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HomeMy WebLinkAbout23-62S1tA INBOUND NOTIFICATION : FAX RECEIVED SUCCESSFULLY TIME RECEIVED REMOTE CSID DURATION PAGES STATUS June 4, 2025 at 9:16:15 AM CDT 7153730646 38 1 Received Jun 0425, 08:18a Cady Plumbing andHVAC lb c 7153730646 p.1 Request for Sanitary Inspection (Fax this form to Zoning Dept when you want an inspection — 373-0114) Nota: Time Change D Discrepancy Other From Zoning Dept Phone Number ?l� - orc 7(St373as1& Plumber. !}-c-- Fax Number lir•- 313 oLt(lD Home Owner. Sanitary Permit #: 23 - C0Z S Plumber's Choice Zo ' ept No inspection during these limes 9:30 am —1230 pm Tues. (Tracy) Date: (9. a �� 9:30 am —12:30 pm Thurs. (Tracy) Time: Plumber's Choice Ze ept Immediate Phone Number so Zoning At l>tt Dept can call you right bade (if needed) (a a .30 MS mss �i� T(J' 373- z37& ca i -1uS - 2�t2 cx 5(o CnsQ Township: Address # & Road Name: 2-02 30 51S, s� i w t; or Car r�ucG�io r W i Directions To Site: Comments: Reminder. You must confirm anychange(s) that have been made prior to or this Inspection will not be scheduled and a memo will be sent voiding the inspection. Thank You! *" Plumber must verffy any change(s) by tax or no Inspection will be scheduled uffonnslsarntary/requesifoMspecbon Zoning Dept (©4/12!14) 0 June 2018 Private Onsite Wastewater Treatment $Ps Systems ( POWTS) Inspection Report (Attach to Permit) Industry Services Division General Information Personal infnnnatinn on,.n.,..dde.••-•. %.-••-^'r---------, oses[Privacy Law, s.15.04 (fl(m)] city 9 Village 9 Town of: JOHN W KOWALSKI ET AL PO BOX 912 ELK RIVER MN 55330 BM DescrVon: TankInformation setback to: TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road Septic Y.'l ;Co7O O N/A Dosing N/A Aeration N/A Holding County rsccejd Sanitary Permit No: State Plan Transaction ID#: Parcel Tax No: 3 Pump / Siphon Information Pump Manufacturer Pump Model Demand GPM Filter Manufacturer Filter Model TDH Lift Friction Loss Head Total Forcemain Length ,/ Dia Dist. To Well Dispersal Cell Information DIME N Width Length # of Cells SETBACK F OM P p. Line Building Well OHWM 0 Type of Cell Manufacturer. gxL/ / r, L Model Number. Pretreatment Unit Manufacturer: Model Number. Distribution System Elevation Data STATION BS HI FS ELEV Benchmark 3 3 ao Bldg. Sewer C, Tank Inlet 6 S Tank Outlet $ 7 7zAc Dose Tank Inlet d y Dose Tank Bott 0 Inst. Contour Header I Manifold Distribution Pipe Infiltrative Surface P710 Final Grade X Prassura fi,QtamQ rink, Header / Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length _ Dia _ Length _ Dia Spec _ Spacing ❑ Yes ❑ No Sou cover Depth Over Depth Over Depth of Seeded / Sodded Mulched Cell Center Cell Edges Topsoil 0 Yes 0 No ❑ Yes 0 No COMMENTS: (Include code discrepancies, persons present, etc.) 7 Ccc.e 1/c o+r9, ¢e (� �l �1 �G✓ d`IT/ 5de , 7 /d 2 s f/J �Kn A. �WK �o pnt, t -r� P /c{I /Yu,ar /c' i1 w fe5�lt��ioo / j(5 - c/oyri* v >7'✓sc A/tSurbri'5-Gtt/ A2d4*t'l Plan revision required? 0 Yes No / q Use other side for additional info ti /Y; 3 Date POWTS Inspector's Signature License Number SRnJ 71n rR (Yi1911 A' BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT __ Telephone: (715) 373.6138 Bayfield County Courthouse A_ Fax: (715) 373-0114 Post Office Box 58 e-mail: zonina(vlbayfieldcountV.wi.gov 117 East Fifth Street Web Site: www.bavfieldcountv.wi.aov/147 Washburn, WI 54891 Property Owner Information JOHN W KOWALSKI ET AL PO BOX 912 ELK RIVER MN 55330 As you know Ca was contracted by you to install a private onsite wastewater tre tment system on ur property described as: Notes: Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: o Tank was crushed! removed and pipes disconnected by: on at AM/PM On 1(J at 2 Y (AM / yt a 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: Ulforms/sanilarypropertyowner-input Apri12019 s Department of Safety c°° - o = & Professional Services, Sanitary Permit Number (to be filled in In S �' J�am Pg ''` Industry Services Division 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 Project Address (if different than mailing is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal inf°nnation you provide may be used for secondary address) --ao ^3 �/1 S GI t $ t w I .r Sto�Q✓[5 �Il. O�II0c,J`� l purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. 1T Cp✓LMUCO S to W5"t8 7 I. Application Information - Please Print All Information Property Owner's Name Tc\1^ L3 I (�C:1WG-'Skt Ci /1-L Parcel # Soiy 3 oo" a• 8Z- t4 OO Property Owner's Mailing Address Property Location -b T,cJK 9'12 Govt Lot City, State Zip Code Phone Number / MV Sj"j36 (vtZ-ZBZ-93'1O '/,. Ih,Sec2O T So N R 0 ' E or 1C) U. Type of Building (check all that apply) Lot # Pi ` or 2 Family Dwelling — Numberof Bedrooms Subdivision Name ❑ Public/Commercial.— Describe Use Block # ❑ Cityof ❑ State Owned — Describe Use ❑ Village of CSM Number tN Town of MI. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C it applicable.) A. .New System ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B• ❑ HoldingTank Tn-Ground ❑ At -Grade ❑ Mound 0 Individual Site Design ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision 0 Change of Plumber ❑ Transfer to New Owner 1st Previous Pemut Number and Date Issued Expiration IV, Dispersal/Treatment Area and Tank Information: Design Flow (gpd) Design Soil Application [e(gpd/sf) Dispersal Area Required (at) ✓ I Dispersal Area Proposed (9. I System Elevation 6OO✓ 0.7 gs . I a Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units o , o _vo New Tanks ')je Existing Tanks u3 q u m 0.0 rn s rn a' O Septic or Holding Talc 1 -✓1 i25O ' W l e, eV U�yrJV 7Sa Dosing Chamber 7 5O 75o V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) I Plumber's Si turn MP/MPRS Number Business Phone Number te��( 9zzi39 -1L537-L3-7S Plumber's Address (Street, City, State, Zip Code) 311 t ci c rcue. A. (.,,,3Jrstn .fn try +{fl I VI. County/Department Use Only pro O Disapproved Pe 't Fee Date Issq/ed Issuing Age tore •a�•a ❑ Owner Given Reason for Denial / Conditions Apprelval/Reasons for Disapproval � (1Qt a\\ SAbaU a) n a *wfrn plain \ (iS Attach to complete plans for the system and submit to the County only on paper not less than 8 in x It inches in size SBD-6398 (R. 03/22) RECEIVED 7 g -C UN 162023 Wisconsin Department of Safety and Professional Services TT Page 1 of 3 Division of Industry Services Bayfield Co. SOIL E ALUATION REP8V3n�1ing si-9Loring Agency In accordance with PS 385, Ws. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, BAYIELD but not limited to: vertical and horizontal reference point (BM), directi n and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to neare t road. 8243 Please print all information. Reviewed by Date Property Owner Property Location ❑ JOHN W KOWALSKI ET AL Govt. Lot SE V NW Y. S 20 T 50 N R 06 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# PO BOX 912 4 16 SISKIWIT SHORES City State Zip Code Phone Numi er ❑ City ❑ Village ® Town Nearest Road ELK RIVER MN I 55330 612 282.8 0 BELL I a SISKIWIT SHORES RD ® New Construction Use: ® Residential/Numberofbedrooms 4 C ide derived design flow rate 600 GPD O Replacement ❑ Public or commercial — Describe: Parent material SANDY OUTWASH Flood Plan elevation if applicable NA ft. General comments and recommendations: CONVENTIONAL SEPTIC YSTEM 1❑ ❑ Boring Boring # ® Pit round.surface elev. 97.5 ft. Depth to limiting factor>84 in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu, Az. Cont. Color T xture Structure Cr. Sz. Sh. Consistence Boundary Roots GPD/Ft' Eff#1 •Eff#2 1 0-5 7.5YR 3/2 NA Is 0sg ml cs 3m 0.7 1.6 2 5-11 7.5YR 6/1 NA s osg ml cs 2m 0.7 1.6 3 11-35 7.5YR4/6 NA S Osg ml cw if 0.7 1.6 4 35-84 7.5YR6/6 NA S Osg ml NA 1vf 0.7 1.6 2❑ Boring # ❑ Boring ® PitC Horizon Depth Dominant Color Redox Description Te In. Munsell Qu. Az. Cont. Color ound surface elev. 97.6 ft. Depth to limiting factor '84 in. Soil Application Rate lure Structure Consistence Boundary Roots GPD/Ft2 Cr. Sz. Sh, *Eff#1 *Eff#2 1 0-5 7.5YR 3/2 NA Is Osg ml cs 3m 0.7 1.6 2 5-10 7.5YR 6/1 NA S Osg ml cs 2m 0.7 1.6 3 10-33 7.5YR4/6 NA s Osg ml cw 11 0.7 1.6 4 33-84 7.SYR 6/6 NA s Osg ml NA 1vF 107 1.6 --- ------ CST Name (Please Print) - - -�- �� Signatu ••- cnmem xc=ouu>Jus 4Qm /L and TSS>305150m /L CST Number EDWARD J WROBLEWSKI SP -72000013 Address Date Evaluation Cot Jucted Telephone Number 84805 HATCHERY RD, BAYFIELD, WI 54814 11/9/2022 I 715-209-4055 au -5330 (H04/15) 3❑ ❑ Boring Boring # ® Pit Groun(1 surface elev. 99.4 ft. Depth to limiting factor>84 in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color exture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 •Eff#1 •Eff#2 1 0-4 7.5YR 312 NA I Osg ml cs 3m 0.7 1.6 2 4-10 7.5YR 6/1 NA s Osg ml cs 2m 0.7 1.6 3 10-40 7.5YR4/6 NA s Osg ml cw 1f 0.7 1.6 4 40-84 7.5YR6/6 NA S Osg ml NA tvf 0.7 1.6 ❑ # ❑ Boring Boring ❑ Pit 4round surface elev. _ ft. Depth to limiting factor_, in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color T xture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 •Eff#1 •Eft#2 ❑ Boring # ❑ Boring ❑ Pit C round surface elev. _ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color T xture Structure Sr. Sz. Sh. Consistence Boundary Roots GPD/FP •Eff#1 •Eff#2 Effluent #1 = SOD, > 30 5 220 mg/L and TSS >30 S 150 mg/L • Efflu nt #2 = BOD, > 30 5 220 mg/L and TSS > 30 s 150 mg/L RECEIVED JUN 16 2023 Bayfield Co. Plnnnir:j _..:._ _.. , 7m;:y EDWARD J WROBLEWSKI, CST 9 SP -72000013 SOIL TEST PLOT PLAN JOHN W KOWALSKI ET AL SEi/4 OF NW1/4 SISKIWIT SHORES LOCATED IN GOVT LOT 4 LOT 16 IN DOC 2022R-593117 S20 TSON RO6W TOWN OF BELL, WI SCALE 1' = 50' A =BMNAILIN16"OAKTREE=100' 0 l0 0 a s0 #ISKIWIT LAKE JUN 162023 Bayfeld Co. Planning o„J �;lin3 Agency SHEET 3 OF 3 John Kowalski 4 bedroom Conventional septic system PIN 04-010-2-50-06-20-2 00-282-16000 20230 S Siskiwit Shores Rd Cornucopia WI 54827 Town of Bell Page 1-2: Bayfield Co. checklist for sanitary applications Page 3: Wisconsin sanitary application Page 4: Tax statement (for informational purposes) Page 5: Plot plan Page 6: System elevation view Page 7: Tank information Page 8: Pump information Page 9-11: Soil and site evaluation Page 12: POWTS maintenance agreement Page 13-14: POWTS owners manual, management and contingency plan Reference material; SPS 381-387 POWTS component manual (Version 2.1) (May 2022-2027) O Lu �d am 1,V JUN 16 2023 Cayficid Co. plarrho 4:,d=.:c'.rp Mency These plans prepared by ; Adrien Cady MP922139 31160 Birch Grove Rd Washburn WI. 54891 phone:715-373 2378 RECEIVED JUN 16 2023 5�S`Ll Bayfield Co. Planning „1 __:.ing A;encY K fic 010 / Fu {-vve \" �1 J� L 14mme 0 V �k u a- �cr xtJi ���E�5 tti ` JQ L NI SR3 x°�' o' as' 5O' �� .h f No 47�c L/o-� Cross Section of a'Thrree Cell lin round Component Using Leaching Chambers JUN 162023 Bayfield Co. Planning _„ 1ingAgency Ce11# to fnl leogiu Ciracufla1 Dade = a1 S 5 Cbs®A'vow !�td Top of Chamber= 96S • cell ,f I w�+k ro c•�5 tem SysB!ev. = 45.S Veu Finished Gi'adr = ? 7 6. (� _ Slop© %_._.. �. Top of Chamber ! , ,4 t I Y, Ya •'yA'Y al'v� D:',j1..�a�V,.{daY. WYBIWBUVI •a A' tie' ��f M1; o �Q d a'�'Y1J'', 0 a . $'Y' A'rA �•r GVi.at VA' 1:.'. r+�'tZr)1 ':" ,.d:5. ;^: :a•, •pI+ ay., q•, ::4 :t A' r ' "�. :d a .Y �. J �f to •',dl d'a'�•L+^ CbservatioadVeat pipes to be coustucted snd capped with approved materials for the particular use. W1250/750 -MR TANK SPECIFICATIONS 4" CAST -A -SEAL 4" CAST -A -SEAL ii una A IHIa I I i I IT \�� FILTER ��\ OR II:II Illl BAFFLE TOP VIEW w t bhcl6rLaKlAj couev5 5 31.1AL000e y104cI& w r�'yLPP (Y'1 a a TANKS I' 1 I•I (as 1 ac 11 2'-4" _ ___-_-J•'.Il_,L ___ �• {��]1 M•+ PUMI ofSC(.t,4 �il�l VL5 SIDE VIEW 'FACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 4" VENT W i4R✓wCJ Ca? T rM IA° ted u. About Lxpecfed Fall OUTLET ra U DIMENSIONS: WALL: 2 1/2" BOTTOM: 3" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" LENGTH: 12'-11" WIDTH: 7'-2" BELOW INLET: 53" LIQUID LEVEL: 48" WEIGHT: 14,860 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: 27.66 GAL/IN (SEPTIC) 16.12 GAL/IN (PUMP) LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEP11C/SEPTIC, SEPTIC/SIPHON, OR SEPTIC/SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE PAD /� I-c-:CEIVED JUN 16 2023 Bayfield Co. Planning __r.....A oncy D BY DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: 0 iV /OF 1 Wastewater JUN 16 2023 Bayfield Co. METERS FEET Planning ai.d ZcningAgency 117 5 10 CAPACITY 15 m3/h PERFORMANCE RATINGS PE31 Total Head (feet of water) GPM 5 52 10 42 15 29 20 16 25 0 PUMP INFORMATION PE41 Total Head (feet of water) GPM 8 61 10 57 15 46 20 33 25 16 PE51 (feet of water) GPM 10 67 15 59 20 50 25 39 30 26 Order No. HP Volts Amps Minimum Circuit Phase Float Switch Cord Disc har a Minimum Basin Maximum Solids Shipping Weight BreakerDiameter Style Length Connection Size lbs/kg PE31 M 0.33 115 12 20 Manual / No Switch PE31 P1 Piggyback Float Switch PE41 M Manual / No Switch 0.4 7.5 15 1 20 1.5" 18" .5" 31! 14.1 PE41 P1 Piggyback Float Switch PE42M 230 3.7 10 Manual / No Switch PE42P1 Piggyback Float Switch PE51 M 0.5 115 9.5 20 Manual / No Switch PE51 PI Piggyback Float Switch PE52M 230 4.7 10 Manual/ No Switch PE52P7 Piggyback Float Switch Bayfield County, WI SISKI WIT LAKE paa[oimx Ion LAKE r 16nIUT LC%i9] �_y - P4 � ELI C�UNiI • - t of fi .r t y 1 i .a� .•'�S�s9F V ,ar`� rr,- Irr,�- N� fi»: a -_� - 6/2112023, 2:55:39 PM Rivers L- Approximate Parcel Boundary Lakes Road Type Town Building Footprint 2015 Building 0 0.02 1:1,598 0.04 0.08m1 0 0.03 r-T�—i 0.06 0.12 km eaybeld County Land Romms Department Bayfield County Zoning Appbration tdips'l/maps bayfeidmuntYwi.gov/ZoningWABI BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) ❑ _:e_i; List ❑ Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) ❑ Index Page I Title Sheet (Signed by Plumber) (383.22(2)69(c)) O Original Plot Plan (383.22(2)2. 3. & 4.a) ❑ Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer 0 Pump Tank Diagram, Alarm and Pump Curve (when applicable) 0 Contingency Plan / Management Plan (383.22-3(2)(b)1,f.) O Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(5) (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) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) O Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) ❑ 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies O Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) O State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) ❑ I Application Information must include: ❑ 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) O Project Address or Road Name where driveway is/will come off of) O (Owners Phone Number) ❑ II Type of Building ❑ III Type of Permit ❑ IV Type of POWTS System ❑ V Dispersal / Treatment Area Information ❑ VI Tank Information ❑ VII Responsibility Statement (Plumber's Information) ❑ *Date Stamp* Plot Plan: (To Scale or To Dimension) ❑ 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 O Address Number and Road ❑ North Arrow ❑ Contour Lines ❑ Structures and Driveways ❑ Boring Locations ❑ Property Lines ❑ Well Locations ❑ Legal Descriptions ❑ Piping Material Information (conveyance line, building sewer line, material type and diameter) rTEaiED JUN 16 2023 o=,flab Co. Turn Over ► Cross -Section and Over -Head Profile of the System: ❑ Surface and System Elevation ❑ Position of Observation and Vent Pipes ❑ 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? ❑ Has this property been split? (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 ❑ Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) RECE(VEL JUN 16 2023 sayfl Plannin9.,._ IC7 u/forms/cheCMists/cheddistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012-0c) Proofed by: Real Estate Bayfield County Property Listing Today's Date: 12/12/2022 Property Status: Current: Created On: 3/15/2006 1:15:03 PM Description Updated: 7/8/2022 ' Ownership Updated: 7/8/2022 Tax ID: 8243 JOHN W KOWALSKI ELK RIVER MN PIN: 04-010-2-50-06-20-2 00-282-16000 TYLER J KOWALSKI CAMBRIDGE MN Legacy PIN: 010111801016 Map ID: Billing Address: Mailing Address: Municipality: (010) TOWN OF BELL JOHN W KOWALSKI ET AL JOHN W KOWALSKI ET AL STR: S20 T50N R06W PO BOX 912 PO BOX 912 Description: SISKIWIT SHORES LOCATED IN GOVT ELK RIVER MN 55330 ELK RIVER MN 55330 LOT 4 LOT 16 IN DOC 2022R-593117 Recorded Acres: 4.320 Site Address * indicates Private Road Calculated Acres: 4.232 N/A aOa 30 S 57 wi f S(rove S tvj Lottery Claims: 0 (ovKv coi'_WS 8 x 7 First Dollar: No Property Assessment Updated: 9/22/2022 Zoning: (R-1) Residential -1 ESN: 107 2022 Assessment Detail Code Acres Land Imp. Tax Districts Updated: 3/15/2006 G1 -RESIDENTIAL 4.320 73,900 0 1 STATE 2 -Year Comparison 2021 2022 Change 04 COUNTY Land: 96,700 73,900 -23.6% 010 TOWN OF BELL Improved: 0 0 0.0% 044522 SCHL-SOUTHSHORE Total: 96,700 73,900 -23.6% 001700 TECHNICAL COLLEGE Recorded Documents Updated: 3/15/2006 Property History 2 WARRANTY DEED N/A Date Recorded: 1/24/2022 2022R-593117 0 LAND CONTRACT Date Recorded: 4/13/2021 2021R-588077 RECEIVED 0 CONVERSION Date Recorded: 477213 838-537 JUN 16 2023 Sayfieid Co_ Panning ad .na A;:- y ° `' i Department of Safety c °''^ p = , it & Professional Services, JUN 16 2023 Sanitary Permit Number (to be filled in b Industry Services Division 2�� Bayfield co. •^...... ••-Y-•••••a" s State Transaction Number amtary eimit Application 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 forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary '1.n ^y 3O S GI 5 f fl W I -I-S IS . purposes in accordance with the Privacy Law, s. I5.04(l)(m), Stats. O.IJOe•J`� I. Application Information - Please Print All Information CfJ✓uu/3jQ &)J 5Y-Sa7 Property Owner's Name Li- <<U Wc ISkt ET /a-(_ Parcel # 8oiti3 vcr- ]- V2-- V Up Property Owner's Mailing Address Property Location R) Govt. Lot %. '/.,Section 2O T So N R O L E or City, State I EIIC \2�JQf, MAI Zip Code 51338 Phone Number (otZ-2-R2-93`AU II. Type of Building (check all that apply) Lot # / or 2 Family Dwelling - Number of Bedrooms ❑ Public/Commercial - Describe Use IZB Block # Subdivision Name {L Q� 5 f•-i W 1 ""VI ❑ Cityof ❑ State Owned - Describe Use ❑ Village of •-� LN Town of \J_2.. CSM Number 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 applicable.) A. &New System y ❑ Replacement System(explain) p y ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit ❑ Holding TankDesign � In -Ground ❑ At -Grade ❑ Mound ❑ Individual Site ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration //mod -.vv 16Y / my, w yp. •.\6Y"'o•/ .ope.o... r..w ...•y.. w t / .oye. ...w ..vyo . � oro .. .......... Capacity in Total # of Manufacturer Tank Information 1Gallons Gallons Units y 2 o E NewTanks Existing Tanks c g �° d .o m in%.Y1 0.O fl N iZ C7 E I Septic or Holding Tank 1125O I 1 Ia,) 1 I 1 W iesev Ii5U/7so I I I I I _— — _ /7VI l&WI V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Pi s Name (Print) Plumber's Si tare MP/MPRS Number Business Phone Number lumbe fzsle� C"�f 9zz(3ci ____Z3_S Plumber's Address (Street, City, State, Zip Code) `�ttr.00 6,rc,jc Ri. LJrSI-. if'n i t.-...)1. S't}fjI VI. County/Department Use Only I Ap ❑ Disapproved �Pe tt Fee Date Issued Issuing Age lure Owner Given Reason for Denial YI)UAzJ/d1')f G/.e tb Ott o,\tkba a) YY1a cam t Plan \O awry' Attach to complete plans for the system and on paper not less than 8 12 x SBD-6398 (R. 03/22) ZULJ DOCUMENT NUMBER Private Sewage System Maintenance Agreemit Owner(s) Name Sri. l J• ��� l ska Ba eld Co. 2023 R-599395 Zoning Dept DANIEL J. HEFFNER REGISTER OF DEEDS Owner(s) Mailing Address c1 1 1 Z % BAYFIELD COUNTY, WI RECORDED 06/16/2023 AT 10:55 AM RECORDING FEE: $30.00 Site Address 1 I I o230 5 5'5K"wi-f SLtJIes �1 cfl S9ta Tax ID # 8Zy3 As owner, I (we) do hereby certify the private sewage system will be installed in PAGES: 1 accordance with the certified soil testers 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 20 Township 50 N. Range 0(0 W. Zk:•'. Sict log *s� �A Additional Legal Description: Ccr1T L.%V (4 L * tb ,_Doe- au 2- Str311 J Recording Area Return To: Town of A( (Acreage) `-I. Gov't Lot Planning and Zoning Department Lot Block Subdivision Lot _ CSM # Vol. _ Page _ CSM Doc # Z In -ground gravity 2q 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 be rinsed 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 manufacturers 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 thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically ag es that all the costs and charges maybe placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall lected as provided bylaw. The terms and conditions of the variance shall be binding upon and inure to the benefit of all current and future o ers of oily. FA Owner(s) Name(s) — Please Print Subscribed and sworn to before n ttt04d �y (yA i 0 I -1 u H p w 4'LS /G / oV AO_b'; 444 Nota' Owners))—Signature(s) NotaryPu ( q My C mmission Expires: Drafted by: Date: 9 Proofed by: u/forms/sanitary/septicmaintenceagreement Revised June 2018 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page±of FILE INFORMATION Owner' a LA• Ic , \31c', Cl At Permit # DESIGN PARAMETERS Number of Bedrooms L.f0 NA Number of Public Facility Units L'kNA Estimated (average) flow V gal/day Design (peak) flow = (Estimated >( 1.5) OO gal/day In Situ Soil Application Rate .7 ayda /ftz Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) ≤30 mg/L Biochemical Oxygen Demand (BODE) 220 mg/L O NA Total Suspended Solids (TSS) ≤150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) ≤30 mg/L Total Suspended Solids (TSS) ≤30 mg/L (ANA Fecal Coliform (geometric mean) ≤10° cfu/100ml Maximum Effluent Particle Size 'a in dia. O NA Other: ❑ NA `Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) earls (Maximum 3 years) ❑ NA Pump out contents of tank(s)Nt When combined sludge and scum equals one-third ('h) of tank volume ❑ NA O When the high water alarm is activated Inspect dispersal cell(s) At least once every: "3 5a years)((Maximum 3 years) ❑ NA Clean effluent filter At least once every:3 ❑ month(s) yar(&)) O NA Inspect pump, pump controls & alarm At least once every: ❑ months) t& year(s) �) NA Flush laterals and pressure test At least once every: ❑ month(&) ❑ year(s) NA Other: At least once every: O month(s) O year(s) It] NA Other: Q NA SYSTEM SPECIFICATIONS Tank Manufacturer W reset/ ❑ NA $j Septic O Dose O Holding vol. ( a5O gal Tank Manufacturer W"GJ5O utnt)0 1*" iT ❑ NA ❑ Septic (Dose O Holding vol. 750 gal Effluent Filter Manufacturer R'(y(ott Say ❑ NA Effluent Filter Model 5 L Pump Manufacturer 6- ©o IcIS O NA Pump Model PE Si fI Pretreatment Unit CBJJA ❑ Sand/Gravel Filter O Peat Filter ❑ Mechanical Aeration O Wetland ❑ Disinfection O Other: Manufacturer Dispersal Cell(s) O NA J In -Ground (gravity) O In -Ground (pressurized) ❑ At -Grade O Mound ❑ Drip -Line O Other: Other: O NA Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (h) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of ≤12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.JUN 162023 6ayfleIdGMW (12/02) Page a of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. , ipa 1 6 2023 System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup orsurface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ( 1 lu ,t "t/6c L t c_ Phone SEPTAGE SERVICING OPERATOR (PUMPER) NameB;c S; c. Phone ttS_ 313- SLb3 POWTS MAINTAINER Name, Q\u„40¼A canA k / fc- k tC Phone (-73-Z3-1 LOCAL REGULATORY AUTHORITY Name R&L %¢lC, Cam,n"\j Zun'lr Phone '1t� 373— (ot35' This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. BAYFIELD COUNTY SANITARY PERMIT (#04)-23-62S STATE SANITARY PERMIT OWNER: JOHN KOWALSKI (ET AL) GOVT LOT: LOT: 16 BLK SUBDIVISION: Siskiwit Shores 1/4 1/4 SEC: 20, T 50 N, R 6 W TOWNSHIP: Bell SOIL TEST: 178-22 NEW SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: ADRIAN CADY MCKENZIE SLACK DATE: 6121/2023 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: # MP 922139 Condition: System to meet all setbacks. Management plan to owner. Properly maintain system per recorded agreement. THIS PERMIT EXPIRES 6121120Z5 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION 1