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Request for Sanitary Inspection Fax this form to Zoning Dept when you want an inspection — 373-0114 If you do not have a fax and must email the inspection; you must email all staff members Note fl Time Change fl Discrepancy Other '`` Phone Number Plumber: 1\\2 C(�1�\�W SIB \ I E' Fax Number Home Owner: Sanitary Permit #: -- 0 3 S Plumber's Choice Zoning Dept No inspection during these times 9:30 am —12:30 pm Tues. (Tracy) Date: I\1\ a� O� 12:00 pm - 2:00 pm Wed. (Todd) 9:30 am —12:30 pm Thurs. (Tracy) Plumber's Choice Zonin Dept Immediate Phone Number so Zoning Time: Dept can call you right back (if needed) Township: QC\\ Address # & Road Name: aka 8 S .S C\ lnl Lc1}c or HOC Nv\cbP eel W= Sg2a-1 Directions To Site: Comments: / J �N 7n ��� 'V%l/ fir. Li v,��i G3 ✓� ,& D t ' CS c"/' Reminder: You must confirm any change(s) that have been mad pnor to or this inspection will not be scheduled and a memo will be sent voiding the inspection. Thank You! From Zoning Dept ** Plumber must verify any change(s) by fax or no inspection will be scheduled ** u/forms/sanitary/req uestforinspection Zoning Dept (©4/12/04) ® August 2021 a.PnIRN(�T r R Private Onsite Wastewater Treatment ,L Ps w Systems ( POWTS) Inspection Report Wyk,„ (Attach to Permit) Industry Services Division General Information Personal information you provide may be used for secondary u oses[Privacy Law, s. 15.04 p(m Permit Holder's Name: / a,iaN �' C [[ - _ /1%/�i %Ie5a2/ City Village own of: ow/ CST BM Elev: Insp BM Elev: BM Description: Tank Information TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road Septic e- N/A Dosing N/A Aeration N/A Holding setback to: County Sanitaj Permit No: L2-035 State Plan Transaction ID#: Parcel Tax No: �S3 Pump! Siphon Information Pump Manufacturer ump Model Demand GPM Filter Manufacturer Filter Model TDH Lift Friction Loss Head Total Forcemain Length Dia Dist. To Well Dispersal Cell Information DIMENSIONS Width Length # of Cells SETBACK FROM Prop. Line Building Well OHWM Type of Cell Manufacturer: Model Number: Pretreatment Unit Manufacturer: Model Number: Distribution System Elevation Data STATION BS HI FS ELEV Benchmark Bldg. Sewer Tank Inlet Tank Outlet Dose Tank Inlet Dose Tank Bottom Inst. Contour Header I Manifold Distribution Pipe Infiltrative Surface Final Grade X Pressure Systems Only Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length Dia Length Dia _ Spac Spacing ❑ Yes 0 No Soil Cover Depth Over Depth Over Depth of Seeded / Sodded Mulched Cell Center Cell Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Ml'/4 4 (rev-' O1% 4,)e w/%4NI'1 T 46K 4 9T'' (Vey /&t/di//far4 ) re rvcdv;r-! Air ej/, 7b reYurN �� Plan revision required? ❑ Yes Cy 7 Use other side for additional informa6bbbn. 4- '4 �`oGBss� 19227/3 Date gRn.71n lR M/911 POWTS Inspector's Signature License Number Industry Services Division Bayfield ?^1 D = P 0 R I G 1400 EWashington Ave P.O. Box 7162 Sanitary Permit Number (to be filled in by C cs;Q I N A Madison, WI 53707-7162 J4? —D,Q 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 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 information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law. a. 15.04 1 m Slits. 22285 Siskiwit Lake Road Cornucopia, WI 54827 I. Application Infonnation — Please Print All Information 'e tJV ED Property Owner's Name Karston &Cynthia Anderson JAN 042022 Parcel 8 7539 Property Owner's Mailing Address Bayfield Co. Property Location 846 Westwood Circle planning and Zoning Agency Govt Lot NE' A, NW ¼, Section 22 City, State I Zip Code Phone Number Delano, MN 55328 ((612) 423-3888 ,(t(rcle one) T50N R06E II. Type of Building (check all that apply) Lot!! Subdivision Name ® 1 or 2 Family Dwelling —Number of Bedrooms ____________ 2 ❑ Public/Commercial — Describe Use Block!! ❑ City of ❑ State Owned— Describe Use ❑ Village of CSM Number 880 ® Town of Bell IIL Type of Permit: (Check only one box on line A. Complete Hue B if applicable) A. ❑ New System ❑ Replacement System O Treatment/Holding Replacement Tank p lacement Only I ® Other Modification to Existin System (explain) 4iWi GnI B ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Prevt Permit Number and Date Issued BeforeExpiration Plumber Owner a y IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non -Pressurized In -Ground O Pressurized In -Ground ❑ At -Grade ❑ Mound ≥ 24 in. of suitable soil O Mound <24 in. of suitable soil ® Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsaVfreatment Area Information: Design Flow (gpd) Design Soil Application I Dispersal Area Required (sf) I Dispersal Area Proposed (st) System Elevation 450 Rate(gpdsf) VI. Tank Info Capacity in Gallons Total Gallons (4of Units Manathctrer ,g e U 2 Fc—gs, 2,0004 New Tanks Eldsting Tasks U rn Yn i; t7 F. Septic or Holding Tank 2000 -C' Q90B 4 01 Wieser Concrete O ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb na MP/MFRS Number Business Phone Number Michael Wroblewski 1288503 (715)209-7521 Plumber's Address (Street, City, State, Zip Code) 1491 CountyHighway C, Washburn, W1 54891 VIII. County/Department Use Only Approved ❑ Disapproved 't Date lss Issuing Agent Signature l - i2-'2 77 Owner Given Reason for Denial _ )9 99 S ;v, !� r e7 a IX. Conditions of ApprovaL/Reasons for Disapproval RU (rtj 4n.ei kttt Lt waki ri6i- J13c1iw- t j put( k (o,4 -J v1e44'.. 4 ' ,. e' o -- alb st/c..t I tom/ t cW 1 roc. Attach to domplete plans for the system and subahit to the County only on paper not tea than 8 in x li inches in size 0 SBD-6398 (803/14) IIII IIIIIIIIIll IIIIII IIII IIIIIIIII ill II! III Iullll 2021R-592114 1.* Kracs�ot�a VJ06 ir' An�ocsoal 1\. /1W 5s3a Parcel identifier Number (PIN) Agreement Date -same as Notary Date) 1 S 3 We acknowledge that application Is being made for the installation 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 for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other Wm. of Adm. private onsite or e wastewater VesStattment system as permitted under Ch. SPS 383, JjL1/4 of iv uv 114 Section.a- Township d N. Range o6 W Town of mil_ Additional Legal Description: Gov't Lot — Lot_Blaclt__Subdivision t 1 CSMB Lot � CSM # 88 t Vol Page Li S CSM Doc# k «3c � 2021R-592114 DANIEL J. HEFFNER • BAYFIELD COUNTY, WI REGISTER OF DEEDS • 11/18/2021 09:58AM TF EXEMPT #: I ECEIVEDRECORDING FEE: 30.00 PAGES: 1 JAN 4 AVi Return To: Ed's /1ec\r\on�cs\ LI.-C— JuCJ\ c4 -y I�wy'- 1 eisL\C1 .oJ\ . U S e"C( t As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property, 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 fails to have the holding tank property serviced in response to orders issued by Bayfield County or the Department of Commerce to prevent or abate a human health hazard as described In s. 254.59, Scats., Bayfield County may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. Owner agrees to pay all charges and costs incurred by Bayfield County for Inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. 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 agrees that ail the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 3. The owner agrees to contract with a person who is licensed pursuant to 5281.17 (3) Wis. Scats., and chapter NR 114 Wis. Adm. 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 county within 30 days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed pursuant to s. 281.46 (3) Wis. Scats., and Ch. NR 114, WI's Adm. Code who shall submit to the county within 30 days a report detailing the servicing of the holding 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 the holding tank is not being properly maintained. 5. This agreement will remain in effect only until Bayfield County certifies that the property is served by either a municipal sewer or 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 recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 8. 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. Owner® Name(s) — Please Print Subscribed and sworn to before me on this date: BONNIE R. HOLLIND i c.- Q vin— - if/o v em b s dJd(A blic-Minnesot ed—Slgnsture(s) Notarized Notary Public — My Commission Expires Jan 31, My Commission Expires: f / /- 3I' 2425 ti ��Q'Ll � Drafted by: %� I T e � rJ � L Date: /1/3eJa I Personal inlarmeton you po1de may be used for eecmdery purposes lPMacy law. a 155 Qnkm)l idiom,amileryenelankaBroemeMdrteJuna 2018 HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(s) Name(s) KUcs�oc� L\/ \\A RECED JAN O u `G02?_ Bayfield Co. envy planting and Z�n.n9 H9 Pumper's Name (Print) Pumper's Signature Pumpers' Registration # VOu Ze\ame(' We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PRwECr LOCATION I Legal Destiotlen Tax Statement) Tax IDl{ ""'I 53 C1 1/4, Iv vv tiE114. I I. I 1/� (use Senlon __ ,Tovrnselp N, Range ✓ (� W ___ rownof: I Inge I Aopare fia✓tLot I I Iota a_188O1_s I GM VOL Pqe I GM DecA I Lot(s) No. I 510615)No. sebdbklon: 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; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; 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. Otxne�ejN s) (Print) Owner's Signature(s) Su %< p : G1k H0LLINDER I/vn•�`7, ` /��/� ! On .IP My COrrimission___�� l �V��1 n a-Ll�: �-l'+%i N'� ri xpires Jen 31, 2025 Notary Public Mycommissionexpireson: /- 3/- 2025 Revised: May 2016 (®May 2018) Drafted by Personal information you provide may be used for secondary purposes jPdvacy Law, s.15.04 (9(m)) Wisconsin Depar)ment of Co merge -r- - f :-- 3 QILAND SITE EVALUATION r Dlvielgn of Safety and Bullding{ '� r ?₹.a ,„ Page _ of Bureau of Integrated Services 9.•.�Y7�'.,.jn.QcCFL� with s. ILHR 83.09, Wig. Adm. Code Attadh complete site Ian on node 1I�rY{ In ,�. s5, size. Plan must County P P r Include, but not limited to: ved c61 anQ4or,gR rpflcepFM), direction and 6p(d Id percent slope, scale or dlmenslotn ,p�r i a ro , dJn atic sga, distance to nearest road. Parcel I.D, P9 �i �nlM lk U lPi� APPLICANT INFORMATION - Please print all Information. Reyja d Date you P YryP rP ( Y(1) If I--' - Personal Inronnetlon rovide ins be used for seconds u uses Pdvac Lew, s. 15.04 (m)). r . � I• - J ky1ci L:15 E std Govt. Lot ,g 1/4 &J1/4,S 2,2_.'Ty j ,N,FI (or) W Property Owner's Mailing Address U U Lo I Block# I Subd. Name or CSM# 7 'b 9' — ` City State Zip Code Phone Number ❑ City 0 village LWfown Nearest Road NU �: ( �( () ` (II! ) .3'%474 e t I ew Construction Use: l�Csidential I Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate _)(iP bed, gpdg? —/ P trench, gpd/fl2 Absorption area required — bed, ft2 ' trench, ft2 Maximum design loading rate lip bed, gpd/f12j✓ P trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material % / Z — Flood plain elevation, If applicable Lft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ s a'U ❑ s L+J1 U ❑ s ®'ll ❑ s J ❑ s 1 I7≥( ❑ U SOIL DESCRIPTION REPORT Boring # rT Ground 4r Off. Depth to limiting factor 0 in. Boring # Ground elev. t},24ft. Horizon Depth In. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed , Trench 0-5 5'H(3 -- 2_ 5 -lo ;' 5/z 52 fi tA sc P' N 11r17 -1 �,,y Frf; `jr" - ..I_IV_.a JNU4'LUL saya,1d On, , Depth to limiting factor £ in. Remarks: CST Name (Please Print) Remarks: VIov'9 ??on% 7-S r.+((. ?<' — -- _ — 3 s I% /N fI-f 7 5YR S/s sc —... _ ;NP + z 7H-1fb c2J 7,5 Sa c hi /2-t AAt,ii,<i Signature �� Telephone No. 7 373 5 Date bs (2 c/f-Mm/ 1 IJl- yllvv i ((7/Th/CST Numw //,/ LADE LITTLE SZSK�IT t��ti:.Eivi=r� JAN 04 2022 CO. planaP) act L.S9 Mond ❑#6 - 97.26' u#4-97.2/ / -97.65'// ° #2 - 98.26' 2-3% LOPE ° #3 - 99.66' N z= BM-H&VRP-ELEV.=100' GROUND LEVEL AT RED STAKE SCALE: 1"=r80' SISKWIT LAKE ROAD RECEIVED JAN 0 4 2022 Bayfield Co. Planting and Zoning Agenq CONCRETE HOLDING TANK DESIGN Single Tank Option INDEX AND TITLE SHEET Project Karston & Cynthia Anderson - Holding Tank Owner Karston & Cynthia Anderson Address 22285 Siskiwit Lake Road Cornucopia, WI 54827 (612) 423-3888 Legal Description Lott, CSM#880, Vo16, P45, CSM doc#419370, NE1/4 NW 1/4 522 TSON R06W Township Bell County Bayfield Subdivision Name Parcel ID Number 7539 Plan Transaction ID Number P.O.W.T.S Conditionally APPROVED BAYFIELD COUNTY See Comments Designer Michael Wilewski Lot No. 2 Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Soil test Page 5 Soil test plot plan Page 6 Holding tank agreement Page 7 holding serviicing contract Page 8 Holding tank specifications Page 9 Signature - -' J / ,( A - - - Phone No. 715-373-0566 License Number 1288503 Date 12/09/21 Designed pursuant to: Holding Tank Component Manual For POWTS (Version 2.0) SBD-10855-P (N. 03/07, R. 01/12) HOLDING TANK SPECIFICATIONS �Non-rerd bedrooms Non-residential estimated flow (gpd) 2000.0 Minimum holding tank volume required (gal) 2000.0 I Proposed holding tank capacity (gal) Wieser concrete Tank Manufacturer W2000MR Tank model number SJ Electro systems Alarm manufacturer WH101 lAlarn, model number junction box. n/ blind tsue' outlet isions and Data X for round tank Liquid depth below inlet invert (in) Maximum de th of soil cover (ft) Height (in) Outside Length (in) Dimensions Width (in) Only RECEIVED JAN 042022 eayfieid Co. Planning and Zoning Agency Tank Anchor Calculations 13540 lbs Weight of tank and cover 1.10 Safety factor 20505 Ibs Weight of anchor required 27.3 in Soil cover req. for anchor or 5.1 yd3 Concrete counterweight HOLDING TANK CROSS SECTION manhole coves with locking device and finished warning label grade 14" min. J. in. ������SSSSSS Manhole and vent locations may be reversed. tether weight service alarm on Electrical as per NEC 300 and SPS 316 3 in. bedding under tank. war 41.0 in Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SPS 384. Tank is anctored as necessary to negate buoyancy. Project: Karston & Cynthia Anderson - Holding Tank Transaction Number. vent cap 17 min. vat pipe 18° min. building sewer inlet Page 2 of 9 HOLDING TANK PLOT PLAN KARSTON & CYNTHIA ANDERSON 22285 SISKIWIT LAKE RD LOT 2 OF CSM #880 IN V.6 P.45 (LOCATED IN NE NW) IN DOC 2019R-570718 S22 T50N R06W TOWN OF BELL, WI SCALE 1'=40' SISKIWIT LAKE ROAD RECEIVED JAN 042022 Sayfield Co. Planning and 'Lening Agency was >100' TO LOT LINE 2 3 6 47 N T SHEET 3 of g RkCEIVED JAN 042022 HOLDING TANK MANAGEMENT PLAN eandeld Co. Planning and Zoning Agency This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P N. 03/07, R. 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 inlet (at which time the alarm will activate), the pumper listed in the current Service Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a falling 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 ......................... Ed^s Mechanical LLC Phone: 715-373-0566 b. Service Provider ...............Birch Birch Street Seplic Service Phone: 715-373-5683 c. Co. Zoning or Health Dept. Bayfield County Planning & Zoning Phone: 715-373-6138 11 Project: Karston & Cynthia Anderson - Holding Tank Transaction Number. Page 4 of 9 W2000 -MR TANK SPECIFICATIONS fr 4" CAST -A -SEAL 4" CAST -A -SEAL .) i I I e2 4 , R FILTER OR BAFFLE TOP MEW INLET • - -------1------ I � I � V � d• I � - I � I d 2 4 j. TO MEET OR REQUIREMENTS DIMENSIONS: WALL• 2 1/2" BOTTOM: 4' COVER: 6" MANHOLE 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" LENGTH: 12'-7• WIDTH: 7'-2" BELOW INLET: 53" LIQUID LEVEL • 46" WEIGHT: 15,370 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 42.92 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8'-O" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN #6 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE 0 ri ❑ REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: 0 J O 3 N F ECEIVED BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS JAN 0 4 2022 Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) P� ea, d Co. Check List nn ng aM c0Nog Agency 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) VJ Cross Section, Over -Head Profile of the System dndi Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) ❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) \i Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) jS Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) 0 ATU Servicing Agreement (Recorded at Reg. of Deeds) }Y� Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) tj2 Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) State Plan Review (when applicable) 0 Copy of Warranty/Quit Claim Deed (Optional) Sanitary ADDlication: (Include the following Information) A I Application Information must include: 1 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) Project Address or Road Name where driveway is/will come off of) K II Type of Building III Type of Permit IV Type of POWTS System 0 V Dispersal / Treatment Area Information V VI Tank Information )Q 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 0 Tank and Filter Information and Location ❑ Wetlands / Navigable Bodies of Water 0 Absorption Area (Proposed and Existing) Bench Mark (Location, Elevation and Description) Component Manual Version Piping Material Inicrmation (conveyance line, building sewer line, ,tJ (Owners Phone Number) Address Number and Road North Arrow Contour Lines Structures and Driveways Boring Locations \Q7 Property Lines Well Locations 4egal Descriptions material type and lameter) Turn Over ► Cross -Section and Over -Head Profile of the System: O Surface and System Elevation ❑ Position of Observation and Vent Pipes ❑ Dimensions and Depths ❑ Make, Model & Number of Chamber Units in each Cell t- !: 1� RECEIVED JAN 04202? Bayteld Co. Planning and Zoning Agency X How many systems will there be eelll on __ this parcel of land? . \ • 5 gHas this property been split? Iv L (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) u/forms/checklists/checklisforsanbryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: •/��,% BAYFIELD COUNTY SANITARY PERMIT (#04)-22-03S STATE SANITARY PERMIT OWNER: KARSTON LAMONT & CYNTHIA ANDERSON GOVT LOT: LOT: 2 BLK: K: CSM: 880 SUBDIVISION: Csm #880 NE 114 NW 1/4 SEC: 22, T 50 N, R 6 W TOWNSHIP: Bell SOIL TEST: 4573 OTHER MODIFICATION SYSTEM TYPE: Holding Tank PLUMBER: Eds Mechanical TODD NORWOOD DATE: 1/14/2022 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. a 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 #: 404253 LICENSE: # MP 1288503 Condition: Condition: All black and gray water must discharge to holding tank. Tank must be located within 25' of an all weather access road. Maintain tank per recorded agreement. THIS PERMIT EXPIRES 1/14/2024 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION County Industry Services Division Bayfield p \ S P O R I 1400E Washington Ave P.O. Box 7162 Sanitary Permit Number (to be filled in by C S G I N A Madison, WI 53707-7162 a7y�a3s 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 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 22285 Siskiwit Lake Road purposes in accordance with the Privacy Law, s. 15.04 I m Slots. Cornucopia, WI 54827 E IV I. Application lufonnation — Please Print All Information Property Owner's Name Karston & Cynthia Anderson JAN 0 4 2022 Parcel # 7539 Property Owner's Mailing Address Bayfield Co. Zoning Agency Property Location 846 Westwood Circle planning and Govt Lot NE Y., NW V.., Section 22 City, State I Zip Code Phone Number Delano, MN 55328 ((612) 423-3888 ,(Circle one) T50N R06Eo II. Type of Building (check all that apply) Lot # Subdivision Name ® I or 2 Family Dwelling — Number of Bedrooms 2 ❑ Public/Commercial — Describe Use Block # [1 City of ❑ State Owned — Describe Use ❑ Village of CSM 880 Number 0 Town of Bell III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ❑ Replacement System ❑ TreatmenNHolding Tank Replacement Only I ® Other Modification to Existing System (explain) 1 B ❑ Permit Renewal ❑ Permit Revision O Change of I ❑ Permit Transfer to New List Previou Permit Number and Date Issued BeforeExpiration Plumber Owner IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil O Mound < 24 in. of suitable soil ® Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application I Dispersal Area Required (sf) I Dispersal Area Proposed (sf) I System Elevation 450 Rate(gpdst) VI. Tank Info Capacity in Gallons Total Gallons #f Units Manufacturer .o2 U New Tanks Existing Tanks a 000 Septic or Holding Tank 2000 aOOO 4HB@ '- ). Wieser Concrete ® ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) I MP/MPRS Number I Business Phone Number Michael Wroblewski 1288503 (715)209-7521 Plumber's Address (Street, City, State, Zip Code) 1491 County Highway C, Washburn, WI 54891 VQI. County/Department Use Only Approved ❑ Disapproved Pe 't I Date lss d't '7l Issuing Agent Signature I❑ Owner Given Reason for Denial $ q0— �� t 7 9 IX. Conditions of Approval/Reasons for Disapproval Ph t tj 4AJ UtCj OJA f✓kl- drag- )b Lid -n -ts. jV -t yu4 lx. (ecn4c--) vl . rlLr ti e- ' o a.a at tl- tn/c.r / cart Boa J Jts / .e e- W#*T Attach to &mplete plans for the system and sulAit to the County only on paper not less than 8 1/2 x II inches in size SBD-6398 (803/14) IIIllI IIIII II ill I I IIIIIIII II Ill II II% I 2021R 592114 1.* Document Number/Plan I.D. No. HOLDING TANK 2021R -592114 AGREEMENT DANIEL J. HEFFNER Dwner Name (s) Owners) Mating Address Kacs�of� d- CY'^�Y"� o• $ y V.1 es*w0o� �' BAYFIELD COUNTY, WI A o so1� S'S REGISTER OF DEEDS a.n x«ement Date same ea Notary Date) 11/18/2021 09 : 5BAM -153 Vwe au&iuwwuuv am, err•• ---••.___._o on the following property or that continued use of the existing premises requires that a holding tank be Installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code ,00^rrr ,Ch. 145, Wis Stats. NE1/4 of NI W 1/4 Section 2 Townshlp.5_N. Range o6 W. Town of Fa \\ Additional Legal Description: Gov't Lot _ Lot_ Block_Subdivis on CSM# Lot,2,.CSM # St3D Vol ,Page,-CSM Doc# "f a3c TF EXEMPT #: RECElAbRECORDING FEE: 30.00 PAGES: 1 ,rAA a 4 :('nn Return To: Ed's t'1ec\r'an�ca\ j..c — Iucj1 Ley NWyH As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property, 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 fails to have the holding tank properly serviced in response to orders issued by Bayfield County or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats., Bayield County may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. Owner agrees to pay all charges and costs incurred by Bayfield County for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. 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 agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 3. The owner agrees to contract with a person who is licensed pursuant to s.281.17 (3) Wis. State., and chapter NR 114 Wis. Adm. 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 county within 30 days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed pursuant to s. 281.48 (3) Wis. State., and Ch. NR 114, WI's Adm. Code who shall submit to the county within 30 days a report detailing the servicing of the holding 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 the holding tank is not being properly maintained. 5. This agreement will remain in effect only until Bayfield County certifies that the property is served by either a municipal sewer or 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 recording said certification with reference to this agreement in such manner which will permit the existence 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 recordedby the the holding of ieei deeds in manner which will permit the existence of the agreement to be determined by reference to the property 9 Owner) Name(s) — Please Print Subscribed and swum to before me on this date: a rAl/l-c'r`~ ft-z 4. Q-uir-- I\BNIEA.HOLLINoE c - No' a "b e cfletary PubliMinnesati Notarized Owns ( —Signature(e) Notary Public ;-,i • My Commission Expres Jan 31, My Commission Pxpkea: 1-3/' 2d25 .11 Drafted by't: JI' `� \ n1 S�y7 e i l Date: / 1 WdnWenItWy&ddlMtna0NaomeMd0 QJunex018 Parenel41fem1atlon youproNtle may be used ter secondary purposes tP1IV0oY Law, x,16.04 iI(m)1 R s hEDEIVED HOLDING TANK SERVICING CONTRACT JAN 04 `L022 eayfieldC°. I Contract Date planning acid Z°nin9 Agency L. , \\\o\'-\ This contract is made between the IHolding Tank Owner(s) Name(s) \ n Pumper's Name (Print) Pumper's Signature Pumpers' Registration # iJou e\omec 1x03 We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT I Legal Dews m _I v i1J<• 1Y'iU va LOCATION (usTaxStatemard Lb N. Range W Townn�o', IMStra AoragR Secdon _ _ ,Township GoVt I 3M4 Vol. Page (5M Dots lM(s)No. ebd(s)No. Subdivision: a gso 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; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; 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 Owner(s) Names) (Print) Owner's Signature(s) Sub4'4 $ J1Q}IfTff HOLLINDER S i/K 1 ,2¢Qe ✓Svv� on 3' a✓ a�GBub& ,eS J ER My Commission Expire, Jan 31, 2025 1 - by. Notary Public My commission expires on: /-3/-2025 Revised: May 2018 (®May 2018) Drafted by Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (i)(m)) BAYFIELD COUNTY SANITARY PERMIT (#04)-22-03S STATE SANITARY PERMIT OWNER: KARSTON LAMONT & CYNTHIA ANDERSON GOVT LOT: LOT: 2 BLK: CSM: 880 SUBDIVISION: Csm #880 NE 114 NW 114 SEC:22,T50 N, R6W TOWNSHIP: Bell SOIL TEST: 4573 OTHER MODIFICATION SYSTEM TYPE: Holding Tank PLUMBER: Eds Mechanical TODD NORWOOD Authorized Issuing Officer DATE: 1/14/2022 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 #: 404253 LICENSE: # MP 1288503 Condition: Condition: All black and gray water must discharge to holding tank. Tank must be located within 25' of an all weather access road. Maintain tank per recorded agreement. THIS PERMIT EXPIRES 1/14/2024 POST IN PLAIN VIEW ` \lx R,l;rti County Industry Services Division Bayfield DS 1I 1400 E Washington Ave l P$ P.O. Box 7162 Sanitary Permit Number (to be filled a by Co.) �n Madison, WI 53707-7162 F(i.Hl\Hl 7 Sanitary Permit Application State Transaction Number In accordance with SPS 38321(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 1'm.Kct Address (if different than nailing address) the Department of Safety and Professional Services. Personal information you provide any be used for secondary purposesin accordance with the Privacy Law s. l5. I m Sas. 22285 Siskiwit Lake Road Cornucopia, WI54827 I. Application Information — Please Print All Information (kECEIVED Property Owner's Name Parcel # Karsten & Cynthia Anderson JAN 042022 7539 Property Owner's Mailing Address 846 Bayfield Westwood Circle Planning and Zoning Agency Property Location Govt Lot NE %., NW %., Section 22 City, State Delano, MN Zip Code 55328 Phone Number 423-3888 ((612) acle one) T SON R06Eor� II. Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling —Number of Bedrooms 2 Subdivision Name ❑ Public/Commercial— Describe Use Block # ❑ Sate Owned — Describe Use ❑ City of ❑ Village of CSM Number 880 ® Town of Bell Ill. Type of Permit: (Check only one box on tine A. Complete line B if applicable) A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only I ® Other Modification tog�;;isMg System (explain) 14ad( don Bolan 'conk B, O Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Lis[ Previous PermitNumber and Date Issued BeforeExpiration Plumber Owner 4 x 5 3 3I z. 1 o3") IV. Type of POWTS System/Component/Device; Check all that apply) ❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade O Mound? 24 in. of suitable soil ® ❑ Mound <24 in. of suitable sot Holding Tank O Other Dispersal Component (explain) O Pretreatment Device (explain) V. DIs rsal/rreatment Area Information: Design Flow (gpd) 450 Design Sol Application Dispersal Area Required (st) Dispersal Area Proposed (sf) J System Elevation Rate(gpdsf) VI. Tank Info Capacity in Gallons Total Gallons # of Units Manufacturer .02 ,9 c o y $ v New Tanks Existm Tanks a M Septic or Holding Tank 2000 x.00O a, Wieser Concrete ❑ ❑ Dosing Chamber ❑ O CL ❑ VII. Responsibility ity Statement- 1, the undersigned, assn risibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plain / MP(MPRS Number I Business Phone Number Michael Wroblewski 1288503 I (715)209-7521 Plumber's Address (Street, City, State, Zip Code) 1491 Comity Highway C, Washburn, WI 54891 VIII, County/Department Use Only ®'Approved ❑ Disapproved Perroil Fee Date Issu I Issuing Agent Si - Z ❑ Owner Given Reason for Denial is l� IX. Conditions of Approval/Reasons for Disapproval ( f r 4(1 i(i�� b(a�k lc/ dcsclLLAc it �Ja rvl�sI- /J wt+st (oCAki W't-L- r tc' 0P u.A 4.(1-(,VJaa 1 i e.ttei" rca of Metat 4-y.a4 Aix jot ArraeF M mnlab n6n� f . rh...R,.... -.. ...w...._ . ...r -yv v —nisi -,-v,1 �---H1/t I i1 Wcam111 size SBD-6398 (R03/14) Wisconsin Department of Con Division of Safety and Bulldln4 Bureau of Integrated Services plan ih i9 t � County Aftauh complete site on p� noa rrr)(iinp`� sn 1 3 { In Coun 1 size. Plan must Include, but not limited to: ve ,gnr�_ ty _ M), direction and 'FI ( d percent slope, scale or dimenslrr,A r a rn, in4i&c4lon ana distance to nearest road. Parcel I.D t APPLICANT INFORMATION'- Please print all information. Re(y b�yj/ Date fL Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). b 2 r / e �'_/"' /t� (/ Property Owner Property Location J o lityl d L;15 lGovt. Lot 4 1/4 (,J1/4,S A7—ffSd ,N,R Q (or) W Property Owner's Mailing Lo Block# Subd. Name or CSM# '72 ,'A q tb "l.A /j /i s / I Cl - < 1 { { State Zip Code Phone Number ❑ City ❑ Village iliQ�Town Nearest t'Road L _ // //7 t/j/"L i ru (1 2La61(g/f )1731479 .Sett JI. C. Lt.i: Lo.U' Ed ,ND SITE EVALUATION with s. ILHR 83.09, Wis. Adm. Code Page ` of ew Construction Use; IY) Resldentlal / Number of bedrooms Replacement ❑ Public or commercial- Describe: Addition to existing building Code derived daily flow gpd Recommended design loading rate jiP bed, gpd/1t2'i' trench, gpd/ft2 Absorption area required r bed, ft2 trench, ft2 Maximum design loading rate gybed, gpd/ftjt/P trench, gpd/It2 Recommended Infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material % / Flood plain elevation, it applicable L4- ft S = Suitable for system — / U = Unsuitable for system ❑ S LQ'U ❑ S U ❑ S ❑ S (j'ii I S Q'( ❑ U :. . Ground 4b0ft. Depth to limiting factor _0 in. Boring # 123 Ground Y8.Z SO1L REPORT Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed , Trench 2s 5l3 ;ry z S-rp 51Y- S /2 d J 'tri SG P, .N lo.r Y? s/# .s r a J4No4zu;z Bayfieid Co. Depth to limiting factor ..Ljn. Remarks: Remarks: F1oY'A gong. ) 0-z 7. a `( . ?/z $ I ---- --- .--- z 5(O L4(3 c2d 'Y(7 r/0 s _____ .-. 3 __ c st ---.. X-14 zsf!e yl cz ?.s'i Sa c. . ......-.-.. A CST Name (Please Print, No. CST ddress • ar / 2 7L,i Li a4 /.l /-c< % !:l f Sfi�/8/J/i't/ r w%1 P/qv re l0 / /7/'m" um y // O• I TLESISK vL LET 5-9765'/ A ❑ #6 - 97.26' 0#4-97 °#1-98.16' °#2-98.26' ° #3 - 99.66' 2-3% LOPE Ed.CEIVED JAN 04 2022 p{snnur3 3-s 9oncy ®= BM-H&VRP-ELEV.=100' GROUND LEVEL AT RED STAKE SCALE: 1"80' SISKWIT LAKE ROAD RECEIVED JAN 0 4 2022 Bayfieid Co. Planning and Zoning Agency CONCRETE HOLDING TANK DESIGN Single Tank Option INDEX AND TITLE SHEET Project Karston & Cynthia Anderson - Holding Tank Owner Karston & Cynthia Anderson Address 22285 Siskiwit Lake Road Cornucopia, WI 54827 (612) 423-3888 Legal Description Lot 2, CSM#880, Vd6, P45, CSM doc #419370. NE1/4, NW1/4, S22, T50N, RO6W Township Bell County Bayfield Subdivision Name Parcel ID Number 7539 Plan Transaction ID Number P.O.W.T.S Conditionally APPROVED BAYFIELD COUNTY See Comments Designer Michael Wjlewski Lot No. 2 Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Soil test Page 5 Soil test plot plan Page 6 Holding tank agreement Page 7 holding serviicing contract Page 8 Holding tank specifications Page 9 Signature _-" ) ( ,( k t ' Phone No. 715-373-0566 License Number 1288503 Date 12/09/21 Designed pursuant to: Holding Tank Component Manual For POWTS (Version 2.0) SBD-10855-P (N. 03/07, R. 01/12) HOLDING TANK SPECIFICATIONS Number of bedrooms Non-residential estimated flow (gpd) 2000.0 Minimum holding tank volume required (gal) 2000.0 IPmDosed holding tank capacity (gal) Wieser concrete Tank Manufacturer W2000MR Tank model number SJ Electro systems Alarm manufacturer WH101 lAlarm model number junction box . lW..Y.TD of /W blind is outlet sions and Data X for round tank Liquid depth below inlet invert (in) Maximum de th of soil cover (ft) Height (in) Outside Length (in) Dimensions Width (in) Only RECEIVED JAN 042022 Bayfield Co. Planning and Zoning Agency r Calculations lbs Weight of tank and cover Safety factor lbs Weight of anchor required in Soil cover req. for anchor or yd3 Concrete counter weight HOLDING TANK CROSS SECTION mach le cover with locking device and finished vent cap warning label grade 4" min. 12" min. 23 in. Manhole and vent locations may be reversed. VQf1t ppe 1a" min. tether weight service 1 12.0 in. alarm on Electrical as per NEC 300 and SPS 316 3 in. bedding under tank. 41.0 in Note: All tankjoints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SPS 384. Tardc is anchored as necessary to negate buoyancy. building sewer inlet Project: Karston & Cynthia Anderson - Holding Tank Transaction Number. Page 2 of 9 HOLDING TANK PLOT PLAN KARSTON & CYNTHIAANDERSON 22285 SISKIWIT LAKE RD LOT 2 OF CSM #880 IN V.6 P.45 (LOCATED IN NE NW) IN DOC 2019R-570718 S22T50N R06W TOWN OF BELL, WI SCALE 1'=40' SISKIWIT LAKE ROAD RECEIVED JAN 042022 Bayfield Co. Planning and Zoning Agency N T 2 3 wsi >100'TO LOT LINE SHEET 3 019 RECEIVED JAN 0 4 2022 HOLDING TANK MANAGEMENT PLAN Bayfield Co. Planning and Zoning Agency This Private Onsite Wastewater Treatment System (POWYS) has been designed, and is to be installed and maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-1 0855-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 inlet (at which time the alarm will activate), the pumper listed in the current Service Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being In full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons may be contacted: a. Installer ......................... Ed As Mechanical LLC Phone: 715-373-0566 _ 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 11 Project: Karston & Cynthia Anderson - Holding Tank Transaction Number. Page 4 of 9 W2000 -MR TANK SPECIFICATIONS 12'-7" CAST -A -SEAL 4" CAST -A -SEAL I \� '� TAR• `� '� // \����A FILTER OR BAFFLE i TOP VIEW O w <8 w INLET - fL --- OUTLET I Wa 2r1b-----t--- 1 1 (TANKS ARE MANUFACTURED TO MEET OR DIMENSIONS: WAIL 2 1/2" BOTTOM: 4" COVER: 6" MANHOLE 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" LENGTH: 12'-7" WIDTH: 7-2" BELOW INLET: 53" LIQUID LEVEL 46" WEIGHT: 15,370 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 42.92 CAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE REVIEWED BY REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: fl r � m W W °' C U LD Lo pz000 w o � a N �1h yxox o W_ N Co N w oM 3 0 N V OF 1 BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS JAN 04 Z02Z Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Bayfield Co. and Check List Plannin Z g oning Agency Original Sanitary Application (Submitted in Deed Holders Name — rnot prospective buyers) (383.21(1)1.) Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) Original Plot Plan (383.22(2)2. 3. & 4.a) Cross Section, Over -Head Profile of the System dpi Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) X Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) ❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) }Y� Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) 1�7\2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) A I Application Information must include: F 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) Project Address or Road Name where driveway is/will come off of) K 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) el *Date Stamp* Plot Plan: (To Scale or To Dimension) Signature and Plumber Information El 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 (Owners Phone Number) Address Number and Road ] North Arrow Contour Lines Structures and Driveways Boring Locations Property Lines K Well Locations Legal Descriptions Piping Material Information (conveyance line, building sewer line, material type and diameter) Turn Over ► l- .2Ct.1ti1t,L.niaLL!.i2flilt1ilt.tWn RECEIVED O Surface and System Elevation ❑ Position of Observation and Vent Pipes ❑ Dimensions and Depths ❑ Make, Model & Number of Chamber Units in each Cell !i'llflffltliilM W1 JAN 042022 Baylield Co. Planning and Zoning Agency .� 11 I X How many systems will there be on this parcel of land? \ •\ s gHas this ro p party been split? fl (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) u/forms/checklists/checMislforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: 61�r