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BAYFIELD COUNTY
SANITARY PERMIT APPLICATION
Zoning District
Lakes Class
I. APPLICATION INFORMATION
Soil Test I County
Og
(Please Print All Information)
No: Permit
it No: ii
Property Owner's Name:
Donaldand Patricia 1 Or'ds
County: Bayfield
Address of Property:
'1381' 5 Count`/ Hwy G
Property Location: �1 a, �" 1. YV/ W
14 %,S ED T 50 N, R oly E
(or)
Property Owner's Mailing Address:
PO 8o\ 331
Township:
Be(I
I Gov. Lot #:
City.
rnuioplarW
2 d,
Phone.g4ib4
Lot #
Block #:
CSM #:
CSM Doc #
Subdivision Name
II. TYPE OF BUILDING: (Check One)
❑ State Owned
Tax ID#: RtCEIVED
❑ Public (Explain the use/purpose )
f7 Cam/ _
® 1 or 2 Famil Dwellin - No. of Bedrooms
-�-4 9
Ill. TYPE OF PERMIT: (Check only one box on line A. Check box on B, if applicable)
A) ❑ New []Replacement County Private Interceptor Bayfie!d co.
Planning ao,;
❑ Reconnection ❑ Repair ❑ Revision ❑ Transfer of Owner (List Previous Owner below)
B) ❑ A Sanitary Permit was previously issued. Previous Permit Number. Date Issued:
IV. TYPE OF NON -PLUMBING SYSTEM: (Check One) * Replacements need previous permit number and date filled out above
C) ❑ Pit Privy ❑ Vault Privy (Vault size: gallons or _____cubic yards)
❑ Portable Privy ❑ Camping Transfer Unit Container ❑ Composting Toilets ❑ Incinerating Toilet
V. ABSORPTION
SYSTEM INFORMATION:
1. Gallons
I 2. Absorp. Area
j 3. Absorp. Area
I 4. Loading Rate
I 5. Pert. Rate
I 6. System I
7. Final Grade
Per Day
Required (Sq.Ft.)
Proposed (Sq. Ft.)
(Gals. / Day/ Sq.Ft.)
(Min. Inch)
Elev.(Feet)
Elev. (Feet)
VI. TANK
INFORMATION:
Capacity
In Gallons
Total
Gallons
# of
Tanks
Manufacturer's
Name
Prefab.
Concrete
Site
Constructed
Steel
Fiber
-
glass
Plastic
Exper.
App.
New
Existing
Tanks
I Tanks
Septic Tank or
/cob
x
Holding Tank
WW
coneretC
Lift Pump Tank /
boo
I
Wit
E'
Siphon Chamber
ConCrei"
VII. RESPONSIBILITY STATEMENT:
I the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Owner's Name(s): (Print) ifappryingrnrseceon cabove
Owner's Signature(s): (No Stamps)
9onaid cu�ras Y Sri' -a SeFf-0l(d5
Oo6cuu.s- c 619
Plumbers Name: (Print) if applying for s«nos Hors) sews I
Plumber's Signature Stamps)
MP/MPRSW No:
Plumber's Address: (Street, C' State, Zip Code) I
'5'o
horn Phone:
Z116b
Business Phone:
222 5nf-z 1u- 4,re -a.fty ;r LLar f8f�
7r5� Ztfi -
Vlll. COUNTY! DEPARTMENT USE ONLY
❑ Disapproved
j Sanitary Permit/Transfer Fee: I
Date Issued:
I Issuing Agent's Signature / Detee'.
Approved
I ❑ Owner Given Initial
(i4 rib
0 (r I
Adverse Determination
11
N'Y•I J
IX. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
Plot Plan on reverse side
Lot Line
See aeach ed
VUCEIVED
JUL 162076
Bayfield Co.
Planning and Zoning Agency
Name of Frontage Road
1. Name the frontage road and use as a guideline, fill in the lot dimensions and indicate North (N).
2. Show the approximate location and size of the building. IMPORTANT
DETAILED PLOT PLAN
3. Show the location of the well, septic tank and drain field. IS NECESSARY, FOLLOW
STEPS 1-7 (a -o) COMPLETELY
4. Show the location of any lake, river, stream or pond if applicable.
5. Show the approximate location of other existing structures
6. Show the approximate location of any wetlands or slopes over 20 percent.
7. Show dimensions in feet on the following:
a.
Building to all lot lines
i. Privy to building
b
Building to centerline of road
j. Privy to lake, river, stream or pond
c.
Building to lake, river, stream or pond
k. Drain field to closest lot line
d.
Septic / holding tank to closest lot line
I. Drain field to building
e.
Septic/holding tank to building
m. Drain field to well
f.
Septic / holding tank to well
n. Drain field to lake, river, stream or pond
g.
Septic / holding tank to lake, river, stream or pond
o. Well to building
h.
Privy to closest lot line
Submit To: Bayfield County Zoning Department, PO Box 58, Washburn, WI 54891
u/fonnslsanitary/bayfeldcountysanitaryapplication
Revise: June 2018 Proofed by:
COMPANY _ DATE SHEET NO. 3 _ OF 3
CUSTOMER QFfr,Vd DWG. NO. REV.
SUBJECT DRAWN BY
OTHER (.`%'li)
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RECEIVED
JUL 16 2026
Bayfield Co.
Planning and Zoning Agenc;
B A YFIELD Bayfield County
Planning & Zoning Department
117 E 5w Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-4010
Property Owner: Submission Number:
CS -00171
Transaction Number:
CS-00171-4A0A9
Description Amount
Private Interceptor $50.00
Total: $50.00
Payment Amount $51.25
Reference: 3496733875
Paid by: Patricia Jeffords
Payment Type: Other
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
Town, City, Village, State or Federal
Permits May Also Be Required
LAND USE -
SANITARY - Private Interceptor
SIGN -
SPECIAL -
CONDITIONAL -
BOA —
No. 26-0349 Tax ID: 7564
Issued To: JEFFORDS, DONALD J & PATRICIA L
Location: S26 - T50N - R06W
Town of BELL
Legal Description: N 112 NW 330 IN DOC 2021R-588535
BAYFIELD COUNTY
PERMIT
WEATHERIZE AND POST THIS PERMIT
ON THE PREMISES DURING CONSTRUCTION
Residential Structure in F-1 Zoning District
For: Sanitation Permit — Private Interceptor [Previous Permit # 21-120S (8/12/2021)]
(Disclaimer): Any future expansions or development would require additional permitting.
Condition(s):
You are responsible for complying with state and federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or
modification of construction that violates the law or other penalties or costs. For more information, visit the department of natural resources wetlands identification web page or contact a department of natural resources service center (715) 685-2900.
NOTE: This permit expires two years from date of issuance if the authorized construction
work or land use has not begun.
Changes in plans or specifications shall not be made without obtaining approval.
This permit may be void or revoked if any of the application information is found
to have been misrepresented, erroneous, or incomplete.
This permit may be void or revoked if any performance conditions are not
completed or if any prohibitory conditions are violated.
Emily Macgillivray, AZA
Authorized Issuing Official
July 21, 2026
Date