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HomeMy WebLinkAbout26-66SDepartment of Safety County �` i JUN 6 2026 & Professional Services, Sanitary Permit Number (to be filled in by Co.) S Industry Services Division s^ sayteld co ,nano onm9A9eno/ SS -00773 j oC G — �O Iv Sanitary Permit Application State Transactio NNumber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department Project Address (if different than mailing address) of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. I5.04(1)(m), Stats. .t e I. Application Information — Please Print All Information Property Owner's Na a / /7 Clent�oh (�✓S747-Sox kLD�Bs�� Property Owner's Mailing Addres ' / 7 g 3 o S-><�. -C tTw ! 3 Property Location Govt. Lot Dili Z© a r City, State a Zip Code Phone Number -1 / S 8! 3 floeflOe S 1,, SL 1,,, Scotian 3 O T 5 0 IL Type of Building (check all that apply) Lot # iK I or2 Family Dwelling— Number of Bedrooms 3 N R Subdivision Name O Public/Commercial — Describe Use Block p ❑ City of ❑ State Owned — Describe Use CSM Number 0 Village of Town r ( �y 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. ❑ New System Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. ® Holding Tank ❑ In -Ground ❑ At -Grade ❑ Mound ❑ Individual Site Design ❑ Other Type (explain) (conventional) C. 0 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: Des Flow Design Soil Application Rate(gpd/sf) Dispersal Area Required (80 Dispersal Area Proposed (at) System Elevation ,"f/ Je— Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units e , aC4 E rn a 6 Ncw Tanks Existing Tanks iZO a. Seplie«sHolding Tank 2-.cD0 ,_ 7100 ll)ee5et/ GonC, mbar V. Responsibility Statement- I, the undersigned, assume responsibility for installation of time POWTS shown on the attached plans. Plumber's Name (Print) Plumber's i mature I ImrrtS Number I Business Phone Number Allah f o I l-os k; I 2zoo9 O ,7rsa�a-�{/s4o Plumber's Address (Street, City, State, Zip Code) ODK s za yr.ttJe.r T CY'8V7 VI. County/Department Use Only Approved 0 Disapproved Permit Fee Date Issued,my , Issuing Agenm gn ❑ Owner Given Reason for Denial /ct Conditions of Approval/Reasons for Disapproval / ) 04 Z n Altar!' en mmnlnm uluue fn. u.n....re......a ...e...u._ n._ e.__.... __._ .. .... ...r �.uu... V.,, u.. y.per nu[ tins [ban a 1,, Y II Illehiw in 912, SBD-6395 (R. 03/22) r � •' Iw•+k ��� 16 2026 SR_060 q`(5 Soil Test # Bayfield County ^a Band Zoning A9encY Bayfield ptannin9 Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) i_A II u.i/t Pko S 4 1 a certified soil tester determine that In my professional Judgment the following site (see below) is unsuitable for any treatment component other than holding tanks. Due to soil & site conditions, a thorough soil and site evaluation is not needed to make such a determination. Property Owner 6 ` '0-P O &+ ≤VS a. 5 p Y Pro pert Address 3 S a +'e //4i/ !3 i v Telephone -7 1 S g 13 7 z 60 Accurate Legal Description Is requested: Contractor Authorized Agent Agent's Telephone Written Authorization Attached: Y or N =114 of S1/4 SectionTownship S b N. Range _W. Town of _ r ` `' .� g Additional Legal •Description: z © o Govt. Lot Lot Block Subdivision Lot____ CSM#,_ Vol. _____Page CSM Doc # Volume Pageof Deeds Tax I.D# Acreage Indicate reasoning for your determination:0--3'5'c .3-- /0 "C w�.�e a �rM mn 14 ?4 .. Signaturf of Count Official Date 6 Signature of Certified Soil Tester Date c.≤ 422.0090 Certification # (Submit a Plot Plan & Fee) u/forms/solltestwalver(KLK) June 2018 a�"�;,P.�. �' "'f•� �w ►�1 a �' o c!Ie..i4J'i uf7'41Dki 73t Sfr e /!3 ?av + (4',� w g� Ii d f z≤ `' s4 S St(n ' ON R g w I�;�� odi kote-cos ,II psi. £#LtCkS w. ?)1f Jgp % EI.vIao.e •-, 4 34 5ck /0 hvC vukv 1 o w 1. i s"ev-* 1 o,w q " A STa'kl D 17 195 ct, p��7 v- �+ tJ'�'.. � f� -. •'" ©-r rnl$- -� Sc�..ko I' N+ R: s&y;3 I iz oo 41 v uJ� .ser .Tetbi k •I -a 'loiu C,,,,e. i n1 e- :tt1 #rt , 0 7 / Q ei T H co 146 Ic'; atcjCtbi k Cep, I� a.tQT FY)c vlLtia1 ccs c46�%r�►a..8` ' (vR , C y ) i�rre.L.L)n AY: JOI.P. ..5,Ucoil _LLIJ vv I LnIl1III C LUIV(Nl No,. 9975 P. 2 Pg1of8 Holding Tank Plan RcE;Vt51 OFS Index & Cover Sheet JUN 162026 Bayfield Co. 11 Component Manual Design References: Planning and Zoning Agency IYl Qw-e l i�pe ^' � s.® r l�; C -zoZ7) Pg2of Pg3ofg Pg 4 of 8 Attachments: roc 7 o4!? fir 3 oj- Si Index & Cover Sheet Plot Plan Holding Tank Specifications - z Fe Se S Management Plan POWTS Application for!, Review[sctn; krvPerm, r APP) Soil Evaluation Report & Site Map (if applicable) Holding Tank Pumping Contract (if applicable) Holding Tank Agreement (if aoolicablel Project Name / Description Owner Name(s): on s qfs Phone: 7/S- _ 7 z 00 Owner Address: 7330 S+a e (--f /j 7cc+(J;fly u -3f Zip: 5 Y'LoS Project Address: S« wt P a S Gc t r u e Govt. Lot: uJ aozi ccl,401 /4 of SE 1/4, Section <' ,T ' N -R E ❑ or W Township: f o kt L -U r "S 7 Project Parcel ID #; aX ZASO Designer Information Designer Name: /« Pc, o s Phone: L(/Sr Designer Address: t? ch• r' e /c Szz 1 r„ k, ,,i p e U°l Zip; SOSS''7 E-mail: -(-c in Lam? L •Lr,cocLa tLI . e ` Thiy space reserved for approval stamp. License Number: z z o C.3 C) C Remarks: �� Signature: 1 c--- Date: ' _7 Original signature required on each submitted copy. V,rcp'2V'tyOwcic.ro Lev,,t DescrPi-E"✓10 C12vtJov//i(yus/4{^son se cE4 st�3°Ts0N gKW 7g3D sf4e W11 it3G W? -Des T A l L..cwot Y Cr, ac,.rrT �''ct�ir.cl Jcaeik�z,Ee-Fs d.1( s2UN1. A.1 C•. #6oue 4'.tc( yrctJc -a- .5. 4ht OfN�tor= RME J)`P- J.leulco.o.' 7--,'i—'ay II„AST;`Y) DI? )s$'ctt?�9rc'u'c'_J p.pc_ ctI t1 * c -f 8cArn se 3 m S SCI I 5crsn.Qe/',: II AI S le.o !' � k1C'l+Lo1 less nl97'E (�! 1' NJutvcs+ Rd, sTh l -e 4-w y/ r3 a Ce alien w:ccer Cencre_Ir_T nk= !8 "L -'c 2''uJ e W3" -f'v o'n ba•H-eneiof Tcc ik i-a FlovCo'e, in)E± .4a\ 6Q_i�Qfy� 3e ° k to ^;fit rv5�5 g(p Eke 0�6J 1 C i n He It!' &tI`T« >t tc Cen, panne- IoJ< �v)(anu CL/ Lt S�a dr9Pu✓4 o.g (VER2.I�; Cb�9aY2ezZ^2®L(ay�7) b/rmt.ott 13y: ii'I,P.sS'. zzeoga Pe ekes k, FILL kk, ; flry Pr,43n sz2 lren R+u2t� ur 5yb"Y7 PROPERTY OWNER: PLUMBER: Allan PoikoskV Polk SIGNATURE: 2 -'--- DATE: (c 2-(o LICENSE # —_220090 HOLDING TANK SPECIFICATIONS W „q Number of bedrooms �LGEIVED N Non-residential estimated flow d „ 2b0 l 00,Minimum holding tank volume'required (gal) ) JUN 16 2026 Tank Dimensions and Data for round tank •JW Wawa 6i.0 Liquid depth below inlet invert (in) 8.0 Maximum de th of soil cover (ft) 71.8 Height (in) Outside 169,6 Length (in) Dimensions 93.0 Width (In) Only Junction box _� conduit -- blind plug to seal outlet Bayfeld Co. Planning and Zoning Agency Manufacturer model number manufacturer fiber Tank Anchor Calculations IM'AIY4V ICYq 8880 lbs Weight of tank and cover 1.50 Safety factor 40207 lbs Weight of anchor required 40.8 J In Soil cover req. for anchor or 9.sjjyd3 Concrete counter weight HOLDING TANK CROSS SECTION manhole cover with ,�— looking device and finished vent cap warning label grade 4" min. I I In. Y 12" min. Manhole and vent locations may be reversed, vent pipe T 16" min. service ,� ^12,0 In, _._. ,_._•�._•—,_,_,^._ bulldingaewer alarm on T Note: All ta�l� I l .� Inlet Electrical as per NEC 300 and Comm 16 Joints between tank openings and piping are 39.0 In. sealed watertight, All pips and vent materials compl with;r g '$3 sl. a" 3 In. bedding under tank. Tank Is anchored as necessary to negate buoyancy. WLP2500 TANK SPECIFICATIONS C 183}" 4" CAST -A -SEAL 4" CAST -A -SEAL FILTER OR BAFFLE N o O a � INLET " U t M TOP VIEW SIDE VIEW 73 TLET co i0 M U - d - M il' TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS DIMENSIONS: WALL 3" BOTTOM: 3" HEAVY - 5" COVER: 6" MANHOLE 24" I.D. PRECAST CONCRETE RISER HEIGHT: 52-3/4" O.D. LENGTH: 183-1/4' O.D. WIDTH: 101-1/4" O.D. BELOW INLET: 41" O.D. LIQUID LEVEL 36" WEIGHT: TANK - 3" BOTTOM 12,560 LBS. TANK - 5" BOTTOM 15.527 LBS. WEIGHT: COVER 9,300 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 69.44 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,639 GALLONS LOADING DESIGN: 8' 0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN p8 (NO FIBER) TANK: MIX DESIGN #9 (SMALL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: 041 -b � N OQ N 90 0 0) U15 U) �OF 1 HOLDING TANK MANAGEMENT PLAN JUIV lb 2026 Bayflzld Co. This Private Onsite Wastewater Treatment System (P0WTS) has been designed, and'IVtm1.4t8s1aM1te99sp maintained according to5f%3973 Wis. Admin. Code, the Holding Tank Component to`�nual w5tcJ "'Mo-n v .l type VER2o and the -Pe (4 County Sanitary Ordinance. v E 2 1' j %m �Y ° —zoL7) 1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 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 Servicing 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 6PS 383 and:84 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 10 business 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 6P5 963,33 Wis. Adm, Code. 10. If there is a problem with, or question about this !installation, the following persons should be contacted: a. Installer .............................po psg PjaYnijny tn,P.R.5.$zz.009O Phone: 7nC 37z— WeS b. Service Provider.................. ' 6et4; •R b t t _ Phone: '7,.4- 372.- woo& c. Co. Zoning or Health Dept. ®ay Couwfin Zon:nq Phone: 7/ j ?-fl— 6/it 11 Project Transaction Number: RECEIVED JUN 182076 HOLDING TANK SERVICING CONTRACT Bayfield Co. Planning and Zoning Agency Contract Date S- -Z ZOO G��bo+� �I• Gvts�a�son This contract is made between the Pumpers name (Pent) Pu s Signature Pumpers' Registration # We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION Legal Description: Tax ID# (Use Tax Statement) z u C C' SE 1/4, SE 1/4, t'c zoo Section L, ,Township '-� N,Range W Town of: I Lot Size I Acreage Govt Lot Lot # CSM If Vol. Page CSM Doc U Lot(s) No. Block(s) Na. Subdivision: 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: tit N Igrr II1, a. The name and address of the person responsible for servicing the holding tank; �o` b. The name of the owner of the holding tank; 9 c. The location of the property on which the holding tank is installed; S y �� q,Q t' d. The sanitary permit number issued for the holding tank; _ -1 : A e. The dates on which the holding tank was serviced; = . G8L!c f. The volumes in gallons of the contents pumped from the holding tank for each servicing; p' •.• g. The disposal sites to which the contents from the holding tank were delivered.hhhr,SCpNS�``•�` 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a chan,r! 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 Swom to me: on this 9 d y orH, O/tlld° G��n by: Notary ublic My commission expires on: Revised: May 2016 (®May 2018) Drafted by ) r Personal information you provide may be used for secondary purposes (Privacy Law, 5.15.04 (I)(m)] DOCUMENT NUMBER 2026R-61 2470 ClendUI GuSgion 7336 1/e 13 Parcel Identifier Number (PIN) Agreement Dete (same as Notary•Date) a4-042 2 5b Ot-3D Yfl1oC s-z9�-2 ' on the following property or that continued use of the existing premises requires that t 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 p�piitte1�i under Ch. SPS 383, Wis. Adm. Code or Ch. 145, Wis Scats. &j'&j'f a o 77 0 V 51 114 of 3S 114 Sectlon,31)Townshlp 50 N. Range 0 W. Town of PO f-1 W im Additional Legal Description: -kkS•i 200 -f 1 ($fe, Govt Lot — Lot_Block_Subdivision CSM# Lot_CSM # Vol _Page _CSM Doc# DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED O6/O8/2O26 AT 1 1 :O3 AM RECORDING FEE: $30.00 PAGES: 2 RECEIVED JUN 16 2026 Bayfield Co. Return To: 2"t rz- / ktSk. j'vo �ti. o� i r)l Sq$Y7 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 falls to have the holding tank property serviced In response to orders Issued by Bayfield County or the Department of Commerce to prevent or abate a human health hazard as described In s. 254.59. State., 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, Stets. 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. Scats., and chapter NR 114 Wis. Adm. Code, to have the holding tank serviced in accordance with Ch. NR113, Wis. Adm. Code, and to file a copy of the contract with Bayfield County. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the county within 30 days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed pursuant to s. 281.48 (3) Wis. Scats., and Ch. NR 114, Wis 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 shell 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. `\\\0%111 r� lu,, `\' Owner(s) Name(s) — Please Print Subscribed and sworn to before me on this date:$ ma-i: .' ..... NO? - Notarized Owner(s)—SI ure(s) 7Efl No ry Public = a: (C ��i� OHO'•........ My Cdr in Expires: 4p /Scut"` /&- Drafted by: t O It / ?o I k0 S K r Personal Inronrollon you�e used for secondary purposes iPdvacy Law, s.15.04 (p(m)i Date: 51Z' /&Pa6 ulfom&aanuarymadingmnkegreemenl.doc eJune 2018 UMENT NO. WARRANTY DEED 'i THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 i ------ ----- •...7%_ _.._,.I DOCUMENT NO. J WARRANTY DEED 368474 STATE BAR OF WISCONSIN FORM 2•-1982 --------•• Signed H. York--••-----------•----__.._••--•................•-•......---..__----•.. ................. conveys and warrants to ________________ GUS afson, a--si, man; ............................................................ the following described real estate in ............Ba-jifi el d„ ...... .--- .:...............County, State of Wisconsin: THIS SPACE RESERVED FOR RECORDING DATA REGISTER'S OFFICE f ayft1d County. Wis. 5 RECORDED AT , " It ONE C C i e t99Q Il rrx TaxParcel No :..............................ref 6 The West Two -hundred (200) feet of the Southeast One -quarter of the Southeast One- quarter(SE¼ SEA) of Section Thirty (30), Township Fifty (50) North, Range Eight(8) West. in i � Dom'. No - I ct linty/, Wis. 's'; 388510 DED ATII,•gdA. M. ..31 CT 8 1990 This ......................homestead property. (is) (is not) TWSFER FEE _ FEE EXEMPT OQ # r RENTAL WEJ THERl 1TION S. 0,.Q, _ 'EXE F lON •# Exception to warranties: easements and reservations of prior record' hereto. Dated this ....................................day of _............. ,...�t',_1 -------------- Q Ei -� --- --...- ...----- ... (SEAL) .....--•.. •AU-• .3�►�!'v. '" --• - ..: �::�.:: .... • _Sigri ed .- ,York_. '4: I • ', � +16 a4 'rVN_0_ %T......... .-. (SEAL) . '-�tC)TARIAL. a...............................................................- �.`•mot'. ............. BAYFIELD COUNTY RECEIVED CHECKLIST FOR SANITARY APPLICATONS JUN 16 2026 Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Bayfield Co. (di Check List Planning and Zoning Agency a' Original Sanitary Application (Submitted In Deed Holders Name — no prospective buyers) (383.21(1)1.) Pi Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 9 Original Plot Plan (383.22(2)2. 3. & 4.a) t2(Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer rytl Pump Tank Diagram, Alarm and Pump Curve (when applicable) G+! Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) 0 Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) ii Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) (i Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) a Fee (Make Check Payable to Bayfleld County Zoning) (383.21(2)(c)7) 47! 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) WI Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) ❑ State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) lET I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) M Project Address or Road Name where driveway is/will come off of) WI II Type of Building M III Type of Permit Grf IV Type of POWTS System ❑ V Dispersal / Treatment Area Information id VI Tank Information 56 VII Responsibility Statement (Plumber's Information) ❑ *Date Stamp* Plot Plan: (To Scale or To Dimension) tiff Signature and Plumber Information I 'Surface Elevation of Body of Water ❑ Direction and Percent Land Slope 99 Tank and Filter Information and Location Z Wetlands / Navigable Bodies of Water 0 Absorption Area (Proposed and Existing) iii Bench Mark (Location, Elevation and Description) tI Component Manual Version 1O Legal Descriptions 19 Piping Material Information (conveyance line, building sewer line, material type and diameter) 59 (Owners Phone Number) 19 Address Number and Road 10 North Arrow ❑ Contour Lines ti! Structures and Driveways G3 Boring Location R1 Property Lines Q Well Locations Turn Over ► Cross -Section and Over -Head Profile of the System: ❑ 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? 1 ❑ Has this property been split? N D (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 fit 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/farms/checldlsts/checklistfcrsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: I ti BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): RECEIVED JUN 16 2026 Bayfield Co. Planning and Zoning Agency Z Check List 9 Index Page / Title Sheet (Optional) Irk .Original Soil Evaluation Report (Submitted in Deed Holders Name — rro prospective buyers) I Original Plot Plan O Cross Section Soil Profile Sheet (optional) O Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Repo : (Include the following Information) ® Parcel Identification Number (must be 23 di it Tax ID#) DO NOT USE 12 digit, they are no longer being used Cpl Property Owner's Information (r o prospective buyer's name) 121 Property Location (Accurate Legal Description with Sec/Twp/Range) ld Road Name (where driveway is/will be coming off of) I1 Floodplain Elevation, Flow Rate, Comments and Recommendations i Complete Soil Boring / Pit Information 0 Date Soil Evaluation was conducted L CST Name, Signature, Number, Address and Phone Number 0 *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) 10 Bench Mark (Description, Elevation and Location) 9 Contour Lines (Example = 98.0' /96.0' /94.0') I l Property Location (Sec/Twp/Range/, Accurate Legal Description) 9 Borings (Locations and Elevations) 0 Percent and Direction of Land Slope E0 Well Location (Including Neighboring Wells, If applicable) E6 Location of Wetland Areas, Floodplain and Navigable Waters I Buildings, Driveways, and Structures (Location and Descriptions) 91 Location of Property Lines 96 Existing System Location 121 Address Number and Road Name 9 Current Surface Elevation of Wetlands and Navigable Waters 16 CST, Owner and Property Information 9 North Arrow Fee: ii Certified Soil Tests - Review & Filing Fee . $ 50.00 U/forms/sanitary/checklist/checkiistforests It-A,Ar]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: GUSTAFSON, CLENDON W 7830 STATE HWY 13 PORT WING, WI 54865 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00445 Transaction Number: SR -00445-4809D Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 6321 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 6/19/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. P YFIELD Property Owner: GUSTAFSON, CLENDON W 7830 STATE HWY 13 PORT WING, WI 54865 Bayfield County Planning & Zoning Department 117 E 5th Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-0114 Description Private Sewage System (Holding Tanks) Submission Number: SS -00773 Transaction Number: SS -00773-48099 Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 6321 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 6/19/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-66S STATE SANITARY PERMIT OWNER: CLENDON W GUSTAFSON GOVT LOT: LOT: BLK: SE 1/4 SE 1/4 SEC: 30, T 50 N, R 8 W TOWNSHIP: Port Wing SOIL TEST: 64-26 REPLACEMENT SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: ALLAN POLKOSKI SCOTT ROUSH Authorized Issuing Officer DATE: 6/19/2026 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; 19790.34,221; 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: # 220090 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. Old System needs to be properly abandoned per SPS 383. THIS PERMIT EXPIRES 6/19/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION