HomeMy WebLinkAbout26-116SDepartment of Safety
County
Qay F iel
n s
SS- 00
Ps 1 D
& Professional Services,
Industry Services Division
Sanitary Permit Number (to be filled in by Co.)
Sanitary Permit Application
State Transaction Number
In accordance with SPS 383.21(2), Wis, Ado,. 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
66 H 3O A/u rr\ P0.; rtT Dr.
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats.
I. Application Information — Please Print All Information
tr pr lZ i V t:f lni .Z S N 8 y %
Properly
Property Owner's Name E FRED
ftrcel
AK
S
O9______________
�i M OTh L S l /S
.3 t7
Property Owner's Mailing Address
Property Location
1396 Arrowl\ecacRcAA/C 2..03
Govt. Lot
ZI
A)W,, /.,Sectionl
T H 7 N R E o W
City, State
Dukrrk AtN
Zip Code
SSg i1
Phone Number
Zi$-S9a-7o2_
U. Type of Building (check all that apply)
Lot n
Subdivision Name
10 I or 2 Family Dwelling — Number ofBedrooms 3
D
BI c
❑ Public/Commercial — Describe Use
82026
❑Cityof
0 State Owned — Describe Use
❑ Village of
CSM Number
Baybeld Co.
Zoning A9enc/
S ./N i
NETown of fh ,tr__
planning and
Ill. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box online B. Complete line C i
applicable.)
A.
New System
❑ Replacement System
❑ Other Modification to Existing System (explain)
❑ Additional Pretreatment Unit (explain)
B.
❑ Holding • Tank
Sin -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/TreatmentAreaandTanklnformation:
Design Flow (gpd)
Design Soil Application Rate(gpd/s0
Dispersal Required (sf)
Dispersal Area Proposal tsl)
SystemElevation
�
-I co
•7
(Area
t0 1Ar3
G c CJ
-I q r
Capacity in
Total
/t of
Manufacturer
o
Tank Information
Gallons
Gallons
Units
'Ls
o v
.v
2
New Tanks
Existing Tanks
"
v
U
`
a w
3
a. V
in 's
w
ii U
Septic or Holding Tank
1 O 0 O
1Q00
'
1N t er
X
Dosing Chamber
V. Responsibility Statement— I, the undersigned,
assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
I Plumber's Si afore
/MFRS Number
Business Phone Number
AtIanPnIkok�/S2q2
ti156
Plumber's Address (Street, City, State, Zip Code)
Po ox Sfl .I5r - Riue✓' I.,Z SHBY
VI. C ty/DapartmentUse Only
Approved
0 Disapproved
Permit ilFF%ee
$ qo" `
pDate Issuebt
13 Jm
Issm g Ag t Si a re
❑ Owner Given Reason for Denial
O 1j21,
Conditions of Approval/Reasons for Disapproval
//''
Sc lit. & lie .
Armen to complete plans for the system and submit to the County only on paper not less than 8 IQ z II inches in size
SBD-6398 (R. 03/22)
S R� oo4
�3°�pneT�rC°row Wisconsin Department of Safety & Professional Services SOIL TEST # ja, .....1, b Page 1 of
Division of IndustryServices VQ ✓'�
SOIL EVALUATION REPORT_______________________________
In accordance with SPS 385, Wis. Adm. Code County �+
Q.�.L4t 1 �l a
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include,
but not limited to vertical and horizontal reference point (BM), direction and percent slope, rfl.D.
scale or dimensions, north arrow, and location and distance to nearest road. 'TAX 3 a
"'( $- j(
Please print all information. R viered'.3
I Dat
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)).
Property Owner Property Location
— y m 0 —t4 1e.. k Govt. Lot N( Y. s '/. S 2, T q'7irf E (or) W
Property Owner's Mailing Address Site Address or CSM and Lot #:
t3,46 Ar I$.,h O 2-03 N3O Nor Petri r-tve_
City, State, Zip I Phone Number ❑ City ❑ Village 121 Town I Nearest Road
I-)i,Iirt4.. MAl SS -R I 1 I (2.1Q5)S9D-7O12 -'rd.n R 0ev, 1"e"N P6,AT O .
JA NewConstniction Use: ❑ Residential/Numberofbedrooms 3 c�p derived designflow rate ys0 GPD
❑ Replacement ❑ Public or commercial — Describe: Flood Plan elevation if applicable ft.
Parent material Ti i t 2026 �
General comments and recommendations:
AUG 1 8 RED
o,vf,p_ld Co.
nlnnninn and
� Boring
Boring # Pit Ground surface elev. 1 �Ift. Depth to limiting factor cj in. / elev. Ift.
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
I
6-
0
l
≥.e.j
vy
L
3
.7
Iig
Z.
-2.1
H/
Ls
1wcit
°.S
co
.7
t
-3(o
S /
eve6
o
I
----
2.
1
.- 7
I,
S
aBoring #
Boring
Pit [ Pit Ground surface elev. ` ,i3 ft. Depth to limiting factor 9t in. / elev.yS. oft.
nil Ar,nI ' firm Rita
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
-
Iv 1 3
15
Z r
r -cIr
-2.L
. s (-1/3
_________
Mlc
lsbk..
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c
,
3
- 3
S
—
3'-v
l
L. S
3
1.
Lj
— cfO
7.Ti1
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r
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.
l',
CST Name (Please Print)
Tor1 c k'
Signature
�w�... E,l Zl
CST Number
I 1 O -- S rt-
Address 5 t 1 c 15
Date Evaluation Conducted
Telephone Number
Ie.
-p, --2-c, I
* Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, s 30 mg/L and TSS 5 30 mg/L
SBD-8330 (R03/22)
Combined Soil Evaluation Plot Plan - System Plot Plan 1
0 50 100ft. � I
Component Manual Design References: N
In -Ground Soil Absorption for POWTS Version 2.1
Tax ID: 38604
Owner: TIMOTHY C SIEH
t
1
1
1
Site Address: 66430 NORTH POINT 1
DR, IRON RIVER, WI 54847
1
Legal Description: S21 T47N R08W
N 800' IN NW SE IN 2017R-571079 I 1 1 2 C I
LESS V.257 P.10 & LESS
DOC 2021 R-590953 482
(O
C
fl
(O•
�
2
i
3 Trenches
Quick
4 Plus 1
Standard Chambers
4% Slope
-►
1
of
__
PAR IN Tank - Wieser WLP1000-MR-
1
1
1
1
1
Soil Evaluated By: Tony Polkoski - 11068 -ST
Plumber: Allan Polkoski - PMRS 220090
Filter - PolyLoc PL -525 A I
-� All piping shall conform
Proposed 3 to
Bedroom Home / SPS Table 384.30-3 and
SPS Table 384.30-5
1
Existina 3� 1
Bed
Horr
I
/1'
Pike Lake
Elevation 56.8' 1
----------------_. I
t��:�vE►� In -Ground Gravity Plan
"JG 182026 Index & Cover Sheet
gaud eo A �� Component Manual Design References:
ptanninga�Zg In -Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Page 1 - Index & Cover Sheet
Page 2 - Combined Soil Evaluation -System Plot Plan
Page 3 - Dispersal Area Cross -Section & Plan
Page 4 - Management Plan
Enclosures:
Soil Evaluation Report, Sanitary Permit Application,
Wieser WLP1 000 -MR approved tank specifications,
Soil Test Checklist, Sanitary Application Checklist,
$450 check
Project Name / Description
Owner Name(s): Timothy C Sieh
Phone: 218-590-7012
Owner Address: 1346 Arrowhead Rd, NO 203, Duluth, MN 55811
Project Address: 66430 North Point DR, Iron River, WI 54847
Legal Description: NW SE S21-T47N-R08W
N 800' IN NW SE IN 2017R-571079 LESS V.257 P.10 & LESS PAR IN
DOC 2021 R-590953 482
Document: 2026R-612379
Township: Iron River County: Bayfield
Project Tax ID #: 38604
Designer Information
Designer Name: Allan Polkoski
Phone: 715-292-4156
Designer Address: PO Box 522, Iron River, WI 54847
E-mail: tony@bearguidenorth.com tony@soil2septic.com
License Number: PMRS220090
PAGE 1 OF 4
Remarks: PSSMA sent via USPS to Register of Deeds marked Return to:
Planning and Zoning Department.
Signature: ___ Date:
Original signature required on each submitted copy.
TaxID:38604
Owner: TIMOTHY C SIEH
Site Address: 66430 NORTH POINT
DR, IRON RIVER, WI 54847
Legal Description: S21 T47N R08W
N 800IN NW SE IN 2017R-571079
LESS V.257 P.10 & LESS PAR IN
DOC 2021 R-590953 482
Combined Soil Evaluation Plot Plan - System Plot Plan
Component Manual Design References:
In -Ground Soil Absorption for POWTS Version 2.1
=_i ApproxProperty Line
o Soil Test Pits:
1 - Elevation - 99.1'
2 - Elevation - 97.3'
3 - Elevation - 97.3'
L Benchmark - Screw in White Pine
Elevation - 100'
Soil Evaluated By: Tony Polkoski - 11068 -ST
Plumber: Allan Polkoski - PMRS 220090
Existing Well Permanently Abandoned
by Wayne Holly Well Drilling
0 50
100ft
A
!� I
HUll
2
O
8
ft
N a
a'
'j
an
v�
O
r'
CJ
2
rn
I
3 Trenches Quick 4 Plus
Standard Chambers
4% Slope
2
m \ 3
O O
Tank - Wieser WLP1000-MR -
Filter - PolyLoc PL -525
Proposed 3 �I piping shall conform !.
Bedroom Home SPS Table 384.30-3 and
SPS Table 384.30-5
Exis
Bed
Hon
Pike Lake
Elevation 56.8'
IN -GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard -W Chambers
3 -ft Trench (down -sizing credit)
min. 12"
SOIL COVER ii (typical)
12"
min. trench
depth
(typical)
a"
"
(tYpicai) a' ..
System Elevation = 94.8
(typical)
Septic Tank(s) Manufacturer:
Wieser
Septic Tank(s) Volume(s):
000 gal gal gal gal
Effluent Filter Manufacturer.
Polyloc
Effluent Filter Model #: PL -525
a6
TYPICAL TRENCH — Ill
CROSS SECTION VIEW.g
in
(No Scale) g v
Provide minimum 3 ft 2
ft separation between trenches.
Quick4 Standard -W
w/ End Cap (Show location of inlet / outlet pipe connection on plan view.)
(iypical)
r-----------�- --��
_.ATM----__
T1=47 T2=47
B = T3=43 ft
INSTALL PER TRENCH: (typical)
Trench 1: Iii I Quick4 Std -W @ 20 ft2 EISNchamber + 220 I 112
Trench 2: lii I Quick4 Std -W @ 20 ft2 EISNchamber + 220 I ft2
Trench 3: 10 I Quick4 Std -W @20112 EISNchamber + j200 I ft2
Observation Pipe
(typical)
Install per manufacturers
/ instructions.
TA = 3.0 ft
(typical)
TYPICAL TRENCH
PLAN VIEW
(No Scale)
Standard -W Chamber
Pair of end caps @6 ft2 EISNpair = 16 I ft2
Pair of end caps @6 ft2 EISNpair = 16 I ft2
Pair of end caps @ 6 ft2 EISNpair =j6ft2
Required Infiltration Area = 1643 ft2
Distribution Method:
No. trenches = II Proposed Total EISA = 1658 1112 Gravity
GD
rn
W
AUG �8Z026 PAGE4OF4
In -ground Gravity Management Plan
hayfield ° Agen°J
IMpQ nT mwN
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"1; TSS 5 150 mgL 1; FOG 5 30 mgL 1
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 (Le., 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 (1/3) 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 Phone: 715-373-6138
Iron River Septic
Phone: 715-372-4006
Local government unit address:
117 E 5th Street, PO 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.
WLP1000-MR
TANK SPECIFICATIONS
4" CAST
t
im
T
MP PAD
4" CAST -A -SEAL
DIMENSIONS:
WALL: 2 1/2"
BOTTOM: 3"
COVER: 5"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
HEIGHT: 53 1/4"
LENGTH: 8'-8"
WIDTH: 7'-2"
BELOW INLET: 42"
LIQUID LEVEL: 36"
WEIGHT: 6,790 LBS.
INLET AND OUTLET:
4" CAST -A -SEAL BOOT OR EQUAL GASKET
INLET AND OUTLET BAFFLE AND FILTER:
WISCONSIN, SEE DETAIL #10
(OTHER STATES SEE CHART)
LIQUID CAPACITY: 27.83 GAL/IN
HOLDING TANK:
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 1,085 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 #10 (STRUCTURAL FIBER)
CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WESER CONCRETE
SIDE VIEW
APPROVED
By Glen Schlueter at 8:20 pm, May 30, 2022
;EED ASTM C-1227 REQUIREMENTS
0
Lii
E
J
Q
o
a
G
REVIEWED BY
REVIEW DATE
w
DRAWINGS SUBMITTED
FOR APPROVAL
APPROVED BY:
SHEET No.
APPROVAL DATE:
1
7'
PRODUCTS NEEDED BY:
/
OF
1
SANITARY APPLICATON CHECKLIST - BAYFIELD COUNTY
Submit the Following - (Must be original and written in ink) (Title 15, Section 15-1-10(e))
2 Check List
2 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))
0 Original Plot Plan (383.22(2)2. 3. & 4.a)
2 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)
2 Contingency Plan / Management Plan (383.22-3(2)(b)1.f.)
❑ Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds)
❑ Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds)
❑ Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5)
❑ ATU Servicing Agreement (Recorded at Reg. of Deeds)
2 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.)
❑ State Plan Review (when applicable)
❑ Copy of Warranty/Quit Claim Deed (Optional)
RECEIVED
AUG 18 2026
Bayfield Co.
Sanitary Application: (Include the following Information) Planning and Zoning Agency
0 I 5 digit Tax ID - Project Address or Road Name adjoining driveway - Owners Phone Number
2 II Type of Building
2 III Type of Permit
IV Type of POWTS System
V Dispersal - Treatment Area Information
O 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
MDirection and Percent Land Slope
0 Tank and Filter Information and Location
G6 Wetlands / Navigable Bodies of Water
Ef Absorption Area (Proposed and Existing)
0 Bench Mark (Location, Elevation and Description)
0 Address Number and Road
0 North Arrow
G'Contour Lines
0 Structures and Driveways
0 Boring Locations
0 Property Lines
0 Well Locations
0 Component Manual Version 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
Rf Position of Observation and Vent Pipes _
'Dimensions and Depths RECtivEO
ld Make, Model & Number of Chamber Units in each Cell AUG 18 2026
Property Information Bayfield Co.
Planning and Zoning Agency
6'How many systems will there be on this parcel of land?
4 Has this property been split? N O (Property Statement shows Property History)
Fees:
l Private Sewage System (Septic Tanks)
$ 400.00
❑ Private Sewage System (Holding Tanks)
$ 400.00
❑ Mounds or Systems requiring Pre -Treatment
$ 500.00
❑ Sanitary Revisions
$ 25.00
❑ Private Sewage System Reconnection
$ 50.00
and Private Interceptor
❑ Return Inspection
$ 50.00
❑ Maintenance Agreements +
$ 30.00
(checks made out to Reg of Deeds)
sue- cog)7
Private Sewage System Maintenance Agreement
DOCUMENT NUMBER
2O26R-61 3496
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY. WI
WC 5Y2
RECORDED
08/27/2026 AT 11:01 AM
RECORDING FEE: $30.00
PAGES: 3
As owner, I (we) do hereby canny the private sewage system will be installed in
accordance with the certified soil testers 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)
U1/4 of 5 114 Section Township `r 7 N. Range 6 W.
p/ goo',n NW Sr Dot7R-5'T16-19 Less VZS7
Additional Legal Description: P to r Less Par
D O L J m e h
Town or L v'D n r Je.te (Acreage)
Lot _ Block Subdivision
Lot_CSM#_ Vol._Page_ CSMDoc# Wra 2B ZU26
Return To:
Planning and Zo"Mwo
ing
In -ground gravity ElIn-ground dosed innand
❑ In -ground pressure distributionewage System:
❑ Mound ❑ At -grade Sewage System ❑ Other
Area
,c 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 (1/3) 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.
X Seotic 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.
4 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.
The terms and conditions of the agreement shall be binding upon and inure to the benefit of all current and future owners of such property.
1� �4Y cO%€�
,
No_ nz -Sig s)
Drafted by: 1 P Date: 1-' `i -irony J%Ikos/c;
sworn to before me on
0
L i5• x030 `� '._.�.
Proofed by. v I
ufonns/sanitary/sepffcmaintenceagteement
Revised July 2020
Document Number
THIS DEED, made between
Edwin C. Johnson, Jr., a single person
("Grantor," whether one or more), and
Timothy C. Sieh, a single person
("Grantee," whether one or more).
WARRANTY DEED
Document Name
Grantor, for a valuable consideration, conveys to Grantee the following described real
estate, together with the fixtures, profits, rents, and other appurtenant Interests, In
Bayfield County, State of Wisconsin ("Property') (If more space Is needed, please
attach addendum):
SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF
DOCUMENT NUMBER
2026R-612379
DANIEL J. HEFFNER
REGISTER OF DEEDS
BAYFIELD COUNTY, WI
RECORDED
O6/O2/2O26 AT 1O:37 AM
RECORDING FEE: $30.00
TRANSFER FEE: $720.00
PAGES:2
ELECTRONICALLY RECORDED
Recording Area
Name and Return Address:
Results Title
11200 W. 78Th Street
Eden Prairie, MN 55344
04-024-2.47-08-21-4 02.000-11000
Parcel Identification Number (PIN)
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
Dated:/72�-,a
_ C
Edwin C. Johnson, Jr.
AUTHENTICATION
Signature(s): Edwin C. Johnson, Jr. authenticated on
ACKNOWLEDGMENT
STATE OF WISCONSIN
)ss.
COUNTY
4Print
eon2q aoaC�
TITLE: MEMBER STATE BAR OF WISCONSINore ,
(If not, d Edwin t. Johnson Jr.
authorized by Wis. Stat. § 706.06) tc(me46fle the rson(s) who execute the foregoing
ckn the same.
THIS INSTRUMENT DRAFTED BY: � I r n r'
Suzanne Bushard/Results Title � J
11200 W. 78th Street ��1.)';.•••'••••.�s ��,aten sc nsin�
Eden Prairie, MN 55344 ; co ' O
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= Notary Public, State of isconsin
rP : A ; My Commission(is permanent) (expires:(0.1 2-4)
(Signatures m�4yitrRlca F(�'•`acknowiedged. Both are not necessary.)
'Type name below signatures
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and Zoning Pfl
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Bayfield County Register of Deeds Document #2026R-612379 Page 1 of 2
EXHIBIT "A"
The North 800 feet of the Northwest Quarter of the Southeast Quarter, Section 21, Township 47 North, Range 8 West,
Town of Iron River, Bayfield County, Wisconsin, EXCEPT the South 150 feet thereof lying East of County Trunk Highway
H and West of the Town Road known as North Point Road AND ALSO EXCEPTING therefrom a parcel of land described
as follows: The North 800 feet of the Northwest Quarter of the Southeast Quarter (NW1/45E1/4), Section Twenty-one (21),
Township Forty-seven (47) North, Range Eight (8) West, Town of Iron River, Bayfield County, Wisconsin, LESS the South
150 feet thereof lying East of County Trunk Highway H and West of the Town Road known as North Point Road AND
LESS that portion lying East of the Town Road known as North Point Road, Bayfield County, Wisconsin
Bayfield County Register of Deeds Document #2026R-612379 Page 2 of 2
BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
Submit the Followin4 (Use Permanent Ink):
X Check List
CK Index Page / Title Sheet (Optional)
lB( Original Soil Evaluation Report (Submitted in Deed Holders Name — not prospective buyers)
1 Original Plot Plan
❑ Cross Section Soil Profile Sheet (optional)
❑ Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Report: (Include the following Information)
IR Tax Identification Number (must be 5 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
0 Property Owner's Information (not prospective buyer's name)
[ Property Location (Accurate Legal Description with Sec/Twp/Range)
CK Road Name (where driveway is/will be coming off of)
0 Floodplain Elevation, Flow Rate, Comments and Recommendations
IR Complete Soil Boring / Pit Information
1 Date Soil Evaluation was conducted
Z CST Name, Signature, Number, Address and Phone Number
X *Date Stamp*
' CEIVED
AUG 18 2026
Bayfield Co.
Planning and Zoning Agency
Plot Plan: (Include the following information drawn to dimension or to scale)
R Bench Mark (Description, Elevation and Location)
1B Contour Lines (Example = 98.0' /96.0' /94.0')
X Property Location (Sec/Twp/Range/, Accurate Legal Description)
JR Borings (Locations and Elevations)
1 Percent and Direction of Land Slope
Z Well Location (Including Neighboring Wells, if applicable)
l t Location of Wetland Areas, Floodplain and Navigable Waters
X Buildings, Driveways, and Structures (Location and Descriptions)
R Location of Property Unes
l I Existing System Location
X Address Number and Road Name
10 Current Surface Elevation of Wetlands and Navigable Waters
( CST, Owner and Property Information
9 North Arrow
Fee:
I Certified Soil Tests - Review & Filing Fee •$ 50.00
U/forms/sanitary/checklist/checklistforests
13A 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:
SIEH, TIMOTHY C
1346 Arrowhead Rd No 203
Duluth, MN 55811
Description
Certified Soil Tests - Review & Filing Fee
Submission Number:
SR -00493
Transaction Number:
SR-00493-4DOC0
Amount
$50.00
Total: $50.00
Payment. Amount:
Reference: .6345
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 8/31/2026
$50.00
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:
SIEH, TIMOTHY C
1346 Arrowhead Rd No 203
Duluth, MN 55811
Description
Private Sewage System (Septic Tanks)
Submission Number:
SS -00817
Transaction Number:
SS -00817-4D017
Amount
$400.00
Total: $400.00
Payment Amount: $400.00
Reference: 6345
Paid by: Polkoski Plumbing, PO Box 522, Iron River WI 54847
Payment Type: Check
Transaction Date: 8/31/2026
Receipt of payment does not guarantee eligibility of
permit and is not proof of issuance of a permit.
BAYFIELD COUNTY
SANITARY PERMIT (#04)-26-116S
STATE SANITARY PERMIT
OWNER: TIMOTHY C SIEH
GOVT LOT: LOT: BLK:
NW 1/4 SE 1/4 SEC: 21,T47N,R8W
TOWNSHIP: Iron River
SOIL TEST: 121-26
NEW SYSTEM
SYSTEM TYPE: Non -Pressurized In -Ground
PLUMBER: ALLAN POLKOSKI
EMILY MACGILLIVRAY LLIVRAY DATE: 8/31/2026
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: # 220090
Condition: Properly Maintain System Per Recorded Agreement
THIS PERMIT EXPIRES 8/31/2028
POST IN PLAIN VIEW
MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION