mt itiahtr VbC(d COMPONENTS NOT INSPECTED Plan Revislo squired ❑Yes o Date: I Signatur of Inspector: II umb Sketch on other side 10 of 13 DAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Bayfield County Courthouse Fax: (715) 373-0114 Post Office Box 58 e-mail: zonina(dbavfieldcountv.wi.nov 117 East Fifth Street Web Site: www.bayfieldcounty.wi.gov/147 Washburn, WI 54891 Property Owner MATTHEW J & JODY HIPSHER Information _ 22450 SISKIWIT LAKE RD CORNUCOPIA WI 54827 As you know 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: ❖ Tank was pumped by: aIt_ 111 S"1 on v an 1 at AM PM Tank was crushed / removed and pipes disconnected by: 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 $50 fee are required. System could not be inspected because County could not respond to plumber's time constraints. Comments: ial\ 1h \iPr —1 1' UtcS PMe leg►t1t/e(UAm U/formslsanitarypropertyowner.input Ap,p 2019 ""�.$ Department of Safety County �cky ENTERED & Professional Services, ` 19 ary Services Division Sanitary Permit Number (to b be filled in by Co.) S Indust ss 03 as -/(0a s Sanitary Permit Application State Transaction Number In accordance with SPS 383.2](2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailinaddress) the Department of Safety and Professional Services. Personal information you provi ee n v f r e�Dondary ^a fl 0 S .S r S 1r 0j A- �tlg�`� 1≥.d, purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. �� L�B �� T Qniilt�arinn inFnrmatinn Pleaae'sPriritplrShformatiolr'- _ —_ _ _ _ _ _ CO �I�u COP/ 4 U� Jock t s o Ba eldco. 7483 Property Owner's Mailing Address ` I_ Planning and Zoning Agency Property Location a�.l-{b Q IS R `wLk f� Govt. Lot City, State Zip Code Phone Number Co C© UT Jy8a1Section IIII Type tSf Buil ng (c eck all that apply) �' Lot H T N R E o ) or2 Family Dwelling — Number of Bedrooms Subdivision Name / Block/! ❑ Public/Commercial — Describe Use ❑ City of ❑ State Owned — Describe Use CSM Number ❑ Village of AT.. of mot _ 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 aplicabIe.) A. ❑ 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) ist Previous Permit Number and Date Issued C. ❑ Renewal Before LiRevision LiChange of Plumber ❑ Transfer to New Owner Expiration IV. Dispersal/Treatment Area and Tank Information: Design Flow (gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation Capacity in Total II of Manufacturer Gallons Gallons Units a d Tank Information New Tanks Existing Tanks izo a V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Sig MP/MPRS Number Business Phone Number /ItAAOQE uv, ,% wd-� 1�gF�So 3 7 S-ao --75x1 Plumber's Address (Street, City, State, Zip Code) \Uq) /T„,.d-" NIJtr �, (�6(sk�O�rtnl glggi Approved O Disapproved $.....-.- ____./ 2/7 '7'f4❑ Owner Given Reason for Denial ) 9 als �v Conditions of Approval/Reasons for DisapprovalScLdin cd �(/L &"neh in emmnlele plans SBD-6398 (R. 03/22) to the County only on saner not less than 8 lox I I RECEIVED DEC 19 2025 CONCRETE HOLDING TANK DESIGN Single Tank Option Bayfield Zoning A Planning and Zoning Agency INDEX AND TITLE SHEET Project Matt & Jody Hipsher- Holding Tank Owner Matt & Jody Hipsher Address 21705 Siskiwit Lake Rd Cornucopia, WI 54827 (715) 209-7322 Legal Description NW NE in Doc 2023R-600188 521, T50N, R06W Township Bell Subdivision Name Parcel ID Number 7483 Plan Transaction ID 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 servicing contract Holding tank specifications Designer Michael Wroblewski Signature License Number 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 12/11/25 Designed pursuant to: Holding Tank Component Manual For POWTS (Version 2.0) SBD-10855.P (N. 03107, R. 01!12) Version 7.0 (11/12) Page 1 of 9 HOLDING TANK SPECIFICATIONS LIiI INumberof bedrooms Non-residential estimated flow (gpd) 2000.0 IMinimum holding tank volume required (gal) EWSJH 000.0 IPipposed holding tank ca acit al) eser concrete Tank Manufacturer P2000 -MR Tank model number Electros stems Alarm manufacturer 101 JAlarm model number RECEIVED DEC 192025 Bayfield Co. Planning and Zoning Agency Tank Dimensions and Data Tank Anchor Calculations X for round tank 22230 lbs Weight of tank and cover 43.0 Liquid depth below inlet invert (in) Li.10 Safety factor 8.0 Maximum de th of soil cover (ft) 12166 lbs Weight of anchor required 55.0 Height (in) I Outside 13.4 in Soil cover req. for anchor or 164.0 Length (in) r Dimensions 3.0 yd3 Concrete counterweight 96.0 Width (in) Only HOLDING TANK CROSS SECTION manhole cover with locking device and finished junction warning label grade box , ..p. 4 4"min. Manhole and vent locations conduit may be reversed. bi% sAyg outlet 0o tether weight service 12.0 in. alarm on Electrical as per 31.0 in. NEC 300 and SPS 316 Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SPS 384. 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Matt & Jody Hipsher - Holding Tank Transaction Number: vent cap 12" min. vent pipe 18" min. building sewer inlet Page 2 of 9 HOLDING TANK PLOT PLAN N MATTAAND JODY HIPSHER 21705 SISKIIWIT LAKE RD CORNUCOPIA, WI 54827 NW NE 277 IN DOC 2023R-600188 S21.T50N R06W TOWN OF BELL, WI SCALE 1 = 50' SISKINT LAKE RD �— >100'T 1 2 3 4 50 FT Page 3 of 9 HOLDING TANK MANAGEMENT PLAN 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. 01/12), 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 CE VED (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. DEC 1 9.2025 4. At each service event, the service provider should visually inspect the condition of the tank, risers and Bayfield Co. manhole cover(s) and verify that the alarm system functions and manhole locking devices are presftfning and Zoning Agency 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 Birch Street Sepiic Service Phone: 715-373-5683 c. Co. Zoning or Health Dept. Bayfield County Planning & Zoning Phone: 715-373-6138 Project: Matt & Jody Hipsher- Holding Tank Transaction Number Page 4 of 9 (V N RECEIVED TOP VIEW DEC 192025 Bayfteld Co. ¢ Planning and Zoning Agency IJ io JTINLET — _ OUTLET I I I TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 W2000 -MR TANK SPECIFICATIONS o a I Q. ~ DIMENSIONS: WALL: 2 1/2" n• a 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. w BELOW INLET: 53" O.D. LIQUID LEVEL: 46" o WEIGHT: BOTTOM 9,430 LBS. COVER 5,940 LBS. u 3 E INLET AND OUTLET: o I 4" CAST -A -SEAL BOOT OR EQUAL GASKET w 3 INLET AND OUTLET BAFFLE AND FILTER: N o o WISCONSIN, SEE DETAIL #10 W (OTHER STATES SEE CHART) LO LIQUID CAPACITY: 42.92 GAL/IN LO HOLDING TANK: 1:.7 OUTLET HOLE PLUGGED = ACTUAL CAPACITY: 2,126 GALLONS LOADING DESIGN: 8'-0" UNSATURATED SOIL Lo M TANK CAN BE USED AS: W 0 SEPTIC / HOLDING / PUMP OR SIPHON m s N Ww COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) 1 M CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE Q REVIEWED BY N REVIEW DATE 3 J Z 0 I= a w SHEET NO. 17 OF 1 HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Td N'\ps r We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) 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; DEC `I 9 2025 C. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; sayreld Co. e. The dates on which the holding tank was serviced; ' Planning and Zoning Agency f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal.sites to which the contents'from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local government unit and the County named above within (10) business days from the date of change to this service contract kbeta /7o64 ec I 4 #zsAer Revised: May 2016 (®fvlay 2018) Personal information you providemay be used for secondary purposes on this I by: 4 MADIS N BRINER Kist J41y6gf1tnissic State of Wiscons aw, s.15.04 (i)(m)] rornto me: otJf M4l' .10Th ILoPublic reson: Drafted by /AW Document•Nurnberl lan i:D. No. • Owner Name (8) l .. Parce identifier Number (PiN) •r ((44�� HOLDING TANK AGREEMENT Owners) Mailing Address aqso k.L 1-soW �o J::1Q1 , 1d1 LIg -1 as NC Sf We acknowledge that application- is being made for the'insthliatibn of (a) holding-tank(s) on the following. property or that continued use of the• existing premises requires that a holding :tank be installed on the property #orthe purpose df proper cohtalnthent of sewage. Also,. the property cannot now be sewed by.a municipal sewer, br.any other type- of. private onsita wastewater treatment system as'perrpitted under Ch. SPS 383, Wis'. Adm. Code or'Ch.145, Wis Staffs. NW 1/4 of :1/4 Section .\ Township SD N. Range _____w. Town ofd Additional Legal Description: _/'tJ W E t oC.2n 6ao Gov't LotLot8lockSubdivislon CSM# i_o._G$M #. 1/Ol• Page CSM Doc# DOCUMENT NUMBER 2025R-610269 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY, WI RECORDED 12/10/2025 AT 8:20 AM RECORDING FEE: $30.00 PAGES: 1 Recur- fi As- an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described piQYerty. we agree -to. do .the following: 1. Owner- agrees to conform to all applicable requirements of Ch. SPS 383, Wis:. Adm. Code relating to holding tank installation and maintenance. If the owner falls to have the holding tank properly; serviced inresponse to orders issued by BeYfield County or th`e ti Department of Commerce to .prevent or abate a human health hazard .as described in s. 254:59, Mats:, Bayfield County may enter upon the: property and service the -tank orroause to have the tank to be se V Ie:owner by piacing the charges on the tax bill as.a special .assessment for current services -rendered. The charges:will be scribed by 5.66.0703, Stats: 2. Owner agrees to pay all charges and costs incurred by Bayfieldti it ion, pumping, hauling, or otherwise -servicing and maintaining the holding tank .in such a manner :as to prevent or abaTe 'ny 1 'mann hieaitft hazard caused by the holding tank. Bayheld County shall notify the owner of any -costs which shall be paid by the ow iJhirty (30) days from the date.of notice. In the:event.the owner does notpay the costs. within thirty (30) days, the owner sgj r ! he costs and chargesmay be placed on the tax roll as especial assessment for the abatement of a human health hazard and the tax shall be collected as provided bylaw. 3. The owner agrees to contract with a person who is licensed, pursuant to s.281-.17 (3) Wis'. Stats., and chapter NB 114 Wis. Aft. Code, .to have -the holding tank serviced In accordance -with Ch. NR113, Wis: Adm. Code, and to file a copy of the contract with Bayfield County. The owner further agrees to file a copy. of any changes to the service contract, or a copy of a new service contract, with the c unty within 30 days.from the date of change to chi service contract. 4. The owner .agrees to contract With :a pt,7rson licensed pursuant to A. 281.48 (3) Wis.. Stats., and: Ch. NR 1.14, yVl's Adm. Coda who shall submit to the: county within 30 days a report detailing the servicing. of the holdiri€�. tank. Bayfield County may,.!/enter Upon the; property to investigate the condition of the holding tank when pumping reports :and meter readings may indicate that me holding tank ?s not being properly maintained. • r h. This agreement will remain Ineffect only'untii•Bayfield County certifies that the property Is served by. either:zf.Miun`iclp l sewer er *a private onsite wastewater' treatment system that complies with Ch SPS 383, WI's Adm. Code. In addition, this agreement ,may be cancelled by executing And feeording said` certification with reference to- tilts agreement in itch 'manner -.which will perm $ exT A' ice of -the certification to be. determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner, and. assignees of the owner. The owner shall submit this 'agreement -to the register -of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement -to -be determined by reference to the property where the holding tank Is installed: wwnee(s) —Plea a tint - P"g,c,)t Ac Subscribed and sworn' -before me on this date: ' �J ON BRI ` C� Notary Publi Notarized I e s) — Sig ture(s) Notary Pu io State of Wisco My Commission Expires: D3 Dy ZvL g.. PER sin Drafted I4( IS4Q ,1 S� P�J kt Date: '�a a s Person information you provide titaybe finedfot sedondary purposes [Privacy Law, s.15.04 (I)(m)I uffomslsanitary/hordingtankagteementdoc ®June 2013 BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) ^ 1 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)) RECEIVED Original Plot Plan (383.22(2)2. 3. & 4.a) Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer DEC 192025 Pump Tank Diagram, Alarm and Pump Curve (when applicable) Bayfield co. Planning and Zoning Agency 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) KHolding 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) ❑ 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 }o 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 Application: (Include the following Information) I Application Information must include2423 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) 7 Project Address or Road Name where driveway is/will come off of) .(Owners Phone Number) II Type of Building III Type of Permit R7 IV Type of POWTS System �V Dispersal / Treatment Area Information Iikl VI Tank Information IR VII Responsibility Statement (Plumber's Information) 't *Date Stamp* Plot Plan: (To Scale or To Dimension) ,X Signature and Plumber Information ❑ Surface Elevation of Body of Water ❑ Direction and Percent Land Slope ) Tank and Filter Information and Location ❑ Wetlands / Navigable Bodies of Water ❑ Absorption Area (Proposed and Existing) ❑ Bench Mark (Location, Elevation and Description) Component Manual Version Address Number and Road North Arrow 1J Contour Lines _Structures and Driveways Boring Locations Property Lines Well Locations Turn Over ► Cross -Section and Over -Head Profile of the System: ❑ Surface and System Elevation ❑ Position of Observation and Vent Pipes _ ❑ Dimensions and Depths RECEIVED ❑ Make, Model & Number of Chamber Units in each Cell DEC 19 2025 Property Information Bayfield Co. Planning and Zoning Agency ), How many systems will there be on this parcel of land? XHas this property been split? a (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 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 O Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) u/forms/checklists/checklistforsanitaryapps (10/2009);(07/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: S Z-oo37H Soil Test # Bayfield County •/ J 7 Waiver of a Thorough Soil & Site Evaluation EId'd'ERED (subject to 15-1-10(d)) I4?.//9/S EDWARD J WROBLEWSKI 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 MATTHEW J & JODY HIPSHER Property Address 21705 SISKIWIT LAKE RD Telephone, CORNUCOPIA, WI 54827 715-209-7322 Accurate Legal Description is requested: NW 114 of NE 1/4 Contractor ED'S MECHANICAL LLC Authorized Agent EDWARD J WROBLEWSKI Agent's Telephone 715-209-4055 Written Authorization Attached: Y or Q Section 21 Township 50 N. Range 06 W. Town of Additional Legal Description: NW NE 277 IN DOC 2023R-600188 Govt. Lot Lot Block Subdivision Lot CSM# Vol. Page CSM Doc # Volume Page of Deeds Tax I.D# 7483 Indicate reasoning for your determination: CLAY SOILS DECEIVED DEC 19.2025 ay1etd Co. Planning and Zoning AgenCY /1?,?13 Signs re of County Official /L49/'Ac BELL Acreage 40.00 Signature of Certified Soil Tester If 117 2025` Date SP -72000013 Certification # (Submit a Plot Plan & Fee) Date u/forms/soiltestwaiver(KLK) June 2018 EDWARD J. WIROB,LEW$KI. CST #SP -72000013 SOIL TEST PLOT PLAN MATT AAND JODY HIPSHER 21705 SISKIWIT LAKE RD CORNUCOPIA, WI 54827 NW NE 277 IN DOC 2023R-600188 S21 T50N R06W TOWN OF BELL, WI SCALE 1" = 50' SISKIWIT LAKE RD >100' T( 0 10 )0 30 413 60T SHEET 2 OF 2 BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): Check List ❑ Index Page / Title Sheet (Optional) Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospecRE� Original Plot Plan DEC 2Q25 19. 0 Cross Section Soil Profile Sheet (optional) ❑ Additional Information (Warranty/Quit Claim Deed) (Optional) BandeZon Zoning A9encY ( ty ( p ) �k�nning Soil Evaluation Report: (Include the following Information) ' C Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used Property Owner's Information not prospective buyer's name) 4Property Location (Accurate Legal Description with SecjTwp/Range) Road Name (where driveway is/will be coming off of) Floodplain Elevation, Flow Rate, Comments and Recommendations 0 Complete Soil Boring / Pit Information Date 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) 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 0 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/checklistforests BAYFIELD COUNTY SANITARY PERMIT (#04)-25-162S STATE SANITARY PERMIT OWNER: MATTHEW J & JODY HIPSHER G OV'T LOT: LOT: B L K: 1/4 1/4 SEC: 21, T 50 N, R 6 W TOWNSHIP: Bell SOIL TEST: 154-25 REPLACEMENT SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: MICHAEL WROBLEWSKI TRACY POOLER Authorized Issuing Officer DATE: 12/19/2025 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. Old System needs to be properly abandoned per SPS 383. THIS PERMIT EXPIRES 12/19/2027 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION