HomeMy WebLinkAbout26-81SDepartment of Safety
County
Qa
g P5 c S- oo7 $ 3
& Professional Services,
Industry Services Division
�-
Sanitary Permit i umber (to be filled in by Co.)
I' J
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 may be used for secondary
purposes in accordance with the Privacy Law, s. 15.041 l)(m), Stats.
I. Application Information — Please Print All Information
Property Owner's Name
I Fi �1 O
Vii'
Rot no ; J
TAX/j1.,
iJ
Property O ner's Mailing Address ���
Property Location
Sa-7o,u1dit Rd
Govt Lot 1
Q1/"' '1/s. Section �l e
State
Zip Code
Phone Number
-City,
trov.\ R'lvetr W Z
699T7
7IS--37a-966
T N R gE o W
IL Type of Building (check all that apply)
Lot H
Subdivision Name
I or 2 Family Dwelling —Number of Bedrooms
Block H
❑ Public/Commercial— DescribeUse
❑ City of
❑ State Owned — Describe Use
❑ Village of
CSM Number
MTown of Nu9Ifes
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 liable.
A.
❑ New System
y
Replacement System
p y
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatmen a (explain)
JUL 0120
B.
❑ Holding Tank
a�
�In-Ground
❑ A[ -Grade
❑ Mound
❑ Individual Site Design
Other Type (explain)
(conventional)
I
Sayfheid Co.
ptaflflh
C.
❑ Renewal Before
❑ Revision
❑ Change of Plumber
❑ Transfer to New Owner
List Prevmu InghF�# $Date Issued
Expiration
IV.
Dispersal/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
3OO
L43
6.s
Capacity in
Total
Hof
Manufacturer
Tank Information
Gallons
Gallons
Units
o
g
New Tanks
I Existing Tanks
c
ti
2
y n
n
Ch
i% CO
a
Septic or Holding Tank
OD 3ov
(Om
I
I
W es r
Dosing Chamber
V. Responsibility Statement- I, the undersigned,
assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Plumber's umature
W/MPRS Number
Business Phone Number
r'
1 rA oS (C
z_�e—
L
Plumber's Address (Street, City, State, Zip Code)
PO ?uoX SZ2 Zfb R;-, w z s s v
VI. couatylDepartmentunty/Department Use Only
pproved
0 Disapproved
Pemmt Fee e
$
Dale Issued
Q� t L
Issuing Agents Signature —P
w /
❑ Owner Given Reason for Denial
(F�
l
11 i ( I f L IU
Conditions of Approval/Reasons for Disapproval
Ins4afr a' (efrfiOa-
^ p
.
Attach to complete plans for the system and submit to the County only on paper not less than 8 iR x I I inches in size
SBD-6398 (R. 03/22)
-SJZ� ooL51
Wisconsin Department of Safety & Professional Services Page 1 of
Division of IndustryServices
SOIL EVALUATION FQkTTEST 77- 2(AO
In accordance with SPS 385, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, .i al ci
but not limited to vertical and horizontal reference point (BM), direction and percent slope, POf€S14.D.
scale or dimensions, north arrow, and location and distance to nearest road. TAX I 0
Please print all information. Re lewed b �1 � �s �Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). 1(kI v(/c�i6
Property Owner Property Location ❑
Rojmov-c\ L
K Govt. Lot l '/. '/ S Z 6 T 47 N R -1 E (or)
Property Owners Mailing Address Site Address or CSM aild Lo #: I
Sio tl & 5270 W, h dc+L` � r K P 4 J�v 4. Z'SZ
City, State, Zip I Phone Number ❑ City ❑ Village I Town I Nearest Road
Rives'. W.T ≤4847 Hugtie.S It.nro1Ii Rd.
❑ New Construction Use: ® Residential/ Numberof bedrooms
9 Replacement ❑ Public or commercial — Describe:
Parent material soy & j Ti
General comments and recommendations:
Boring #
Code derived designflow rate 3 b GPD
Flood Plan elevation if applicable ft.
Pit Ground surface elev. •,ft. Depth to limiting factor 9a in.! elev. " ft.
IRECiL�1l PhI Soil Annlication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
JUL 0' 1
Roots
GPD/Ft2
*Eff#1
*Eff#2
Is
1 ,r
ww-c
ejc34
•`7
1.6
Z
- a g
ni� zoni
.
i . {o
5
l
-
1v4'
.7
10 G
2-] Boring #
❑Boring
®Pit Ground surface elev.g.7ft. Depth to limiting factor gin., in. / elev� ft.
I Soil Annlication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft2
*Eff#1
*Eff#2
0-
I O 3/Z.
--
tc
l v-
PM
q
3
1.
2
s R'I/
-
s
t
• '?
t.6
-cf,
S YRy
—
S
Osj
—
I v-
.7
'.6
CST Name (Please Print)
To f Kos
I Signature
o �
CST Number
• 1 6 -- S T
o
6 --
Address st l5 C-0U''l`1
bv Klvef 13'-1S'(7 I
Date Evaluation Conducted
6- 23-26
Telephone Number
1 - 3g - 68
* Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 5150 mg/L * Effluent #2= BOO, 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: Raymond Levine JR
Site Address: 5270 Windall Rd
Iron River, WI 54847
Tax ID: 18720
Legal Description:
Ahmeek Lake
Elevation 56.4'A
---------------- Existing N
Concrete
Tank/Pump 1 0 50 100
Chamber
Existing 2
Bedroom
Home
XlStln
arage I
A parcel of land in Government Lot One (1), Section I ( I
Twenty-six (26), Township Forty-seven (47) North, Range Nine
(9) West, Town of Hughes, Bayfield County, Wisconsin, more I I All piping shall
particularly described as follows: Io —'--conform to SPS Table
384.30-3 and SPS
To locate the point of beginning, commence at the point where I I Table 384.30-5
the East line of said Government Lot I intersects the mean
high water mark of Ahmeek Lake; thence South, along said I
East line, 700 feet; thence West, 20 feet, to the point of I I
beginning; thence from said point of beginning, by metes and
bounds: continue West, 125 feet; thence North, parallel to said
East line of Government Lot 1, 700 feet, more or less, to the
mean high water mark of Ahmeek Lake; thence East, along I
said mean high water mark, 125 feet, more or less, to a point I
which is 20 feet West of the East line of Government Lot 1; I I
thence South, parallel to the East line of Government Lot 1,
I I
700 feet, more or less, to the point of beginning.
d
L ; Approx Property Line
o Soil Test Pits:
I - Elevation - 99.6'
2- Elevation - 99.7'
3- Elevation - 99.6'
Benchmark - Screw in Oak Tree
Elevation 100'
Existing Well
Plumber: Allan Polkoski - PMRS 220090
Soil Evaluated By: Tony Polkoski -11068-ST
I da11 F
PAGE 1 OF 4
In -Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Page 1 - Index & Cover Sheet
Page 2 - Combined Soil Evaluation -System Plot Plan
Page 3 - Dispersal Area Cross -Section & Plan
Page 4 - Management Plan
Enclosures:
Private Sewage System Maintenance Agreement, Soil
Evaluation Report, Sanitary Permit Application,
Wieser WLP700/300-MR approved tank specifications,
Soil Test Checklist, Sanitary Application Checklist, $450 check
Project Name / Description
Owner Name(s): Raymond Levine JR Phone: 715-372-8669
Owner Address: 5270 Windall Rd, Iron River, WI 54847 REcElVeD
Project Address: 5270 Windall Rd, Iron River, WI 54847 JUL 0
2pp
Legal Description: 8
P�nning��b Co,
A parcel of land in Government Lot One (1), Section Twenty-six (26), Township Forty-seven (47) North, Range Ibtx�,{g,�y4ery Town of Hughes, Bayfield
County, Wisconsin, more particularly described as follows:
To locate the point of beginning, commence at the point where the East line of said Government Lot 1 intersects the mean high water mark of Ahmeek
Lake: thence South, along said East line, 700 feet; thence West. 20 feet, to the point of beginning: thence from said point of beginning, by metes and
bounds. continue West, 125 feet; thence North, parallel to said East line of Government Lot 1, 700 feet, more or less, to the mean high water mark of
Ahmeek Lake; thence East, along said mean high water mark, 125 feet, more or less, to a point which is 20 feet West of the East line of Government Lot
1; thence South, parallel to the East line of Government Lot 1, 700 feet, more or less, to the point of beginning.
Township: Hughes
Project Tax ID #: 18720
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:
Signature: Date:
Original signature required on each submitted copy.
Combined Soil Evaluation Plot Plan - Ahmeek Lake A
System Plot Plan In -Ground Soil Elevation 56.4'
Absorption for POWTS Version 2.1 p---------------- Existing N
Concrete
Tank/Pump 1 0 50 100
Owner: Raymond Levine JR 1Chamber I , I
Site Address: 5270 Windall Rd Bedroom
m2
Iron River, WI 54847 Home
I
Tax ID: 18720 1 A
Legal Description:
1
A parcel of land in Government Lot One (1), Section
l
Twenty-six (26), Township Forty-seven (47) North, Range Nine
I
(9) West, Town of Hughes, Bayfield County, Wisconsin, more
I All piping shall
particularly described as follows:
I.— conform to SPS Table
1 384.30-3 and SPS
To locate the point of beginning, commence at the point where
j Table 384.30-5
the East line of said Government Lot 1 intersects the mean
high water mark of Ahmeek Lake; thence South, along said
1
East line, 700 feet; thence West, 20 feet, to the point of
LAFilter
beginning; thence from said point of beginning, by metes and1
bounds: continue West, 125 feet; thence North, parallel to said
I
East line of Government Lot 1, 700 feet, more or less, to the
I
mean high water mark of Ahmeek Lake; thence East, along
said mean high water mark, 125 feet, more or less, to a point
which is 20 feet West of the East line of Government Lot 1;
I
l
thence South, parallel to the East line of Government Lot 1,
700 feet, more or less, to the point of beginning.
nk - Wieser I
LP700/300-MRlter-
PolyLoc 1
•
ou
E_; Approx Property Line I
o Soil Test Pits: i 2 2 Trenches
1 Quick 4 Plus
1 - Elevation - 99.6' 1 3 Standard I
2 - Elevation - 99.7' I Chambers RECEtveD
3- Elevation - 99.6' i �,,c Slope
A Benchmark - Screw in Oak Tree
I Existing Drainrield - System JUL 0 12025
Elevation 100 1 abandonment per SPS
1 383.33 prior to new system Bayne kf Co.
Existing Well ; installation. lannin9 and Zoning Agent,
Plumber: Allan Polkoski - PMRS 220090
I i
Soil Evaluated By: Tony Polkoski - 11068 -ST
IPage
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. 1T
(typical)
f 34•
(typical)
System Elevation = 96.5
(typical)
Septic Tank(s) Manufacturer
Wieser WLP700/300-MR
Septic Tank(s) Volume(s):
700 gal 300 gal gal gal
Effluent Filter Manufacturer:
Polyloc
Effluent Filter Model #: PL -525
TYPICAL TRENCH
CROSS SECTION VIEW
(No Scale)
LL
Quick4 Standard -W
w/ End Cap (Show location of inlet / outlet pipe connection on plan view.)
(typical)
L
T1=47
B = T2=43 ft
INSTALL PER TRENCH: (typical)
Trench 1: Iii I Quick4 Std -W @ 20 ft2 EISA/chamber + 220
Trench 2: 10 I Quick4 Std -W @ 20 ft2 EISA/chamber + 200
Trench 3: II Quick4 Std -W @ 20 ft2 EISA/chamber + II
No. trenches = 0
Provide minimum 3 ft
separation between trenches.
Observation Pipe
(typical)
Install per manufacturers
/ instructions.
TYPICAL TRENCH
PLAN VIEW
(No Scale)
IA=3.0ft
(typical)
Standard -W Chamber
UJ
m
W
�
L
�
pairs end caps @ 6 ft2 = ft2
G
On
pairs end caps@6ft2= 16 Iff2
g o
C
pairs end caps @ 6 ft2 = I Ift2
a
ni
Mequired Infiltration Area = 1429 Ift2
Distribution Method:
Proposed Total EISA = 1432
Ift2
Gravity
PAGE 4 OF 4
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 ≤ 220 mgL''; TSS ≤ 150 mgL-'; FOG ≤ 30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (Le., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (Le., 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.
Scats. when the volume of solids in the tank(s) exceeds one-third (1/3) the lidq the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, is . ode.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when ng ks t /(9nove any
accumulated solids according to manufacturers specifications. A servicing period will alwaysvbgreater than 12
months. Plannln aYfiekl Co.
9 and Zoning
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:
Local government unit: Bayfield County Planning & Zoning Phone: 715-373-6138
Iron River Septic
Phone: 715-372-4006
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.
WLP700/300-MR
TANK SPECIFICATIONS
81-8"
4" CAST -A -SEAL
4" CAST -A -SEAL
\2";- I1\�
(-p
W yQ. II
py �
N I 1 O II'i1 I fY'. 7
r
II.
n
FLOW 11 ii FILTER OR
H �'i BAFFLE
DIMENSIONS:
WALL: 2 1/2"
BOTTOM: 3"
COVER: 5"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 53 1/4"
�.� LENGTH: 8'-8"
fi WIDTH: 7-2"
BELOW INLET: 42"
g LIQUID LEVEL: 36
WEIGHT: 6,790 LBS.
C
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: 26.79 GAL/IN
LOADING DESIGN: 8'-0" UNSATURATED SOIL
TANK CAN BE USED AS:
SEPTIC / HOLDING
COVER: MIX DESIGN #8 (NO FIBER)
TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
iN
INLET - _ OUTLET
-llII _
t rya 4
a M HI I
2., mo---JU
--�-- Li -- J _______1_
3
M
SIDE VIEW
APPROVED
By Glen Schlueter at 10:12 pm, May 30, 2022
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
REVIEWED BY
REVIEW DATE
DRAWINGS SUBMITTED
FOR APPROVAL
APPROVED BY:
APPROVAL DATE:
PRODUCTS NEEDED BY:
II 3
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In
/ OF
Private Sewage System Maintenance Agreement
I�Q�rnmn� £ G�v,S4' L2 J f Le
uwnertel manmg raarese
Fb a,H H/3
Site Address
Sz7o I,,�;� �a�I �� y7oT1r�e,ls A
I IaxlO# 1 9720
Ms owner, I twel do nereoy Willy the private sewage system will be installed In
accordance with the certified soil tester's report and approved plans and specifications
on file with Bayfleld 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 !i N. Range / W.
Additional Legs! Description: V. lb7z p_ 862 $Nor SNoS: , Dacu.{/, z7�
Town of f)uc h¢5 (Acreage) 2.O Gov't Lot 1
Lot _ Block Subdivision
Lot _ CSM # _ Vol. _ Page _ CSM Doe #
DOCUMENT NUMBER
2026R-61 2675
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
06/24/2026 AT 1 1 : 1 5 AM
RECORDING FEE: $30.00
PAGES:3
Area
Irn To: Tory Pa / (tos/C
Po 57-2-
1ymil JerL4)ZS7VVi"/7 Try
In -ground gravity ❑ In -ground dosed ❑ In -ground pressure distribution Sewage System:
❑ 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 th septic tank is serviced as provided
above. The switches and pump controls shall also be Inspected and maintained to ensure operability of said comp @CC h ie0
Septic Tank Effluent Filter (system types A through E): The septic tank effluent filter shall be inspected and maintained as necessadry[gJand In accordance
with manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS j%55QNf�.LULn. Code.
Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall Uj v suallyy inspected by a certified
septage servicing operator, POWTS Inspector, or licensed master plumber within three (3) years of the date t iJ�l@Ifdcatleast once every three
(3) years thereafter to determine whether wastewater or effluent from the system is ponding on the ground surface, and Zoning Agon,✓
Mounds At -grade and In ground Pressure System Laterals (system types C, 0 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. Bayfleld 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 low.
tuuu,,..
The terms and conditions of the agreement shall be'�gr••' ^ to the benefit of all current and future owners of such property.
Own Na s) — Please Print �ubscrlbed and sworn to before me on this date:
c , G j/rt/)'L_� w . =O�ARy' G� T
/Ul %7/VE Lc(//.vE__ : �C _ cJ une lSFl,, ZUZIo
Notariz O s)— ure(s)
"lit
M Com
A Dion y ndss s:
Drafted by: IO n y. re i -KOS K t Date:
Proofed by:
u/formsisanitarylsepticmelntenceagreemenl
Revised July 2020
State Bar of Wisconsin Form 3-2003
QUTf CLAIM DEED
Document Number Document Name
THIS DEED, made between
("Grantor," whether one or more),
and RAYMOND A. LEVINE JR. and CHRISTINES. LEVINE,
"whether one or more).
Grantor, quit claims to Grantee the following described real estate, together
with the rents, profits, fixtures and other appurtenant interests, in
Hayfield County, State of Wisconsin ("Property")
(if more space is needed, please attach addendum):
SEE ATTACHED EXHIBIT "A"
Dated September 10, 2024
DOCUMENT NUMBER
2024R-604676
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
09/109/11/2024 AT 1O:51 AM
RECORDING FEE: $30.00
TF EXEMPT #: 8M
PAGES:2
Recording Area
Name and Return Address
Smith Law LLC
P.O. Box 613
Ashland, NI 54806
04-022-2-47-09-26-3 05-001-10000
Parcel Idendfabon Number (PIN)
This is hot
(is) (is not)
JUL 012026
Bayed Co.
%fanning and Zoning Age,
(SEAL) (SEAL)
• RAYI4DND . LEVINE JR.
(SEAL) _
(SEAL)
AUTHENTICATION% ACKNOWLEDGMENT
/)!'►T H STATE OF WISCONSIN
) ss.
on ' U•:��' ASHLAND COUNTY)
e O. Personally came before me on seDtamber 10, 2024
E -- . 7 ism 3 the above -named RAYMOND A. LEVINE JR.
TITLE: MEMBER STATE BAR OF ISCON&N •• F :' to me known to be the person(s) who executed the
(If not, '�ay STAB M+ foregoi Instnu ent and acknowledged the same.
authorized by Wis. Stat. § 706.06) "'
THIS INSTRUMENT DRAFTED BY:
• r J
Attorney Carla J. Smith, SBNt 1123340 Notary Public, S of Wisconsin
Smith Law LLC, Ashland, NI 54806 My Commission (is permanent) (expires:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3-2003
•Type name below signatures.
Smith rawU.C, P.O. 8m 613 Asblod WI .54806 Pbom: (115)979-5321 F.: fWlmam.(6dt
Curls smith Reduced aim npFm"m bybpinplr 18070F8bmt Moe Road, Fraser, MMlpen 68029 vrffl"naa.mn
Bayfeld County Register of Deeds Document #2024R-604676 Page 1 of 2
EXHIBIT "A"
A parcel of land in Government Lot One (1), Section Twenty-six (26), Township Forty-seven (47) North,
Range Nine (9) West, Town of Hughes, Bayfield County, Wisconsin, more particularly described as follows:
To locate the point of beginning, commence at the point where the East line of said Government Lot 1 intersects
the mean high water mark of Ahmeek Lake; thence South, along said East line, 700 feet; thence West, 20 feet,
to the point of beginning; thence from said point of beginning, by metes and bounds: continue West, 125 feet;
thence North, parallel to said East line of Government Lot 1, 700 feet, more or less, to the mean high water
mark of Ahmeek Lake; thence East, along said mean high water mark, 125 feet, more or less, to a point which is
20 feet West of the East line of Government Lot I; thence South, parallel to the East line of Government Lot 1,
700 feet, more or less, to the point of beginning.
JUL 012026
Plannlog�nd Zoning Ag y,,,
Bayfield County Register of Deeds Document #2024R-604676 Page 2 of 2
BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
Submit the Following (Use Permanent Ink):
X Check List
l Index Page / Title Sheet (Optional)
l Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers)
1 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
N Property Owner's Information not prospective buyer's name)
I Property Location (Accurate Legal Description with Sec/Twp/Range)
CK Road Name (where driveway is/will be coming off of)
❑ Floodplain Elevation, Flow Rate, Comments and Recommendations
D( Complete Soil Boring / Pit Information
1 Date Soil Evaluation was conducted
l CST Name, Signature, Number, Address and Phone Number
X *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
R Bench Mark (Description, Elevation and Location)
I Contour Lines (Example = 98.0' /96.0' /94.0')
B Property Location (Sec/Twp/Range/, Accurate Legal Description)
g Borings (Locations and Elevations)
X Percent and Direction of Land Slope
t Well Location (Including Neighboring Wells, if applicable)
54 Location of Wetland Areas, Floodplain and Navigable Waters
1 Buildings, Driveways, and Structures (Location and Descriptions)
R Location of Property Lines
50 Existing System Location
Address Number and Road Name
Current Surface Elevation of Wetlands and Navigable Waters
X CST, Owner and Property Information
9 North Arrow
Itace nD
JUL 01202H
Bavfielc
Planning and Zonirny
Fee:
14 Certified Soil Tests - Review & Filing Fee $ 50.00
U/forms/sanitary/checklist/checkl istforests
SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY
Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e))
2 Check List
2 Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.)
0 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
0 Original Plot Plan (383.22(2)2. 3. & 4.a)
2 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)
0 Contingency Plan / Management Plan (383.22-3(2)(b)1.f.)
V 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)
2 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)
2 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)
2 I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number
2 II Type of Building
0 III Type of Permit
2 IV Type of POWTS System
2 V Dispersal - Treatment Area Information
ffi VI Tank Information
0 VII Responsibility Statement (Plumber's Information)
Plot Plan: (To Scale or To Dimension)
2 Signature and Plumber Information
ISurface Elevation of Body of Water
00 Direction and Percent Land Slope
0 Tank and Filter Information and Location
i� Wetlands / Navigable Bodies of Water
RrAbsorption Area (Proposed and Existing)
2 Bench Mark (Location, Elevation and Description)
2 Component Manual Version
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JUL 012026
Planning ,,y b Co.
ZOni' 9 Agency
0 Address Number and Road
2 North Arrow
0Contour Lines
2 Structures and Driveways
2 Boring Locations
0 Property Lines
2 Well Locations
0 Legal Descriptions
2 Piping Material Information (conveyance line, building sewer line, material type and diameter)
Turn Over ►
Cross -Section and Over -Head Profile of the System:
I6 Surface and System Elevation
lT Position of Observation and Vent Pipes
tT Dimensions and Depths
C1d Make, Model & Number of Chamber Units in each Cell
Property Information
V How many systems will there be on this parcel of land? I
KI Has this property been split? M&) (Property Statement shows Property History)
Fees:
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
tJ 0120Th
❑ Maintenance Agreements +
$ 30.00
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9 Age^
(checks made out to Reg of Deeds)
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VA�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:
LEVINE,CHRISTINE S
PO BOX 613
ASHLAND, WI 54806
LEVINE, RAYMOND A JR
PO BOX 613
ASHLAND, WI 54806
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00451
Transaction Number:
SR -00451-49A39
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
Reference: 6330
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 7/9/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
I 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:
LEVINE,CHRISTINE S
PO BOX 613
ASHLAND, WI 54806
LEVINE, RAYMOND A JR
PO BOX 613
ASHLAND, WI 54806
Description
Private Sewage System (Septic Tanks)
Submission Number:
SS -00783
Transaction Number:
SS-00783-49A3D
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 6330
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 7/9/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-81 S
STATE SANITARY PERMIT
OWNER: RAYMOND A LEVINE JR
GOV'T LOT: 1 LOT: B L K:
1/4 1/4 SEC: 26, T 47 N, R 9 W
TOWNSHIP: Hughes
SOIL TEST: 77-26
REPLACEMENT SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: ALLAN POLKOSKI
EMILY MACGILLIVRAY LLIVRAY DATE: 7/9/2026
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: # 220090
Condition: Insulate as required. Properly Maintain System Per Recorded Agreement. Old System
needs to be properly abandoned per SPS 383.
THIS PERMIT EXPIRES 7/9/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION