HomeMy WebLinkAbout26-0290BAYFIELD COUNTY Zoning District
C S,00) 6/ SANITARY PERMIT APPLICATION Lakes Class
I. APPLICATION INFORMATION
Soil Test
I County O b
r (Please Print All Information) -.
No:
I Permit No:
Property Owner's Name:
Post- (
County;, Bayfleld
Address of Property:
Property Location:
11
55C.SS rcIct44 1�. f:�
'/4 ¼.517 T L{SN,R 9 E (orVl
Property Owner's Mailing Address:
Township: I
Gov. Lot #:
Sa_r n is
City, State
I Zip Code
I Phone Number
Lot #
I Block #: I
CSM #: I
CSM Doc #
Subdivision Name
Srdon r
5`
II. TYPE OF BUILDI : (Check One)
❑ State Owned
Tax ID#:
public (Explain the use/purpose )
3 co oZS ENiE EO
or 2 Family Dwelling - No. of Bedrooms
JUN 2 3
111. TYPE OF PERMIT: (Checkonly one box on line A. Check box on line B, if applicable)
A) 4�yNew ❑ Replacement County Private Interceptor Plant';n ; 'IC Zcr„ _s, agency
Reconnection ❑ Repair ❑ Revision " ❑ Transfer of Owner (List Previous Owner below)
3fa�
B) A Sanitary Permit was previously issued. Previous Permit Number. /mate Issued: _ / 5
IV. TYPE OF NON -PLUMBING SYSTEM: (Check One) * Replacements need previous permit number and date filled out above
C) ❑ Pit Privy ❑ Vault Privy (Vault size: _gallons or _cubic yards)
❑ Portable Privy ❑ Camping Transfer Unit Container ❑ Composting Toilets ❑ Incinerating Toilet
V. ABSORPTION SYSTEM INFORMATION:
1. Gallons
2. Absorp. Area
I 3. Absorp. Area I
4. Loading Rate
I 5. Perc. Rate
I 6. System I
7. Final Grade
Per Day
Required (Sq.Ft.)
Proposed (Sq. Ft.)
(Gals. / Day / Sq.Ft.)
(Min. Inch)
Elev.(Feet)
Elev. (Feet)
VI. TANK
Capacity
Fiber
INFORMATION:
In Gallons
Total
Gallons
# of
Tanks
Manufacturer's
Name
Prefab.
Concrete
Site
Constructed
Steel
-
glass
Plastic
Exper.
App.
New
Existing
Tanks
Tanks
Septic Tank or
_0 08
Holding Tank
Lift Pump Tank /
Siphon Chamber
VII. RESPONSIBILITY STATEMENT:
I the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Owner's Name(s: (Print) Ifapplyingfor Section Cabove Owner'sSignature(s): (No Stamps)
Plumber, rvam : (Print) ifap tyrigfor Section or a) above I Plumber's Sig t No Stamps) MP/MPRSW No:
�a y o 3
Plumber's Address: (Street, Cit
`d
State, ip Code)
l�dMe
Home Phone:
3a33
Business Phone:
Sawt,
/C/ £2LJ'cIr
C Q/,
7/C828
VIII. COUNTY / DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit/Transfer Fee:
Date Is ued: Issuing A e is Signature / Date:
6/aN�2b
Approved ❑ Owner Given Initial
`� Adverse Determination
/3,7/3
4j21z2-
IX. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
Plot Plan on reverse side
Lot Line
Loft
Is -c'
V
Ld+J* 7
C.
cL
wtl1
JUN 23
2026
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u/forms/sanitary/bayfieldcountysanitaryapplication
Revise: June 2018
Proofed by:
13M FIELD Bayfield County
Planning & Zoning Department
117 E 5th Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-4010
Property Owner: Submission Number:
CS -00166
Transaction Number:
CS -00166-4886F
Description Amount
Private Sewage System Reconnection $50.00
Total: $50.00
Payment Amount: $51.25
Reference: 1969724435
Paid by: Paul Malinovsky
Payment Type: Other
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
Town, City, Village, State or Federal
Permits May Also Be Required
LAND USE -
SANITARY - Reconnection
SIGN -
SPECIAL -
CONDITIONAL -
BOA -
BAYFIELD COUNTY
PERMIT
WEATHERIZE AND POST THIS PERMIT
ON THE PREMISES DURING CONSTRUCTION
No. 26-0290 Tax ID: 3354
Issued To: MALINOVSKY, PAUL R & MICHELLE L
Location: S18 - T45N - R09W
Town of BARNES
Legal Description: BLACKDEERS ADD TO POTAWATOMI LOT 69 IN V.1163 P.768 1852
Residential Structure in R-1 Zoning District
For: Sanitation Permit — Reconnection [Previous Permit # 404270 (05/14/2003)]
(Disclaimer): Any future expansions or development would require additional permitting.
Condition(s):
You are responsible for complying with state and federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or
modification of construction that violates the law or other penalties or costs. For more information, visit the department of natural resources wetlands identification web page or contact a department of natural resources service center (715) 685-2900.
NOTE: This permit expires two years from date of issuance if the authorized construction
work or land use has not begun.
Changes in plans or specifications shall not be made without obtaining approval.
This permit may be void or revoked if any of the application information is found
to have been misrepresented, erroneous, or incomplete.
This permit may be void or revoked if any performance conditions are not
completed or if any prohibitory conditions are violated.
Tracy Pooler, AZA
Authorized Issuing Official
June 24, 2026
Date