HomeMy WebLinkAbout26-74SDepartment of Safety
county is c 1 I
O-] qj
& Professional Services,
Sanitary Permit Number (to be filled in by Co.)
s - v
Industry Services Division
H
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 (ifdiflerent than mailing address
3 q s C T -y Hwy
is required prior to obtaining a sanitary permit. Note: Application forms for - are submitted to
the Department of Safety and Professional Services. Personal information -i=N Se'tlSed far secondary
purposes in accordance with the Privacy Law, s. 15.04(1)O), Stats.
t�
I tr r `` s V e r w S Sy 9
1. Application Information — Please Print All Information
JUN 24 2076
Property Owner's Nam(e� r.lw
Panel #
Amy I� 0.T d eld Co. �ra>
Property Own is Mailing Address planning
and Zoom
Property Location
I
�L I^ r f V t
Govt. Lot
S,V.y/
•,/'A, Section 33
City, State
�f^
/ip Code
Phone Number
'
�j
LAk 1 L J-- L
60o y
e u
047-/0 —Y6—t
Ll1J
T N R 8 E o
I1. Type of Building (check all that apply)
Lot #
Subdivision Name
QC I or 2 Family Dwelling — Number of Bedrooms D[
Block #
❑ Public/Commercial — Describe Use
O City of
❑ State Owned— Describe Use
❑ Village of
CSM Number
)zTownof =rove RIvey
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 licable.)
A.
❑ New System
_a.
pt 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.
❑ Renewal Before
❑ Revision
❑ Change of Plumber
❑ Transfer to New Owner
ist Previous Permit Number and Date Issued
Expiration
IV.
Dis ersal/Treatment Area and Tank Information:
Design Flow (gpd)
Design Soil Application Rate(gpd/sf)
I Dispersal Area Required (so
I Dispersal Area Proposed (sf)
I System Elevation
o
4a9
I43
9s.a
Capacity in
Total
# of
Manufacturer
o
Tank Information
Gallons
Gallons
Units
$
New Tanks
Existing Tanks
c
—
a C:
in y
rn
iz 0
a
Septic or Holding Tank
7
750
VV r A ) I e e f.
'9, it FixwtI v,
-
.--
^-
—
_
V. Responsibility Statement- I, the undersigned,
assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
I Plumber's Signature
-NIPMIPRS Nwnber
Business Phone Number
A1k P I kos k't
poogp715--zq2-T5'6
Plumber's Address (Street, City, State, Zip Code)
Pie gok n.,Tr R. e WS .C'-IL/7
VI ounty/Department Use Only
Approve)
O Disapproved
Permit Fee
s
Date Issued „ I
L
Issuing Agent nature
Si
(NCO/?
O Owner Given Reason for Denial
—
i
L
Conditions of Approval/Reasons for Disapproval
SeQ
Attach to complete plans for the system and submit to the Count) only on paper net less than 8 to s 11 inches in size
SBD-6398 (R. 03/22)
.S fZ.� oogf q
r�sARruk�T Wisconsin Department of Safety& Professional Services SOUL "EST Page 1 of 2
(1t
- Division of IndustryServices (over)
p , SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code County Bayfield
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include,
but not limited to vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. 20021
scale or dimensions, north arrow, and location and distance to nearest road. Ci
Please print all information. Re ' we by �D�ayt�e f
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). t� �L { (,1� ((�s' I £ '! bf
Property Owner Property Location £1 ❑
Amy Richards Govt. Lot NE% SW% S33 T 47 N R 8 E (or) W
Property Owner's Mailing Address Site Address or CSM and Lot #:
157 Beech Drive 64395 County HWY H
City, State, Tip Phone Number ❑ City ❑ Village ® Town I Nearest Road
Lake Zurich, IL 60047 I 847-708-4642 Iron River I County HWY H
❑ New Construction Use: I ResidentialI Numberof bedrooms 2
® Replacement ❑ Public or commercial — Describe:
Parent material: Sandy Glaciofluvial Deposits
General comments and recommendations:
REC'VD derived designflow rate 300 GPD
Flood Plan elevation if applicable ft.
JUN 242026
planning and Zoning
1 Boring # Llaonng
® Pit Ground surface elev. 98.2 ft. Depth to limiting factor 105 in. / elev. 89.5 ft.
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
1
0-9
10YR2/2
-
Is
2mgr
mvfr
cs
3m
.7
1.6
2
-24
5YR3/4
-
s
0sg
ml
cs
2m
.7
1.6
3
-105
2.5YR4/4
-
s
Osg
ml
-
1f
.7
1.6
1-i- J
Boring #
[]Boring
®Pit Ground surface elev. 99.6 ft. Depth to limiting factor 106 in. I elev 90.8 ft.
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
1
0-11
7.5YR2.5/2
-
Is
2mgr
mvfr
cs
3m
.7
1.6
2
-23
5YR3/4
-
Is
Osg
ml
cs
2m
.7
1.6
3
-106
7.5YR5/4
-
s
Osg
ml
-
If
.7
1.6
CST Name (Please Print)
Signatur
CST Number
Tony Polkoski.
�s
11068 - ST
Address
Date Evaluation Conducted I
Telephone Number
5115 County HWY B, Iron River, WI 54847
I 5-28-26 I
715-319-9668
* Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 5150 mglL * Effluent #2= BOD, 5 30 mg/L and TSS 5 30 mg/L
SBD-8330 (R03/22)
Combined Soil Evaluation Plot Plan - System Plot Plan
In -Ground Soil Absorption for POWTS Version 2.1
Owner: Amy Richards 0 50 100 ft
Site -Address: 64395 Cty Hwy H, Iron River, WI 54847
TaxID: D: 18556 N
Legal Description: See Schedule C (OVER)
r----------------------------------------------------------------------9
III
2 Trenches Quick 4 3� Existing Garage
Plus Standard °2 I Pipe Material / ASTM Standard
i
Chambers N, (Tables 384.30-3 & 384.30-5)
I 4 Existing Tank to be replaced
1
t /
/
0
gawith Wieser WLP750-MR
Filter - PolyLoc PL -525
!
.—Existing Well
II
xisting 2 MN-CEIVEO
o
Nestle Lake Bedroom Dome
1 :
Elevation 91.5JUN 24 2026
i '
ExistingN..
i
Bayfeld Co.
p ning and Zoning Agency
/ ?•
1
1
j
,` __; Approximate Property Line \
/1 I
° Soil Test Pits:
e�d
if I
1 - Elevation - 98.2'
,'/ /
2 - Elevation - 99.6'
3 - Elevation - 100' 1/
,I
A Benchmark - Screw in Maple tree II
Elevation - 100' l
Ill
If ii
II
I
I
III
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ii
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Existing system abandonment i
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a
per 383.33 38333 prior to new i
C
system installation. Ii
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PAGE 1 OF 4
In -Ground Gravity Plan
Index & Cover Sheet ZE.CE2VED
Component Manual Design References:
In -Ground Soil Absorption for POWTS Version 2.1 (May 2U22 -20 7l 242026
Page 1 - Index & Cover Sheet Bayfield Co.
Page 2 - Combined Soil Evaluation -System Plot PlaP_lanning and Zoning Agency
Page 3 - Dispersal Area Cross -Section & Plan f1
Page 4 - Management Plan
Enclosures:
Soil Evaluation Report, Sanitary Permit Application,
Wieser WLP750-MR approved tank specifications,
Soil Test Checklist, Sanitary Application Checklist, $450 check
Project Name / Description
Owner Name(s): Amy Richards Phone: 847-708-4642
Owner Address: 157 Beech Dr. Lake Zurich, IL 60047
Project Address: 64395 County HWY H, Iron River, WI 54847
Legal Description: See attached Schedule C
Township: Iron River
Project Tax ID #: 20021
County: Bayfield
Designer Information
Designer Name: Allan Polkoski
Phone: 715-292-4156
Designer Address: PO Box 522, Iron River, WI 54847
E-mail: tony@bearguidenorth.com
License Number: PMRS220090
Remarks: Recorded
PSSMA sent direct to Zoning from Reg
Signature: (��1 `^-� / �'� Date:
Original signature required on each submitted copy.
of Deeds
-;EP EKED
uUN 242626
SCHEDULE C — LEGAL DESCRIPTION planningandAgency
The North 240 feet of that part of Government Lot Two (2), Section Thirty-three (33),
Township Forty-seven (47) North, Range Eight (8) West, lying west of the westerly
boundary of County Trunk "H" in Bayfield County, Wisconsin.
That part of Gov. Lot Three (3), Section Thirty-three (33), Township Forty-seven (47) North,
Range Eight (8) West lying West of County Trunk "H" with the exception of the North 320
feet of said parcel in Bayfield County, Wisconsin.
A parcel of land in the Northeast Quarter of the Southwest Quarter (NEl/a-SWra) in Thirty-
three (33), Township Forty-seven (47) North, Range Eight (8) West, more particularly
described as follows: Commencing at the Southeast corner of said NE'/4-SW'/4, which is the
point of beginning; thence run westerly along the south line of said NE%4-SW'/4 a distance of
250 feet; thence run northerly and parallel with the east line of said NE'-SWM4 a distance of
750 feet; thence run easterly and parallel with the south line of said NEl/4-SW'/4 a distance of
250 feet and to the east line of said NE'/4-SW'4; thence run southerly along the east line of
said NE'/4-SW'4 to the point of beginning.
The foregoing descriptions include all of Nestle Lake and entirely surround said Lake. The
entire acreage of the afore -described property, including Nestle Lake, contains fifteen (15)
acres or in excess thereof. The descriptions located in Governments Lots 2 and 3 border on
County Trunk "H".
Combined Soil Evaluation Plot Plan - System Plot Plan
In -Ground Soil Absorption for POWTS Version 2.1
Owner: Amy Richards
Site Address: 64395 Cty Hwy H, Iron River, WI 54847
Tax ID: 18556
Legal Description: See Schedule C (OVER)
0 50 100 ft A
N
100..
2 Trenches Quick 4 30 Existing Garage
Plus Standard o2$ Pipe Material /ASTM Standard
Chambers (Tables 384.30-3 & 384.30-5)
10 Existing Tank to be replaced
9e with Wieser WLP750-MR
/Filter - PolyLoc PL -525
a s� f Existing Well
Existing 2
Nestle Lake ` ) Bedroom Home
Elevation 91.5' I}
Existing Garage
__t Approximate Property Line
° Soil Test Pits:
1 - Elevation - 98.2'
2 - Elevation - 99.6'
3- Elevation - 100'
Benchmark - Screw in Maple tree
Elevation - 100'
Li
Existing system abandonment I c
per SPS 383.33 prior to new /CD
system installation. 1 D
JUN 242026 ; 0
Bayfield Co. O
Planning and Zoning Ag0flCY /
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SCHEDULE C - LEGAL DESCRIPTION
The North 240 feet of that part of Government Lot Two (2), Section
Thirty-three (33), Township Forty-seven (47) North, Range Eight (8)
West, lying west of the westerly boundary of County Trunk "H" in
Bayfield County, Wisconsin.
That part of Gov. Lot Three (3), Section Thirty-three (33), Township
Forty-seven (47) North, Range Eight (8) West lying West of County
Trunk "H" with the exception of the North 320 feet of said parcel in
Bayfield County, Wisconsin.
A parcel of land in the Northeast Quarter of the Southwest Quarter
(NEI/4-SW%) in Thirty-three (33), Township Forty-seven (47) North,
Range Eight (8) West, more particularly described as follows:
Commencing at the Southeast corner of said NE1/4-SW1 , which is the
point of beginning; thence run westerly along the south line of said
NE1/4-SW1/4 a distance of 250 feet; thence run northerly and parallel
with the east line of said NE1/4-SW'/4 a distance of 750 feet; thence run
easterly and parallel with the south line of said NE1/4-SW1/4 a distance
of 250 feet and to the east line of said NE1/4-SW1/4; thence run
southerly along the east line of said NE1/4-SW1/4 to the point of
beginning.
The foregoing descriptions include all of Nestle Lake and entirely
surround said Lake. The entire acreage of the afore -described
property, including Nestle Lake, contains fifteen (15) acres or in
excess thereof. The descriptions located in Governments Lots 2 and 3
border on County Trunk "H".
IN -GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard -W Chambers
3 -ft Trench (down -sizing credit)
SOIL COVER
12"
min. trench
depth
(typical)
min. 12"
(typical)
(typical)
an
System Elevation = 95.2
(typical)
Septic Tank(s) Manufacturer:
Wieser
Septic Tank(s) Volume(s):
750 gal gal gal gal
Effluent Filter Manufacturer.
Polyloc
Effluent Filter Model #: PL -525
TYPICAL TRENCH
CROSS SECTION VIEW
(No Scale)
ii
Quick4 Standard -W
w/End Cap (Show location on of inlet / outlet pipe connection on plan view.)
ypical)
r- ----------------
H -��----
B= 44eyy ft
INSTALL PER TRENCH: (typical)
Provide minimum 3 ft
separation between trenches.
Observation Pipe
(typical)
Install per manufacturers
/ instructions.
IA=3.0ft
(typical)
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2
TYPICAL TRENCH
PLAN VIEW
(No Scale)
Standard -W Chamber
Trench 1: Iii I
Quick4 Std -W @20112 EISA/chamber+ 220 I
pairs end caps @6 ft2 =
ft2
6
Trench 2: 10 I
Quick4 Std -W @ 20 ft2 EISA/chamber+ 1200 I
pairs end caps @6112 =
ft2
16 I
Trench 3: I
Quick4 Std -W @ 20 ft2 EISA/chamber + II
pairs end caps @ 6 ft2 =
ft2
Required Infiltration Area =
ft2
1429
Distribution Method:
ft2
No. trenches = 12 I Proposed Total EISA = 1432 I IGravity
m
W
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 =
300
gpd; BOD5 S 220 mgL-'; TSS 5150 mgL-1; FOG 530 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use -,LCEWEU
o age of system
o nuisance factors (i.e. odors, user complaints, etc.) JUN 242026
o mechanical malfunction (Le., pumps, valves, switches, floats, etc.)
o material fatigue (Le., leaks, breaks, corrosion, etc.) Bayfield Co.
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e.,R trlbiit? ief'd 9 9 ces)
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.
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.
WLP750-MR
TANK SPECIFICATIONS
DIMENSIONS:
WALL: 2 1/2"
BOTTOM: 3"
4 CAST -A -SE
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Lii
as
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c
a
a
CAST -A -SEAL COVER: 5"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 54"
OUTSIDE DIAMETER: 7'-0"
BELOW INLET: 42"
LIQUID LEVEL: 37"
WEIGHT: 6,150 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: 20.28 GAL/IN
HOLDING TANK:
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 790 GALLONS
LOADING DESIGN: 8'-0" UNSATURATED SOIL
TANK CAN BE USED AS:
SEPTIC / HOLDING / PUMP OR SIPHON
COVER: MIX DESIGN #8 (NO FIBER)
TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
I
T OUTLET
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CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
SIDE VIEW APPROVED
By Glen Schlueter at 8:19 pm, May 30, 2022
REVIEWED BY
REVIEW DATE
DRAWINGS SUBMITTED
FOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
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ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227
SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY
Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e))
0 Check List
19 Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.)
f9 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
0 Original Plot Plan (383.22(2)2. 3. & 4.a)
91 Cross Section, Over -Head Profile of the System and DSPS APPROVED Schematic of Tank from Manufacturer
❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable)
V 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).- y D
IZ Soil and Site Evaluation Report (383.22-3(2)(b)1.e.)
❑ State Plan Review (when applicable)
❑ Copy of Warranty/Quit Claim Deed (Optional)
JUN 24 2026
Bayfield Co.
Planning and Zoning Agency
Sanitary Application: (Include the following Information)
i� I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number
671 II Type of Building
iZ III Type of Permit
0 IV Type of POWTS System
t21 V Dispersal - Treatment Area Information
0 VI Tank Information
0 VII Responsibility Statement (Plumber's Information)
Plot Plan: (To Scale or To Dimension)
E71 Signature and Plumber Information
la Surface Elevation of Body of Water
I Direction and Percent Land Slope
0 Tank and Filter Information and Location
® Wetlands / Navigable Bodies of Water
X Absorption Area (Proposed and Existing)
0 Bench Mark (Location, Elevation and Description)
0 Component Manual Version
iZ Address Number and Road
0 North Arrow
M 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:
Surface and System Elevation
IN Position of Observation and Vent Pipes
6P Dimensions and Depths
E$ Make, Model & Number of Chamber Units in each Cell
Property Information
0 How many systems will there be on this parcel of land? I
tp Has this property been split? f/ C (Property Statement shows Property History)
Fees:
10 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
❑ Return Inspection $ 50.00
❑ Maintenance Agreements $ $ 30.00
(checks made out to Reg of Deeds)
RECEIVED
UN 242026
Bayiield Co.
Planning and Zoning Agency
f'1- 00 a -9't
Private Sewage System Maintenance Agreement
AMY ELIZABETH RICHARDS
Owner(s) Mailing Address
157 BEECH DR, LAKE ZURICH, IL 60047
164395 COUNTY HWY H, IRON RIVER, WI 54847
Tax ID # 20021
As owner, I (we) do hereby certify the private sewage system will be installed in
accordance with the certified soil testers 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: $2.C. for /o `J ' S
Town of i✓ o tZ , J '€.-r (Acreage) Gov't Lot
Lot Block Subdivision
Lot _ CSM # Vol. _ Page__, CSM Doc #
DOCUMENT NUMBER
2O26R-612638
DANIEL.. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
06/22/2026 AT 1 1:08 AM
RECORDING FEE: $30.00
PAGES: 3
RECEIVED
JUN 232026
p vfleld Co. Recording Area
R1aF81ng and zonuiv
Retu POLKOSKI sp4C 2 SEPTIC
TONY PO OSKI
Znniv 3 51159UNTYHWYB a3
IR,96RIVER, WI 54847
XIn -ground gravity
❑
In -ground dosed
❑
In -ground pressure distribution Sewage System:
0 Mound
❑
At -grade Sewage System
❑
Other
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. Filter 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 Inaround 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 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.
Owner(s) Name(s) — Please Print
Subscribed and sworn to before me on this date:
AMY ELIZABETH RICHARDS
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Notarized Ownerss))—signatures)
Notary PPuublllic
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My Commission Ex
Drafted by: TONY POLKOSKI Date: 5-26-26
by: AP
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Revised July 2020
STAG! BAR OF WISCONSIN FORM 3- 2010
DncsmxnlNrnn,a QUIT AlbOE'!1)
This Deed, made between Charles Eduard ItichaNr _ '�c•I1 ^':A +, !rcu
Grantor, and Amy Ellalelh Richard,
Grantee.
Gramor quit chains to Grantee the following dcstibed reel estate In ..
Baal eld County, Slate of Wisconsin (if more
space is needed, please attach addendum):
A mitt) perwnt (30:41 Interest, a, tenants In romman, in the real estate liaoding Area described an attached Eshibll A.
RECEIVED
JUN 237025
Bayfield Co.
Planning and Zoning Agency
This Is not homestead Iropaty.
tc) (Snot)
Together with all appurtenant rights, title and interests.
Dated Uus l3 . day of August , 2004
/ ch.rin Edw Richards �'
AUTHENTICATION
aWrmdcand Bus dayof
-v819rTf1 657
TfGE: MEMBER STATE BAR OF WISCONSIN
(I(set,
authorized by (706.06. Wis. Suits.)
11118 INSTRUMENT WAS DIMArTFI) DY
Arty. Jack A. Carbon SINN 1016698
122 W. Baysleld St., Washburn. W1 51891
(Siemens may W auNenuated or aciraole4BN.11x4 are not neon sy )
QUIT CLAIM DEED
STATE BAR OF WISCONSIN
FORM Na.3- 2000
ACKNOWLEDGMENT
STATE OF WISCONSIN
ss
Buyfdd Comity )
Personallycamebcfore me this 13 day of
August , 2004 the above rumral
Charles Edward Richards
to me lea sus to bo to le. m(s) ash <$ecutni •Ibregousg
instr m I cknms Ith ap..
L it r rtt%a o 1"1
Notary Public, State of WISCONSIN
My Commission is Iennnn nt. (Irvin state cepi)Alion dale
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ie North 240 feet of that part of Government Lot Two (2)/ ✓
action Thirty-three (33), Township Forty-seven (47) North,
inge Eight (8) West, lying west of the westerly boundary
or County Trunk "H" in Bayfield County, Wisconsin.
That part of Gov. Lot Three (3), section Thirty-three (33),
Township Forty-seven (47) North, Range Eight (8) West lying
West of County Trunk "H" with the exception of the North 320
feet of said parcel in Bayfield County, Wisconsin.
A parcel of land ,,n the Northeast Quarter of the Southwest
Quarter (NEb-SW'), Section Thirty-three (33), Township
Forty-seven (47) North, Range Eight (8) West, more particularly
described as follows: Commence at the Southeast corner of said
NEB -SW¼, which is the point of beginning; thence run westerly
along the south line of said NE'-SW'a a distance of 250 feet;
Thence run northerly and parallel with the east line of said
NEB -SW¼ a distance of 750 feet; thence run easterly and parallel
with the south line of said NEB -SW¼ a distance of 250 feet and
to the east line of said NEB -SW'; thence run southerly along
the east line of said NE'-SWa to the point of beginning.
The foregoing descriptions include all of Nestle Lake and
entirely surround said Lake. The entire acreage of the
afore -described property, including Nestle Lake, contains
fifteen (15) acres or in excess thereof. The descriptions
located in Governments Lots 2 and 3 border on County Trunk "H".
RECEIVED
JUN 232026
Bayfield Co.
Planning and Zoning Agency
V899 P564
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BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
Submit the Following (Use Permanent Ink):
:iV E E
X Check List
L Index Page / Title Sheet (Optional) duiJ 2 4 2026
F Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyyers)ay,ield co.
Pzhn!ng and Zoning Agency
X Original Plot Plan
❑ Cross Section Soil Profile Sheet (optional)
❑ Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Report: (Include the following Information)
IR Tax Identification Number (must be 5 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
* Property Owner's Information (not prospective buyer's name)
* Property Location (Accurate Legal Description with Sec/Twp/Range)
IZ Road Name (where driveway is/will be coming off of)
❑ Floodplain Elevation, Flow Rate, Comments and Recommendations
a Complete Soil Boring / Pit Information
1 Date Soil Evaluation was conducted
t CST Name, Signature, Number, Address and Phone Number
5( *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
R Bench Mark (Description, Elevation and Location)
X Contour Lines (Example = 98.0' /96.0' /94.0')
a Property Location (Sec/Twp/Range/, Accurate Legal Description)
R Borings (Locations and Elevations)
a Percent and Direction of Land Slope
CK Well Location (Including Neighboring Wells, if applicable)
® Location of Wetland Areas, Floodplain and Navigable Waters
CK Buildings, Driveways, and Structures (Location and Descriptions)
Location of Property Lines
Existing System Location
Address Number and Road Name
IRl Current Surface Elevation of Wetlands and Navigable Waters
D( CST, Owner and Property Information
X North Arrow
Fee:
JR Certified Soil Tests - Review & Filing Fee $ 50.00 u/forms/sanitary/checklist/checklistforests
A 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:
RICHARDS, CHARLES EDWARD & AMY
ELIZABETH
157 BEECH DR
LAKE ZURICH, IL 60047
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00449
Transaction Number:
. SR-00449-48FE5
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
Reference: 6325
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 7/1/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
I tYFIELD 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:
RICHARDS, CHARLES EDWARD & AMY
ELIZABETH
157 BEECH DR
LAKE ZURICH, IL 60047
Description
Private Sewage System (Septic Tanks)
Submission Number:
SS -00780
Transaction Number:
SS -00780-49008
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 6325
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 7/1/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-74S
STATE SANITARY PERMIT
OWNER: CHARLES EDWARD & AMY ELIZABETH RICHARDS
GOVT LOT: LOT: BLK:
NE 1/4 SW 1/4 SEC: 33, T 47 N, R 8 W
TOWNSHIP: Iron River
SOIL TEST: 73-26
REPLACEMENT SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: ALLAN POLKOSKI
EMILY MACG I LLIVRAY DATE: 7/1/2026
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. Old System needs to be properly
abandoned per SPS 383.
THIS PERMIT EXPIRES 7/1/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION