HomeMy WebLinkAbout26-76Sr,,'
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Industry Services Division
County
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4822 Madison Yards Way
Sanitary Permit Number (to be filled in by Co.)
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Madison, WI 53705
P.O. Box 7302
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Madison, WI 5302
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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 (if different than mailing address)
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide Ra�bo-usedVElydary
purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. 11''CCCCtt++�G �I VV GG IIJJ
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I. Application Information —Please Print All Information -
Property Owner's C
JUN 0 8 2026
Parcel 4 ��, r �,( Z
`Na�me
SM, Vota� (�V tf��V
Bayleld
na*1-Z`-M,.bs� j a5 avar
Go,
Property Owner's Mailing Address Planning and Zoning Agency
Property Location
��
M,t�
S S S f= \moo �0
Govt. Lot Z
City, State
I Zip Code
Phone Number
C�nRrae Cv t, —a r
.SM W
2.18- S%_kg _ W "
Section
T y N R O1 E orQ
II. Type of Building (check all that apply)
Lot 4
Subdivision Name
-
�lor 2 Family Dwelling-' of Bedrooms
NT��
Block #
❑ Public/Commercial - Describe Use
O Cityof
❑ State Owned — Describe Use
O Village of
CSM Number
i 'own of 2.4aNe$.
III. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i
a licable.
A.
❑ New System
"teplacement System
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatment Unit (explain)
B•
❑ Holding Tank
'In -Ground
❑ At•Grade
❑ Mound
❑ Individual Site Design
❑ Other Type (explain)
(conventional)
C.
❑ Renewal Before
Expiration
❑ Revision
❑ Change of Plumber
❑ Transfer to New Owner
(Permit Number a Date Issued
ListPrevious � 2 x'75 /�/�
0
,3
7n ptW3
IV.
Dispersal/Treatment Area and Tank Information:
Design Flow (gpd)
Design Soil Application Rate(gpd/sf)
I Dispersal Area Required (sf)
I Dispersal Area Proposed (sf)
I System Elevation
ySc�
/,�
2CPf
33a
93.E
Capacity in
Total
N of
Manufacturer
Tank Information
Gallons
Gallons
Units
o v
u
New Tanks
I Existing Tanks
c
v
y
a—
a.L)
in w
y
i% 0
n.
Septic or Holding Tank
IeOb
(
•j
Dosing Chamber
V. Responsibility Statement- 1, the undersigned,
assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
I Plumber's SignatureI
MP/MPRS Number
I Business Phone Number
t2E'6 h SN10
f3fotft0
3�tS-24t2�
Plumber's Address (Street, City, State, Zip Code)
5azZs-n4L ha.. S te. t -sr
VI, County/Department Use Only
pproved
❑ Disapproved
Permit Fee
Date Issued
m 3L
u g Si amore —7
❑ Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval
Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size
SBD-6398 (R. 02/22)
S# _____
Wisconsin Department of Safety and Professional Services ®�L TEST Page 1 of 2
• '` dos Division of Industry Services K! SOIL EVALUATION REPORT
p$
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. ( ��
scale or dimensions, north arrow, and location and distance to nearest road. 123/041.00 • Z 44 -4 48 1 aS'�Z -I1o�
7 Please print all information. y 7 Date
Personal information you provide may be used for seconda acy Law, s. 15.04(1)(m))JffA
Property Owner Property Location
MITH JOINT REVOCABLE TRUST Govt. Lot Z '/. Y. S , 8 T 4t j N R E (or) W
roperty Owner's Mailing Address Site Address or CSM and Lot #:
1885 SMART ROAD I'8g5 ftVAIL - Rc P ,p
City State Zip Code Phone Number 0 City ❑ Village Town Nearest Road
GORDON WI I 54838 ( ) BARNES
[] New Construction Use: Residential/Numberof bedrooms 3 Code derived designflow rate O GPD
Replacement 0 Public or commercial -- Describe: Flood Plan elevation If applicable/ft. N
Parent material________________________________________��
General comments and recommendations:
Boring # CBoring
1
Pit
Ground surface elev. ft. Depth to limiting factor in. / elev. ft.
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
1
-6
__._
S
OMSG
1F
.7
1.6
-4S
.5YR6/4
--
S
OMSG
W
IF
7
1.6
5-70
r.5YR414
---
S
OMSG
W
7
1.6
0-184
.SYR4/6
----
S
OMSG
AL
3W
.7
1.6
Boring #
Boring
Pit Ground surface elev. ft. Depth to limiting factor in. I elev. 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
ECE
VE
2026
Planr
ng and Zc
ing Agency
CST Name (Please Print)
Signature
CST Number
GREG YOUNG
231040
Address
Date Evaluation Conducted
Telephone Number
6502 TOWER AVE 1
6-3-26 l
3952929
* Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2= BOD, s 30 mglL and TSS s 30 mg/L
SBD-8330 (R04/21)
e. %
(2e tiE EW S-nKk, f oeb �9..
ref .._ . �M
I
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1,,.sk 8tr5.8 i
AScsti-t r4 i
F ECEIV�D
JUN 082026
PlannFng and Zon Rf g Agen
GSF WI IN -GROUND DESIGN PROGRAM
INDEX AND TITLE PAGE
Project Name:
SMITH
Owner's Name:
SMITH JOINT REV TRUST
Owner's Address:
1885 SMART ROAD
GORDON WI 54838
Legal Description:
18-44-09
Township:
BARNES
County:
BAYFIELD
Subdivision Name:
Lot Number: 2 Block Number:
Parcel I.D. Number: 04-004-2-44-09-18-1 05-002-14000
Plan Transaction No.:
Page 1 Index and title
Paget
Data entry
RECEIVED
Page 3
GSF system views
Page 4
Lateral and dose tank
JUN 0 8 2026
Page 5
Distribution media
Page 6
System maintenance specifications
Bayfie d Co.
Page 7
Management and contingency plan
Planning and Zoning Agency
Page 8
Pump curve and specifications
Designer: GREG YOUNG License Number: 231040
Date: 6/5/2026 ..-7 Phone Number: 3952929
Signature:
Designed Pursuant to the
GSF In -Ground Component Manual (N. 11/19), and
SSWMP Publication 9.6 Design Pressure Distribution Networks for STSAS (01/81)
GSF In -Ground Version 3.1 Page 1
GSF WI IN -GROUND DESIGN PROGRAM
DATA ENTRY
Site Information
R Residential or Commercial Design
300 Design Flow (gpd)
1.6 In -Situ Soil Application Rate (gpd/ft2) EFF #2
Trench Information
B43 Unit Used
10 Cell Width (ft) 3,4,5,6,8,9
]Additional Units per Row or Trench
Number of Bedrooms (
99.6 Original Grade
2
33 1= Length (ft)
Are the laterals the highest point
in the distribution N J
Pressure Distribution Information network? Enter Y or I
G Center, End, No Manifold (Pump to Gravity), or Gravity (No Pump)
5 Lateral Spacing If N above, enter the elevation (ft)
2 Number of Laterals of the highest point. __
Orifice Diameter (in) (e.g. 0.25)
Estimated Orifice Spacing (ft) _/orifice
Forcemain Diameter (in) _._--
Forcemain Length (ft) Does the forcemain drain back?
L Inside Pump Tank Elevation (ft)
System Head (ft) x 1.3
Vertical Lift (ft)
Friction Loss (ft)
Add'I Fitting Friction Loss (ft)
_________ITotal Dynamic Head (ft)
Lateral Diameter Selection
in. diam.
options choice
0.75
1.00-_
-_---_-
1.25
1.50
2.00
3.00
Septic Tank Information
1000 Septic T_ ank Capacity (gal)
WIESER Mfg.
Manufacturer
Dose Tank Information
Dose Tank Capacity (gal)
Dose Tank Volume (gal/in)
Mfg.
Forcemain Drainback (gal)
5x Void Volume (gal)
Minimum Dose Volume (gal)
System Demand (gpm)
RECEIVED
JUN 082076
hayfield Co.
Planning and Zoning Agency
Gallons/Inch Calculator
Total Tank Capacity (gal)
Total Working Liquid Depth (in)
gal/in
Effluent Filter Information
POLYLOCK _ I Filter Manufacturer
525 Filter Model Number
Project: SMITH Page 2
GSF WI IN -GROUND DESIGN PROGRAM
GSF IN -GROUND DRAWINGS
Plan View
In -Ground Component Dimensions
Al10.00 ft BI 33.00 ft DI 0.50 ft F 7.00 in
H l_ 1.00 ft Excavation Depth 5.90 ft
From Grade
660.00 (ft2) Basal Area Available Finished Grade q q
Lateral Invert Elevation 94.78
Dispersal Cell Elevation 94.2
Bottom of Excavation 93.7
Typical Cross Section Trench View
---Rwsr�GRAD
MN1rOF FABRCGECIIERLE
CLEAN FILL(H) FABRIC UITERAL NWAW
ELEVATION
T (F) Bt}$ piEVARSALCELL
ELEVATION
(I MOUNDAND MOUND snND
BOTTOM OF
EXCAVATION
L ,Xr
��- 2ft
or
(no
cUZ
Xu
vo
0.5 ft
Typical Dispersal Cell
See Page 5
Geotextile
Fabric —
I 1
A
See details on page 4 for number, size and spacing of laterals.
Laterals are located in the 4" gravity distribution pipes as shown on page 5.
Project: Page 3 of 8
GSF WI IN -GROUND DESIGN PROGRAM
DISTRIBUTION MEDIA
GSF Distribution Cell Media Layout
10 Cell Width (ft) I 2.5 Sidewall to Lateral (ft)
Distribution Cell Cross-section Arrangements
Drag appropriate drawing to space below.
nd
r
Lateral
Turn -up (contained in Turn -up Enclosure)
Distribution Cell Plan View Layout -Typical
10 Cell Width - A (ft) I 33.00 Cell Length - B (ft)
8 B43 Modules Required per Row
16 B43 Total Modules Required
Pump to Gravity Diagram
Drag appropriate drawing from left to space below.
RECENEU
JUN 082026
Bayfield Co.
planning and Zoning Agency
f'�vYw��`j: .:oaf.;; raixn.�+.hr �, Ya�tS g�p�•hyy �rJn•uu.:i,� 'NY���v Fn i*��.ih'L4n'„y,�����`
{^ � y �a5d.� .t YF. Y�l Sik. J 'i e` R 4-1 k� ( �Y ? N "i'� �wt+ `!� � .�✓
+'� 9 ( "� i �,. @•i yes"=R,.3�.g�£el y�'.!^r�Sa ,J 3 -�' `4e:
,«"`;r+�. fi� yu,,,-'�z°•"-�';:; Vie• y +i: „� .� w.y�i�,.�3;.,��',eY-�e; "t•',R
Project: SMITH Page 5
GSF WI IN -GROUND DESIGN PROGRAM
SYSTEM MAINTENANCE SPECIFICATIONS
System Maintenance and Operation Specifications
Service Provider's Name YOUNG PLUMBING I Phone (715) 395-2929
POWTS Regulator's Name BAYFIELD COUNTY j Phone I 715-373-6156
System Flow and Load Parameters
Design Flow - Peak 300 gpd Maximum Influent Particle Size 1/8
Estimated Flow -Average 200 gpd Maximum BODSI 30
Septic Tank Capacity 1000 gal Maximum TSS 30
Soil Absorption Component Size 330 ftz Maximum FOG 10
Maximum Fecal Coliform 10E4
Service Frequency
Septic and Pump Tank
Effluent Filter
Pump and Controls
Alarm
Pressure System
In -Ground System
Oth ,
Inspect and/or service once every 3 years
Should inspect and clean at least once every 3 years
Test once every 3 years
Should test monthly
Laterals should be flushed and pressure tested every 1.5 years
Inspect for ponding and seepageonce every 3 years
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to the standards, have a watertight cap, and are secure
shown in the Eljen In -Ground component manual.
2. Dispersal cell media conforms to Eljen products approved for use with the most recent Eljen In -Ground Coml
Manual. Eljen media is covered with the manufacturer's geotextile fabric.
3. All gravity and pressure piping materials conform the requirements in the state code.
4. Tillage of the basal area is accomplished with a mold board or chisel plow.
5. The system structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help
penetration.
RECEIVED
Lateral Turn -up Detail
6-8 DIAMETER
LAWN SPRINKLER
FINISHEDGRADE - - - - - -
LATERAL ENDS AT LAST 4" PERFORATED PIPE
ORIFICE WHERE VARIABLE 4" ENI
LENGTH CLEANOUT BEGINS CA
DISTRIBUTION LATERAL
LATERAL CLEANOUT
JUN 082026
Bayfield Co.
Planning and Zoning Agency
THREADED
CLEANOUT PLUG
%-"] LONG SWEEP 90 OR
/// TVW 45 DEGREE BEI
SAME DIAMETER
AS LATERAL
Project: SMITH Page 6
GSF WI IN -GROUND DESIGN PROGRAM
MANAGEMENT AND CONTINGENCY PLAN
System Management Plan
General
This system shall be operated in accordance with SPS 82-84 Wis. Adm. Code, and shall maintained in accordance
with its' component manuals Eljen In -Ground Component manual November 2019 and SSWMP Publication 9.6
(01/81)] and local or state rules pertaining to system maintenance and maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death.
Septic and pump tank abandonment shall be in accordance with SPS 83.33, Wis. Adm. Code when the tanks are no
longer used as POWTS components.
Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness.
Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any
opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 -
inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entryRECE VED
tank or component.
Septic Tank JUN 082026
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The Id Co.
contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operatawwming Agency
of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection.
The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed
unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure.
If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter
alarms may indicate surge flows or an impending continuous alarm.
The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the
liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment,
maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than
maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not required.
However, if such products are used they shall be approved for septic tank use by the Department of Commerce.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be
tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as
In -Ground and Pressure Distribution System
No trees or shrubs should be planted on the system. Plantings may be made around the system's perimeter, and the
system shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost
penetration. Traffic (other than for vegetative maintenance) on the system is not recommended since soil compaction
may hinder aeration of the infiltrative surface within the system and snow compaction in the winter will promote frost
penetration. Cold weather installations (October -February) dictate that the system be heavily mulched as protection
from freezing.
The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended
that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed
it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred
and if orifice cleaning is required to maintain equal distribution within the dispersal cell.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to
the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more
frequent monitoring.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to
keep the system in proper operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall
be immediately repaired or replaced with a component of the same or equal performance.
If the in -ground component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will
be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing
biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed
necessary to bring the system into proper operating condition.
See Page 6 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: SMITH Page 7
�-N
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RECEIVED
JUN 082026
Bayf eld Co
Planning and Zoning Agency
g _ Fe;gin
JUL 3 0 200 ^Qu 81
OIJ,ALUATION REPORTPe e0 3Wiscon of$ fertmentofCO l-- Young'asoilTasting
WofSafelyandBulldings Inaccordancewith5,WIe.Adm.Code County
Attach complete no Bald en. ni 0Pisi
mcbrde but not !mitedd to: verf and hhoorizontal reference fs�'
� �eQph �jdJ� aroel l.D.Beyflddpercent ebpe, Scale ofdimemeions, north stariresresxoan. Qv 1 �„ OPlease pent sit lnformetlon.JUL 1 5 2003, n1 emewred By n z
Perwnalbrameden you prodder maybe used foraecondayphep Laa,s
'ropertyowner
U L' V 11%11"
Freiman, Made
property Owner's Mailing Address
2911 Rd Oak Dr
City
State Zip Code Phone Number
Harvard
I IL 18003315'/5"-9¢3 -ri3
NewConetructlon
Use: a Residential/Numberofbadrooms
Replacement
Q1I Public or commetctai • De'soiibe: _
Parent material till
General comments
Int J 1M 1/48 18 T 4t NR 9 W
Block # 8ubd. Name or CSM#
F City g Village Ai Town Nearest Road
Barnes 1 J tnca' nrd
2 Code derhred design flow rate 300 GPO
Flood plain atevatlon, It applicable N/A
Boring
i Bcdng # Pa Ground Surface elev. 104'8"
lti¢grJ 4epti ooneraitColor ftedoxDees$rton
8. Dapth to limiting
Texture I Structure
factor
Gonaielence I
152
Soumiay
In.
Rooter
SollAppicedanRd
GPW
1 0-46 7.5y 014
a Omsg
rot
gd
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• Efnuent#2= 80D !°A mgh and TSS s2
• Efltuerd.#1 = 800120c_2WA m and TSS n30 c 150 mg1L CST idur
caTNameiPiseaePrhitl 9lgnatu� 2'31040
Property Ovmer Frd5nan Mama
F'dre.ai
3 f
Boring #
184'8"
li' Depth to
limiting factor
152 in.
Soil AppAcetlon Refs
L�
Pit
im Pit
Ground Surface elev.
Texture
Structure
Consistence
Boundary Roots
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" Efguent #2 = BODgeyO mgtand TSS S�0 mg/L
" EBluent-#4e= BOD h.3D <?20 mgtL- ee is au ?CO a1 po mglL der and mnployec If Y�neeil assstance to access services of
The Depafhnatt of Commeece is an equal oppoihwity service prow'
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RECEIVED
JUN 082026
Bayfield Co.
Planning and Zoning Agency
SS - 007 63
Private Sewage System Maintenance Agreement
vwoeqsj Plume
MACt Srn r'flA ► 4 o t Sru r7N TRv crec p s
s.t, tTh .a., -sr Qev TRvsr
18$5 Srrtnp& Ro+�
1vtsW.. ` Par n
prt�ppK. Z- MM• o4 —t$ —1 oS-OC2— 19.80
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 1/4 Section Township L4 N. Range o9 W.
Additional Legal Description: s' #t"�`&t' L 3l
Town of tat2I SS (Acreage) • ___ Gov't Lot
Lot Z Block Subdivision
Lot _ CSM # Vol. _ Page _ CSM Doc #
DOCUMENT NUMBER
2026R-6 1 2479
DANIEL J_ HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY, WI
RECORDED
06/08/2026 AT 1:58 PM
RECORDING FEE: $30.00
PAGES:2
Area
Return To: �+d.. t
Planning and Zoning DgM�rtl'VE®
JUN 092026
Planning and Zrg honi'
In -ground gravity
❑ In -ground dosed
❑
In -ground pressure distribution Sewage System:
❑
Mound
❑ At -grade Sewage System
❑
Other E L-Cci.EP4
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 (113) 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, Ws. Admin. Code.
Private Sewaoe 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. Atarade, and In -around 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 Bay?leld 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.
Ow r(s) Name(s) — Plea J a Pd t
f�1 tr%ls- ct
Subscribed and sworn to before me on this date: ;••'
Jwvw. L av a
r
`41
No ner(s)— na
No u
ry Pblic r111 A nd.b -
My Corn ssion Expires:
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Drafted by: ��•16 ' r'tiy Date: (7— 1 -, ZL
Proofed by:
u/fonns/sanitarylsepticmeintenceagreement
RevIsed July 2020
File Code: HAY-BayFA
File Number: 154564
ADDENDUM/EXHIBIT A
That part of Government Lot Two (2), Section Eighteen (18), Township Forty-four (44) North, Range Nine (9)
West, Town of Barnes, Bayfield County, Wisconsin, described as follows: Commencing at the Northwest corner
of said Government Lot 2; thence running South, on the West line of said Government Lot 2, 1290 feet to a
point; thence running East, parallel with the East-West quarter line of said Section 18, 2190.9 feet, to a point;
thence North variation 18° East 114 feet to the Point of Beginning; thence running North 18° 00' East, 105
feet to a point; thence running South 89° 30' East, 216 feet to a point; thence running South, 100 feet along
shore of Middle Eau Claire Lake to a point; thence running West 228 feet to the Point of Beginning.
ECEWVED
JUN 09 2026
Bayfield Co.
Planning and Zoning Age
BAYFIELD COUNTY
CHECKLIST FOR SANITARY APPLICATONS
\ Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e))
i Check List
X67 Original Sanitary Application (Submitted in Deed Holders Name — ii 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) (R=CS WED
Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer JUN 08 2026
0 Pump Tank Diagram, Alarm and Pump Curve (when applicable)
Bayfield Co.
\\ Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) Planning and Zoning Agency
`9 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)
Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
N 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached
\ to all copies)
D 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)
\l I Application Information must include: ❑ 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete)
❑ Project Address Q Road Name where driveway is/will come off of) ❑ (Owners Phone Number)
\bl II Type of Building
\mil III Type of Permit
SI IV Type of POWTS System
V Dispersal / Treatment Area Information
VI Tank Information
L'] VII Responsibility Statement (Plumber's Information)
*Date Stamp*
Plot Plan: (To Scale or To Dimension)
Signature and Plumber Information \"ID Address Number and Road
Surface Elevation of Body of Water `❑ North Arrow
Direction and Percent Land Slope \'tJ Contour Lines
Tank and Filter Information and Location EI Structures and Driveways
\ Wetlands / Navigable Bodies of Water "E] Boring Locations
'1!I Absorption Area (Proposed and Existing) 7 Property Lines
\`F] Bench Mark (Location, Elevation and Description) E7 Well Locations
0 Component Manual Version '51 Legal Descriptions
Turn Over ►
Cross -Section and Over -Head Profile of the System:
\ Surface and System Elevation
"C Position of Observation and Vent Pipes
'E] Dimensions and Depths
"i
i Make, Model & Number of Chamber Units in each Cell
Property Information
\
\`C] How many systems will there be on this parcel of land? $
`El Has this property been split? N (Property Statement shows Property History)
\Fees:
�] Private Sewage System Tanks)
$ 400.00
(Septic
❑ Private Sewage System (Holding Tanks)
$ 400.00
RECEIVED
❑ Mounds or Systems requiring Pre -Treatment
$ 500.00
❑ Sanitary Revisions
$ 25.00
JUN 082026
❑ Private Sewage System Reconnection
$ 50.00
Bayfield co.
and Private Interceptor
Planning and Zoning Agency
❑ Return Inspection
$ 50.00
\
`E] Maintenance Agreements +
$ 30.00
(checks made out to Reg of Deeds)
u/forms/cheddists/checkristforsanitaryapps (10/2009);(®7/2011);(®2/2012X@5/2R012-dc) Proofed by:
BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
Submit the Followin4 (Use Permanent Ink):
eck List
Index Page / Tide Sheet (Optional)
Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers)
l 'Original Plot Plan
❑ Cross Section Soil Profile Sheet (optional)
❑ Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Reaort: (Include the following Information)
11Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
"Propertyi Owner's Information not prospective buyer's name)
liProperty Location (Accurate Legal Description with Sec/Twp/Range)
l7' Road Name (where driveway is/will be coming off of)
Floodplain Elevation, Flow Rate, Comments and Recommendations
l3Complete Soil Boring / Pit Information
[Date Soil Evaluation was conducted
C?�CST Name, Signature, Number, Address and Phone Number
gr*Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
ABench Mark (Description, Elevation and Location)
UContour Lines (Example = 98.0' /96.0' /94.0')
11Property Location (Sec/Twp/Range/, Accurate Legal Description)
Borings (Locations and Elevations)
Lf'Percent and Direction of Land Slope
Well Location (Including Neighboring Wells, if applicable)
l(Location of Wetland Areas, Floodplain and Navigable Waters
[(Buildings, Driveways, and Structures (Location and Descriptions)
9 Location of Property Lines
[(Existing System Location
Address Number and Road Name
❑4irrent Surface Elevation of Wetlands and Navigable Waters
Ga CST, Owner and Property Information
[(North Arrow
RECEIVED
JUN 082026
Bayfield Co.
Planning and Zoning Agency
Fe
Certified Soil Tests - Review & Filing Fee $ 50.00
U/forms/sanitary/checklist/checkHstforsts
6FIELD Bayfield County
A
Planning & Zoning Department
117 E 5th Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-0114
Property Owner:
SMITH JOINT REV TRUST
1885 SMART RD
GORDON, WI 54838
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00433
Transaction Number:
SR-00433-475BA
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
Reference: 21014
Paid by: Young Plumbing & Heating, 6502 Tower Ave, Superior WI 54880
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.
13AYFIELD 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:
SMITH JOINT REV TRUST
1885 SMART RD
GORDON, WI 54838
Description
Private Sewage System (Septic Tanks)
Submission Number:
SS -00763
Transaction Number:
SS -00763-49192
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 21014
Paid by: Young Plumbing & Heating, 6502 Tower Ave, Superior WI 54880
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)-26-76S
STATE SANITARY PERMIT
OWNER: SMITH JOINT REV TRUST
G OV'T LOT: 2 LOT: B LK:
1/4 1/4 SEC:18, T 44 N, R 9 W
TOWNSHIP: Barnes
SOIL TEST: 74-26
REPLACEMENT SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: GREG YOUNG
TRACY POOLER
Authorized Issuing Officer
DATE: 7/1/2026
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 #: 404375
LICENSE: # 231040
Condition: Properly Maintain System Per Recorded Agreement
THIS PERMIT EXPIRES 7/1/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION