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HomeMy WebLinkAbout26-57SIndustry Services Division County . 6 4822 Madison Yards Way Bayfeld `,�_' ^ Madison, WI 53705 P.O. Box 7302 Sanitary Permit Number(to be filled in by Co.) -OOtH Madison, WI 53707 — 517 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 (if different than mailing address) the Department of Safety and Professional Services. Personal information you prticktnaRbrrtlBeels ,secondary purposes in accordance with the Privacy Law, s. 15.14(1 Xm), Stats. anlCC VV CC �1 YY 8— LLJJ 69990 W Long Lake Rd. Iron River, WI I. Application Information — Please Print All Infor Property Owner's Name 1 MAY 2 LU 2026r rrr�rkW I L Parcel # Dan & Gail Schourek 20233 Property Owner's Mailing Address Planning and Zoning Agency Property Location 404 Fieldstone LnGovt. Lot City. State I Zip Code Phone Number Hampshire, IL 60140 218-428-5123 1 ¼, Section 02 T47 N R 08 E or W II. Type of Building (check all that apply) Lot # ✓❑ I or2 Family Dwelling— Number of Bedrooms 3 1 & 2 Subdivision Name ❑Public/Commercial — Describe Use Block # ❑City of ❑State Owned — Describe Use CSM Number jvillage of QTown of Iron River 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 licahle.) A. New System ❑Replacement System EllOther Modification to Existing System (explain) Additional Pretreatment Unit (explain) ❑Holding Tank JIn-Ground IlAt-Grade Mound Individual Site Design IliOther Type (explain) (conventional) C. ❑ Renewal Before []Revision Change of Plumber Transfer to New Owner List Previous Permit Number and Date Issued Expiration NA IV. Dispersal/freatment Area and Tank Information: Design Flow (gpd) Design Soil Application Rate(gpd/st) I Dispersal Area Required (st) I Dispersal Area Proposed (st) I System Elevation 450 0.7 642 1652 96.5 Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units .o ` o v New Tanta I Existing Tanks S o 2 — g m 0.O rn G, CC LEO iY Septic or Holding Tank 1000 1000 1 Superior Precast ✓ Dosing Chamber D D 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 Jason Kuettel - ice 1675751 1715-798-3355 Plumber's Address (Street, City, State, Zip Code) PO Box 66 Cable, WI 54821 VI. unty/Department Use Only Approved 0 Disapproved Permit Fee I Date Issued „ Issuing Agent Signature `fir/_ P/ r (/ rO/ 1fV� ,p I ❑ Owner Given Reason for Denial o Lb 11 1. I41a2fr Conditions of Approval/Reasons for Disa proval bus{ i azk ≤-baclle (fills an rer6hba t� (otS. Attach to complete plans for the system and submit to the County only on paper not less than 8 /2' II inches in size SBD-6398 (R. 02/22) ' �tr�serut+t Wisconsin Department of Safety and Professional Services R. 00 j Page [ of Division of IndustryServices SOIL EVALUATION REPORT SOIL TEST # 47- a2 , *t /� In accordance with SPS 385, Wis. Adm. Code County stiinwafl ' Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, >Flt 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. 2-� 2�� Please print all information. Renewed by Al Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). UY' 1 l lao/vAig' Property Owner Property Location6 ❑ Da q- AIL S L \-t-O v (Z-1 fL Govt. Lot '/. Y. S OZ_ T W? N R o a E (or) W Property Owner's Mailing Address Site Address or CSM and Lot #: Y d L..1 L-6S'TO t L, CP 9133) o I" 1 L. o , LA-( 21 City I State I Zip Code I Phone Number ❑ City ❑ Village ,® Town I Nearest Road i-}rg, MPS 1 t l JZ-t;I 1k— (0 )t'4)t'4O ( Zj ) si23 / ila n' 1 - " c`"--- I i,.1 Lo i J (, 4'1I \'L] M NewConstruction Use: Residential/Numberof bedrooms Code derived designflow rate 4'O GPD ❑ Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft. Parent material O %J rW Af 1+ S.^N 4 �►f 11 General comments and recommendations: G S l a nr 'Th � .7 Ej1 ❑ Boring Boring # [Pit Ground surface elev, l ft. Depth to limiting factor in. / eiev. I6 G eft. Soil Aoolication Rate Horizon Depth In. Dominant Color Munseil Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 I n- S .Sy'tZ's1� — _5 ot$c t 0,) /-4' Z - Z. I S/2ice\/ 14 1c C _ I-- �t (r o. / I c -- S _rtG r l -- �-� o.? /. aayneiu L.U. ❑Boring Planning and Zoning Agency �{�y Boring # Pit Ground surface elerl!?0. �l ft. Depth to limiting factor >' in. / elev alt. f I 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 6 -/b .7 .� .� t•a/ ._._ (+ L.7 oS 6 ,-vi (.. kJ v'& t7 /, y `_ /o - Z? )rfl-// / &/ r-- .c oS6 W ( /i'. o7 / 4 3.;Z7-7t5?4V6 --- o S CE ! /. CST Name (Please Print) Signature CST Number oQd Zu Address 'Date Evaluation Conducted Telephone Number 0 1rJ o K Ci ?L I'— S / 2 h,c --? 5`Y —?1SS * 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 # Page of Ground surface elev. 84�t. Depth to limiting factor> #5 in. / eievy/ • $6t. 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 7.5 ) toa , �S dS 6 6' k1 d•7 1, 4 6 _ S 56 n-.. 1 rr• ► o 1 ' 3 Z - � s 7.5 :ti � 6 — S S 6 / I o ) I LiBoring # ❑ Boring 4.,� ❑ Pit Ground surface elev. ft. Depth to limiting factor In. / elev. ft. I 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. I 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 s 220 mg/L and TSS > 30 5150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L RECEIVED MAY 12 2026 Bayfeld Co. planning and Zoning Agency CHECK BOX AS APPLICABLE. 0 SOIL EVALUATION Scale: 1"=40' SITE MAP 0 40 60 80 PROJECT NAME: I / (10 ft grid) 102 CHECK BOX AS APPLICABLE. U SYSTEM PAGE 2 OF PLOT PLAN DESIGN FLOW: s b GPD Attach design flow calculations for commercial plans. PROJECT ADDRESS: b ! 0 W C. -a ri G L'7 ( P Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) �OV N Sanitary Sewer. BM Symbol: 4 BM Elevation: FT Force Main: J BM Description: N L t C o/y !Z' AA4f LA5 Indicate north by IMPORTANT: Slope Gradient (96) o Well Symbol (If applicable): Q drawing an arrwv Show ground elevation contours at suitable intervals. of Tested Area: _� on the approprlte toe. RECEIVED MAY 12 2026 Bayfield Co. Planning and Zoning Agency 'S3M- l od .0 t3 -9g.4 tAN(c' $ o'• Le" kt- '€ ?o.a 5�1 PL. i1 * NC '-�4( ON cr. 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) RECEIVED Pg 1 of 4 Index & Cover Sheet MAY 12 2026 Pg 2 of 4 Plot Plan gamyfield Ci�o�.p� Pg 3 of 4 Dispersal Area Cross-SectionP8r1PfJ?1Men`y Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Schourek 3 Bed Owner Name(s): Dan & Gail Schourek Phone: 218 -428 - 5123 Owner Address: 404 Fieldstone Ln. Hampshire, IL Zip: 60140 Project Address: 69990 W Long Lake Rd. Iron River, WI Govt. Lot: 1/4 of 1/4, Section 02 , T47 N -R 08 E ❑ or W Township: Iron River County: Bayfield Project Parcel ID #: 20233 Designer Information Designer Name: Jason Kuettel Phone: 715 -798 -3355 Designer Address: PO Box 66 Cable, WI Zip: 54821 E-mail: tim@andryras.corn d for approval camp. License Number: 675751 Remarks: Signature: ;_"" ' Date: zCo Origin6l sit nature required on each submitted copy. CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE. fl SOIL EVALUATION Scale: a"D 40 © SYSTEM PAGE 2 OF D SITE MAP 60 80 PLOT PLAN PROJECT NAME: n DESIGN FLOW: q5 O GPD (10 grid) Sck py /�-e,ILp '7 1�E� tp= Attach design flow Calculations for commercial plans. PROJECT ADDRESS: )SS U W LcN (. 6 ,�17CE v Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) N BM Syrnbd: 4 BM Elevation: /OO • O Sanitary Sewer: KI $c'4 `f0/eVc_- fr.h%L/(citoAs jL" 8M Description: A A%Pl_.( Force Main: / Slope Gradient(%) / a/ Indicate north by of Tested Area: Well Symbol (irapptcable): 0 drawing ananow IMPORTANT: Show ground elevation contours at suitable intervals. on the appropdte ine. oWuet - S— 6'rl- S'CFrouZt`1L__ A f t2 5C ' 6 c' 5'o G—' Lo /.! G L4-1cL Z - 12C N R_t" c'Yc_, f JC— - Lc'&S C d3'K-L S C7 T L % N (Z_o 6' Cx/ �1V?K Ib co. cr2tCeIVF6 MAY 122026 Bayfield Co. Planning and Zoning Agency 1000 3Z /ov,61 (33 78.� / 4„uK 4ePQc I�r-kt1 N'i � W L' " -j (SkC /gr..e.�y � luS c S�_ �rL 90.0 12 3 '-ti Z5 0� \ I I 1 1 a. 4 Qn^ - I s d rA.L- ,N li. ♦♦.. uu LLLIII C, M44PL` $U..il-r PL _c$/ u<n' pnc�Ji- L� /oce k// ore —C.. L/r$a fv(p67SIS NC 'tu( oN Pflr rv( IN -GROUND GRAVITY DISPERSAL AREA Uniform Elevation Trenches with Quick4 Standard -W Chambers 3 -ft Trench (down -sizing credit) SOIL COVER min. trench depth (typical) min. 12•' (typical) Luff (typical) •' .. System Elevation = 96.5 (typical) Septic Tank(s) Manufacturer: Superior Precast Septic Tank(s) Volume(s): 1000 gal gal gal gal Effluent Filter Manufacturer: Orenco Effluent Filter Model a: FT -0822 TYPICAL TRENCH CROSS SECTION VIEW (No Scale) ft Quick4 Standard -W w/ End Cap (Show location of inlet / outlet pipe connection on plan view.) (typical) -----77- ---//----- jt B= 66 ft (typical) INSTALL PER TRENCH: 16 Quick4 Std -W @ 20 ft' EISA/chamber = 320 + 1 Pairs of end caps @6 ft2 EISA/pair = 6 ft2 ft2 = Proposed EISA per trench = 326 ft2 Provide minimum 3 ft separation between trenches. Observation Pipe (typical) Install per manufacturers / instructions. o N CNJ Required Infiltration Area = 642 ft2 TYPICAL TRENCH PLAN VIEW (No Scale) Distribution Method: x 2 trenches = Proposed Total EISA = 652 ft2 branched manifold GD m co O ii a 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 ≤ 150 mgL'; FOG ≤ 30 mgL-' Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) MAY 12 2026 o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) aayfield co. o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., & 1tS1 i' "68s) 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 (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. Scats. 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: Andry Rasmussen & Sons Local government unit: Bayfield Co. Zoning Phone: 715-373-6138 Local government unit address: 117 E 5th St. Washburn, WI ZIP: 54891 Phone: 715-798-3355 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. SEPTIC TAN SS SECTION AND SPECI'ICATIOFIS 4" Gclt.y-OPVC INSP. PTDE 6 " MIN. A30VF G ,J'.('opT) (When %n(ei- ma&k Ys buried APPROVED MANHOLE FTPI=SHED GRADE W/ Lm4,$ W4Rtc. LAO& I i y 4" MIN. 18" HIN. I I I HLET OUTLET 'H BA-FF3—E— O FILTER APPROVED MEG.Ot-e{�CO PIPE 3' RECEIVED ONTO SOLID model Td$ ,2 SOIL MAY 12 2026 I Baylield Co. Planning and Zing Agen oncy 3" APPROVED BEDDING UHDEP, TANK SPEZIFICATIONS SEPTIC TANK MANUFACTURE SUt. ot_ lR S'T— TA,NK SIZES: S=?TIC (OoO CA.L. NOTES: Private Sewage System Maintenance Agreement fd�l E. SGNoVeEV_ LAICF 2D Tax ID# Zo2?j'j 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 t4\(L1/4 Section 2 4 Township 1 N. Range _LW. 14T' 1 p.t 10 CF±% )JORTN 50 VET O%F WV Z Additional Legal Description: ifp fl4 tttimn S+"1 ' 'To r mlr kE Town of I LOU R\U (Acreage) 0,9 6 'r Gov't Lot Lot Block Subdivision Lot _ CSM # Vol. Page _ CSM Doc # DOCUMENT NUMBER 2026R-61 2337 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 05/29/2026 AT 1:50 PM RECORDING FEE: $30.00 PAGES: 1 Return To: Planning and Zoning Department RECEIVED Bayfield Co. In -ground gravity ❑ In -ground dosed ❑ In -ground pressmen iMeibUtS Save System: ❑ Mound ❑ At -grade Sewage System O Other Area 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. Fitter 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 bylaw. 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. F Owner(s) Name(s) — Please Print Subscribed and sworn to before me on this date: ill Notarized Owner(s) — Signature(s)'Notary . / Public My Commission Expires: Drafted by: _I1 __ti CLAJVf_ Date: _ SUSAN TASCHE NOTARY PUBLIC, STATE OF ILLINOIS MY COMMISSION EXPIRES 5/29/2027 Proofed by: septiomaintenceagreement Revised July 2020 I3 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: SCHOUREK, DAN E & GAIL ANN 404 FIELDSTONE LN HAMPSHIRE, IL 60140-9672 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00412 Transaction Number: SR -00412-47002 Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 15033 Paid by: Andry Rasmussen & Sons, PO Box 66, Cable WI 54821 Payment Type: Check Transaction Date: 6/2/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. P 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: SCHOUREK, DAN E & GAIL ANN 404 FIELDSTONE LN HAMPSHIRE, IL 60140-9672 Description Private Sewage System (Septic Tanks) Submission Number: SS -00747 Transaction Number: SS -00747-4700B Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 15033 Paid by: Andry Rasmussen & Sons, PO Box 66, Cable WI 54821 Payment Type: Check Transaction Date: 6/2/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-57S STATE SANITARY PERMIT OWNER: DAN E & GAIL ANN SCHOUREK GOVT LOT: LOT: 1 &2 BLK: 1/4 114 SEC: 2, T 47 N, R 8 W TOWNSHIP: Iron River SOIL TEST: 47-26 NEW SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: JASON KUETTEL EMILY MACGILLIVRAY DATE: 6/2/2026 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: # MP 675751 Condition: Must meet setbacks for wells on neighboring lots. Properly Maintain System Per Recorded Agreement THIS PERMIT EXPIRES 6/2/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION