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HomeMy WebLinkAbout26-105SDepartment of Safety County p 9 _ & Professional Services o 0. •i e� ' ! $ Services, Sanitary Permit N tuber (to be filled in by Co.) p$ Industry Services Division fA"ss-0060b a(- loss 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 are submitted to Project Address (ifdifferent than mailing address) the Department of Safety and Professional Services Personal information you provide may be used for secondary '] a'430 t400 Vert L i tq6 Rd purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. r� I. Application Information - Please Print All Information t r ov% R t V Cl/ ti S Y Q fl Property Owner's Name lineal-# r I I rr J C_inc l: e rAx 'k 7 o I Govt. Lot I r I Gl le ..!_ S4 BC's 7 I S a 97_- 000 IVC �''/e. //.'1. Section Z�_ —L U. Type of Building (check all that apply) Lot # T N R E or v T I or 2 Family Dwelling— Number fBedrooms 3 Subdivision Name RECEIVED Block ft ❑ Public/Commercial — Describe Use O City of ❑ State Owned -Describe Use JUL282026 O Village of CSM Number le Town of 0l) I V � � III. Type of POWTS Permit: (Ghee eW ' or Replacement^ and other applicable on line A. Check one box on line B. Complete line c if a licable. A. µ New System y ❑ Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) B' Holding Tank ❑ In -Ground ❑ At -Grade ❑ 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 Rate(gpd/s0 I Dispersal Area Required (st) I Dispersal Area Proposed (sf) I System Elevation '-I So - -- - - Capacity in I Total I # of I Manufacturer Tank Information Gallons I Gallons I Units I I ,o $ 2 New Tanks Existing Tanks 'L° c as 2 'w v A dU » h iiU a --p{1CJ1Irinloingr anK 41500 8500 I Wi€St WLPaSW X V. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's amre-HR"MPRS Number Business Phone Number s.ri Siy hlI&Av\ re)( KoSK; Plumber's Address (Street, City, State, Zip Code) tab 13o)c SZ'L zro„. R;uE VI. unty/Department Use Only Pproved O Disapproved Peril Pcc s i O Owner Given Reason for Denial z to complete olans fur the system and submit to the Count' only on naoer not less than 8 14 c 1l — L7rL /o046 - A 1 SBD-6398 (R. 03/22) Wisconsin Department of Safety & Professional Services Page I of 2 Division of Industry Services C)hI7 ✓' s ! D x, ('h) ., 4 SOIL EVALUATION REPORT /O5- z( In accordance with SPS 385, Wiis. Adm. Code County &U-C! �� Attach complete site plat�lon ga e> joss than 8 1/2 x 11 inches in size. Plan must include C' but not limited to verti d� o izontal reference point (BM), direction and percent sl pew Pereel I.D. scale or dimensions, northad location and distance to nearest road. `,' TAX Z- O t g and � t all information. Revie ed b pinj� '� Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). t ��� d I a/'o+r✓ E Property Owt' �•.-wner Property Location ❑ c. 1 ' l q L Govt. Lot %$ t41 % S Z, 2 T Li e N R Cf E (or) HIV Property Owner's Mailing Address Site Address or CSM and Lot #: O ec 2. t 7a4o 'c-toover LRd City, State, Zip I Phone Number ❑ City ❑ Village Zt Town I Nearest Road ie &I S-4 99 (7/s) 2.9 2- 0146vve/ New Construction Use: Residential/Numberofbedrooms _,3 Code derived designflow rate GPD ❑ Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft. Parent material RA e' jay General comments and recommendations:[cA 'vI7/ 1, t, 9 'C c4.h Ic. � Boring # ❑ BoringCf l J} Pit Ground surface elev. ft. Depth to limiting factory in. / elev. ft. Soil Anolication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 p-3 7, O ry v"n v a. 3l © Boring # ❑Boring [Pit Ground surface elev. ft. Depth to limiting factor_in. / elev. ft. Soil Annlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 o-i icyt/ hn v• t L O O I.S R3/ — L Ow CSTVame (Please Print) S l SignatureNumber , B T !b — S Address Si 1 L'ty II " B I Date Evaluation Conducted I Telephone Number r * Effluent #1 = BOD > 30 5 220 mg/L and TSS > 30 5150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L SBD-8330 (R03122) Page *2- . of Boring # ❑ Boring CO Pit Ground surface elev.T S ft. Depth to limiting factor_O in. / elev. ft. nil Annlirtatinn Rm♦o Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 o- ' 7 q vi; G mow, C d G Z- 3S0z. 3 - VMM Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. I Soil Annlicatinn Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. I Sail Annlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS s 30mg/L Combined Soil Evaluation Plot Plan - System Plot Plan Component Manual Design References: Holding Tank Version 2.1 0 50 100ft Illillilill N ---------------------------------------1-- Owner: Clifford Follis Site Address: 72430 Hoover Line Road, Iron River, WI 54847 Tax ID: 27011 Legal Description: NESW S22-T48N-R09W N1/2N 1/2 SW INDOC 2026R-612263 394 Document: 2026R-612263 Acreage: 40.000 Town of Oulu, Bayfield County, WI Existing Well O Soil Pits --- Approximate Property Line A Benchmark Screw in pine tree 0 w C J L J 0 0 on Approx. 2615' to East Property Line m C0 Proposed 3 Bedroom Home 1 All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5 ____ Wieser IJ—WLP250o O1 O2 -------------------------- Soil Evaluated By: Tony Polkkps i -11068-ST ll�.�• Ye��ieS/' ------------------------------------- Plumber: Allan Polkoski - PMRS 220090 PAGE 1 OF 4 RECEIVED Holding Tank Plan JUL 282026 Index & Cover Sheet Baynes Co. Component Manual Design References: piandrpandZonin9ABCY Holding Tank Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan Enclosures: HoIarnq TANk A3ree.me_vi7 , Ho(ciyls Tam k SL✓'W Lr\9 Cov TracT, $o.n tofy Pc.rnn i App Iicc.y oh Project Name / Description Owner Name(s): C_ I t $co'tc Fo II1 S Phone:7 /S -0292- 000 I Owner Address: PO 130) Q 1, Ac.ple, W I Zip: S'/9r`1 ProjectAddress: 7I30 Flooveir Live RcI, .Ifov, kiV2Y-, wzcysv7 Govt. Lot: WE 1/4 of S k/ 1/4, Section , T _N-R_E ❑ or W �'❑ Township: 0 V I L) County: QQM4'ie(OA Project -Parcel ID #: t4)c Designer Information Designer Name: A Ilan Po l koskPhone:?/c-27- HiS-6 Designer Address: PO 13ox SZ2..,=ro-- Rjytfl W = Zip: SY$YD E-mail: fo via Q- b Gay- O V 1 eke Y1 o✓''th . c -o !M This space reserved (or apps, ,d stamp. License Number: PMRS S '2...20 ejg 0 Remarks: Signature: /' (F Original signature required on each submitted copy. Date: -zz-Z6 Combined Soil Evaluation Plot Plan - System Plot Plan ^ Component Manual Design References: Holding Tank Version 2.1 0 50 100 ft11111 Ii iii !/N Owner: Clifford Follis Site Address: 72430 Hoover Line Road, Iron River, WI 54847 Tax ID: 27011 Legal Description: NESW S22-T48N-R09W N 1/2 N 1/2 SW IN DOC 2026R-612263 394 Document: 2026R-61 2263 Acreage: 40.000 Town of Oulu, Bayfield County, WI Existing Well O Soil Pits --- Approximate Property Line A Benchmark Screw in pine tree O (0 O 0 C J e) O O 2 RECENED JUL 28 2026 Bayfield Co. Planning and Zoning Agency Proposed Proposed n 3 Bedroom Garage —�I I Home Approx. 2615' to East Property Line All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5 Wieser O1 O2 Soil Evaluated By: Tony Polkoski - 11068 -ST Plumber: Allan Polkoski - PMRS 220090 RECENED JUL 28 226 — ptanniand ZonM9 � HOLDING TANK SPECIFICATIONS (No Scale) Weatherproof Junction and Alarm Box Electrical must comply with SPS 316 and NEC 300 Conduit 18" Min. FT (typical) I: Inletf Approved Joints with Approved Pipe 3 ft onto Solid Ground a PAGE 3 OF 4 12" Min. or 2.0 ft above Approved Established Flood Elevation Vent Cap (typical) Approved Locking Manhole 40 Vent Pipe with Warning Label Attached .10 ft from (typical) 4" Min. or 2.0 ft above Building Established Flood Elevation 1 — / (typical) _ Airtight Seal Inlet Invert Max. 12" or 90% of total volume if more than one tank Alarm -On HOLDING TANK VOLUME = oZ .r0 O gal 3" Approved Bedding Material Beneath Tank TANK MANUFACTURER: W i GSC✓ w L Pacoo Anchor tank as necessary pursuant to SPS 383.43(8)(g) Finished Grade Plug WLP2500 TANK SPECIFICATIONS 1831" 4" CAST —A —SEAL 4" CAST —A —SEAL �IIII \ FILTER OR I BAFFLE o TOP VIEW ≥ `D o Mi N s 2 U W a m DIMENSIONS: WALL: 3" BOTTOM: 5" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 55 1/4" O.D. LENGTH: 183-1/4" O.D. WIDTH: 101-1/4" O.D. BELOW INLET: 43" O.D. LIQUID LEVEL: 36" WEIGHT: TANK - 15,527 LBS. COVER 9,300 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: 69.44 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,639 GALLONS LOADING DESIGN: 8' 0" UNSATURATED SOIL 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 WESER CONCRETE SIDE VIEW APPROVED By Glen Schlueter at 8:23 pm, May 30, 2022 TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS J DRAWINGS GAPPROVALTED11 FOR APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: 0 Z 0< 0. U H 0_ U 1n F1 NI R�CCIVEL� PAGE 4 OF 4 JUL 282026 Holding Tank Management Plan The owner of this holding tank(s) 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 holding tank(s) 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. Estimated Daily Wastewater Flow = 1150 gpd 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 neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o electrical components (to., wiring, connections, switches, controls, timers, alarms, etc.) o surface discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats. when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s). Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Iron River Septic Phone: 715-372-4006 Local government unit: Bayfield County Zoning Local government unit address: Washburn, WI Phone: 715-373-6138 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 component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agecy for review and approval. System Abandonment If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. m� 0004 Clifford Scott Fouls Lindsay Suzanne Follis 27011 TANK PO BOX 21 MAPLE WI 54854 T Ly C) r —o.2(o we acicnowleoge mat 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 Stats. NE 1/4 of SW 1/4 Section 22 Township 48 N. Range9W. W. Town of Oulu Additional Legal Description: NESW S22-T48N-R09WN 12 N 1/2 SW IN DOG 2026R-612263 394 Galt Lot — Lot Bbek Subdivision LotCSM # Vol _Page _CSM Doc# DOCUMENT NUMBER 2O26R-61 2978 DANIEL J. HEFFNER REGISTER OF DEEDS BAYFIELD COUNTY. WI RECORDED 07/17/2026 AT 1 1:10AM RECORDING FEE: $30.00 PAGES: 1 Return To: Allan Polkoski / Iony PO Box 522 Iron River, WI 54847 A_. • 0"M JUL 20 2026 Planning As an inducement to Bayfield County to issue a sanitary permit for a holding tank on the above described property, we agr a lodo the following: 1. Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tank installation and maintenance. If the owner fails to have the holding tank property 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, Stalls., Bayfield County may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats, 2. Owner agrees to pay all charges and costs incurred by Bayfield County for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. Bayfield County shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 3. The owner agrees to contract with a person who is licensed pursuant to s.281.17 (3) Wis. Slats., 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. State., 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 shall 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. Owner(s) Name(s) —Please Print Subscribed and swom to before me on this date: LinCldssa Suzannord Scott e Follis is y ( - 1_ �� EliM/�R Notary Public •• My mission Expires: B�\ Drafted by. Tony Polkoski Pvaonal Inbn don YOU prewm nay be used for secondary purposes IPnyacy taw, s.15.04 (Ixm)1 'I Date: 7-7-26 \\\`\ uJonrelsanhIaryf,ddnglankagreemenLdoc €June 2018 HOLDING TANK SERVICING CONTRACT Contract Date acar� This contract is made between the Holding Tank Owner(s) Name(s) Clifford Scoff Follis Lindsay Suzanne Follis per's Name (Print) mas Polkoski E Putnrhi's Signature ✓/ U Pumpers' Registration # 81271 We acknowledge the installation of (a) holding tank(s) on the following property: (Provide COMPLETE legal descriptions) PROJECT Legal De4Motbn: Tax IDR NESW S22-T48N-R09W LOCATION (Use Tax Statement) 27011 N 1/2 N 1/2 SW IN DOC 2026R-612263 394 Town of: I Lot Size Acreage Section 22 ,TawnsWp 48N, Range 9W Oulu 40 Gov'ttot Intl CSMI Vol. Page CSMDocp Lot(s)No. elocll(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 holding tank; 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; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; 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) Clifford Scott Follis Lindsay Suzanne Follis fit on 1 t-5 by: My Revised: May 2016 (®May 2018) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (I)(m)] ibed and Sworn to me: day of `\t till IE Ir �/oTA i blic truission *sires or :*_ � --J) dl •�f/B��v. 2 Tony Polkoski SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e)) 0 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) 0 Cross Section, Over -Head Profile of the System and DSPS APPROVED Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) 0 Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) O Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) V Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) 0 ATU Servicing Agreement (Recorded at Reg. of Deeds) 0 Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) 0 1 Complete Set of Plans (Note: Sanitary Application and Maintenance Agreements are to be attached) 0 Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) RECEIVED ❑ State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) u L 28 2026 Bayfield Co. Planning and Zoning Agency Sanitary Application: (Include the following Information) 0 I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number 0 II Type of Building 0 III Type of Permit 0 IV Type of POWTS System 0 V Dispersal - Treatment Area Information 0 VI Tank Information 0 VII Responsibility Statement (Plumber's Information) Plot Plan: (To Scale or To Dimension) 0 Signature and Plumber Information ❑ Surface Elevation of Body of Water ❑ Direction and Percent Land Slope 0 Tank and Filter Information and Location ❑ Wetlands / Navigable Bodies of Water ❑ Absorption Area (Proposed and Existing) 0 Bench Mark (Location, Elevation and Description) 0 Component Manual Version 0 Address Number and Road 0 North Arrow O Contour Lines 0 Structures and Driveways 0 Boring Locations 0 Property Lines 0 Well Locations 0 Legal Descriptions 0 Piping Material Information (conveyance line, building sewer line, material type and diameter) Turn Over ► Cross -Section and Over -Head Profile of the System: ❑ Surface and System Elevation ❑ Position of Observation and Vent Pipes O Dimensions and Depths O Make, Model & Number of Chamber Units in each Cell Property Information W How many systems will there be on this parcel of land? 0] Has this property been split? N !7 (Property Statement shows Property History) Fees: ❑ Private Sewage System (Septic Tanks) $ 400.00 1 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) BAYFIELD COUNTY CHECKLIST FOR CERTIFIED SOIL TESTS RECEIVED Submit the Following (Use Permanent Ink): JUL 28 2026 X Check List Baysea Co. ER Index Page / Title Sheet (Optional) Planning and Zoning Agency ER Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers) aOriginal Plot Plan ❑ Cross Section Soil Profile Sheet (optional) O Additional Information (Warranty/Quit Claim Deed) (Optional) Soil Evaluation Report: (Include the following Information) i% Tax Identification Number (must be 5 digitTax ID#) DO NOT USE 12 digit, they are no longer being used Z Property Owner's Information (not prospective buyer's name) ER Property Location (Accurate Legal Description with Sec/Twp/Range) ($ Road Name (where driveway is/will be coming off of) ❑ Floodplain Elevation, Flow Rate, Comments and Recommendations R Complete Soil Boring / Pit Information X Date Soil Evaluation was conducted ER CST Name, Signature, Number, Address and Phone Number ($ *Date Stamp* Plot Plan: (Include the following information drawn to dimension or to scale) R Bench Mark (Description, Elevation and Location) C5 Contour Lines (Example = 98.0' /96.0' /94.09 D( Property Location (Sec/Twp/Range/, Accurate Legal Description) 14 Borings (Locations and Elevations) a Percent and Direction of Land Slope ER Well Location (Including Neighboring Wells, if applicable) O Location of Wetland Areas, Floodplain and Navigable Waters R Buildings, Driveways, and Structures (Location and Descriptions) R Location of Property Lines O Existing System Location X Address Number and Road Name O Current Surface Elevation of Wetlands and Navigable Waters X CST, Owner and Property Information X North Arrow Fee: X Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/san ilary/check) ist/checklistforests 13MFi E LD 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: FOLLIS, CLIFFORD SCOTT 72430 HOOVER LINE RD IRON RIVER, WI 54847 Description Certified Soil Tests - Review & Filing Fee Submission Number: SR -00478 Transaction Number: . SR-00478-4AF79 Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 6337 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 8/6/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. p TFIELD 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: FOLLIS, CLIFFORD SCOTT SS -00806 72430 Hoover Line Rd IRON RIVER, WI 54847 Transaction Number: SS-00806-4B5BA Description Private Sewage System (Holding Tanks) Amount $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 6337 Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847 Payment Type: Check Transaction Date: 8/6/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-105S STATE SANITARY PERMIT OWNER: CLIFFORD SCOTT FOLLIS GOV'T LOT: LOT: BLK: NE1/4 /4 SW1/4 /4 SEC: 22, T 48 N, R 9 W TOWNSHIP: Oulu SOIL TEST: 105-26 NEW SYSTEM SYSTEM TYPE: Holding Tank PLUMBER: ALLAN POLKOSKI EMILY MACGILLIVRAY Authorized Issuing Officer DATE: 8 2 26 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 ,ondition: Properly Maintain System Per Recorded Agreement. Must be within 25 ft of an all- Neather road. THIS PERMIT EXPIRES 8/6/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION