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Home My WebLink About26-4Se'T1"> Department of Safety Cowry & Professional Services, Industry Services Divi ' n Sanitary Permit Number (to be filled in by Co.) 99 - oo 6q t { ENTERED a � - � s 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(ifdifferent than mailing address) the Department of Safety and Professional Services. Personal information you provide may he used for secondary a 3 QO /Mc4jt,rN jcJ purposes in accordance with the Privacy Law. s. 15.04(1 )(m). Slats. I. Application Information - Please Print All Information RECEIVED C0Ct\tiCp Ics (rx%r 5'/&a -1 Property Owner's Name Parcel # �� 3 (o/\onsorN JAN 062026 Property Owner's Mailing Address Property Location P C) Ox g Lj ( Bayrea co. Planning and Zoning Agency Govt. Lot City. State I Zip Code Phone Number G o cLC'\\ UJE- 5y 8C 678- 36o -6O \_'4_14, Section It. Type of Building (check all that apply) l.ot # T 50 N R o6 E or I or2 Family Dwelling— Numbcroll3edrooms I Subdivision Name Block # ❑ Public/Commercial — Describe Use O Cityof ❑ State Owned — Describe Use CSM Number ❑ Village of � XTown of Ib! III. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if a livable. A. Y Replacement System Existing System (explain) (explain) New S stem ❑ ❑ Other Modification to ❑ Additional Pretreatment Unit B' Holding Tank ❑ In -Ground ❑ At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision 0 Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration Tank Information wpue.q m Gallons Gallons Units o New Tanks i Existing Tanks 'i°- c a U v y 3 s a in y iZ c Septic or Holding Tank W OoO .�oo ' Cd nc V /� Dosing Chamber V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's a e 1 MP/MPRS Number Business Phone Number c�ae� ob k; �-CJ�' iaRQso� 715-309 -3sal Plumber's Address (Street, City, State, Mk (or*,l ww\-ICt Zip Code) Approved ❑ Disapproved Permit I've Date Issued m�tss mg Age[ gna ❑ Owner Given Reason for Denial' ;25 ara t�IfC ��j Conditions of ApprovallReasons for Disapproval 5"c_, a d44e Attach to complete plans for the system and submit to the County only on paper not less than 8 lax I1 inches in size S13D-6398 (R. 03/22) Wisconsin Department of Safety and Professional Services 32075 L Division of Industry Services SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code County BAYFIELD Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope. Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 39431 Please print all information. rev y� Page 1 of 3 -tea Property Owner Property Location t] CONNIE L MONSON Govt. Lot SW '/. NW '/. S 14 T 50 N R 06 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# PO BOX 841 3 2371 City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road BAYFIELD I WI I 54814 (678) 360-6089 BELL j MOUNTAIN RD ® New Construction Use: ® Residential/ Numberof bedrooms 1 Code derived design flow rate 150 GPD ❑ Replacement ❑ Public or commercial — Describe: Parent material SANDY OUTWASH Flood Plan elevation if applicable NA ft. General comments and recommendations: SITE SUITABLE FOR A MOUND SYSTEM 1❑ Boring ❑ Boring # ® Pit Ground surface elev. 99.2 ft. Depth to limiting factor 21 in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ftl *Eff#1 Eff#2 1 0-6 7.5YR 3/2 NA Is Osg ml cs 3m 0.7 1.6 2 6-10 7.5YR 6/3 NA s Osg ml cs 2f 0.7 1.6 3 10-16 7.5YR 4/6 NA S Osg ml gw if 0.7 1.6 4 16-21 SYR 5/6 NA S Osg ml gs 1vf 0.7 1.6 5 21-26 2.5YR 4/6 C2D 2.5YR 6/4 sl lfgr ml NA tvf 0.0 0.0 2❑ # ❑ Boring Boring ® Pit Ground surface elev. 98.6 ft. Depth to limiting factor 26 in. Soil Applica Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' Eff#1 -Eff#2 1 0-4 7.5YR 312 NA Is Osg ml cs 3m 0.7 1.6 2 4-9 7.5YR 6/3 NA s Osg ml cs 2f 0.7 1.6 3 9-16 7.5YR4/6 NA s Osg ml gw 1f 0.7 1.6 4 16-26 5YR4/6 NA S Osg ml gs 1vf 0.7 1.6 5 26-30 2.5YR 4/6 C2D 2.5YR 6/4 sl lfgr ml NA 1vf 0.0 0.0 - Ffflupnt *1 = ROn >30<770 mn/I. anti TSS >30< 1Fn mn/I . - Ffflunnt ft9 = Rnrl > 3n < 99n mnn and TSS > 3n < 1 cn mn/I CST Name (Please Print) I Signal CST Number EDWARD J WROBLEWSKI SP -72000013 Address I Date Evaluation Conducted Telephone Number 84805 HATCHERY RD, BAYFIELD, WI 54814 I 6/12/2025 715-209-4055 buU-6330 (K04!15) UJ Is 17 3❑ Boring# O Boring �,: �0 UL 32025 Pit Ground surface elev. 97.0 ft. LO( mq Dept. Soil Application 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 0-5 7.5YR 3/2 NA Is Osg ml cs 3m 0.7 1.6 2 5-9 7.5YR 6/3 NA s Osg ml cs 2f 0.7 1.6 3 9-17 7.5YR 4/6 NA s osg ml gw 1f 0.7 1.6 4 17-21 5YR 4/6 NA s osg ml gs fl'f 0.7 1.6 5 21-24 2.5YR 416 c2d 2.5YR 6/4 sl lfgr ml NA 1vf 0.0 0.0 Depth to limiting factor 21 in. ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. _ ft. Depth to limiting factor _ in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Cr. Sz. Sh. Consistence Boundary Roots GPD/Ft' Eff#1 Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. _ ft. Depth to limiting factor — in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Or. Sz. Sh. Consistence Boundary Roots GPD/Ft' Eff#1 -Eff#2 Effluent #1 = BOD, > 30 S 220 mg/L and TSS > 30£ 150 mg/L ' Effluent #2 = BOD, > 30 S 220 mg/L and TSS > 30 s 150 mg/L EDWARD J. WROBLEWSKI, CST #SP -72000013 SOIL TEST PLOT PLAN CONNIE L MONSON XTXXX MOUNTAIN RD CORNUCOPIA WI 54827 LOT 3 CSM 2371 IN DOC 2024R-605351 514 TSON R06W TOWN OF BELL, WI SCALE 1" = 60' APPRO%200' TO WEST LOT LINE FUTURE 1 BORA1 HOUSE 32025 J V 10% SLOPE APPROX 75U TO NORTH LOT LINE A 0 a rn SOUTH LOT UNE MOUNTAIN RD A. BM 6 MAPLE. NAIL IN BASE .100' B o�o SATr SHEET 0 0'r 3 RECEIVED CONCRETE HOLDING TANK DESIGN JAN 06 2026 Single Tank Option Bayfield Co. INDEX AND TITLE SHEET Planning and Zoning Agency Project Connie Monson - Holding Tank Owner Connie Monson Address Bayfield, WI 54814 (678) 360-6089 Legal Description Lot 3 CSM 2371 Doc 2024R-605351, S14, T50N, R06W Township Bell Subdivision Name Parcel ID Number 39431 Plan Transaction ID Number Designer Michael Wroblewski County Bayfield Lot No. 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 /-t/K(- Phone No. (715) 209-7521 License Number 1288503 Date 12/30/25 Designed pursuant to: Holding Tank Component Manual For POWTS (Version 2.0) SBD-1O855-P (N. 03/07, R. 01/12) version7.0(11/12) Page 1 of 9 HOLDING TANK SPECIFICATIONS Number of bedrooms Non-residential estimated flow (gpd) 2000.0 Minimum holding tank volume required (gal) 2000.0 IPm�osed holding tank capacity (gal) Wieser concrete Tank Manufacturer WLP2000-MR Tank model number SJ Electro systems Alarm manufacturer WH101 Alarm model number junction box conduit 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 062026 Baylleld Co. Planning and Zoning Agency Tank Anchor Calculations 22230 Ibs Weight of tank and cover 1 .IQJ Safety factor 12166 lbs Weight of anchor required in Soil cover req. for anchor or yd3 Concrete counterweight 13.4 3.0 HOLDING TANK CROSS SECTION manhole cover with locking device and finished vent cap warning label grade min. 1 12mn. 23 in. Manhole and vent locations maybe reversed. vans ppe 1a^ min. K tether weight JI building sewer O service 12 .0 in Inlet Bind g alarm on Note: All tank joints, and outlet joints between tank openings and piping are Electrical as per 31.0 in. sealed watertight. All pipe NEC 300 and vent materials comply and SPS 316 with SPS 384. 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Connie Monson - Holding Tank Transaction Number. Page 2 of 9 CONNIE MONSON HOLDING TANK PLOT PLAN CONNIE L MONSON XXXXX MOUNTAIN RD CORNUCOPIA,'WI 54827 LOT 3 CSM 2371 IN DOC 2024R-605351 S14 T5QN R06W TOWN OF BELL, WI SCALE 1 ° = 60' APPROX 200'TO WEST LOT LINE FUTURE 1 BORM HOUSE CleanoW h 40 ppe 2P'O galbn Mbhg lank 2 APPROX 750' TO NORTH LOT LINE 41 0 2' p2 80.8' 97 6I 97 v V 10% SLOPE RECEIVED JAN 062026 Barfield Co. Planning and Zoning Agency SOUTH LOT LINE MOUNTAIN RD = EM 0' MAPLE, NAIL IN BASE = 100 1 2 3 46 5 60T HEETa OF9 RECEIVED JAN 052026 HOLDING TANK MANAGEMENT PLAN Bayfleld 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 40.0 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 .........................Big Big Lake Plumbing Phone: 715-209-7521 b. Service Provider ...............Birch Birch Street Sepiic Service Phone: 715-373-5683 c. Co. Zoning or Health Dept. Bayfield County Planning & Zoning Phone: 715-373-6138 11 Project: Connie Monson - Holding Tank Transaction Number. Page 4 o19 W2000 -MR TANK SPECIFICATIONS 12'-7" DIMENSIONS: WALL 2 1/2" BOTTOM: 4" COVER: 6" �___-=-----------____ MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 66" O.D. •• •• `�� LENGTH: 12'-7" O.D. ii 4" CAST -A -SEAL 4" CAST -A -SEAL WIDTH: 7'-2" O.D. BELOW INLET: 53" O.D. LIQUID LEVEL: 46" Nl l l WEIGHT: BOTTOM 9,430 LBS. ?R, COVER 5,940 LBS. 1�� f iiJ �� FILTER OR BAFFLE ii 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) RECEIVED LIQUID CAPACITY: 42.92 GALAN TOP VIEW HOLDING TANK: JAN 0 6 2026 OUTLET HOLE PLUGGED a ACTUAL CAPACITY: 2,126 GALLONS ¢ a Bayi5&dCo. Planning and Zoning ng Agency LOADING DESIGN: 6'—O" UNSATURATED SOIL w TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON - COVER: MIX DESIGN #8 (NO FIBER) INLET - —L TANK: MIX DESIGN #10 (STRUCTURAL FIBER) ti __ � OUTLET � CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE CD; I U D * 2k, j IN IJa II--------1---_-`---------'j 0 REVIEWED BY a REVIEW DATE SIDE VIEW DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: JKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 0 w W U, C U L0 co G.7w � < N � I HMOO W_ N r w D z oI M 0 U a w I 1 SS-oo6Qq HOLDING TANK SERVICING CONTRACT Contract Date al J.la.a7 do?(. This contract is made between the Holding Tank Owner(s) Name(s) o iL Pumper's Name (Print) Pumper's Signature Pumpers' Registration # We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT I LOCATION Legal Description: (Use Tax Statement) Tag lea 57') 31 �f 1/4, �[IdL 1/4, section /y .S7),&/ N, Range 04 W Town of: I Lot Size I I Acreage ,Township 'I Gov't Lot I I Lot# I CSM# Vol. Page I CSM Doc# Lot(s)No. I elock(s)No. Subdivision: 3 2371 1. The owner agrees to file a copy of this contract with Bayfield 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; RECEIVED c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; JAN 212026 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; Bayfield Co. g. The disposal sites to which the contents from the holding tank were delivered. Planning and Zoning Agency 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) Name(s) (Print) Owner's Signature(s) Subscribed and Sworn to me: onthisotlfldayof n'Jabll Lo/1/gic.L Mon°JNSY.. by. ,M �1 O� Notary Public : _ — commission expires on: Revised: May 2016 (®May 2018) Drafted by Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (p(m)] m- CoMi2 L X104SON r� (UI Sy&I� ame as Notary Dal 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 �or(�C�h. 145, Wis Stats. „] '1/4 of / V Wi 1/4 Section 14 Township SON. Range fo W. Town of it 11 Additional Legal Description: Gov't Lot _ Lot Block_ Subdivision CSM# Lot 3 CSM # 237I Vol 13 Page3 �g_CSM Doc# 2024i-fod5188 DOCUMENT NUMBER 2025R-610236 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 12/O8/2O25 AT 11:42 AM RECORDING FEE: $30.00 PAGES: 1 Return To: to r(I rg DEC 092025 Bayfieid Planning and Zo ENTERED la/9/a 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, 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, Scats. 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. Stats., 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. 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 property 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 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(s) Name(s)— Please Print Subscribed and swom to before me on this date: Cmnnie C IMOASLW rZ-3-z025 vo Notarized Owner(s) — Signatures) NotaryPublic� Q. � / C 1 t e ,` Gt1tZ - 1oLW VJ �` My Commission Expi s: 1-12029 N ..a,, A Drafted by: %7�(C tQC/ C)(tA, 4uYh.41cvit Date: Personal Information you provde may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)I BAYFIELD COUNTY RECEIVED CHECKLIST FOR SANITARY APPLICATONS JAN 06 2026 Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Bayfiekl Co. Check List Planning and Zoning Agency X❑ 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) Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) )l 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) )) Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) k 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.) 0 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) 'Project Address or Road Name where driveway is/will come off of) "t-' (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) 1 Signature and Plumber Information ❑ Surface Elevation of Body of Water A 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) I�f Component Manual Version Address Number and Road North Arrow Contour Lines Structures and Driveways Boring Locations Property Lines Well Locations Turn Over ► dross -Section and Over -Head Profile of the System: O Surface and System Elevation RECEIVED ❑ Position of Observation and Vent Pipes ❑ Dimensions and Depths UE id U 6 2026 ❑ Make, Model & Number of Chamber Units in each Cell aayheid co. Planning and Zoning Agency Property Information AHow many systems will there be on this parcel of land? 9Has this property been split? Mo (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 ,F 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/checklistforsanitaryapps (10/2009);(OO7/2011);(®2/2012)(®5/2/2012-dc) Proofed by: BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): C✓7 Check List dex Page / Title Sheet (Optional) LI:'! L'.JL ., 3 /UZ5 i rf. B 6/i9inal Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) C9 'Original Plot Plan __-8-fross Section Soil Profile Sheet (optional) _ .-8 dditional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) lWParcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used Cooerty Owner's Information (not prospective buyer's name) ooperty Location (Accurate Legal Description with 1j21(oad Name (where driveway is/will be coming off of) C"iodplain Elevation, Flow Rate, Comments and Recommendations I'mplete Soil Boring / Pit Information Ia Soil Evaluation was conducted VEST Name, Signature, Number, Address and Phone Number ❑ *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) bench Mark (Description, Elevation and Location) Lrl C�ontour Lines (Example = 98.0' /96.0' /94.0') IH"Property Location (Sec/Twp/Range/, Accurate Legal Description) @'l6orings (Locations and Elevations) -Percent and Direction of Land Slope NSF ❑ Well Location (Including Neighboring Wells, if applicable) N4- ❑ Location of Wetland Areas, Floodplain and Navigable Waters uildings, Driveways, and Structures (Location and Descriptions) cation of Property Lines O Existing System Location la'Address Number and Road Name ► k ❑ Current Surface Elevation of Wetlands and Navigable Waters &PE�ST, Owner and Property Information 'No Brth Arrow Fee: s, Certified Soil Tests - Review & Filing Fee $ 50.00 U/Forms/sanitary/checklisVchecklistfarests B VF ILLD Bayfield County Planning & Zoning Department 117 E 511, Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-0114 Property Owner: MONSON, CONNIE L PO BOX 841 BAYFIELD, WI 54814 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00280 Transaction Number: SR -00280-2F737 Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 2698 Paid by: Ed's Mechanical, 1491 County Hwy C, Washburn WI 54891 Payment Type: Check Transaction Date: 7/11/2025 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. 13". (FIELD Bayfield County Planning & Zoning Department 117 E 5th Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-0114 Property Owner: MONSON, CONNIE L PO BOX 841 BAYFIELD, WI 54814 Description Private Sewage System (Holding Tanks) Submission Number: SS -00694 Transaction Number: SS-00694-3C05E Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 2872 Paid by: Ed's Mechanical, 1491 County Hwy C, Washburn WI 54891 Payment Type: Check Transaction Date: 1/22/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-4S STATE SANITARY PERMIT OWNER: CONNIE L MONSON GOVT LOT: LOT: 3 BLK: CSM: 2371 1/4 1/4 SEC: 14,T50 N, R 6 W TOWNSHIP: Bell SOIL TEST: 66-25 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: MICHAEL WROBLEWSKI TRACY POOLER Authorized Issuing Officer DATE: 1 /22/2026 CHAPTER 145.135(2) WISCONSIN STATUTES a. The purpose of the sanitary permit is to allow Installation of the private sewage system described in the permit. b. The approval of the sanitary permit is based on regulations in force on the date of approval. c. The sanitary permit Is valid and may be renewed for specified period. d. Changed regulations will not Impair the validity of a sanitary permit. e. Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. f. The sanitary permit Is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. PREVIOUS PERMIT #: LICENSE: # MP 1288503 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 1/22/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION