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HomeMy WebLinkAbout26-100SRequest 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 zonincicEbayfieldcounty.wi.gov Note fl Time Change fl Discrepancy fl Other Phone Number Plumber: / pO /poskl' Fax Number Homeowner: �L �fQ Email Address Immediate Phone Number So Zoning Sanitary OOJ Dept can call you right back (if needed) Permit #: l Plumber's Choice Z pt No Inspection(s) during this time Date: Chi / Tuesday (9:30 am - 12:15 pm) (Tracy) Plumber's Choice yg ept Time: (anti b Township: Address # & Road Name: or /170 !7 Ouf1L/ (v TIC/e Directions / ) 242/ S To Site: Comments: *' Plumbers you must verify any change(s) by fax or email ** Notes from Zoning Dept: July 2025 L { FABIAN, FRED J JR & FABIAN, SUSAN V 14032 EVERGREEN LN BRULE WI 54820 DLDING TANK INSPECTION REPORT TVi�-Ac1nO- PERMIT) f .MI IDnt IMI C ≥PAOTIrM Permit Holder's Name I ❑ City ❑ Village ❑ Town of Sanitary Permit No. Plan ID No. Tax Parcel No. Property ddress if Av able TAKI(INFfRMATION TYPE MANUFACTURER/MODEL # CAPACITY SETBACKS I Property Line Well Water Service Building All -Weather Road OHWM Swimming Pool DEVIATIONS FROM APPROVED PLAN 4 COMMENTS P_ ersons present, discre hies, etc.) +\odk r fA ... Y r`• kv\ • COMPONENTS NOT INSBOTED Plan Revision equired ❑ Yes o D Signature In pec • Nu qr,� — �[[ s,ketcn on other side 10 of 13 \J U J III Property Owner Information BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Fax: (715)373-0114 e-mail: zonina(iDbayfieldcounw.wi.gov Web Site: www bavfleldcounty wl.govl147 FABIAN, FRED J JR & FABIAN, SUSAN V 14032 EVERGREEN LN BRULE WI 54820 Bayfield County Courthouse Post Office Box 58 117 East Fifth Street Washburn, WI 54891 As you know was contracted by you to install a private onsite wastewater treatment system on your property described as: Notes Abandonment of Old System to meet all applicable code requirements: ❑ on at AM I PM :• Tank was pumped by: :• Tank was crushed I removed and pipes disconnected by: On at (AM/PM) the above -mentioned plumber contacted our office to conducta pre -cover inspection as required under DSPS 383. One of the following applies: L� 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 $50 fee are required. System could not be inspected because County could not respond to plumber's time constraints. Comments: Wformslsaniiarypmpartymvner-Input April 2019 �,,t�pnaTtir ti�,�w Cot .. Department of Safety •.D$ - 00� O� & Professional Services, Sanitary P 't Number (to be filled in r�q pS Industry Services.Division by Co.) ` �Ty+Stth�L� , - l oO 5 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 is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc submitted to Project Address (if different than mailing addrei the Department of Safety and Professional Services. Personal information you Prov1de,fitbe2s� i'fgf. secondary purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. ! 1 ,� Q I. Application Information -- Please Print All Information tom! Property Owner's Name Parcel # Sr t1 Govt. Lot City, State Zip Code Phone Number1.3 L (r -e 1.�+• ' '�L( F �tO °7 / ≤ 1 l I -- O s w 4,_5U1 '/, Section / II. Type of Bitllding (check all that apply) Lot # T N R l I or 2•Family Dwelling —Number ofBcdrooms Subdivision Name Block # O Public/Commercial — Describe Use ENTERED 3 0 City of ❑ State Owned —Describe Use CSM Number 0 Village of n ✓i -C vt Town oC 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 !pRlfcabie.) A. New System ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B. Holding Tank 0 In -Ground ❑ At -Grade I 0 Mound ❑ Individual Site Design ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV. Dispersal/Treatment Area and Tank Information! Design Flow (gpd) I Design Soil Application Ratc(gpd/sl) Dispersal Area Required (at) Dispersal Area Proposed (sfl System Elevation Capacity in Total # of Manufacturer Tank Information Gallons Gallons Units New Tanks IExisting Tanks a d rn vi Ito C7 A. 8eplico�►Holding Tank •Z O Q o Aeslug.�hee+ber ZG' CtLZ W t• is •� V (.`.tr vl. G' , � V. Responsibility Statement- I, the undersigned, assume responsibility for installation f the POWTS shown on the attached plans. Plumber's Name (Print) f Plumb 's Sin re 'MIPRS Number Business Phone Number • -�•-� �2 0 o q v � t �" z� z -- � I SAO Plumber's Address (Street, City, State, Zip Code) c A ignatu Approved O Disapproved Permit Fee Date 1ssucd Is urn O Owner Given Reason for Denial1fig 3 Conditions of Approval/Reasons for Disapproval 'Sub afi6o, coq earl. Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 Inches In size SBD-6398 (It 03/22) I LnJVIVI IV[1 01 LUEV JNU No,. 9975 P. 2 JUL 2 F,r. Pg .1 of 8 Holding PAGE '� OF$ ng Tank Plan Index & Cover Sheet ' Component Manual Design Raferencee: I1��nua.1 /P&" 1 4 $ieh�e�., � z-zoz- . Index & Cover Sheet Plot Pln Pg 2of9 a Pg3of9 Pg4of Attachments: Holding Tank Specifications - -Z r 5t f Management Plan Project Name I Description I 'g.v-P)►, Ali 'licable) 210-5 cr .able) !t e, I'e a 5 Owner Name(a): �r e ti J r 15— Phone: :7 -. Owner Address: 1 D Lt ve vi ,,3 vd-e Ltit tip.. 5 ' Y Project Address: ±1 '7° £-1 ,.J13 '3 r J4JT s'1' Govt. Lot: ___•-__ 1/4 of S 1/4, Section 3-- ---_► T ..__..N -R E or W i Township: (9 v . ot f County: Project Parcel ID #: - 7 Designer Information orrnation Designer Name: //CL A,%te' c, / /. - a s kL Phone: i IS f S"' Designer Address: R. Ste- '""` - a 1C ?..r�-,�' .2' :Zip: S~`{�'.f17 E-mail: `f -� b r.�- v r+.----L.� �• �. Thi4 space reserve . for approval stamp. License Number: 2. rz e1 O Remarks: Signature: ��-- l �.. or teal s1gnotuae required on each submitted copy. Jrtl. 6L,4& -1 .Jr q U 3 L.�EJ e vr v �e oett L Th)( fl(czI? a Ct L � c, l .sc✓ p +i girt .. IJ J14 St331 rLe1u M w Orvi.44 Y r 100 O I' �o r 30 - o f- t5 rvr�S; . I f3ar'ssr,cJ, ., N 1' f 8' 2 i l e.�s N RJ; L I(")y L . C VLai e. ! 1-7O }yiLfvJyH /j e �tije. it �`Q• 6ti s j j i ____ ___ .1 111 \ 1 yL .. \ \ - __ C -a Ft w / 13 AL'ie. .cPLC( cpP-CtJE. ;'io 1ratlt.4 14a: ( owl i vaP=JElev,/00.0. + 5ch L/® PvC;, v..)/ I & VJ C{ ;"e.. -l-' e -Pt M H 'i"ASTP D 1'71'S "i'�� v-�+ V�' g p^ j�e. 1/i�,EW�'.b•c etI 1 JUL 2 2026 vi H ii; 4rM k p&&t ,Ykl'i1tL/ sI1yP (vii R �x,�y� C 014,Y26 i2. 2. a i) L ra.,;3 bt / a 22 c cio Ra,Lac. sz.2. 0 164" . L 4" CAST -A -SEAL 4" CAST--A-SEAL m 4" rn T{4 FILTER OR BAFFLE 0 (flQ INLET U d. C.0 TOP VIEW SIDE VIEW TANK; E3 OUTLET PUMP PAD WLP2000-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 3" BOTTOM: SEPTIC 3" HEAVY DUTY 5" (ADD 2,800 LBS.) COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 53" O.D. LENGTH: 164" O.D. WIDTH: 96" O.D. BELOW INLET: 41" O.D. LIQUID LEVEL 36" WEIGHT: BOTTOM 11,260 LBS. COVER 8,170 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 56.27 GAL/AN LOADING DESIGN: 8' 0" UNSATURATED SOIL HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,138 GALLONS TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #9 (SMALL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: O N J O c N Q cc o U p Wv) w > w SHEET NO. 1 � OF. f PROPERTY OW — v - -�: L OWNER: PLUMBER: Allan Polkoski/ Polkoski Plumbi SIGNATURE: uh1 --/�" DATE: `7 ^ P I -- LICENSE # 220090 HOLDING TANK SPECIFICATIONS • j:r .Number of bedrooms ;Non-residential estimated flow (gpd) 1"'2060'.C Minimum holding tank volume required (gal) • •+10100.0 Pro osed holding tank capacity �ZO26 -.. :r sa•.� • rr�- :rwrzrs rY«:: . — — - • Wieser : r • �9all - ! 1 ` t_ Tank Manufacturer Electro ,.S.l .....,:_s—: `Tank model number �t�Alarm manufacturer J ITAi.:.3fTtlAka.U.:.tT1T•71.pL:7L:7s7.pG:'S+1'•"•"`xrr.lL'C.:A•r `t -.L ••.:':'.:.ti.71..:r �f • HWIO1 :Alarm model number .-. .. .,..•. W'4r3f 9!'T?.•tJ.fV6•i2".'q^R`.".;f:.+J'+.:7'.^..1.7w .,t. Tank Dimensions and Data Tank Anchor Calculations !•X for round tank " 15 5 7 m 370 Ibs Weight of tank and cover 47.0 Liquid depth below inlet invert (in) 1.50 ,.. ' Safety factor •8.0 lMaximum depth of soil cover (ft) K. r• ���� . _.�,�•31055 Ibs Weight of anchor required 66.0 .Height (in) 1 Outside 36.0 in Soil cover req. for anchor or 151.0 ;Length (in) Dimensions L 7.7 yd" Concrete counterweight •86.0 Width (in) Only HOLDING TANK CROSS SECTION junction box.._-._� conduit --> blind plug to•seat outlet manhole cover with looking device and finished warning label grade 4' min. <-24 in. -�j Manhole and vent locations may be reversed. :: service '� 2.0 in. alarm on Note: All tank joints, and joints between -tank openings and piping are Electrical as per 35.0 in. sealed watertight. All NEC 300 pipe and vent m 1terials and Comm 16 comply with •5P5 a83. 1vent cap 12" min. vent pipe . 16" min. I building sewer inlet 3 in. bedding under tank. Tank Is anchored as necessary to negate buoyancy. Project: HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and s, dnaintained according to Ef 33 Wis. Admin. Code, the Holding Tank Component Anual r.o,s�dW)n I''�'�/P'�'- e�lEf:22,o and the Ic�.y4e. tL County Sanitary Ordinance. o00 ' y1 1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 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 Servicing 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 'PS 383 andi84 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 10 business 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 5PS p83.33 Wis. Adm. Code. 10. If there is a problem with, or question about this 'nstallation, the following persons should be contacted: a. Installer............................P©J1'osk P1uw► =rat M.jI,S.02:.Oo o Phone: -7, f 372.- /lf(, b. Service Provider .................. ; .R Phone: 'vc- 372 - Qa(p c. Co. Zoning or Health Dept. j "zCri; Phone: 7/S 3-7x h0/g1 11. Project Transaction Number: 11 tJTM icier BAYFIELD COUNTY CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) Check List ®' 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)) 2I Original Plot Plan (383.22(2)2.3. & 4.a) Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer JUL Ili Pump Tank Diagram, Alarm and Pump Curve (when applicable) 22 ar?`c' (7 Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) 0 Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) 1211 Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) 121 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) 19 Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) V 1 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary A 1pp ication and Maintenance Agreements are to be attaclied to all copies) 0 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) 1211 Application Information must include: ❑ 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) 10 Project Address or Road Name where driveway is/will come off of) t 1(Owners Phone Number) 12111 Type of Building 121111 Type of Permit I2' IV Type of POWTS System ❑ V Dispersal / Treatment Area Information 121 VI Tank Information 121 VII Responsibility Statement (Plumber's Information) ❑ *Date Stamp* Plot Plan: (To Scale or To Dimension) 121 Signature and Plumber Information I 'Surface Elevation of Body of Water ❑ Direction and Percent Land Slope lTank and Filter Information and Location 0 Wetlands / Navigable Bodies of Water ❑ Absorption Area (Proposed and Existing) 19 Address Number and Road 11 North Arrow 0 Contour Lines [if Structures and Driveways 121 Boring Location I Property Lines 121 Bench Mark (Location, Elevation and Description) [ Well Locations 19 Component Manual Version C Legal Descriptions .� �T�T,".•, ,. ),�• ..r.-.. �, -ter;-- — ?Ipng Ma#rialiiformatior� (conye)ance. l(ne, building sewerline material type and diamter)` �.a r ...{... ..... ....�y..v. .. sir n...r Turn Over ► BAYFIELD COUNTY • CHECKLIST FOR CERTIFIED SOIL TESTS Submit the Following (Use Permanent Ink): i 5 Check List I Index Page / Title Sheet (Optional) JUL- • 10 Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers)2 2 2U!n 175 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 21 Property Owner's Information (r,�ot prospective buyer's name) Ga Property Location (Accurate Legal Description with Sec/Twp/Range) lZ1 Road Name (where driveway is/will be coming off of) @1 Floodplain Elevation, Flow Rate, Comments and Recommendations t�J Complete Soil Boring / Pit Information 10 Date Soil Evaluation was conducted 0 CST Name, Signature, Number, Address and Phone Number O *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) [0 Bench Mark (Description, Elevation and Location) U Contour Lines (Example = 98.0' /96.0' /94.0') 0 Property Location (Sec/Twp/Range/, Accurate Legal Description) 9 Borings (Locations and Elevations) U Percent and Direction of Land Slope 0 Well Location (Including Neighboring Wells, if applicable) Ll Location of Wetland Areas, Floodplain and Navigable Waters m Buildings, Driveways, and Structures (Location and Descriptions) Cf Location of Property Lines (9 Existing System Location Z Address Number and Road Name 171 Current Surface Elevation of Wetlands and Navigable Waters 17.1 CST, Owner and Property Information L6 North Arrow Fee: Certified Soil Tests - Review & Filing Fee • $ 50.00 u/forms/sanitary/checkllst/checkiistforc sts HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(s) Name(s) Pumper's Name (Print)Ikcsk Pu 7r,sSignature Pumpers' Registration # 5t/r�� ' 6J�er C4Lle ;Ct �"� / We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT LOCATION Legal Descriodon: (Use Tax Statement) Tax iD# 'Z' ''?r `L , [ S 1/4,, _S Li cI i Town of: // Lot Size < ' Acreage Section , Township I N, Range W its r , .e •., T� . Govt Lot Lot #, CSM # Vol. Page CSM Doc# Lot(s) No. Block(s) Na. 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 holding tank; 4` b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; " ".. & . r_ vi u e. The dates on which the holding tank was serviced; bdYj.*dlu t. f. The volumes in gallons of the contents pumped from the holding tank for each ,,��,. g. The disposal sites to which the contents from the holding tank were delivered. 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) Name(s) (Print) • e.4 /"c 6 sti Z 7. 5 L f `Gc, 4ra X - n tutsI Subscribed and.Sworn to me: on this /Odayof\jA.\_ , 2Y24 b• Notary Public Revised: May 2016 (®May 2018) Personal information you provide may be used for secondary My commission expires on: I 0 ! t f9 ONN Drafted by 1I _ dvacy Lawn�$$ �1' 4�i �j IV�7i a ry ublic State of Wisconsin -� 00;�2O ant Number/Plan I.D. No. HOLDING TANK AGREEMENT Owner Name (� L' Owner(s)Matting Address Y Q,1 414 L r' i .i {/ 1 pp -z- L. , S N� . Parcel Identifier Number (PIN) Agreement Date (same as Notary -Date) o2 f'. % 9 - x /. We acknowledge that application is being made for the installation of (a) holding tank(, 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 Slats. tJ'Jii4 of)1/4 . Section 3! Township N. Range , W. Town of' ti �� Additional Legal Description: Gov't Lot ^ Lot Block Subdivision CSM# Lot CSM # Vol Page CSN! Doc# DOCUMENT NUMBER 2026R-612953 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFiELD COUNTY. WI RECORDED 07/16/2026 AT 10:00 AM RECORDING FEE: $30.00 PAGES: 1 ,a JUL 17 2026 Return T; Planni^ =- nq ter cy 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. if the 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 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. 88.0703, 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. NR1 13, 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 may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shalt submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds In a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank Is installed. Owners Name(s) -- Please Print Subscribed and sworn to before me on this date: Notarized } lure ) otary Public _____ p11 Drafted by:ID D it ! k5 Gam. Personal information you prov da may be used for secondary purposes IPrtvacy Law, 8.15.04 (I)(m)J My Commission Expires: MELISSA TONN Notary Public. Date; 'Z_1 O ,. State of Wisconsin ulformslsenttarylhotdingtankegreemenLdoc ®Juno 2018 gRo&1T7S Soil Test # Bayfield County Waiver of a Thorough Soil & Site Evaluation (subject to 15-1-10(d)) 1/ Allck-kl J� / P1, o S t 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. ELATE E Property Owner s '� I `� V. p ntractor Authorized Agent Agent's Telephone Written Authorization Attached: Y or N Accurate Legal Description is requested: 1/4 of 5 L J 114 Section 31 Township ___N. N. Range __W, Town of c: v -e Additional Legal Description: Govt. Lot Lot Block Subdivision Lot CSM# Vol, Page CSM Doc # Volume___ Page of Deeds Tax I.D# Z 4' L- _ Acreage Indicate reasoning for your determination: S( _Ei ✓ c f c n • A�77 43 Signature of CounW Official i Date Signature of Certified Soil Tester .-(5-a( Date c;r Zocgo Certification # (Submit a Plot Plan & Fee) u/forms/soiitestwalver(KLK) June 2018 Wisconsin Department of Safety and Professional Services Page ` p of Division of industry Services SOIL EVALUATION REPORT '°rxxac 4` in accordance with SPS 385, WIs. Adm. Code County! / Attach complete site plan on paper not less than 81/2 x 11 Inches In size. Plan must Include, l but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D.,,,-- scale or dimensions, north arrow, and location and distance to nearest road. L c� k 7 Z 2..� Z•• � ' Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). Prop rty Owner r Property Location L Govt. Lot )"JW'/a ,s W'/ S j / T N R 7 E (or) 1� Property Owner's Mailing Address Site Address or CSM and Lot #: City !I State I Zip Code Phone Number ❑ City 0 Village ® Town Nearest Road f ( •�. IL1:I�� 2e) (7ls-) & ~ © V , Q YL Icf-4-,v� ( tAJ5' NewConstruction Use: Residential/Number of bedrooms Code derived designflow rate JS7 GPD Replacement , ❑ Public or I ommerclal — Describe: Flood Plan elevation If applicable ft. Parent material i;- I4.. a4 ( ""fie I General comments and recommendations: i /t * `i o Boring y Boring # Plt Ground surface elev. ft. Depth to limiting factor in. / elev. ft. 222026 Qwil A....li...�ai.... M -4 — Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Strubture , Gr. Sz. Sh. ;.,P"b' nsistence r Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 b—/ i a Y 13 3 i 0 IV � 11'1 ,14f'- Q -S I v f ... z__ . s' Z. 'c ��ci i r9 s 1 i C m e. -P — . V .0 . o Boring # ❑Boring PPIt Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 CST A Name (Please Print) ,?� l k o Signature. _ , CST Number Address '1? 0. ((�� &.1g. G Z- ' {��/ Date Evalu-aation* Conducted Telephone 7Number * Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS s 30 mg/L SBD-8330 (R04/21) YrertrTf Url.(r"o L. b1 zi'r I4J4. $tc j r T47N w 013 ��ruevc ve k* -m U1 r -'? G LI Ct4 a F -5e'y -: `, ELI -I 1; wv rU;%j:r&? x IV w r 1 a V . 8-;:I.. a N Nc+ : LI-y !-hiJy /3 T& `Ila rat i p3 'v-ebya b �• -e ��► Q ` * F�c w G b•f. i n I p.+ +;:::;L::;-----jt 4'ffl4;i, 5,4L.c1Es cps) AFk ALa - °,�.tcrj `� rrctJE )J o vJ I �-e41 ' 4 j 'h w�arit \-------iz scj1 qo PVC, VL!/1a W c "ASTO !)37P5S "-a'?cf V't9g •p , ^VL4 Lw,ctt 1 �Iire l 110 G Jy AJ Liirinncr m 1-i.e 11 ClptIAi •r vv�c v 1.a j .tsf.(:' i L& 11" . cvr- 1 It) ) ' ZiL7) O Lv'ea;3h i3/: r P.M. i2coo BAYFIELD COUNTY SANITARY PERMIT (#04)-26-1 00S STATE SANITARY PERMIT OWNER: FABIAN, FRED J JR & FABIAN, SUSAN V G OV'T LOT: LOT: BLK: NW 1/4 SW 1/4 SEC: 31, T 49 N, R 9 W TOWNSHIP: Orienta SOIL TEST: 102-26 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: ALLAN POLKOSKI TRACY POOLER Authorized Issuing Officer DATE: 8/3/2026 CHAPTER 145.135(2) WISCONSIN STATUTES a. The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. b. The approval of the sanitary permit is based on regulations in force on the date of approval. c. The sanitary permit Is valid and may be renewed for specified period. d. Changed regulations will not impair the validity of a sanitary permit. e. Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. f. The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. PREVIOUS PERMIT #: LICENSE: # 220090 Condition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- weather road. THIS PERMIT EXPIRES 8/3/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION