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HomeMy WebLinkAbout23-60SRequest for Sanitary Inspection (Fax this form to Zoning Dept when you want an inspection — 373-0114) Note: ❑ Time Change ❑ Discrepancy Other From Zoning Dept Superior Plumbing and Mech. Inc Phone Number Ed Redinger 715-292-6670 Plumber: Fax Number NA Sam Olby Home Owner: 23-60S Sanitary Permit #: Plumber's Choice Zoning Dept No inspection during these times 6/28/2023 Date: 9:30 am —12:30 pm Tues. (Tracy) OK 9:30 am —12:30 pm Thurs. (Tracy) Time: Plumber's Choice 2:30 Zoning Dept Immediate Phone Number so Zoning OK Dept can call you right back (if needed) Township: Kelly Address # & 58720 Roy Anderson Rd Road Name: Mason, WI or Directions To Site: Comments: Septic tank and drainfield installation Reminder: You must confirm any change(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 verify any change(s) by fax or no inspection will be scheduled ** u/forms/sanitary/req uestfori ns pecti on Zoning Dept (©4/12/04) ® June 2018 rljttf eIaafl6Vi - R IUVetigation a(&VITi . VAan,y4r I �A Y'I � 1)'"�i Industry Services Division General Information Persnnal inf aN•..,.•�••�—-'_ ---- SAMUEL A & CHERYL K OLBY 58720 ROY ANDERSON RD MASON WI 54856 - Taiik information Private Onsite Wastewater Treatment Systems ( POWTS) Inspection Report (Attach to Permit) [Privacy raw, s. 15.04 (1 m) City fl Village fl Town of: setback to: COU 3J4QJ Sanitary Permit No: State Plan Transaction ID#: Parcel Tax No: TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road Septic N/A Dosing N/A Aeration N/A Holding Pump I 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 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 / Manifold Distribution Pipe Infiltrative Surface Final Grade X Pressure Systems Only Header/ Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length Dia Length _ Dia Spac Spacing ❑ Yes ❑ No soil cover Depth Over Depth Over Depth of Seeded I Sodded Mulched Cell Center Cell Ed es Topsoil 0 Yes 0 No ❑ Yes ❑ No COMMEN.T:: (l ude I{ii�ssc thsicies, persons present, etc.) ��auf fl cl h. ,N lea°"1"���d✓ Plan revision qadditional O Yes 0 No __ Use other side for additional information. ___ tYA3r Date CRnfs71n (P mnn POWTS Inspector's Signature License Number BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT t-`` _ Telephone: (715) 373-6138 Bayfield County Courthouse Fax: (715) 373-0114 Post Office Box 58 _ e-mail: zoning(a-bayfieldcountv.wi.gov 117 East Fifth Street Web Site: www.bayfieldcounty.wi.gov/147 Washburn, WI 54891 Property Owner SAMUEL A & CHERYL K OLBY Information 58720 ROY ANDERSON RD MASON WI 54856 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: C. Tank was crushed / removed and pipes disconnected by: on at AM/PM 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: U/tormslsanitarypropertyowner-input April2019 .�""""—r Is Industry Services Divjs(tU `'. i `! ir-1A 4822 Madison Yards Way )County Bayfield l Sanitary Permit Number (to be in by Co. $ = `1: >/ Madison, WI 53705 rfilled P.O. Box 7302 JUN 1 3 202 Madison, WI 53707 eavfiel.f i),� Sanitary Permit Application Pnh' ._ BsteTansaction Numbcr 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 Sam e purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. L Application Information — Please Print All Information Property Owner's Name Parcel ft Samuel & Cheryl Olby 21606 Property Owner's Mailing Address Property Location 58720 Roy Anderson Rd. Govt Lot City, State Zip Code Phone Number Mason, WI 54856 715-765-4576 NW %.SW Section 34 T46 N R 5 E or W IL Type. of Building (check all that apply) Lot ft Fl or 2 Family Dwelling — Number ofBedrooms 3 Subdivision Name �ublie/Commercial — Describe Use Block k City of State Owned — Describe Use JVillage of CSM Number ❑✓Town of Kelly IIL Type of POWTS Permit (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete tine C' a licable. A. �lew System --..,� 11l--IIypeeplacement System LS Other Modification to Existing System(explain) ❑Additional Pretreatment Unit (explain) B. Holding Tank In -Ground L f`t-Grade E] ❑ Mound Individual Site Design flother Type (explain) (conventional) C. []Renewal Before ❑Revision]Change of Plumber ❑Transfer to New Owner .,ist Previous Permit Number and Date Issued Expiration IV. Dispersslfrreahnent Area and Tank Information: Design Flo d) 450 Design S 1 Application Rate(gpd/st) �% Dispersal Area Required (si) Dispersal Area Pro (st) System Elevation,,,_.... -' .4 1125'-"___1158 '-' 95-95.6' Capacity in Total ft of Manufacturer Tank Information Gallons Gallons Units y S ° ' o New Tanks Existing Tanks ' c 4CJ rn — i2 w[7 d Septic or Holding Tank X 1000 1 Wieser Concrete 121J Dosing Chamber [J fl V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Edward B. Redinger L.Jgs�L.tj 221939 715-292-6670 Plumber's Address (Street, City, State, Zip Code) 1015 11th Ave. E. Ashland, WI 54806 VL County/Department Use Only App O Disapproved Permit Fee $trW Date Issued Issuin A Signatu Owner Given Reason for Denial onditions of proval/Reasons for sapproval Disapproval y(`Q oW o f a)w SySa�n bQ L%SOO to as 3$3. Attach to complete plans for the system and submit to the County only on paper not leas than 85/2 x l l inches in size SBD-6398 (R. 02/22) JUN 13 2023 1 Wisconsin Department of Safety and Professional Services Page of '!' o "\ Division of Industry Services Pannr Bane, y Pg SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, Bayfield but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 21606 Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). 'fl'1S I b •d�a Property Owner Property Location El Samuel & Cheryl Olby Govt. Lot NW '/ SW Y. s 34 T 46 N R 5 E (or) W Property Owner's Mailing Address Site Address or CSM and Lot #: 58720 Roy Anderson Rd. same City State Zip Code Phone Number ❑ City ❑ Village 0 Town Nearest Road Mason WI 54856 765-4576 Kelly Roy Anderson New Construction Use: Q Residential/ Numberof bedrooms3 Code derived designflow rate450 GPD Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft. Parent material Outwash General comments and recommendations: Conventional System 12-18" below grade 95.6'/ lowest 91.9' 1 Boring # ❑Boring 95.3 84 88.3 MPit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Sail Annilcation Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 0-12 5yr 4/2 - sl 2mabk dl gw 3f .6 1.0 2 12-48 5yr 5/3 - sl 1 fabk ml gw 3f .4 .7 3 48-84 5yr 7/2 - S Osg ml - - .7 106 v • 2 Boring # ❑Boring 966 8689.5 ©Pit Ground surface elev. ft. Depth to limiting factor in. / eiev. ft. Soil Aoolicatlon Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 0-8 5yr 5/3 - sl 2mabk dl gw 3co .6 1.0 2 8-40 5yr 5/6 - sl 1 fabk mvfi gw 2m .4 .7 3 40-60 5yr 5/3 - Is Om ml gw - .4 .6 4 60-86 5yr 6/2 - s Osg ml - - .7 1.6 CST Name (Please Print) Si na ure CST Number Edward B. Redinger V 221939 Address I Date Evaluation Conducted Telephone Number 1015 11th Ave. E. Ashland, WI 54806 6/8/23 I715-292-70 * Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 5150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L SBD-8330 (R04/21) ❑ Boring Boring # 0 Pit Page 2 of 3 78 88.9 Ground surface elev. LLL. ft. Depth to limiting factor in./elev. ft. I Sall Annlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 0-10 5yr 6/3 sl 2mabk dl gw 3f .6 .7 2 10-24 5yr 4/4 - sl 1 fabk dl gw 2f .4 1.0 3 24-60 5yr 5/3 - sl 1 fpl mvfi cw - .4 .6 4 60-78 5yr 7/2 - s 0sg ml - - .7 1.6 �1g ____ ___ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Annlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Annlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 5 220 mg1L and TSS > 30 5150 mg/L * Effluent #2= BOO, s 30 mg/L and TSS 5 30 mg/L SUPERIOR PLUMBING MECHANICAL (715) 278.3456 CST# 221939 Scale: 1" = 40' PIN; 21606 40 Acres NW SW 534 T46N R5W Town of Kelly Bayfield Co. F-Jlk,I L e• Se'JM S/"r te Customer Name: Samuel & Cheryl Olby 4 Adress: 58720 Roy Anderson Rd I� Mason, WI 54854 SITE: Same Phone #: 715-765-4576 Email: Sf.e? Irc-c1..e≤ Mue.d-4 Sysfo I t/tv, 9≤ 9/"9' Eu "1/ 2oiccJn.,� ✓ �5.3' 4-� PAGE 1 OF 4 In -Ground Gravity Plan Index & Cover Sheet JUN •J LJ'a Component Manual Design References: In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersal Area Cross -Section & Plan View Pg 4 of 4 Management Plan Attachments: Enclose POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Replacement System 3 bed home Owner Name(s): Samuel & Cheryl Olby Owner Address: 58720 Roy Anderson Rd. Mason, WI Phone: 715 -765 -4576 Zip: 54856 Project Address: same Govt. Lot: NW H1/4 of SW 01/4, Section34 T46 N -R5 E ❑ or W ✓❑ Township: Project Parcel ID #: 21606 County: Bayfield Designer Information Designer Name: Edward B. Redinger Phone: 715 -292 -6670 Designer Address: 1015 11th Ave. E. Ashland, WI Zip: 54806 E-mail: ed@superiorpmw.eom This space reserved for approval stamp. License Number: 221939 Remarks: Signature: fQ_ Date: 6/8/23 Original signature required on each ubmitted copy. RECEIVED JUN 13 2023 i SUPERIOR PLUMBING MECHANICAL (715) 278.3456 CST# 221939 Scale: 1" = 40' PIN: 21606 40 Acres NW SW 534 T46N R5W Town of Kelly Bayfield Co. L. rr t%FF': rP / GP.. $F.c 1% s/ePEJ, --k Customer Name: Samuel & Cheryl Olby Adress: 58720 Roy Anderson Rd Mason, WI 54854 SITE: Same Phone#: 715-765-4576 Email: Planning a..d Zo.iing AOfCY B.M• = 166' 1oP aC y��c ocI4LJ -4�GJr 99.7' Sys ne'. 96.C-9/9' $ p.ts 111 c ,'Jc '/ car 52 CI.w Lccs /Od I. /%5//fie .A N S C 3 95;-y IN -GROUND GRAVITY DISPERSAL AREA Stepped Elevation Trenches with Quick4 Standard -W Chambers 3 -ft Trench (down -sizing credit) IIf SOIL COVER min. 12" (typical) 12" TYPICAL TRENCH mid enc CROSS SECTION VIEW (tywmo (No Scale) 1. (typicical) Highest Trench System Elevations = 95.6 ft; 95 ft. 95 ft. Septic Tank(s) Manufacturer. Wieser Concrete Septic Tank(s) Volume(s): 1 000 gal gal gal gal Effluent Filter Manufacturer. Poly Lock Effluent Filter Model #: 525 Provide minimum 3 ft separation between trenches. Lowest Trench (as applicable) Quick4 Standard -W wl End Cap (Show location of inlet I outlet pipe connection on plan view.) (typical) ., jp�t --------------------��--- g= 76 ft (typical) INSTALL PER TRENCH: 19 Quick4 Std -W @ 20 ft' EISAlchamber = 380 ft' + 3 Pairs of end caps @ 6 ft2 EISAlpair = 18 ft2 = Proposed EISA per trench = 386 x3 I1 Observation Pipe (typical) Install per manufacturers / Instructions. TYPICAL TRENCH PLAN VIEW (No Scale) IA = 3.0 ft (typical) `—Quick4 Standard -W Chamber (typical) (mfd by Infiltrator Systems, Inc.) Install pursuant to manufacturer's instructions. ft2 Required Infiltration Area = 1 125 trenches = Proposed Total EISA = 1158 l91 D C a W _ O o N o TI rV ft2 Distribution Method: ft' branched manifold 0 WLP1000-MR TANK SPECIFICATIONS = C*-) 104" DIMENSIONS: o WALL: 2 1/2" N s BOTTOM: SEPTIC 3" C!-> HOLDING 5" (ADD 1,300 LB.) COVER: 4" ; MANHOLE:24" I.D. PRECAST CONCRETE RISER HEIGHT: DOME COVER 61" O.D. _FLAT COVER 53 1/4" O.D. 4" CAST-A-SEALLENGTH: 104" O.D. n: -SEAL WIDTH: 86" O.D. BELOW INLET: 42" O.D. LIQUID LEVEL: 36" tD fm WEIGHT: 6,790 LBS. INLET AND OUTLET: FILTEROR4" CAST -A -SEAL BOOT OR EQUAL BAFFLE/ GASKET, CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: _� WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.83 GAL/IN TOP VIEW HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8' 0" UNSATURATED SOIL MN TANKS: WILL HAVE ONE VENT OVER OUTLET I 2 1UJ, HI OPTIONAL FLAT COVER AND WILL HAVE TWO VENTS IN COVER OVER 1, r IS AVAILABLE FOR EXCHANGE FOR DOME COVER. TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #8 NO FIBER) OUTLET TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE M ;n I '—PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS JOB INFORMATION: CUSTOMER: JOB NAME: DATE NEEDED: APPROVED BY: kPPROVAL DATE: z o 90 a w N SHEET NO.I /OF 1 Bayfield County, WI 6/20/2023, 8:35:53 AM 1:3.457 Wetlands Approximate Parcel Boundary Building Footprint 2015 0 0.04 0.09 0.n ml Rivers Road Type ' Building 0 0.05 0.1 0.2 km Town Lakes Bayfam County Lana Records Department Bayfl&d County Zoning Application nnps:fimapsoayfrdcountyvn.govIZoningWABf .6/20/23, 8:35 AM Novus-Wisconsin Access rev. 12.0206 Real Estate Bayfield County Property Listing Property Status: Current Today's Date: 6/20/2023 Created On: 3/15/2006 1:15:39 PM LAP Description Updated: 8/22/2006 Tax ID: 21606 PIN: 04-026-2-46-05-34-3 02-000-10000 Legacy PIN: 026107104000 Map ID: Municipality: (026) TOWN OF KELLY STR: 534 T46N R05W Description: NW SW 691 Recorded Acres: 40.000 Calculated Acres: 38.462 Lottery Claims: 0 First Dollar: No Zoning: (AG -1) Agricultural -1 ESN: 119 'S Tax Districts Updated: 3/15/2006 1 STATE 04 COUNTY 2 -Year Comparison 2022 2023 Change 026 TOWN OF KELLY Land: 21,700 21,700 0.0% 041491 SCHL-DRUMMOND Improved: 0 0 0.0% 001700 TECHNICAL COLLEGE Total: 21,700 21,700 0.0% `" Ownership SAMUEL A & CHERYL K OLBY Billing Address: SAMUEL A & CHERYL K OLBY 58720 ROY ANDERSON RD MASON WI 54856 P Site Address N/A Updated: 3/15/2006 MASON WI Mailing Address: SAMUEL A & CHERYL K OLBY 58720 ROY ANDERSON RD MASON WI 54856 * indicates Private Road Property Assessment 2023 Assessment Detail Code 5m -AGRICULTURAL FOREST G4 -AGRICULTURAL Updated: 4/25/2017 Acres Land Imp. 37.000 21,300 0 3.000 400 0 Recorded Documents Updated: 3/15/2006 IM CONVERSION E Property History Date Recorded: 548-20 N/A https:l/novus.bayFieldcounty.wi.gov/access/master.asp?paprpid=21606 1/1 Industry Services DivktUtIVt1 ) County 4822 Madison Yards Way Bayfleld Madison, WI 53705 JUN 13 202 Sanitary Permit Number (to be filled in by Co.) n P.O. Box 7302 Madison, WI 53707 Bavfield Co. Sanitary Permit Application Plannlr=._ StareTransactionNumber 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 address) 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 Same purposes in accordance with the Privacy Law, s. 15.04(l)(m), Scats, I. Application Information — Please Print All Information Property Owner's Name Parcel # Samuel & Cheryl Olby 21606 Property Owner's Mailing Address Property Location 58720 Roy Anderson Rd. Govt Lot NW ..S- !, Section 34 City, State Mason, WI Zip Code 54856 Phone Number 715-765-4576 T46 N R 5 E or W II. Type of Building (check all that apply) Lot N Subdivision Name I or 2 Family Dwelling— Number of Bedrooms 3 Public/Commercial — Describe Use Black N City of ❑State Owned — Describe Use Village of CSM Number Town of Kelly 111. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if a licable.) A. New System 11 ----II (Replacement System LLJJ Other Modification to Existing System (explain) ❑Additional Pretreatment Unit (explain) B' ]Holding Tank In -Ground Dkt-Grade Mound Individual Site Design Other Type (explain) (conventional) C. El Renewal Before ❑Revision ❑Change of Plumber Orransfer to New Owner ist Previous Permit Number and Date Issued Expiration IV. Dispersal/Treatment Area and 'lank Information: Design Flo pd) Design S I Application Rate(gpd/st) Dispersal Area Required (sf) Dispersal Area Pro (st) System Elevatioq.- 450 .4 1125'-__1158 95-95.6' Capacity in Total # of Manufacturer "rank Information Gallons Gallons Units , c oo $ U u o m 2 m NewTanks ExisGo Taacs x .O in rn ii. O o Septic or Holding Tank X 1000 1 Wieser Concrete ✓ Dosing Chamber CJ V. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Edward B. Redinger 221939 715-292-6670 Plumber's Address (Street, City, State, Zip Code) 1015 11th Ave. E. Ashland, WI 54806 VI. County/Department Use Only ved 0 Disapproved Permit Fee Date Issued Issuin A Signatu - ❑ Owner Given Reason for Denial W"o3 Conditions o Approval/Reasons for Disapproval 4& 10 oit 50p a) o� Sysae�u� bYa 0WLMMl pax SVS 3 $3 _ Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size SBD-6398 (R. 02/22) r Plumbing & Mechanical, Inc. 101511th Avenue East • Ashland, WI 54806 (715) 292-6670 www.superiorplumbingmech. corn V V,c Wou/cL 7,1 e k his syrt' %'2 fhe enS O7/2 fIzJs ry617'`fi tZcS 7L7 syc fen7 /c i4Ir ll JUN.114 20'LJ Private Sewage System Maintenance Agreement As owner, I (we) do hereby certify the private sewage system will be installed in 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) iU4_) 1/4 of SAJ 1/4 Section IV Township N. Range S W Additional Legal Description: Town of t Lot Block Subdivision (Acreage) —� ;— Govt Lot Lot_CSM# Vol._ Page_ CSM Doc# DOCUME 2O23R-599352 i F DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED O6/13/2O23 AT 1 1: 1 9 AM RECORDING FEE: $30.00 PAGES:1 Return To: Planning and Zoning Department Area In -ground gravity ❑ In -ground dosed ❑ In -ground pressure distribution Sewage System: ❑ Mound ❑ At -grade Sewage System ❑ Other Septic Tank (system types A through E): The septic tank shall be pumped by a certified septage servicing operator within three (3) years of the date of Installation and at least once every three (3) years thereafter unless, upon inspection by a licensed master plumber or other person authorized to make such inspection, the tank is found to have less than one-third (1/3) of the volume occupied by sludge and scum. Pump Chamber (system types B, C, D. and E): The pump chamber shall also 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 manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin. Code. Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually inspected by a certified septage servicing operator, POWTS inspector, or licensed master plumber within three (3) years of the date of installation and at least once every three (3) years thereafter to determine whether wastewater or effluent from the system is ponding on the ground surface. Mounds At -grade and In -ground Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbed if needed when the wastewater distribution cell component is inspected as provided above. Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs incurred by Bayfield County for inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate any human health hazard caused by the system. Bayfield County shall notify the owner of any costs which shall be paid by the owner within 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. The terms and conditions of the agreement shall be binding upon and inure to the benefit of all current and future owners of such property. Owner(s) Name(s) — Please Print S Subscribed and sworn to before me on this date: ��aoa3 ffl U j ocb Notarized Owner(s) — Signature(s) Notary Pubf My Co mission Expires: q / / ao Drafted by: Date: 3 r WENDY M. MILLER NOTARY PUBLIC STATE OF WISCONSIN Proofed by: Revised July 2020 PAGE 4 OF 4 In -ground Gravity Management Plan IMPORTANT: The owner of this in -ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow = 450 gpd; BOD5 5 220 mgL''; TSS 5150 mgL"'; FOG 530 mgL"' Inspection Checklist INSPECT EVERY 3 YEARSEIVED o type of use o age of system JUN 13 2023 o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (Le., pumps, valves, switches, floats, etc.) - `= o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (Le., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities - if applicable (i.e., pump re -cycling, float switch settings, etc.) o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Superior Plumbing & Mech. Inc. Local government unit: Bayfield CO. Zoning Phone: 715-373-6138 Local government unit address: 117 5th St. E. Washburn, WI Phone: 715-292-6670 ZIP: 54891 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contingency Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in -ground dispersal component may be abandoned and replaced by a code -complying dispersal component in a pre -determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. BAYFIELD COUNTY SANITARY PERMIT (#04)-23-60S STATE SANITARY PERMIT OWNER: SAMUEL A & CHERYL K OLBY GOVT LOT: LOT: BLK: NW 1/4 SW 1/4 SEC: 34, T 46 N, R 5 W TOWNSHIP: Kelly SOIL TEST: 56-23 REPLACEMENT SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: Edward Redinger MCKENZIE SLACK DATE: 6/21/2023 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 #: 40439/200-02 LICENSE: # 221939 Condition: System to meet all setbacks. Management plan to owner. Old system to be abandoned per SPS 383. Properly maintain system per recorded agreement. THIS PERMIT EXPIRES 6/21/2025 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION