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Home My WebLink About26-89Snrnwl\/Cll SBD-6398, Sanitary Permit Application 7/9/2026 6:20:20AM Introduction Ool Dx' 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 8 1/2 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 Name: Michael Wroblewski Email: mike@biglakeplumbing.com Owner Name: Payne Family Rev Living Trust Email: Phone Number: Mailing Address Address Line 1: 136 Tuke Ln Address Line 2: City: Twin Bridges State: Montana Zip: 59754 Project and Site Parcel ID: 28954 RECEIVED JUL 09 2026 Bayfield Co. planning and Zoning Agency NV 1t(t') II 8 I ci0 --Sued -1\lb(2O26 ML. Sea, atFa a)ed ux-cj 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: SO4 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 09 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 092026 Bayfield Co. Planning and Zoning Agency Total Capacity of Septic Tanks: 0 Gallons Total Capacity of Holding Tanks: 2000 Gallons RECEIVEDTotal Capacity of Dosing Tanks: 0 Gallons Total Capacity of All Tanks: 2000 Gallons JUL 09 2026 Bayfield Co. Total Number of Tanks: 1 Planning and d ZZoninoning A9COY 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 ro Soil Test # Bayfield County I Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) I 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 Property Address Telephone PAYNE FAMILY REV LIVING TRUST Contractor ED'S MECHANICAL LLC 93195 LITTLE SAND BAY RD BAYFIELD, W 54814 406-431-1345 Accurate Legal Description is requested: Authorized Agent EDWARD J WROBLEWSKI Agent's Telephone, 715-209-4055 Written Authorization Attached: Y or N() SE 114 of SW 114 Section 04 Township 51 N. Range 04 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 I.D# 28954 Acreage 9.969 Indicate reasoning for your determination: CLAY SOILS RECEl1/ED JUL 0,9 2026 Bayfield Co. Planning and Zoning Agency Signatur o Coun fficial 14t 61/ NO& UNC�-c Date Signature of Certified Soil Tester Date SP -72000013 Certification # (inrta:PlatPln &:Fee) u/forms/sol testwaiver(KLK) June 2018 EDWARD J. WROBLEWSKI, CST #SP -72000013 SOIL TEST PLOT PLAN PAYNE FAMILY REV LIVING TRUST 83185 LITTLE SAND BAY RD BAYFIELD, WI 54814 PCL IN SE SW DESC IN V.847 P.555 IN DOC 2021R-580283 S04 T61 N R04W TOWN OF RUSSELL, WI SCALE 1" = 60' g 9 n EXISTING PRIVY w z 21100' TO NORTH LOT LINE EXISTING POLE BUILDING OWELL DRIVEWAY OSOtL BORING >100' TO SOUTH LOT LINE �z11,gss C• l4 ' Iv Qc� rn own u rV O m 0 Jo 0 o60 6 FT 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 SESW, SO4,T51N, R04W Township Russell Subdivision Name Parcel ID Number 28954 Plan Transaction ID Number Designer Michaeljroblewski County Bayfield Lot No. Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Soil test Page 5 Soil test plot plan Page 6 Holding tank agreement Page 7 holding serviicing contract Page 8 Holding tank specifications Page 9 Signature,, moo )L -'j Phone No. 715-373-0566 License Number 1288503 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 HOLDING TANK SPECIFICATIO,fD RECe 3 Number of bedrooms JUL 09 2026 Non-residential estimated flow (gpd) sayfield Co. 2000.0 Minimum holding tank volume required (gal) planning and zoningAge"CY 2000.0 IPitposed holding tank capacity (gal) Wieser concrete Tank Manufacturer W2000MR Tank model number SJ Electro systems Alarm manufacturer WH101 Alarm model number lsions and Data Tank Anchor Calculations X for round tank 13540 lbs Weight of tank and cover Liquid depth below inlet invert (in) 1.10 Safety factor Maximum de th of soil cover (ft) 20505 lbs Weight of anchor required Height (in) I Outside 27.3 in Soil cover req. for anchor or Length (in) r DiOnlmensions 5.1 yd3 Concrete counterweight Width (in) • y HOLDING TANK CROSS SECTION manhole cover with locking device and finished vent cap junction warning label grade box ) _ 4" min. 4 12" min. E- 23 in. Manhole and vent locations conduit may be reversed, vent pipe 18" min. o tether weight service 4, 12.0 in. alarm on Electrical as per NEC 300 and SPS 316 3 in. bedding under tank. 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. 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, WI 54814 PCL IN SE SW DESC IN V.847 P.555 IN DOG 2021 R-589283 S04 T51N R04W TOWN OF RUSSELL, WI SCALE i"= 60' ri Co W CD U' !YI o 8 >10010 NORTH LOT LINE EXISTING PRIVY CkennE°1 BUI ❑ o POLE 5110DING for RV hookup Iron, building >ID0' TO SOUTH LOT LINE OKELL ORIVEV W o 2000 gallon noting lank 1 314 5 80�T SHEET 3OF9 RECEIVED 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-10855-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 Big Lake Plumbing Phone: (715) 209-7521 b. Service Provider ...............Birch 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 o19 0 w w at ITT- o OUTLET roQ 2" in J VCT -L J ASTM C-1227 W2000 -MR TANK SPECIFICATIONS O DIMENSIONS: w rc WALL• 2 1/2" 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" `ol WEIGHT: BOTTOM 9,430 LBS. COVER 5.940 LBS. n 3 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) o I� a LIQUID CAPACITY: 42.92 GALAN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,126 GALLONS LOADING DESIGN: 8'-0" UNSATURATED SOIL M TANK CAN BE USED AS: W 0 SEPTIC / HOLDING / PUMP OR SIPHON v, 0 W COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE J Q m z r jY f'd z o p o �� REVIEWED BY 0 0C'l 0 CC REVIEW DATE m 3 N C" 0 la DRAWINGS SUBMITTED s FOR APPROVAL APPROVED BY: SHEET NO. APPROVAL DATE: 1 Z /OF PRODUCTS NEEDED BY: 1 RECEIVED HOLDING TANK SERVICING CONTRACT UI. 09 2026 Bayfield Co. Contract Date Planning and Zoning Agency This contract is made between the P�y�le rnt�yV.ReJ LluNT'\xsc Pumper's Name (Print) Pumper's Signature Pumpers' Registration # We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION Legal Saemen: (Use Tax Statement) raxio# •d pp 514 5 1/4, 5W sla. -'S ^� O1.1c Section ,Township 5 N, Rage. W Town of: \� Lot Size Acreage I 1 Govt Lot Lot # CSM # Vol. Page CSM Doc It Lot(s) No. Block(s) No. Subdivision: 1. The owner agrees to file a copy of this contract with Bayfield County as required in SPS 383.55, Wis. Adm. Code. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local government unit which has signed the pumping agreement required by SPS 383.55, Wis. Adm. Code, and the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holdii FEDERSCN b. The name of the owner of the holding tank; The location the holding is installed; £,:_OD+, RUCW NOfRRY Pllfncntafcrthe c. of the property on which tank a°"` q d. The sanitary permit number issued for the holding tank; SCAT ?w a t c: on, Monena e. The dates on which the holding tank was serviced; `?.. or Expi es f. The volumes in gallons of the contents pumped from the holding tank fo a ` O'tyid'ing: .:: f • 2726 g. The disposal sites to which the contents from the holding tank were deli 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) rvame(s) trrru � 5c rcetk Pa,,nC -kQs4ee 4- 4tvn,)) CJ, IN:msr 'Tc4kr Dro J. Subscribed and Sworn to me: on this /nlday of (vim q by: NA —T l w Notary Public My commission expires Revised: May 2016 (®May 2018) Drafted by Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (0(m)] Document Number/Plan I.O. No. HOLDING TANK AGREEMENT Owner Name (s) Pay( Fc m\y Rev Owner(s) Mailing Address J36 TUf`t✓L+\ Lis 1 .S T 1t l MT5g1s Parcel Irian Number (PIN) Agreement e ( me as Notary Date) ' 89s9 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 municpal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code or Ch. 145, Wis Slats. S� _114 of SUJ _114 Section ay Township 5 I N. Range y W. Town of ____ _ Additional Legal Description: QC t t. SE SvJ S G t gW 7 I\ '85 poc_ an ct 9 Gov't Lot — LoL_Block_Subdivision _CSM#_._ Lot ,_ CSM a_ _ Vol _Page CSM Doc# ___ _ DOCUMENT NUMBER 2O26R-612611 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 06/16/2026 AT 8:07 AM RECORDING FEE: $30.00 P`' edEIVED JUL 0 9 2026 Bayfield Co. Planning arid Zoning Agency Retu•-' z — B I GLAKE -491 CountyHighway C tPLUMBINGWashhurn, WI mlig, 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: Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tank Installation and maintenance. lithe owner fails 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, Slats., Bayfield County may enter upon the properly 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 a. 66.0703, Slats. 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. Scats., 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. Slats., 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 may be cance11ed1by executing and recording said certification with reference to this agreement in such manner which will permit t e ' of Ihe certification to be determined by reference to the property. Iav' 4,. 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. -rites runtn �Y' osL "n/f 4r 4cjSt.¢ oc i'° a 2cm,\-) 2. I{n'•.) .frgjee. °&v Drafted by: Personal mtormaoon you prowoe may be used'or secondary pirposes tPnvncy Law x 1SAe Alm)) auoscnoea aria swam to cetore me on mis awe: s, _ i < j P No Public o 0 0 m of at_ dao My Co mission 6tpires: I Date:6/ qJ oaL6 .J1an64anean:naasgIankagreemam plot *June 2018 h IL I Ili III IIII111111I III IIOM II I III! II IilI III II IIII *2021R 589283 5* Prepared By: ) 2021R-589283 Scott M. Payne ) DANIEL J. HEFFNER 136 Tuke Ln ) BAYFIELD COUNTY, WI Twin Bridges, MT 59754 ) REGISTER OF DEEDS 06/15/2021 01:18PM After Recording Return To: IF EXEMPT #: ) RECORDING FEE: 30.00 Payne Family Revocable Living Trust ) TRANSFER FEE: 180.00 do Scott Payne ) PAGES: 5 136 Tuke Ln ) TAX PARCEL ID #:' Twin Bridges, MT 59754 o9- &A(&_2'S I —oaf -esi -3 oq-000,loocr� QUIT CLAIM DEED BE IT KNOWN BY ALL, that made effective on & I S -2t2 , 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 '/< of the SW 'b, 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, T5 IN, 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 NOD 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 09 2026 CHECKLIST FOR SANITARY APPLICATONS SayfieyCo. Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Punning and zoning Agency 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 ❑ 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) ❑ All) Servicing Agreement (Recorded at Reg. of Deeds) Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) I Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all to all coolies) 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 Aoolication: (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 �riveway is/will come off of) (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) lk *Date Stamp* Plot Plan: (To Scale or To Dimension) Signature and Plumber Information Address Number and Road ❑ Surface Elevation of Body of Water North Arrow ❑ Direction and Percent Land Slope O Contour Lines ❑ Tank and Filter Information and Location Structures and Driveways ❑ Wetlands / Navigable Bodies of Water Boring Locations ✓� ❑ Absorption Area (Proposed and Existing) Property Unes ❑ Bench Mark (Location, Elevation and Description) Well Locations .Component Manual Version Legal Descriptions Turn Over ► 1\GVLr a �. JUL 092076 Cross -Section and Over -Head Profile of the System: sayfieid 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? N— (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/checklistforsanmtaryapps (10/2009);(®7/2011);(®2/2012)(05/2/2012 -dc) Proofed by: • BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): p g 2426 J Check List gayfield CO. A encY ❑ Index Page / Title Sheet (Optional) planning and 7-0ftn9 9 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) f 7 Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used Property Owner's Information not prospective buyer's name) Property Location (Accurate Legal Description with Sec/Twp/Range) 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) 0 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 j 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 Unes ❑ Existing System Location Address Number and Road Name 0 Current Surface Elevation of Wetlands and Navigable Waters CST, Owner and Property Information orth Arrow Fee: A -Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checldist/checklistforests AFIELD 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: PAYNE FAMILY REV LIVING TRUST, 136 TUKE LN TWIN BRIDGES, mt 59754 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00462 Transaction Number: SR-00462-4A0AD Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 3037 Paid by: Ed's Mechanical, 1491 County Hwy C, Washburn WI 54891 Payment Type: Check Transaction Date: 7/16/2026 Receipt of payment does not guarantee eligibility of .permit and is not proof of issuance of a permit. W '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: Submission Number: PAYNE FAMILY REV LIVING TRUST, SS -00794 136 TUKE LN TWIN BRIDGES, mt 59754 Transaction Number: SS -00794-49B79 Description Amount Private Sewage System (Holding Tanks) $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 3036 Paid by: Ed's Mechanical, 1491 County Hwy C, Washburn WI 54891 Payment Type: Check Transaction Date: 7/16/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-89S STATE SANITARY PERMIT OWNER: PAYNE FAMILY REV LIVING TRUST G OV'T LOT: LOT: B L K: 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 MACGILLIVRAY 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 PLA111"10 VIEW'.. MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION