HomeMy WebLinkAbout26-73SDepartment of Safety
County
Y$"S. & Professional Services,
Sanitary Permit Number (to be filled in by Co.)
CS _Obrl �1 Q b Industry Services Division
J L U
Sanitary Permit Application
State Tansaction 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 stale -owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
N/f
purposes in accordance with the Privacy Law. s 15.04t I)(m), Slats.
I. Application Information —Please Print All Information
Property Owner's Name
`Pare P -
38 1IS
D ra L PcJ-re✓' JUN 2220
Property Owner's Mailing Address
\ Bayfield Co.
Property Location
p R
a ( R a le\l N so vt Planning and Zoning Agency
Govt. Lot
W
�E �—
City, State I
Zip Code
Phone Number
6trvle wz
sydZo
71S -517 -old s
'• .section
T 18 N R F o®
II. Type of Building (check all that apply)
Lot
11 I or 2 Family Dwelling — Number of Bedrooms
Subdivision Name
Block #
❑ Public/Commercial — Describe Use
O Cityof
❑ State Owned — Describe Use
O Village of
CSM Number
Kl Townof Quid
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
a licable.
A.
�. New System
❑ Replacement System
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatment Unit (explain)
e'
Holding Tank
❑ In -Ground
❑ At -Grade
❑ Mound
❑ Individual Site Design
I ❑ Other Type (explain)
(conventional)
C.
❑ Renewal Before
❑ Revision
❑ Change of Plumber
g
❑ 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/sf)
I Dispersal Area Required (sf)
I Dispersal Area Proposed (sf)
I System Elevation
SO
—
Capacity in
Total
k of
Manufacturer
Tank Information
Gallons
Gallons
Units
o
o
New Tanks
I Existing Tanks
' o
o
v
y
o
q
r= Urn
.Septiq or Holding Tank
flea
.'
2
t
w iesef WLP
X
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
-MPfMPRS Number
Business Phone Number
4Ilot tPelkosk,
4-
noogv
715'-292-91Sfo
Plumber's Address (Street, City, State, Zip Code)
Po @oz &fl. Trv.n P. Qe✓ w = 5 I2 Y
VI. ountyADepartment Use Only
Approved
O Disapproved
Permit Fee
I Date Issued
Issuing Agent Si mature //
f
O Owner Given Reason for Denial
_ 306
Y
(GJ/rhl
Conditions of Approval/Reasons for Disapproval
Attach to complete plans for the system and submit to the County only on paper not less than 8 V2 x 11 inches in size
SBD-6398 (R. 03/22)
Soil Test #
Bayfield County
5 12- � Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1 -1 0(d))
P01 kos r ; a certified soil tester determine that in my professional
judgment th� 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.
RECEiVED
Property Owner Dminc. L Fet t re.i Contractor
JUN 222026
Bayfield Co.
Property Address /1// 1\ T'e.x ID - 38 LIr Authorized Agent Planning and Zoning Agency
Agent's Telephone
Telephone -7 I S.- 19 (i — O 1 O Written Authorization Attached: Y or N
Accurate Legal Description is requested:
1/4 of Stu Section _Township N. Range 9 W. Town of L iJ
Additional Legal Description: [ X12. S k) M Doe- a o 1 q K —S7 q l(o £17
Govt. Lot Lot Block Subdivision
Lot CSM# Vol. Page CSM Doc #
Volume Page of Deeds Tax I.D# 38 II S Acreage S
Indicate reasoning for your determination: fk e ox % rw,.r Alii � -C Loo'y fe. t ud'e. PreSev►-r
W clne.s o.c -rt,e t4 In o (a) C b) £
g/4
Signature of tertified Soil Tester
ijV18c'
Sign fur o County icial.
(2/Ofo ,
Date
Date
ll0618--sT
Certification #
(Submit a Plot Plan & Fee)
ufforms/soiltestwaiver(KLK)
June 2018
Soil Evaluation Plot Plan - System Plot Plan
Component Manual Design References:
Holding Tank Version 2.1
Owner: Dana L Falter
Site Address: No Fire Number
Shared driveway with 2515
Rankinson Rd, Brule, WI 54820
Tax ID: 38115
Legal Description: NE SW
S29-T48N-R09W
E 1/2 SW IN DOC 2019R-579647
Town of Oulu, Bayfield County, W
o Soil Test Pits
Approx. Property Line
® Benchmark
Screw in Birch tree
Elevation - 100'
---------------------
E1VED
JUN 222026
Bayfield Co.
Plann:rlg and ?c,nn rc Agency
I
I
Wieser WLP2500
Pipe Material:j&1BVj00PM::e:
ASTM Standa
(Tables 384.3
384.30-5)
0 50 100 ft
o
II C//
II
CLto
moo
t4� I
I .CCU
L
Q
Proposed
Garage
O1
o2
No existing wells or existing POWTS on Property
1 I
I I
I I
I I
I I
I I
I I
I I
1 I
I I
I I
I I
I I
I I
I I
I I
I I
I I
I 1
1 1
I I
L---------------- -- ----- - - ----- - !
Plumber: Allan Polkoski - PMRS 220090 Soil Evaluated By:39n Polk ski - 11068-ST
a,+-rte-
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Holding Tank Version 2.1 (May 2022-2027) RECEIVED
Pg 1 of 4 Index & Cover Sheet JUN 222026
Pg 2 of 4 Plot Plan Bayfield Co.
Planning and Zoning Agency
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Enclosures: �}lct„ Te.rd< c& /ecY»e,'(i , RdlJina "Rxvtk
W L -P a soo T&N k Spas, Sovod1 c Lie CJ —f , $1 Sv ct,e-c.k
Project Name / Description
OwnerName(s): Dana. L 1-oal-re_r Phone:?/�_-'17 -DtoS
Owner Address: Q S I S Ro.n K',r\ sor. Rd (3r u lt, W 2 Zip: 5991 o
Project Address: NI A
Govt. Lot: AJ E 1/4 of Ski 1/4, Section a 9 , T W N -R g E❑ or w
Township: ()u LU County: 13a�t-Field
Project MD #: 3 8 l IS
TAX
Designer Information
Designer Name: A I l o � hPo I kOS ki Phone: 7 /S -aqa - 91 S 6
Designer Address: PO f qc S'L-L1, Irv. Ref, Wt Zip: S 9 g Y )
E-mail: Tov j@6earoo�Uenoe-T- .corr-.
License Number: P,rR S Z Z 0 0 9 b
Remarks:
Signature: ___� '______ Date: - ( O -Z
Original signature required on each submitted copy.
Soil Evaluation Plot Plan - System Plot Plan
Component Manual Design References:
---___--_-_-
Holding Tank Version 2.1
Owner: Dana L Falter
Site Address: No Fire Number
Shared driveway with 2515
Rankinson Rd, Brule, WI 54820
Tax ID: 38115
Legal Description: NE SW
S29-T48N-R09W
E 1/2 SW IN DOC 2019R-579647
Town of Oulu, Bayfield County, WI
0 Soil Test Pits
Wieser
0 50 100 ft
.11
f N
/ p
C
c
J
au-)
o a c m
0c>
o c
• Z 0O
Na
O Y �
ac
o_ cu -C
¢ofd
_; Approx. Property Line
® Benchmark
Screw in Birch tree I Pipe Material: proposed3 waged RECEIVED
ASTM Standard Bedroom
Elevation - 100' I (Tables 384.30-3 & Home JUN 2 2 2026
384.30-5)
I O 1 Bayfield Co.
03 Planning and Zoning Agency
o2
No existing wells or existing POWTS on Property
Plumber: Allan Polkoski - PMRS 220090 Soil Evaluated By: Tony Polkoski - 11068 -ST
PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
JUN 222026
Bayfield Co.
Plann'
Electrical must comply with
SPS 316 and NEC 300
18" Min. V
(typical)
e
Inlet/
Approved Joints vrith J
Approved Pipe 3 ft onto
Solid Ground e
A
e
Weatherproof
12" Min. or 2.0 ft above
Ong Cu Zoning Agency
Junction and
Approved
Established Flood Elevation
Alarm Box
Vent Cap
(typical)
Approved Locking Manhole
40 Vent Pipe
with Warning Label Attached
onduit
>10 ft from
(typical)
4" Min. or 2.0 ft above
Building
Established Flood Elevation
1
(typical)
\/
Airtight Seal
Finished Grade
Plug
Max. 12" or 90% of total volume
if more than one tank
Alarm -On
HOLDING TANK
VOLUME = 2500 gal
3" Approved Bedding Material Beneath Tank
TANK MANUFACTURER: Wieser WLP2500
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
PAGE4OF4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s) 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 holding tank(s)
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.
Estimated Daily Wastewater Flow = 450 gpd
Inspection Checklist INSPECT EVERY 3 YEARS RECEIVED
o type of use
o age of system JUN 22 2026
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) Bayfield co.
o material fatigue (i.e., leaks, breaks, corrosion, etc.) Planning and Zoning Agency
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o surface discharge of effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Scats.
when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s).
Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Name of individual or company:
Local government unit: Bayfield County Zoning Phone:
Local government unit address: Washburn, WI
Iron River Septic
Phone: 715-372-4006
715-373-6138
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 component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
System Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
WLP2500
TANK SPECIFICATIONS
183j"
DIMENSIONS:
WALL: 3"
BOTTOM: 5"
COVER: 6"
- - - - - - - - - - - - - - - - --
II 4" CAST -A -SEAL 4" CAST-A-SEAL��III
I/r-s. ^XI
I \ FILTER OR
BAFFLE
- - - - - - - - - - - - - - - - -
TOP VIEW
€CElVED
JUN 222026
Bayfleld Co.
planning and Zoning Agency
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 55 1/4" O.D.
LENGTH: 183-1/4" O.D.
WIDTH: 101-1/4" O.D.
BELOW INLET: 43" O.D.
LIQUID LEVEL: 36"
WEIGHT: TANK - 15,527 LBS.
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
DESIGN #8 (NO FIBER)
ESIGN #9 (SMALL FIBER)
TANKS:
;TOM TANKS CONTACT WIESER CONCRETE
DRAWINGS SUBMITTED(
FOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
NI
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Holding Tank Owner(s) Name(s)
A LI3lLTg?
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
PROIECr
LOCATION
Legal Description:
Tax
Tax ID# y �/! �
I t K
1 �� u_
14, 1/4, E-_ 5u_
(Use Statement)
,,.JS
.-L=_c
Section ,Township N, Range 7_ w
Town of:
J /
I Lot Size I
Acreage
Gov't Lot
Lot #
CSM Of
Vol. Page
CSM Doe St
Lot(s) No.
Black(s) No,
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:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank; JUN 222026
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank; eayfieid Co.
a. The dates on which the holding tank was serviced; Planning and Zoning Agency
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
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) bLH
s Siigq tur (s) Subscribed and•Sworn to me:
-Duo / /1��� onthlae2 day of i�
by...,PLiM
tpull llOuri�
My commission expires on:
Revised: May 2016 (®May 2018) Drekadyy.' YJ gVB LtC' .I.
Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (I)(m)] -V •., ::��
HOLDING TANK
Vwner Name (s) I uwnerta) Mailing Aooreso n d
p1,IR ( cALT L SS t2.rc"sa.r "
(vaa,t y. $NSL=
Parcel Identifier Number (PIN) Agreement Date (same as Notary Date)
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 Ch, 145, Wis Stets.
N E 1/4 of c� S Ui 1/4 Section Z f Township `f d N. Range W,
Town of CuR'
v
Additional Legal Description: SW'Vnboc-Zb19 R_5'79ipl{7
Gov't Lot _ Lot_Block_Subdivision CSM#
Lot CSM # Vol _Page _CSM Doc#
DOCUMENT NUMBER
2026R-6 1 2507
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
O6/1O/2O26 AT 1 1 :O3 AM
RECORDING FEE: $30.00
PAGES: 1
Return To: '2 /
vtt �c. / k-es/c.
'Svc. �:�er-�r13 SY8Y7
As an inducement to Bayfeld 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 properly serviced in response to orders Issued by Bayfield County or ihq
Department of Commerce to prevent or abate a human health hazard as described Ins. 254.59, State., Bayfield County may enter.uporb!C.D
the proparty 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. 68.0703, State. N 22 2026
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 lank. Bayffefd=c.
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 th& O Agency
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.261.17 (3) Wis. Stets., and chapter NR 114 Wis. Adm. Code, to
have the holding tank serviced in accordance with Ch. NR1 13, 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. State., 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.
1111111 fill
wner(s) Name(s) — Please Print
Subscribed and sworn to before me on this da e\ Q N
JDF�NA � i4�r�R
`y�P ,.......!!
05/.2q/A `
_ oTAR
N Y
No izedOwner(s)—Slgnature(s)
NotaryP blic
mil, PUBLIC
My mission Expires:
' �c •...,,,,...'0
Drafted by:1O o &t/ Fo I koS K.r Date; t
Personal Information you may be used for secondary purposes lPrlvacy taw, x.15.04 (Ij(m)j
Wfon lafsanitaryd,oldingtenkegreemenl.dos eLune 2018
SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY
Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e))
O Check List
• 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 DSPS APPROVED Schematic of Tank from Manufacturer
El Pump Tank Diagram, Alarm and Pump Curve (when applicable)
O Contingency Plan / Management Plan (383.22-3(2)(b)1.f.)
El Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds)
R 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)
O ATU Servicing Agreement (Recorded at Reg. of Deeds)
6d Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
V 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.) RECEIVED
El State Plan Review (when applicable)
O Copy of Warranty/Quit Claim Deed (Optional)
JUN 222026
Bayfield Co.
Planning and Zoning Agency
Sanitary Application: (Include the following Information)
V I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number
V II Type of Building
0 III Type of Permit
V IV Type of POWTS System
0 V Dispersal - Treatment Area Information
0 VI Tank Information
V VII Responsibility Statement (Plumber's Information)
Plot Plan: (To Scale or To Dimension)
0 Signature and Plumber Information
❑ Surface Elevation of Body of Water
❑ Direction and Percent Land Slope
0 Tank and Filter Information and Location
❑ Wetlands / Navigable Bodies of Water
El Absorption Area (Proposed and Existing)
0 Bench Mark (Location, Elevation and Description)
O Component Manual Version
0 Address Number and Road
O North Arrow
O Contour Lines
O Structures and Driveways
0 Boring Locations
0 Property Lines
0 Well Locations
60 Legal Descriptions
O Piping Material Information (conveyance line, building sewer line, material type and diameter)
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
1 How many systems will there be on this parcel of land? I
IQ Has this property been split? (Property Statement shows Property History)
Fees:
❑ Private Sewage System (Septic Tanks)
�I Private Sewage System (Holding Tanks)
❑ Mounds or Systems requiring Pre -Treatment
❑ Sanitary Revisions
❑ Private Sewage System Reconnection
and Private Interceptor
❑ Return Inspection
$ 400.00
$ 400.00
$ 500.00
$ 25.00
$ 50.00
$ 50.00
❑ Maintenance Agreements + $ 30.00
(checks made out to Reg of Deeds)
VA,Y--.F1ELDBayfield 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:
FALTER, DANA L
2515 RANKINSON RD
BRULE, WI 54820
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00448
Transaction Number:
SR-00448-48FB1
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
Reference: 6323
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 6/30/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
3 A -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:
FALTER, DANA L
2515 RANKINSON RD
BRULE, WI 54820
Description
Private Sewage System (Holding Tanks)
Submission Number:
SS -00778
Transaction Number:
SS-00778-48FB8
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 6323
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 6/30/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-73S
STATE SANITARY PERMIT
OWNER: DANA L FALTER
G OV'T LOT: LOT: B LK:
NE 1/4 SW 1/4 SEC: 29, T 48 N, R 09 W
TOWNSHIP: Oulu
SOIL TEST: 72-26
NEW SYSTEM
SYSTEM TYPE: Holding Tank
PLUMBER: ALLAN POLKOSKI
EMILY MACGILLIVRAY
Authorized Issuing Officer
DATE: 6/30/2026
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: # MPRS 220090
Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all-
weather road.
THIS PERMIT EXPIRES 6/30/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION