HomeMy WebLinkAbout26-103SDepartment of Safety
County
x.g$
& Professional Services,
Sanitary Permit Number (to be filled in by Co.)
pg�
Industry Services Division
a6_ /d 3J
Sanitary Permit Application
State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
Project Address (if different than mailing address)
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats.
Gt"i t'J (oS Ui 1345 $ La Re Rd
I. Application Information — Please Print All Information
Property Owner's Name RECEIVED
Parcel# TIAIA 1O'. 19'175
t)eosn M + Lonni M ar;CXson
o9-0 -08- - o3•tOo-o
Property Owner's Mailing Address JUL 161016
Property Location
53"18 Soosevei4 Or
Govt. Lot
NE 33
City, State
Zip Code
pj ° ing Agency
Hdrrn4n4OWn, MW
SSSIJ
a18-sqo-8o3a
-`1i'I /. ,Section
T '11 N R O -wor
IL Type of Building (check all that apply)
Lot #
XI or 2 Family Dwelling -Number of Bedrooms 3
Subdivision Name
❑ Public/Commercial - Describe Use
Block #
O City of
❑State Owned - Describe Use
❑ Village of
CSM Number
XTown of Iran Q: Jer
M. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if
applicable.)
A.
to y
New System
❑ Replacement System
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatment Unit (explain)
B.
❑ Holding Tank
.Xln-Ground
❑ At -Grade
❑ Mound
❑ Individual Site Design
❑ Other
Type (explain )
(conventional)I
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: .s; eK - 4 P /u3 Choa. be r e w f Set o F end
Design Flow (gpd)
Design Soil Application Rate(gpd/sf)
I Dispersal Area Required (si)
I Dispersal Area Proposed (sl)
I System Elevation
HSO
0.7
(.93
451 *
93.,5
Capacity in
Total
# of
Manufacturer
Tank Information
Gallons
Gallons
Units
o I
New Tanks
I Existing Tanks
a
u o
u
v
a w
m
P. U
i1 ,n
A
&
W O
4
Septic or Holding Tank
i0 O
'0QO
1
u riot r }
X
Dosing Chamber
V. Responsibility Statement- I, the undersigned, assume lity onsibifor installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Plumb ignature
MP/MPRS Number
Business Phone Number
Trc...rls &J,trFeeld
GSta'1`3
7t5 -3q-9)74
Plumber's Address (Street, City, State, Zip Code)
A/3114 W 54th Road 77 U&y i. rerd, LOX 6-%489,3
VI. County/Department Use Only
Approved
O Disapproved
Permit Fee
I Date Issued �
issu' g Agent Signature rsl`/ ,^
O Owner Given Reason for Denial
LIW
1'h
hJ II u i/
Conditions of Approval/Reasons for Disapproval
Attach to complete plans for the system and submit to the County only on paper not less than 8 I/ax It Inches in size
SBD-6398 (R. 03/22)
i Istrai 1
5PooL&9 __
Wisconsin Department of Safety& Professional Services SOI j� TEST 104
�, Page of
DivisiZ d�{str�rServices 1114.0
SOIL EVALUATION REPORT
d4 JUL 16 2Q26 In accordance with SPS 385, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, r C a
but not limited to vertical n.d idnzantal reference point (BM), direction and per t slo e, Parcel I.D. TAX 1 U 1 tai . S
scale or dimensip nn.arth;arrovl►�;����7t c1ation and distance to nearest road. (�� . �y.}y . p - p up - 4zOC p
Please print all information. Reviewed lI -≤t Date
Personal information you provide may be used for secondary purposes (Privacy L 4(1)(m)). I
Property Owner Property Location ❑
DecA. i c: C'N4 so Govt. Lot S W 14 4e '/ S 33 T 'I'? N R a$ E (or) W
Property Owner's Mailing Address Site Address or CSM and Lot #:
S19 c - c-
City, State, Zip Phone Number ❑ City ❑ Village 10 Town Nearest Road ((,44 7(o S
14rrw.dn t�..sn . MN £Sg %I (%)5C108�3 ran zc cr l Bass_ La.ue Rd
New Construction Use: ® Residential/Numberof bedrooms Code derived designflow rate 4" 50 GPD
❑ Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft.
Parent material Oa.* wash S &v, s
General comments and recommendations:
'10rn - ress•sc' cc d 1n- G ro uv'id $ Ie m
Boring # ❑ Boring
® Pit
Ground surface elev.95,� ft. Depth to limiting factor -100 in. / elev. 9Jft.
I Soil Anolication Rate
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
v- 'i
1 O04R3/z
--
1
Cr
o •7
1. C,
'7 •J
I n`t R y N
—
1
0.-?
t.
3.
»-CDO
1-%4P.M1.4
nr.1
o.-7
l.C,
/
Boring #
❑Boring
E]Pit Ground surface elev.95.75 ft. Depth to limiting factor Z>roi'? in. / elev. 8Z.w'ft.
Soil Annlication Rate
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
o•.
1oKR312
fr-
ca•7
1.
4
2-1oO
7.t/'
—
5
Mt
--
--
o.
•.
CST Name (Please Print)
Signature
CST Number
!d A S rec4..js Tr
SP- aw4oado
Address
Date valuation Con u d
Telephone Number
P13N%ssS+Rd77 1*, kWJ WXS'i8'13
C(, /a
-43 -817lo
* Effluent #1 = BOD > 30 ≤ 220 mg/L and TSS > 30 ≤ 150 mg/L * Effluent #2 = BOD, ≤ 30 mg/L and TSS ≤ 30 mg/L
SBD-8330 (R03/22)
❑ Boring
3] Boring # $a Pit Ground surface elev.9 ft.
Page
Depth to limiting factor % ad in. I eiev.82.a5ft.
Soil Anolication Rate
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
n V
cJ
0.7
I. le
4.
1 D Y ly
Is
(d
w.
.7
1 • ti
3
p
7'S "J4
.._
�
�.tW
o.
t.
q_
'o-1
7• )
✓ c
^
♦.
Boring #
❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. I elev. ft.
I Soil Annlicatinn Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDIFt2
*Eff#1
*Eff#2
Boring # ❑ Boring
❑ Pit
Ground surface elev. ft. Depth to limiting factor in. / elev. ft.
I Soil Anolication Rate
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
* Effluent #1 = BOD>30 30 s 220 mg/L and TSS > 30 5150 mg/L
3UL 16 2026
ed CO.
Plannino
* Effluent #2 = BOD, 5 30 mg/L and TSS s 30 mg/L
SCALE = 1:50
64765 W Bass Lake Rd
SW 1/4, NE 1/4
Sec. 33, T47N, R08W
Town of Iron River
Bayfield County
TAX ID: 19975
BM = Nail w/ ribbon in
11 " Oak Tree
ELEVATIONS
BM - 100.00'
B1 - 95.25'
B2 - 95.75'
B3 - 98.25'
ll
N L �d C�
Q 6 o) C . / 0.
/24//
oG l a71 4
O
Pr.0 pa sCC
�w
4r
SOIL PROFILE SHEET
OWNER: 1��, an %'1_+
M t: c+GKson SOIL
TESTER: v%&% A
SYSTEM ELEVATION:
LOAD RATE: O. i 1.
(o SYSTEM RANGE: . �+z
to X13.
33
T
==
::
z .S.
JUL 6 2026 =_
__ ______
---
--
------
�3`i; 47
Planning —_
-------
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--
5,75 --
--
Is --
__
99
--- ___ ____
93
------
Re eoe�,�,u,
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--
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Sy
( £iej&#
+-^9e.
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3(0
Page of
REC-JVED PAGE 1 OF 4
In -Ground Gravity Plan
JUL 16 2026 Index & Cover Sheet
8ayfie1d CO
planning andzonningAgency Component Manual Design References:
In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross -Section & Plan View
Pg 4 of 4 Management Plan
Attachments:
POWTS Applic
Soil Evaluation
Project Name / Description
for Review
Brickson - 64765 W Bass Lake Rd
Owner Name(s): Dean M & Lonni M Brickson
Owner Address: 5378 Roosevelt Dr; Hermantown, MN
& Site
Phone: 218 590 8032
Zip: 55811
Project Address: 64765 W Bass Lake Rd
Govt. Lot: 1/4 of 1/4, Section 33 J47 N -R 08 E❑or W ❑✓
Township: Iron River County: Bayfield
Project Parcel ID #:
04-024-2-47-08-33-2 03-000-02000 (TAX ID: 19975)
Designer Information
Designer Name: Travis Butterfield
Designer Address: 14346W State Road 77 ; Hayward, WI
E-mail: office@butterfielddrilling.com
License Number: 652879
Remarks:
Phone: 715 634 8176
Zip: 54843
This space reserved for approval stamp.
Signature: Date: o7 /ba (�
Original signature required on each submitted copy.
SCALE=1:50 1:50 1 i
II O St
64765 W Bass Lake Rd
SW 1/4, NE 1/4
Sec. 33/95.25'
T47NR08W
Town ofiver
Bayfieldy
IN TAX ID:
BM = Nabon in
11ree
ELEVS
BM - 1
B1 -
B2 - '
B3 ' 2v
ST
Go '
q t
V G a y `` �•�%
v o
4" PVC Sch40 ASTM F891
a
S
ST = 1000gal prefab concrete septic tank made by Superior Precast
w/ Lifetime LT -1/8 Filter
AA = Absorption Area consisting of two cells, spaced >3ft apart, containing
32 Quick -4 Plus Chambers
PLOT PLAN
a (�
Vd / Il!
/'Q/ /7,
1(3Rs5
/ //
≥)Ok61x►e aL'SM
�a' 1r1e%I s?O e-etFGl l (f
Scl oCKrcqu•remeof5
f / Page 2 of 4
IN -GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard -W Chambers
3 -ft Trench (down -sizing credit)
SOIL COVER
min. 12"
(typical)
Septic Tank(s) Manufacturer:
Superior Precast Concrete
Septic Tank(s) Volume(s):
1 000 gal gal gal gal
Effluent Filter Manufacturer:
Lifetime Filter LLC
Effluent Filter Model #: LT -1 /8
12"
min. trench
depth
(typical) • ' TYPICAL TRENCH
r34" .
CROSS SECTION VIEW
(typical) ,. (No Scale)
System Elevation = 93.25 ft
(typical)
Quick4 Standard -W
w/ End Cap (Show location of inlet / outlet pipe connection on plan view.)
(typical)
r-------------------�f---
r r
----------------
B=67 ft
(typical)
INSTALL PER TRENCH:
16 Quick4 Std -W @ 20 ff EISA/chamber = 320 ft2
+ 1 Pairs of end caps @6 ft2 EISA/pair = 6 ft2
= Proposed EISA per trench = 326 ft2
Provide minimum 3 ft
separation between trenches.
Observation Pipe
(typical)
install per manufacturers
/ Instructions.
TA = 3.0 ft
(typical)
v
to
. COD
ga
a
C
C-
o
mm^
TYPICAL TRENCH
PLAN VIEW
(No Scale)
"—Quick4 Standard -W Chamber
(typical)
(mfd by Infiltrator Systems, Inc.)
Install pursuant to manufacturer's instructions.
Required Infiltration Area = 643
x 2 trenches = Proposed Total EISA = 652
D
C)
m
W
O
ii
a
ft2 Distribution Method:
ft2 branched manifold El
JUL 167- PAGE 4 OF 4
BaYfie,d Co. In -ground Gravity Management Plan
pp nning and Zoning Agency
IMPORTANT:
The owner of this in -ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow = 450 gpd; BOD5 5 220 mgL-'; TSS 5 150 mgL-'; FOG 530 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re -cycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company:
Local government unit: Bayfield County Planning & Zoning
Butterfield Inc
Local government unit address:
Phone: 715-634-8176
Phone: 715-373-6138
117 E 5th Street P.O. Box 58 Washburn, WI
ZIP: 54891
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in -ground dispersal component may be
abandoned and replaced by a code -complying dispersal component in a pre -determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
SUPERIOR 1,000 1 -Compartment Tank "SUPERIOR
PRECAST CONCRETE
TOP VIEW
JUL 16 2026
Weight (in lbs aayfieid Co.
Tank: e, and ZoningAgenc/
Lid: 3,683
Total: 9,495
Volume of Concrete
Total : 2.4Yd'
Gallons Per Inch: 24,4
Lid
----s9-1+2„-
83-12
73"' 7g_
SIDE VIEW I8,�
Enlarged Detail
Conditionally
4n
APPROVED 9"ri' it Space
DEPT. OF SAFETY AND PROFESSIONAL 4"
SERVICES I11W
DIVISION OF INDUSTRY SERVICES
/4a R4 a 42 Lulmd 6O,
SEE CORRESPONDENCE I I I '$ 45^
Manhole Openings - 4
\� ?-1 Tapea
Polyethylene
Produced by Superior Precast Concrete, LLC
PO Box 1390
Hayward, WI 54843
5
SUPERIOR
PRECAST CONCRETE
Design contorms to AS I M 01221, Specification for
Precast Concrete Septic Tanks and WI SPS 384.25,
POWTS Holding Components or Treatment Components.
The information provided on any Superior Precast
Concrete (SPC) drawing or document shall be verified by
the purchasers licensed professional engineer for
suitability of use.
Configuration may change from drawing, consult with
SPC.
I
_.. I This is proprietary Infarmation,and remalnsme propertyof SuperiorPrecasl Concrete.LLC. I R.305-19.20241
BAYFIELD COUNTY
CHECKLIST FOR SANITARY APPLICATONS
Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e))
Check List
LiOriginal Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.)
W"index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c))
ESOriginal Plot Plan (383.22(2)2. 3. & 4.a)
L4'Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer
❑// )
&'Contingency Plan / Management Plan (383.22-3(2)(b)1.f.)
P1 Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds)
383.21(2)(c)(5) (Recorded at Reg. of Deeds)
ract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5)
.E1 AIU4or:icing Recorded at Reg. of Deeds)
PfFee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7)
�.Cornfete Setfof 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.)
EThUtote Nan ltvicw (when applicable)
ld Copy of Warranty/Quit Claim Deed (Optional)
Sanitary Application: (Include the following Information)
I Application Information must include: "23 digit Parcel ID # -- (do not �
Project Address or Road Name where driveway is/will come off of) &'(0wners Phone Number)
Er II Type of Building
i4II Type of Permit
I"IV Type of POWTS System
EN Dispersal / Treatment Area Information
L9 VI Tank Information
[Vwi Responsibility Statement (Plumber's Information)
(w' *Date Stamp*
Plot Plan: (To Scale or To Dimension)
Q"/Signature and Plumber Information (oa )ade. Pngc)
Cf SeaFlevation of Body of Water ()oFi bola.+ BM)
(�irection and Percent Land Slope
IR"TTank and Filter Information and Location
lQ' etlands / Navigable Bodies of Water
G'sorption Area (Proposed and Existing)
CWIench Mark (Location, Elevation and Description)
L9'Component Manual Version (or 1 n ad' Pole-)
RECEIVED
JUL 16 2026
oayfield Co.
Planning and Zoning Agency
Lfl/Address Number and Road
/North Arrow
LRContour Lines
L9'Structures and Driveways
Z/Boring Locations
&/Property Lines
Well Locations
&'L/egal Descriptions
Piping Material Information (conveyance line, building sewer line, material type and diameter)
Tum Over ►
Cross -Section and Over -Head Profile of the System:
L' urface and System Elevation
P sition of Observation and Vent Pipes
EYfimensions and Depths
ake, Model & Number of Chamber Units in each Cell
Property Information
E ow many systems will there be on this parcel of land? I
Has this property been split? O (Property Statement shows Property History)
Fees:
rivate Sewage System (Septic Tanks)
❑ Private Sewage System (Holding Tanks)
❑ Mounds or Systems requiring Pre-Treatr
❑ Sanitary Revisions
❑ Private Sewage System Reconnection
and Private Interceptor
❑ Return Inspection
&KMaintenance Agreements
(checks made out to Reg of Deeds)
$ 400.00
$ 400.00
ient $ 500.00
$ 25.00
$ 50.00
$ 50.00
$ 30.00
T'O C ko
R'stirC5F s.
u/forms/checklists/checklistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by:
Private Sewage System Maintenance Agreement
4
(0V765 W bass 1o4 fzd ?^, tye.>e
Tax ID # /^q 75
As owner, I (wb) do hereby certify the private sewage system will be installed in
accordance with the certified soil tester's report and approved plans and specifications
on file with Bayfield County Planning and Zoning Department. The system will be
operated in such a manner as to meet the designed plans. I (we) agree to maintain said
private system at the below listed location in accordance with rules established in the WI
Adm. Code, as from time to time amended. (COMPLETE Legal is required)
1fL /F 4d. —Section ,Township N. Range _____W
Additional Legal Description:
Town of 7 "peJ RIIJC'L_ (Acreage)
Lot
Subdivision
Lot_CSMIt Vol._Page_ CSM Doc#
he In -ground gravity
❑ Mound
Gov't Lot
DOCUMENT NUMBER
2026R-613177
DANIEL,. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
RECORDED
08/03/2026 AT 8:00 AM
RECORDING FEE: $30.00
PAGES:2
Return To:
Planning and Zoning Department
RECEIVED
❑ In -ground dosed ❑ In -ground pressure distribution S@�
Planning a
❑ At -grade Sewage System ❑ Other
Area
Septic Tank (system types A through E): The septic tank shall be pumped by a certified septage servicing operator within three (3) years of the date of
installation and at least once every three (3) years thereafter unless, upon inspection by a licensed master plumber or other person authorized to make
such inspection, the tank is found to have less than one-third (113) of the volume occupied by sludge and scum.
Pump Chamber (system types B, C, D, and E): The pump chamber shall also be rinsed and pumped out when the septic tank is serviced as provided
above. The switches and pump controls shall also be inspected and maintained to ensure operability of said components.
Septic Tank Effluent Filter (system types A through E): The septic tank effluent filter shall be inspected and maintained as necessary and in accordance
with manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin. Code.
Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually inspected by a certified
septage servicing operator, POWTS inspector, or licensed master plumber within three (3) years of the date of installation and at least once every three
(3) years thereafter to determine whether wastewater or effluent from the system is ponding on the ground surface.
Mounds. At -grade, and In -around Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbed if needed when
the wastewater distribution cell component is inspected as provided above.
Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs incurred by Bayfield County for
inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate any
human health hazard caused by the system. 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.
'',``\11111111111//
The terms and conditions of the agreement shall be bi�t to the benefit of all current and future owners of such property.
Owner(s) Name(s Please Print
r �Sv'r
A)vu � r c.
tGG5o�
; -c PR Y .
:-° ,K
? rA . V
scribed and sworn to before me on this date:
_ jCi4 3 /;S i-, Z (0
N tarized Owner(s) —Si natures) !� '
n lilt%0\
tary
y Co fission spires:
Drafted by Cy) Date: % _ 1=ai_____
Proofed by:
ulorms/sanitary/septicmaintenceagreement
Revised July 2020
FirstAmerican Title Insurance Company
Commitment Na: IF -30135R
EXHIBIT A
Located in the Town of Iron River, Bayfield County, Wisconsin
A parcel of land located inthe Northwest%, Section 33, Township 47 North, Range 8 West, described asfdlows:
Con menting. at the quarter comer between Sedions28 and 33, Township47 North, Range 8 West;
thence West along the North line of Secton 33, a distance of1,3162 feetto an iron pipe, whichIs.a 1/8 comer,
thence angle to the let90°21', a distance of 1,309.5 feetan iron pipewhlc h isfirstpointofdetenninatlon;
thence angle to the [eft 90°, a distance of429.3 feetiq an iron pipe;
thence angle tothe right46°11', a distance of 2112 feetto an iron pipe located on the Iakeshore of Wilderness Lake which Is known as
PLACE OF BEGINNING;
thence retracing on the same line to first point ofdefermination;
thence angle to the left 90°, adistance of 202 feet to an iron pipe;
thenoeangle tothe right 90°, a distance of 538:8 feet to an Iron pipe;
thence angle to the 1eft90°; a distance of 378.8 feet to an Iron pipe;
thence angle to the. left 90°, a distance of 7520 feet to an Iron pipe;
thence angle to the right 32°58`, a distance of 171.5 feetto an iron pipe located on the waters edge of Wilderness Lake;
thence Northeasterly along thewatees edge a distance of 400.0 feet to PLACE OF BEGINNING.
NOTE: The historical legal descriptlon fw'the above parcel erroneously indicated the land was in the Southwest'/, of the Northeast''/.,
Sectlon 33, Township 47 North, Range 8 West. 4
Reviewed and Approved:
RECEIVED
AUG 04 2026
gay5eld Co.
Planning and Zoning Agency
ALTACommitnerrl
E4iIbIW: (F-30135RPFd1F-30195Rr4)
f ,
Real Estate Bayfield County Property Listing Property Status: Current
Today's Date: 7/1/2026 Created On: 3/15/2006 1:15:34 PM
tom' Description Updated: 5/5/2026 81 Ownership Updated: 5/5/2026
Tax ID:
PIN:
Legacy PIN:
Map ID:
Municipality:
STR:
Description:
Recorded Acres:
Calculated Acres:
Lottery Claims:
First Dollar:
Zoning:
ESN:
I Tax Districts
19975
DEAN M & LONNI M BRICKSON HERMANTOWN MN
04-024-2-47-08-33-2 03-000-02000
024109001000
Billing Address:
Mailing Address:
DEAN M & LONNI M
DEAN M & LONNI M
(024) TOWN OF IRON RIVER
BRICKSON
BRICKSON
S33 T47N R08W
5378 ROOSEVELT DR
5378 ROOSEVELT DR
PAR IN SW NE IN V.1012 P.954 711A
HERMANTOWN MN 55811
HERMANTOWN MN 55811
(RAYMOND A KUBISTA FAMILY TRUST
CREATED UNDER KUBISTA LIVING
Site Address * indicates Private Road
TRUST DTD 08/15/2002)
64765 W BASS LAKE RD
IRON RIVER 54847
8.700
9.490
Property Assessment
Updated: 8/11/2024
0
No
2026 Assessment Detail
(R-1) Residential -1
Code
Acres Land Imp.
118
G1 -RESIDENTIAL
8.700 136,300 0
1
04
024
163297
001700
Recorded Documents
® WARRANTY DEED
Date Recorded: 3/10/2026
® TRUSTEES DEED
Date Recorded: 9/14/2009
® CONVERSION
Date Recorded: 3/15/2006
® WARRANTY DEED
Date Recorded: 12/4/2002
Updated: 3/15/2006
2 -Year Comparison
2025
2026
Change
Land:
136,300
136,300
0.0%
STATE
Improved:
0
0
0.0%
COUNTY
Total:
136,300
136,300
0.0%
TOWN OF IRON RIVER
SCHL-MAPLE
TECHNICAL COLLEGE
Nw
Property History
Undated: 10/7/2009
N/A
2026R-611373
2009R-528750 1025-789
475871 229-552;833-
597;833-597
2002R-477770 840-459
JUL 16 2026
Bayfield Co.
Planninard ZcningA�ucncy
f .
BAYFIELD COUNTY
JUL 16 206 CHECKLIST FOR CERTIFIED SOIL TESTS
Submittlh I ollowing (Use Permanent Ink):
Ptanrnng at
L�J Check List
I)
I"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)
ET Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
Ef'Property Owner's Information (not prospective buyer's name)
1l Property Location (Accurate Legal Description with Sec/Twp/Range)
4 Road Name (where driveway is/will be coming off of)
❑ dations
Complete Soil Boring / Pit Information
l9 Date Soil Evaluation was conducted
EET" CST Name, Signature, Number, Address and Phone Number
l3' *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
�f nch Mark (Description, Elevation and Location)
Contour Lines (Example = 98.0' /96.0' /94.0')
Property Location (Sec/Twp/Range/, Accurate Legal Description)
i B rings (Locations and Elevations)
Pe
rcent and Direction of Land Slope
ell Location (Including Neighboring Wells, if applicable)
l 'L cation of Wetland Areas, Floodplain and Navigable Waters
;Buildings, Driveways, and Structures (Location and Descriptions)
Lf Location of Property Lines
n
CAddress Number and Road Name
❑ €went-wFaee Elevation Waters
L9'CST, Owner and Property Information
"North Arrow
Fe •
Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checklist/checklistforests
]3M 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:
BRICKSON, DEAN M & LONNI M
5378 ROOSEVELT DR
HERMANTO'VVN, MN 55811
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00469
Transaction Number:
SR-00469-4A31A
Amount
$50.00
Total: $50.00
Payment Amount: $50.00
.Reference: 5429
Paid by: Butterfield, 14346W State Rd 77, Hayward WI 54843
Payment Type: Check
Transaction Date: 8/4/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
B' -YFIELD Bayfield County
Planning & Zoning Department
117 E 5th Street
P.O. Box 58
Washburn, WI 54891
Phone: 715-373-6138
Fax: 715-373-0114
Property Owner: Submission Number:
BRICKSON, DEAN M & LONNI M SS -00802
5378 ROOSEVELT DR
HERMANTOWN, MN 55811 Transaction Number:
SS-00802-4A33B
Description
Private Sewage System (Septic Tanks)
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 5429
Paid by: Butterfield, 14346W State Rd 77, Hayward WI 54843
Payment Type: Check
Transaction Date: 8/4/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-103S
STATE SANITARY PERMIT
OWNER: DEAN M & LONNI M BRICKSON
GOVT LOT: LOT: BLK:
SW 1/4 NE 1/4 SEC: 33, T 47 N, R 8 W
TOWNSHIP: Iron River
SOIL TEST: 104-26
NEW SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: TRAVIS BUTTERFIELD
EMILY MACGILLIVRAY DATE: 8/4/2026
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: # 652879
Condition: Properly Maintain System Per Recorded Agreement
THIS PERMIT EXPIRES 8/4/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION