HomeMy WebLinkAbout26-89SRequest for Sanitary Inspection (24 Hrs. in Advance)
Fax or email this form to Zoning Dept (24 Hrs.) prior to when you want an inspection
Fax (715) 373-0114 or Email zoning@bavfieldcounty.wi.gov
Note
fl Time Change fl Discrepancy fl Other
Phone Number
Plumber:
l5 aC - 7 S '\
Fax Number
Homeowner:
cc*
Email Address
Immediate Ph ne Nu ber So Zdning
Sanitary
S9 J `
Dept can call you right back (if needed)
Permit #:
Plumber's Choice
Zoning Dept
No Inspection(s) during this time
Date:
1' l'
Tuesday (9:30 am - 12:15 pm) (Tracy)
Plumber's Choice
Zoni ept
Time:
Township:
Address #
Road Name:
� 1� \%c L-1 e Scrc cj Rck
or
�3G,,� �, 6A L3 SY V9
Directions
To Site:
zg 9 5 —�
Comments:
**
Plumbers you must verify any change(s) by fax or email **
Notes from Zoning Dept:
July 2025
PAYNE FAMILY REV LIVING
TRUST
136 TUKE LN
TWIN BRIDGES MT 59754 ,DING TANK INSPECTION REPORT
Ili I I Harr TO PERMIT)
nFNFRAI INFORMATION
Permit Holder's Name
❑ City ❑ Village ❑ Town of
' Sanitary Permit No.
Plan ID No.
Tax Parcel No.
Property ddress lf Av able
TANK INFORMATION
TYPE MANUFACTURER/MODEL# CAPACITY
LttgI goo
SETBACKS
Property Line
Well
Water Service
Building
All -Weather
Road
OHWM
Swimming Pool
DEVIATIONS FROM APPROVED PLAN
COMMENTS (Persons present, discrepancies, etc.)
1 ( \ns\o\\ecl ec..deir (ice
1S Jy n\S-( der sfl
`ko ups Views kvk l'Wl-e d�
pct a& \n
-UV ec4& o .
COMPONENTS NOT INSPECTED
Plan Revislo Required
❑ Yes No
Date:
Signature o Inspe t r.
L✓
C . Number
Sjcetch on other side
10 of 13
` U U .J
Property Owner
Information
DAYFIELD COUNTY PLANNING & ZONING DEPARTMENT
Telephone: (715) 373-6138
Fax: (715) 373-0114
e-mail: zonino(u)bavfieldcountv.wi.gov
Web Site: www bayfieldcounty wi.gov/147
PAYNE FAMILY REV LIVING
TRUST
136 TUKE LN
TWIN BRIDGES MT 59754
As you know
onsite wastewater treatment system on your property described as:
Notes:
Bayfield County Courthouse
Post Office Box 58
117 East Fifth Street
Washburn, WI 54891
was contracted by you to install a private
Abandonment of Old System to meet all applicable code requirements:
Tank was pumped by: on at AM/PM
S Tank was crushed I removed and pipes disconnected by:
On at (AM / PM) the above -mentioned plumber contacted our office to
condu t'� pre -cover inspection as required under DSPS 383. One of the following applies:
System was inspected and appears to meet all applicable code requirements.
❑ System was inspected and appears to meet all applicable code requirements; however, a plan revision
is necessary because the installation was substantially different than the original approval.
System could not be inspected because plumber covered prior to scheduled time of inspection.
❑ System could not be inspected because plumber was not ready at scheduled time of inspection.
County was unable to return to complete inspection.
System could not be inspected because plumber was not ready at scheduled time of inspection.
A re -inspection and $50 fee are required.
System could not be inspected because County could not respond to plumber's time constraints.
Comments:
U/forms/sanilarypropertyw ar-input April 2019
s1,-rV.r,nrwr u
Sri n �-%a tin.mL
SBD-6398, Sanitary Permit Application
7/9/2026 620.20 AM se:;
Introduction
Wisconsin Department of Safety and Professional
Services
In accordance with Wis. Admin. Code sec. SPS 383.21(2), submission of this form to the appropriate
governmental unit is required prior to obtaining a sanitary permit. Upon completion, you will be
emailed a copy of the completed form for submittal. Include a complete plan on paper not less
than 81 /2 x 11 inches. Check with your local POWTS authority about additional requirements and
fees.
Note that applications for state-owned POWTS are submitted to the Department via esla.wi.gov.
(Rev. 02/26/2026)
General
Information
Applicant RECEIVED
Name: Michael Wroblewski JUL 0:9 ZOZ6
Email: mike@biglakeplumbing.com Bayfield Co.
Planning and Zoning AgenCY
Owner
Name: Payne Family Rev Living Trust
Email:
Phone Number:
Mailing Address 1JNt'' a6IML)VV
Address Line 1: 136 Tuke Ln
f �(J
��!� 0
Address Line 2: "�
City: Twin Bridges
State: Montana Qom`` F -<-Q--
Zip: 59754 � c IZ M1
wed 1 b 02� Pj L.
Project and Site
Parcel ID: 28954 �� cutfQ c,t'ed C�rcI
State Transaction Number: PWTS-
Project Address
Address Line 1: 93195 Little Sand Bay Road
Address Line 2:
City: Bayfield
State: Wisconsin
Zip: 54814
CSM and Lot Number:
Subdivision:
Block and/or Lot:
Legal Description:
Government Lot
X PLSS
1/4 of: SE
1/4 of: SW
Section: 504
Township: T51 N
Range (E or W): R04W
Municipality Type:
City
X Town
Village
Municpality Name: Russell
County: Bayfield
Building
Type:
X 1- or 2 -Family Dwelling
Public/Commercial
State -Owned
Number of Bedrooms: 3
POWTS Permit
RECEIVED
JUL 0; 9 2026
Bayfield Co.
Planning and Zoning Agency
Permit Type:
X New System
Replacement System
Other Modification to Existing System
Additional Pretreatment Unit
POWTS Type:
X Holding Tank
In -Ground (conventional)
At -Grade
Mound
Individual Site Design
Other
Is there a previously issued permit?:
Yes
X No
Dispersal/Treatment Area and Tank
Estimated Flow: 300 GPD
Tank Information
Type:
Septic
X Holding
Dosing
New or Existing:
X New
Existing
Material:
X Prefab Concrete
Site Constructed
Steel
Fiberglass
Plastic
Manufacturer: Wieser Concrete
Holding Tank Capacity: 2000 Gallons
RECEIVED
JUL 09 2026
Bayfield Co.
Planning and Zoning Agency
Total Capacity of Septic Tanks: 0 Gallons
Total Capacity of Holding Tanks: 2000 Gallons
Total Capacity of Dosing Tanks: 0 Gallons
Total Capacity of All Tanks: 2000 Gallons JUL 09 2026
gayfieid Co.
Total Number of Tanks: 1
Planning and Zoning Agency
Responsibility Statement
Signature
Plumber Name: Michael Wroblewski
Plumber Email: mike@biglakeplumbing.com
Phone Number: (715) 209-7521
Plumber Credential Type:
X Master Plumber
Master Plumber Restricted Service
Credential Number: 1288503 - PM
Address
Address Line 1:1491 County Highway C
Address Line 2:
City: Washburn
State: Wisconsin
Zip: 54891
By inserting my typed signature below, I attest that the information provided is complete and
accurate to the best of my knowledge and belief. I, as the licensed plumber, assume responsibility
for installation of the POWTS shown on the submitted plans.
Electronic Signature of Plumber: Michael Wroblewski
Date: 7/9/2026
HOLDING TANK SPECIFICATIO` 1
g ECG
3 Number of bedroom
s JUL 09 2026
Non-residential estimated flow (gpd) - Bayfield co.
2000.0 IMinimum holding tank volume required (gal) Planning and zoningAgencY
2000.0 Proosed holding tank ca acit (gal)
Wieser concrete jTank Manufacturer
W2000MR ITank model number
SJ Electro systems jAlarm manufacturer
WH101 Alarm model number
Tank Dimensions
and Data
Tank Anchor Calculations
X for round tank
13540 Ibs
Weight of tank and cover
53.0
Liquid depth below inlet invert (in)
1.10J
Safety factor
8.0
Maximum de th of soil cover (ft)
20505 lbs
Weight of anchor required
66.0
Height (in)
Outside
27.3 in
Soil cover req. for anchor or
151.0
Length (in)5
Dimensions
5.1 yd3
Concrete counterweight
86.0
Width (in) Only
HOLDING TANK CROSS SECTION
junction
box
conduit
blinto seal "
outlet
manhole cover with
4— locking device and finished
warning label grade
4" min. Jr
23 in.
Manhole and vent locations
may be reversed.
tether weight
service
alarm on
Electrical as per
NEC 300
and SPS 316
3 in. bedding under tank.
12.0 in.
41.0 in.
Note: All tank joints, and
joints between tank
openings and piping are
sealed watertight. All pipe
and vent materials comply
with SPS 384.
Tank is anchored as necessary to negate buoyancy.
vent cap
12"min.
vent pipe
18" min.
building sewer
inlet
Project: Payne Family Rev Living Trust - Holding Tank
Transaction Number: Page 2 of 9
HOLDING TANK PLOT PLAN
PAYNE FAMILY REV LIVING TRUST
93195 LITTLE SAND BAY RD
BAYFIELD, W 54814
PCLIN SE SWDESC IN V.847 P.555 IN
DOC 2021 R-589283
S04 T51 N R04W
TOWN OF RUSSELL, WI
SCALE 1" = 60'
w
z
0
O,.
>100TO NORTH LOT LINE
EXISTING PRIVY
I
D ING
Cleanoul POLE BUILDING
BUILDING
4*pv Roe
Cleanout for RV hookup Insulated >30' from building
>100' TO SOUTH LOT LINE
O -
DRIVEWAY
9
-R
2000 gallon holding tank
1 3 413 5601:T
SHEET 3 OF 9
RLLl:IVIrL)
JUL 092026
Bayfield Co.
Planning and Zoning Agency
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-1 0855-P
N. 03/07, R. 01/12), and the Bayfield County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow of 60.0 to 400.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Service Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 30 days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with SPS 383.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons may be contacted:
a. Installer ......................... Big Lake Plumbing Phone: (715) 209-7521
b. Service Provider ............... Birch Street Sepiic Service Phone: 715-373-5683
c. Co. Zoning or Health Dept. Bayfield County Planning & Zoning Phone: 715-373-6138
11.
Project: Payne Family Rev Living Trust - Holding Tank
Transaction Number Page 4 of 9
12'-7"
4-." CAST -A -SEAL 4" CAST -A -SEAL ii
I I
FILTER OR BAFFLE 4
0
w
cn
or
w
z
co
INLET
21, i~--L__L_--------J
I TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
OUTLET
'•tv N
ao
U
D* 0
to
UN
W2000 -MR
TANK SPECIFICATIONS
a
a
a
I
DIMENSIONS:
ui
o
WALL 2 1/2"
a
a
BOTTOM: 4"
COVER: 6"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 66" O.D.
LENGTH: 12'-7" O.D.
WIDTH: 7'-2" O.D.
BELOW INLET: 53" O.D.
LIQUID LEVEL: 46"
WEIGHT: BOTTOM 9,430 LBS.
COVER 5,940 LBS.
LI
v
E
INLET AND OUTLET:
m
c
e
4" CAST -A -SEAL BOOT OR EQUAL GASKET
3
INLET AND OUTLET BAFFLE AND FILTER:
�;
N
o
o
m
WISCONSIN, SEE DETAIL #10
(OTHER STATES SEE CHART)
W 0
Ln
LIQUID CAPACITY: 42.92 GAL/IN
HOLDING TANK:
U
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 2,126 GALLONS
z 00
w
LOADING DESIGN: 8'-0" UNSATURATED SOIL
L()
04
TANK CAN BE USED AS:
o_
W
SEPTIC / HOLDING / PUMP OR SIPHON
o
y = o0
cn
COVER: MIX DESIGN #8 (NO FIBER)
TANK: MIX DESIGN #10 (STRUCTURAL FIBER)
R
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
REVIEWED BY N
REVIEW DATE
J
D
Z
F
a_
w
N
SHEET NO.
i7
OF
1
RECEIVED
HOLDING TANK SERVICING CONTRACT ,Iu.l_ .o g 2026
Bayfield
Pnning and Zoning
Contract Date �onin Agency
" laJJ This contract is made between the
EHoldingnk Owner(s) Name(s)
Pumper's Name (Print)
Pumper's Signature
Pumpers' Registration #
p �
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions)
RltotE CT•
r 4gat ri aTaiID#
b> DTI
t `
LOCAMON
-., tUse�T 5t t )
•' �
•:. �_.�:. �..:. _-
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-
SatdOn 1 Towrmship N, Ie�,., W
:Tawr►Y�- 'i
11
it
s
, n
3
Go✓%l.ot
Lat#
ill i1
Vol. Page
CSM Dec #t
4Lot(s) No
alock{sj No.
Subdi i y r
1. The owner agrees to file a copy of this contract with Bayfield County as required in SPS 383.55, Wis. Adm. Code.
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have
access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain
the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by
the owner and pumper.
3. The pumper agrees to submit to the local government unit which has signed the pumping agreement required by SPS
383.55, Wis. Adm. Code, and the County, a report for the servicing of the holding tank(s) on a semiannual basis. The
pumper further agrees to include the following in the semiannual report:
a.
The name and address of the person responsible for servicing the holdi�•--
b.
c.
The name of the owner of the holding tank;
The location of the property on which the holding tank is installed;
ALICA i'EDERSON
NOTARY PBLICMont for the
S of Montana
one
d.
The sanitary permit number issued for the holding tank;
Su4ir i
Residing at Colon, Montana
e.
The dates on which the holding tank was serviced;
My Commission Expires
f.
The volumes in gallons of the contents pumped from the holding tank fo ea
ing;
July 1, 2026
g.
The disposal sites to which the contents from the holding tank were delivere
.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this
contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract
with the local government unit and the County named above within (10) business days from the date of change to this
service contract.
Owner(s) Names) t1�r f `- r
3e. nett Q 'k.,S44e r
'Tcx k� 0 rQ
Subscribed and Sworn to me:
on this _day of
b C% �6w'
y� Notary Public
My commission expires one
Revised: May 2016 (®May 2018) Drafted by
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (I)(m)1
Document Number/Plan 1.0. No. HOLDING TANK
AGREEMENT
Owner Name (s) uwnerts) mamng Aoaress
PGj o� Fug 1j6 T , in
3 � L
'j_. w • TC S \sN SC Q /SITS r1S
Parcel ldentifi& Number (PIN) Agreement �ate ( me as Notary Date)
We acknowledge that application Is being made for the installation of (a) holding tank(s)
on the following property or that continued use of the existing premises requires that a
holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other
type of private onsite wastewater treatment system as permitted under Ch. SPS 383.
Wis. Adm. Code or Ch. 145, Wis Stats. ,1
__114 o1 . _114 Section Township 5.LN. Range G `7 W.
Town of�.
Additional Legal Description: fjJ SvJ .$�� 7 �• "
op �- aS
c... a a.i R �
Gov't Lot_ Lot____Block Subdivision CSM# r
Lot CSM Vol Page CSM Doc#
DOCUMENT NUMBER
2O26R-61261 I
DANIEL. J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY, Wl
RECORDED
06/i 8/2O26 AT 8:O7 AM
RECORDING FEE: $3O.OO
P 5m.cr.1VED
JUL 09 2026
Bayfield Co.
Retu►-z — - _. .. _..
LAKE =99i County Highway C
PLMB1�J Washburn, WI 4891
As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property, we agree to do the
following:
1. Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tank Installation and
maintenance. If the owner falls to have the holding tank properly serviced in response to orders issued by Bayfield County or the
Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats., Bayfield County may enter upon
the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a
special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats.
2. Owner agrees to pay all charges and costs incurred by Bayfield County for inspection, pumping, hauling, or otherwise servicing and
maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. 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.
3. The owner agrees to contract with a person who is licensed pursuant to s.281.17 (3) Wis. Stats., and chapter NR 114 Wis. Adm. Code, to
have the holding tank serviced in accordance with Ch. NR113, Wis. Adm. Code, and to file a copy of the contract with Bayfield County.
The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the county within
30 days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed pursuant to s. 281.48 (3) Wis. Stats., and Ch. NR 114, Wi's Adm. Code who shall
submit to the county within 30 days a report detailing the servicing of the holding tank. Bayfield County may enter upon the property to
investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being
properly maintained.
5. This agreement will remain in effect only until Bayfield County certifies that the property is served by either a municipal sewer or a private
onsite wastewater treatment system that complies With Ch. SPS 383, WI's Adm. Code. In addition, this agreement ma be canceiiedby
executing and recording said certification with reference to this agreement in such manner which will permit t e of he
certification to be determined by reference to the property. I
6. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The of
agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner
existence of the agreement to be determined by reference to the property where the holding tank is Installed.
Owner(s),Jame(s) - Please Print ��v�
.s,1uj.� T�j
, �m,t.� ev. Icy;.
' kk� . .e -� �sk� G� �,�� � 2 a �-�s �-
Subscribed and sworn to before me on this date:
o� �,� 5!
3 u �
'zed ar(s) - Signa refs n
/
r�
h �-W . i�"✓�k
No Public
o
My Co mission Expires:
CD
Drafted by: , l t.t Date: 6/4/_'16
Personal inlormahon you provide may be uted'or secondary p,uposes (Privacy Law. s.15.04 (J)(m))mstsanitaryAioidingtankagreomens.doc dune 20113
'.1 T•) E t
,i f
s
Prepared By:
Scott M. Payne
136 Tuke Ln
Twin Bridges, MT 59754
After Recording Return To:
Payne Family Revocable Living Trust
c%o Scott Payne
136 Tuke Ln
Twin Bridges MT 59754
UhliliIIIH hhhhh1llhI1hIIhIllIflIIllI hIUIhIllll
*2021R-559283 5*
20218-589283
DANIEL J. HEFFNER
BAYFIELD COUNTY, WI
REGISTER OF DEEDS
06/15/2021 01:18PM
IF EXEMPT #:
RECORDING FEE: 30.00
TRANSFER FEE: 180.00
PAGES: 5
TAX PARCEL ID #:'
og- b(2 - ! -c1( _eq —3 Oq_d&)..looco
QUIT CLAIM DEED
BE IT KNOWN BY ALL, that made effective on C� '` 1 - 2 D2 I , Wayne E. Schoepke Jr,
• ("Grantor'), a married individual, whose address is 14420 12th Ave. Merrill, WI 54452, TO Payne
• Family Revocable'Living Trust (dated 12/02/2020) ("Grantee'), whose address is 136 Tuke Ln, Twin
Bridges, MT 59754, all right, title, interest and claim to the following real estate property commonly
known as 93195 Little Sand Bay Rd.. in the City/Township of Russel, located in the County of Bayfield
and State of Wisconsin and ZIP code of 54814, to -wit:
A Parcel of land located in the SE 'A of the SW '/4, Section 4, Township 51 North, Range 4 West, Town
of Russell, Bayfield County, Wisconsin, described as:
Commencing at the quarter corner common to Sections 4 & 9, T5IN, R4W, which is at the intersection
between Little Sand Bay Road and Old County Hwy. "K"; thence Due North along Little Sand Bay
Road on the North -South centerline of Section 4, 657.46 feet to the POINT OF BEGINNING; thence
N89 .degrees 39'54"W 660.80 feet; thence N00 degrees 00'08"E 656.89 feet, .thence S89 degrees
42'49"E 660.77 feet; thence Due South along Little Sand Bay Road on the North -South centerline of
Section 4, 657.45 feet to the POINT OF BEGINNING; containing 434,240 square feet, which is 9.97
acres, and is subject to driveway and utility easements of record shown on SSI Map No. 070102526 date
July 1, 2002.
RECEIVED
JUL. 0-9 2026
• Bayfield Co.
Planning and Zoning Agency
Bayfield County Register of Deeds i Document # 2021 R-589283 Page 1 of 5
RECEIVED
BAYFIELD COUNTY JUL 0 9 2026
CHECKLIST FOR SANITARY APPLICATONS
Pt30
Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) ning�dza Co
Check List
Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.)
Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
Original Plot Plan (383.22(2)2. 3. & 4.a)
Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer
0 Pump Tank Diagram, Alarm and Pump Curve (when applicable)
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)
0 ATU Servicing Agreement (Recorded at Reg. of Deeds)
Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
t Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached
to all copies)
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)
' \ I Application Information must include: '23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete)
Project Address or Road Name where ariveway is/will come off of) ✓7 (Owners Phone Number)
II Type of Building
III Type of Permit
IV Type of POWTS System
V Dispersal / Treatment Area Information
VI Tank Information
VII Responsibility Statement (Plumber's Information)
*Date Stamp*
Plot Plan: (To Scale or To Dimension)
Signature and Plumber Information
❑ Surface Elevation of Body of Water
❑ Direction and Percent Land Slope
❑ Tank and Filter Information and Location
❑ Wetlands / Navigable Bodies of Water
❑ Absorption Area (Proposed and Existing)
❑ Bench Mark (Location, Elevation and Description)
Component Manual Version
Material Information (conveyance line.
Address Number and Road
North Arrow
0 Contour Lines
Structures and Driveways
Boring Locations
Property Lines
Well Locations
frJ Legal Descriptions
building sewer line, material type a d diameter)
Turn Over ►
JUL 092026
Cross -Section and Over -Head Profile of the System: Bayfield Co.
Planning and Zoning Agency
❑ Surface and System Elevation
❑ Position of Observation and Vent Pipes
❑ Dimensions and Depths
❑ Make, Model & Number of Chamber Units in each Cell
Property Information
How many systems will there be on this parcel of land? I
Has this property been split? C (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
❑ Maintenance Agreements +
$ 30.00
(checks made out to Reg of Deeds)
u/forms/checklists/chedciistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by:
t T
BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
Submit the Following (Use Permanent Ink):
J
Ul p g 2026
I Check List
gaytield Co. A en�l
❑ Index Page / Title Sheet (Optional) Piann�ng and zoning g
Original Soil Evaluation Report (Submitted in Deed Holders Name -- not prospective buyers)
Original Plot Plan
❑ Cross Section Soil Profile Sheet (optional)
❑ Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Report: (Include the following Information)
Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
Jl Property Owner's Information not prospective buyer's name)
Property Location (Accurate Legal Description with Sec/Twp/Range)
Road Name (where driveway is/will be coming off of)
0 Floodplain Elevation, Flow Rate, Comments and Recommendations
0 Complete Soil Boring / Pit Information
Date Soil Evaluation was conducted
CST Name, Signature, Number, Address and Phone Number
*Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
0 Bench Mark (Description, Elevation and Location)
❑ Contour Lines (Example = 98.0' /96.0' /94.0')
Property Location (Sec/Twp/Range/, Accurate Legal Description)
Borings (Locations and Elevations)
❑ Percent and Direction of Land Slope
Well Location (Including Neighboring Wells, if applicable)
❑ Location of Wetland Areas, Floodplain, and Navigable Waters
Buildings, Driveways, and Structures (Location and Descriptions)
Location of Property Lines ,
❑ Existing System Location
Address Number and Road Name
❑ Current Surface Elevation of Wetlands and Navigable Waters
CST, Owner and Property Information
North Arrow
Fee:
A -Certified Soil Tests - Review & Filing Fee $ 50.00
U/forms/sanitary/checklist'checkiistforesfis
Z r
Soil Test #
• �. � Bayfield County
8S ��
Waiver of a Thorough Soil & Site Evaluation
(subject to 15-1-10(d))
EDWARD J WROBLEWSKI a certified soil tester determine that in my professional
judgment the following site (see below) is unsuitable for any treatment component other than holding
tanks. Due to soil & site conditions, a thorough soil and site evaluation is not needed to make such a
determination.
Property Owner
PAYNE FAMILY REV LIVING TRUST
ProDertv Address 93195 LITTLE SAND BAY RD
Telephone
BAYFIELD, W 54814
406-431-1345
4•
Accurate Legal Description is requested:
Contractor ED'S MECHANICAL LLC
Authorized Agent EDWARD J WROBLEWSKI
Agent's Telephone 715-209-4055
Written Authorization Attached: Y or j)
_1!4 of SW Section04 Township 51 N. Range_, W. Town of RUSSELL
Additional Legal Description:
PCL IN SE SW DESC IN V.847 P555 IN DOC 2021 R-589283
Govt. Lot Lot Block Subdivision
Lot CSM# Vol. Page CSM Doc #
Volume Page of Deeds Tax l.D#
28954
Indicate reasoning for your determination: CLAY SOILS
RECEIVED
sUL 0t9 2026
Bayfield Co.
Planning and Zoning Agency
&1ILl'1\'M dklzAi
SignaturJ Coun ctal
61/ (6f99cc !(oC-�'i
Date
Acreage 9.969
Signature of Certified Soil Tester
z/ -Z(
Date
SP -72000013
Certification #
( ub i t a:pletPlrn &.Fee)
u/forms/soiltestwalver(KLK)
June 2018
EDWARD J. WROBLEWSKI. CST 0SP 72000013
SOIL TEST PLOT PLAN
PAYNE FAMILY REV LIVING TRUST
93195 LITTLE SAND BAY RD
BAYFIELD, WI 54814
PCL IN SE SW DESC IN V.847 P.555 IN
DOC 2021R-589283
SO4 T51 N R04W
TOWN OF RUSSELL, WI
SCALE 1" = 80,
g
A
EXISTING PRIVY
>100' TO NORTH LOT UHE
EXISTING
POLE BUILDING
)100TO SOUTH LOT UNE
OWELL
DRIVEWAY
OSOIL BORING
.a
licD
92
Q3-
N
o
m
s
2
0 Jo o 410a w
• RECEIVED
JUL 0.9 2026
Bayfield Co.
Planning and Zoning Agency
CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project Payne Family Rev Living Trust - Holding Tank
Owner Payne Family Rev Living Trust
Address 136 Tuke Ln
Twin Bridges, MT 59754
(406) 431-1345
Legal Description PCL in SE SW, SO4, T51N, R04W
Township Russell
Subdivision Name
Parcel ID Number 28954
Plan Transaction ID Number
Designer Michael roblewski
Signature .
')ti
County Bayfield
Index and title sheet
Holding tank specifications
Site plan
Maintenance and contingency plan
Soil test
Soil test plot plan
Holding tank agreement
holding servilcing contract
Holding tank specifications
License Number 1288503
Lot No.
Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 7
Page 8
Page 9
Phone No. 715-373-0566
Date 07/09/26
• Designed pursuant to:
Holding Tank Component Manual For POWTS (Version 2.0)
SBD-10855-P (N. 03/07, R. 01/12)
Version 7.0 (11112) Page 1 of 9
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-89S
STATE SANITARY PERMIT
OWNER: PAYNE FAMILY REV LIVING TRUST
G OV'T LOT: LOT: B LK:
SE1/4 /4 SW1/4 /4 SEC: 4, T 51 N, R 4 W
TOWNSHIP: Russell
SOIL TEST: 88-26
NEW SYSTEM
SYSTEM TYPE: Holding Tank
PLUMBER: MICHAEL WROBLEWSKI
EMILY MACG I LLIVRAY DATE: 7/16/2026
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: # MP 1288503
Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all-
weather road.
THIS PERMIT EXPIRES 7/16/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION