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HomeMy WebLinkAbout26-42Sznot „ (11S) Department of Safety & Professional Services° County Q !JG �1e1 Sanitary Permit umber (to be filled in by Co.) Industry Services Division(tLa_oQ73 Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Project Address (if different than mailing 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 1'0570 2ro,n Lw Ka- R og.oI purposes in accordance with the Privacy Law, s. Ii.04(l)(m), Stats. _ rf Oh R i V e✓' w Z J 4 8 ti I. Application Information - Please Print All Information Property Owner's Name Jon Shta 'Pree1 # TAX 3586.5 Property Owner's Mailing Address Property Location of cTks Ate Govt. Lot /,,' /..<E x_./., Section �3 T y 7 N R 9 E o City, State I Meo^ Ro.tr1 Zip Code sN4 -i Phone Number Sld-47I-2333 If. Type of Building (check all that apply) Lot>f �9 I or 2 Family Dwelling — Number of Bedroom, _3 oC Subdivision Name Block ❑ Public/Commercial — Describe Use ❑ City of ❑ State Owned— Describe Use O Village of CSM Number DA5- aTownof NV9t eS 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 i applicable. A. y (K New System ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B, ❑ Holding Tank K In -Ground ❑ At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV. Dispersal/Treatment Area and Tank Information: Design Flow (gpd) Design Soil Application Rate(gpd/st) I Dispersal Area Required (so I Dispersal Area Proposed (sl) System Elevation 450 e-7 6y3 61,46 9S.�{ Capacity in Total H of Manufacturer Tank Information Gallons Gallons Units B F — "' u New Tanks Existing Tanks e v a A '� aU :! r rn e,3 a Septic or Holding Tank I O L.boo ` Q Dosing Chamber V. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) I Plumber's Sig lure MP/MPRS Number Business Phone Number Atkv Polkosk; oo9O _____ Plumber's Address (Street, City, State, Zip Code) Po 3& ct≥ Iro.-\ Uvec WI S9L7 VI. ounty/DepartmentUseOnly Approved O Disapproved Permit Fee 8Wth Date Issued Issuing Agent Sign re /' ❑ Owner Given Reason for Denial — ((;� I t l )I �/ Conditions of Approval/Reasons for Disapproval RECEIVED MAY 072026 oLM del CI�� Bayfleld Ca. Plannkc and Zoning Apenq Attach to complete plans for the system and submit to the County only on paper not less than a I/I x 11 inches in size SBD-6398 (R. 03/22) • c_coL/OI7 • ��e t'' '�q� Wisconsi of Safety & Professional SeNlc�s Page 1 oLZ.._ U Dill rvices ®8�U ES oVe+� T# I ) SOIL EVALUATION REPORT3��� MAY _0 7 2026 In accordance with SPS 385, Wiis. Adm. Code County ___ Attach complete site plan on j 81 /2 x 11 inches in size. Plan must include, but not limited to vertWiNI'lairow, Jufl4ka ire ce point (BM), direction and percent slope, Peel I.D. scale or dimensions, and location and distance to nearest road. 'r 8 S Please print all Information. evi wecj�y ( I `V Da PersoJ ,nal information you provide may be used for secondary •purposes (Privacy Law, s. 15.04(1)(m)). +� �1 �'57 I /� a cQ Property Owner Property L.ocation ❑ 0 Q Govt. Lot NLdrJIK 5 "K S T 7 N R E (or) W Property Owner's Mailing Address Site Address or CSM and Lot #: 79 s- S -rcpt Ave.- 6S O Xro,n. Loy, ke. R000 City, State, Zip I Phone Number ❑ City '❑ Village ® Town Nearest Road l '.__ ID �_ln.r 1A 1'i' CuAtl''7 /al n i �i-71 -A2?2 1-1. )Atw a �l'/�.a.w j l._ D�JI New Construction Use: 0 Residential/ Numberof bedrooms 3 Code derived designflow rate SO GPD ❑ Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft. Parent material So.rii4f & • t'ID1/' iG 1 DpotT3 General comments and recommendations: Boring # ❑ Boring ® Pit Ground surface elev 9ft. Depth to limiting factoi 11in. / elev.�gft. J t Snil Annlicatinn RateI 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 0-4 S R l - l �s -t - f G5 Boring # Boring [4Pit s v Pit Ground surface elev.gC.J ft. Depth to limiting factor•3_in. / elevl. Soil Aoolication 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 cS 5YR/( - Is J'-Qr rt .7 J., ____ ~Lrnvr S 4 .7 1 3 83 1a~ 5Jvsbk .7 j1g CST Name (Please Print) P0Rzosk. Signature CST Number W Co —�-r✓ Tovvj Address S'l S �i`� [�w� Date Evaluation Con ucted Telephone Number IrOv-. R Q. . - I * Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L SBD-8330 (R03/22) © Boring # ❑ Boring J Pit Ground,.surface elev. left. Page. of Depth to limiting factorrO__in. / elevgjZft. Soil Annlicatinn Rata 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 Q..sz/ L Js ij r rr I . /�. 3 2O gyttffr c. I Boring # ❑ Boring ❑ Pit Ground surface eiev. ft. Depth to limiting factor in. / elev, ft. 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 ti T Boring # ❑ Boring' ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. I Sail 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 * Effluent #1 = BOD > 30 S 220 mglL and TSS > 30 s 150 mg/L * Effluent #2= BOO, s 30 mg/L and TSS 5 30 mg/L 0 fC� Mai 01 2026 Bald GO• planning a� Z° Soil Evaluation Site Map System Plot Plan In -Ground Soil Absorption for POWTS Version 2.1 Owner: Jon Shea Site Address: 6570 Iron Lake Rd Iron River, WI 54847 Tax ID: 38865 Legal Description: NWSE S13-T47N-R09W LOT 2 CSM #2245 IN V.13 P.79 AS DOC 2022R-595874 (LOCATED IN NW SE & SW SE) IN DOC 2022R-597108 Town of Hughes, Bayfield County, WI Soil Evaluated By: Tony Polkoski Certified Soil Tester 11068 -ST Licensed Master Plumber: Allan Polkoski - PMRS 220090 PAGE 2 OF 4 PAGE 1 OF 4 In -Ground Gravity Plan Index & Cover Sheet Component Manual Design References: In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027) Page 1 - Index & Cover Sheet RECEIVED Page 2 - Plot Plan Page 3 - Dispersal Area Cross -Section & MAY 012026 Plan Page 4 - Management Plan BaSid co. Planning and Zoning Agency Enclosures: Recorded Private Sewage System Maintenance Agreement, Soil Evaluation Report, Sanitary Permit Application, Wieser WLP1 000 -MR approved tank specifications, Soil Test Checklist, Sanitary Application Checklist, $450 check Project Name / Description Owner Name(s): Jon S nea. Phone: 810 -471 333 Owner Address: 79�S S -t -c Ales Ave Troy, R(Jer-, wT Zip: Sy94-7 Project Address: 6S7O.T,-y,%L.a-ke_iRoad,.Zrorn R;Jer, W2 S4S'i7 Legal Description: VWJSE- S13--t-47N -Rpgw LoTa cSM #.-aays IN V. 13 R-29 AS Doc 2oaaR- J 9SS79 (Lc .A-terJW nll..l SE : S lv CE') .IN OQC. ZO2.2.1Z -S9-1108 -f-bwu o.- b4vGHES , BAgpIC-CLD Cc'UtttY, w -F Township: R'V3I.e.S County: T;elcl Project-Pafeel.ID #: 3 9 QJ 6 S -rAX Designer Information Designer Name: A I Ilay 1PO1 Los k1 Phone: /.S- -2.92 - y/S Designer Address: BoK £2 2, =ro., R iy et, W Z Zip: S 'qq7 E-mail: -royrVE. 6ec�.egVtrite-.nor-rh,Gom License Number: PM RS %D Oo 9 O Remarks: Signature: Date: S _ ' Ori a signature required on each submitted copy. WLP1000-MR TANK SPECIFICATIONS 4" CAST - T DIMENSIONS: WALL: 2 1/2" CAST -A -SEAL BOTTOM: 3" COVER: 5" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 53 1/4" LENGTH: 8'-8" WIDTH: 7'-2" BELOW INLET: 42" LIQUID LEVEL: 36" WEIGHT: 6,790 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.83 GAL/IN TOP VIEW HOLDING TANK: O c2 OUTLET HOLE PLUGGED IyJ o a ACTUAL CAPACITY: 1,085 GALLONS N �. 8 w LOADING DESIGN: 8'-0" UNSATURATED SOIL o TANK CAN BE USED AS: hULI s. E SEPTIC / HOLDING / PUMP OR SIPHON a COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: --- -- FOR CUSTOM TANKS CONTACT WIESER CONCRETE 0 o0 v 0 m 0 0 JLii a - w U K Q LI1 0 0 W I" a W v g co D v w ru N y o I W 3 a II ^II U Q -- -----__-r 0 REVIEWED BY O o PUMP PAD REVIEW DATE a. a Iii U) DRAWINGS SUBMITTED SIDE VIEW APPROVED FOR APPROVAL SHEET NO. APPROVED BY: By Glen Schlueter at 8:20 pm, May 30, 2022J L ________ _____________ APPROVAL DATE: 1 PRODUCTS NEEDED BY: OF OR EXCEED ASTM C-1227 REQUIREMENTS PAGE 2 OF 4 Soil Evaluation Site Map System Plot Plan In -Ground Soil Absorption for POWTS Version 2.1 Owner: Jon Shea Site Address: 6570 Iron Lake Rd Iron River, WI 54847 Tax ID: 38865 Legal Description: NWSE S13-T47N-R09W LOT 2 CSM #2245 IN V.13 P.79 AS DOC 2022R-595874 (LOCATED IN NW SE & SW SE) IN DOC 2022R-597108 Town of Hughes, Bayfield County, WI MAY 0 12026 Bayfield Co. Planning and Zoning A9enc9 Soil Evaluated By: Tony Polkoski Certified Soil Tester 11068 -ST Licensed Master Plumber: Allan Polkoski - PMRS 220090 0 100 200 ft N Suitable Absorbtion Area O Soil Borings: SB1 - Elevation 98.9' SB2 - Elevation 98.5' SB3 - Elevation 98.4 ® Benchmark -Screw in 4"x4" Post Elevation 100' No Existing Wells on Property 16� s/ope IN -GROUND GRAVITY DISPERSAL AREA Uniform Elevation Trenches with Quick4 Standard -W Chambers 3 -ft Trench (down -sizing credit) SOIL COVER min. 12" (typical) Septic Tank(s) Manufacturer: Wieser Septic Tank(s) Volume(s): 1000 gal gal gal gal Effluent Filter Manufacturer: POIVIOC Effluent Filter Model #: PL -525 12" min. bench tlepth (typlC') • ' TYPICAL TRENCH CROSS SECTION VIEW (typical) < . (No Scale) System Elevation =91 H ft (typical) Quick4 Standard -W w/ End Cap (Show location of inlet / outlet pipe connection on plan view.) (typical) r------------t-------��---- -----------yf--------��--- B = 131 ft (typical) INSTALL PER TRENCH: 32 Quick4 Std -W @ 20 ft= EISA/chamber = 640 ft2 + 1 Pairs of end caps @ 6 ftz EISA/pair = 6 ft' 'o E - C Provide minimum 3 ft s v separation between trenches. C C7) Observation Pipe (typical) Install per manufacturers / Instructions. TYPICAL TRENCH PLAN VIEW (No Scale) IA = 3.0 ft (typical) "—Quick4 Standard -W Chamber (typical) (mid by Infiltrator Systems, Inc.) Install pursuant to manufacturers instructions. = Proposed EISA per trench = 646 ft' Required Infiltration Area = 643 ft2 Distribution Method: x 1 trenches = Proposed Total EISA = 646 ft2 Gravity C m W O m a 73 M RESET RECEIVED Iir1Y 072026 PAGE4OF4 In -ground Gravity Management Plan Bayfield Co. I MP0 :Zwing Agen(Y 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; BODS S 220 mgL-'; TSS 5 150 mgL-'; FOG 5 30 mgU1 Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., 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 (i.e., 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 (Le., 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: Iron River Septic Phone: 715-372-4006 Local government unit: Bayfield County Planning & Zoning Phone: 715-373-6138 Local government unit address: 117 E 5th Street, PO Box 58, Washburn, WI 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. RECEIVED Private Sewage System Maintenance Agre9�,pt0 Jon S11eq q / / 1i9S70 1✓on L-r`cJ1✓z•, oe%uLl Tax ID# 31ie240S 3 -" - I As owner, I (we) do hereby certify the private sewage system will be installed in accordance with the certified soil tester's report and approved plans and specifications on file with Bayfield County Planning and Zoning Department. The system will be operated In such a manner as to meet the designed plans. I (we) agree to maintain said private system at the below listed location in accordance with rules established in the WI Adm. Code, as from time to time amended. (COMPLETE Legal Is required) 1/4 of 1/4 Section Township _N. Range _W. Additional Legal Description: Town of n ✓9 " e5 (Acreage) ) 9 • Gov't Lot Lot _ Block Subdivision II// o: Lot? CSM # 22 VS0i, J.j. Page.ZI.CSM Doc # 20 DOCUMENT NUMBER 2026R-61 1514 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 03/24/2026 AT 1 1 :04 AM RECORDING FEE: $30.00 PAGES: 1 Recording Area Return To: 1of11' ?d/kcosA_ Ra 3e')C SL'Z •rtn ldty .j'LS V7 ® In -ground gravity ❑ In -ground dosed ❑ In -ground pressure distribution Sewage System: ❑ Mound ❑ At -grade Sewage System ❑ Other it, 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. A 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. )E 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 -around Pressure System Laterals (system types C. band E): The laterals shall be flushed out and swabbed if needed when the wastewater distribution cell component is insnec.ted as provided above. Owner(s) agree that (allure to comply with this agreement will result in action being taken to pay all charges and costs incurred by Bayfeld 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. Bayfleld 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. `�vtlltit illlllff// Owner(s) Name(s) — Please Print Subscribed and sworn to before me on this date: jo Notarized Owner(s)—Signature(s) Not y •. 9 MY omm' ______. �. iz-'t-z0Z9 Drafted by: '7O n k'oi IC; Date: 2' G 3 `Z Proofed by: u/forms/sanits ry/seplicmalntefloe agroom ont Revised July 2020 • n WEIVED BAYFIELD COUNTY cta( .o .T 2026 CHECKLIST FOR CERTIFIED SOIL TESTS Submittheok&itr(Use Permanent Ink): 10 Check List JC Index Page / Title Sheet (Optional) II Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) I Original Plot Plan ❑ Cross Section Soil Profile Sheet (optional) ❑ Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) TAX L19-PdrCE1 Identification Number (must be digit Tax ID#) DO NOT USE 12 digit, they are no longer being used I] Property Owner's Information (not prospective buyer's name) t] Property Location (Accurate Legal Description with Sec/Twp/Range) i Road Name (where driveway is/will be coming off of) O Floodplain Elevation, Flow Rate, Comments and Recommendations Il Complete Soil Boring / Pit Information X Date Soil Evaluation was conducted 1 CST Name, Signature, Number, Address and Phone Number *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) im Bench Mark (Description, Elevation and Location) ill Contour Lines (Example = 98.0' /96.0' /94.0') '] Property Location (Sec/Twp/Range/, Accurate Legal Description) [A Borings (Locations and Elevations) 0 Percent and Direction of Land Slope ❑ Well Location (Including Neighboring Wells, if applicable) ❑ Location of Wetland Areas, Floodplain and Navigable Waters �1 Buildings, Driveways, and Structures (Location and Descriptions) it Location of Property Unes ❑ Existing System Location l Address Number and Road Name O Current Surface Elevation of Wetlands and Navigable Waters 0 CST, Owner and Property Information 40 North Arrow Fee: Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checklist/checklistforests SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e)) V Check List 0 Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) 21 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 0 Original Plot Plan (383.22(2)2. 3. & 4.a) 0 Cross Section, Over -Head Profile of the System and DSPS APPROVED Schematic of Tank from Manufacturer 0 Pump Tank Diagram, Alarm and Pump Curve (when applicable) 0 Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) 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) 0 Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) 0 1 Complete Set of Plans (Note: Sanitary Application and Maintenance Agreements are to be attached) 0 Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) :EC.IVEB ❑ State Plan Review (when applicable) 0 Copy of Warranty/Quit Claim Deed (Optional) Lid U (2026 Bayfield Co. Planning and Zoning Agency Sanitary Application: (Include the following Information) ffi I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number 0 II Type of Building E� III Type of Permit E71 IV Type of POWTS System 0 V Dispersal - Treatment Area Information 0 VI Tank Information f9 VII Responsibility Statement (Plumber's Information) Plot Plan: (To Scale or To Dimension) iZ Signature and Plumber Information ❑ Surface Elevation of Body of Water IJ Direction and Percent Land Slope Z Tank and Filter Information and Location ❑ Wetlands / Navigable Bodies of Water 1O Absorption Area (Proposed and Existing) 0 Bench Mark (Location, Elevation and Description) 0 Component Manual Version 0 Address Number and Road 0 North Arrow Contour Lines 0 Structures and Driveways 0 Boring Locations 0 Property Lines 0 Well Locations 0 Legal Descriptions 0 Piping Material Information (conveyance line, building sewer line, material type and diameter) Turn Over ► Cross -Section and Over -Head Profile of the System: l Surface and System Elevation Position of Observation and Vent Pipes Dimensions and Depths Make, Model & Number of Chamber Units in each Cell Property Information ' How many systems will there be on this parcel of land? ❑ Has this property been split? (Property Statement shows Property History) Fees: 4 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 O Return Inspection $ 50.00 ❑ Maintenance Agreements i $ 30.00 (checks made out to Reg of Deeds) V��Y. FIELD Ba�ield 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: SHEA, JON R & GENIA M 7925 STAPLES AVE IRON RIVER, WI 54847 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00407 Transaction Number: SR -00407-45436 Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 6307 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 5/12/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. B'-YFIELD 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: SHEA, JON R & GENIA M 7925 STAPLES AVE IRON RIVER, WI 54847 Description Private Sewage System (Septic Tanks) Submission Number: SS -00738 Transaction Number: SS -00738-45416 Amount $400.00 Total: $4UU.UU Payment Amount: $400.00 Reference: 6307 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 5/12/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-42S STATE SANITARY PERMIT OWNER: JON R & GENIA M SHEA GOVT LOT: LOT: 2 BLK: CSM: 2245 NW 1/4 SE 1/4 SEC: 13, T 47 N, R 9 W TOWNSHIP: Hughes SOIL TEST: 36-26 NEW SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: ALLAN POLKOSKI EMILY MACGILLIVRAY LLIVRAY DATE: 5/12/2026 Authorized Issuing Officer CHAPTER 145.135(2) WISCONSIN STATUTES a. The purpose of the sanitary permit Is to allow installation of the private sewage system described in the permit. b. The approval of the sanitary permit Is based on regulations in force on the date of approval. c. The sanitary permit is valid and may be renewed for specified period. d. Changed regulations will not impair the validity of a sanitary permit. e. Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may Impede renewal. f. The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 C. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. PREVIOUS PERMIT #: LICENSE: # MPRS 220090 Condition: Properly Maintain System Per Recorded Agreement THIS PERMIT EXPIRES 5/12/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION