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HomeMy WebLinkAbout26-0476BAYFIELD COUNTY I Zoning District CS- o& I p CY SANITARY PERMIT APPLICATION Lakes Class I. APPLICATION INFORMATION Soil Test I County �, 6 - o K 16 (Please Print All Information) No: Permit No: Property Owner's Name: 7E ED County: Bayfield Stephen M & Rebecca A Carey Address of Property: Property Location: 27395 Brown Rd Mason, WI 54856 " %. S 33 T 46 N, R 05 E (or) W Property Owner's Mailing Address: Township: I Gov. Lot #: N5647 N Franklin Street Kelly City, State Zip Code I Phone Number Lot # I Block #: I CSM #: I CSM Doc # I Subdivision Name Shawano, Wl 54166 715-851-8090 It. TYPE OF BUILDING: (Check One) ❑ State Owned Tax ID#: ❑ Public (Explain the use/purpose ) 21568 ® 1 or 2 Family Dwelling - No. of Bedrooms 2 III. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) ❑ New ❑ Replacement ® County Private Interceptor ❑ Reconnection ❑ Repair ❑ Revision " ❑ Transfer of Owner (List Previous Owner below) B) ® A Sanitary Permit was previously issued. Previous Permit Number. 17150 Date Issued: 06-18-92 IV. TYPE OF NON -PLUMBING SYSTEM: (Check One) * Replacements need previous permit number and date filled out above C) ❑ Pit Privy ❑ Vault Privy (Vault size: gallons or _____cubic yards) ❑ Portable Privy ❑ Camping Transfer Unit Container ❑ Composting Toilets ❑ Incinerating Toilet V. ABSORPTION SYSTEM INFORMATION: 1. Gallons I 2. Absorp. Area I 3. Absorp. Area I 4. Loading Rate I 5. Perc. Rate I 6. System I 7. Final Grade Per Day I Required (Sq.Ft.) Proposed (Sq. Ft.) I (Gals. / Day / Sq.Ft.) I (Min. Inch) I Elev.(Feet) Elev. (Feet) 300 480 480 .625 <10 96.25 99.25 VI. TANK Capacity Fiber INFORMATION: In Gallons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Constructed Steel - glass Plastic Exper. App. New Existing Tanks Tanks Septic Tank or 800 1 RASCAB X RECEIVED Holding Tank 800 Lift Pump Tank / S P 0 3 207fi Siphon Chamber VII. RESPONSIBILITY STATEMENT: I the undersigned, assume responsibility for installation of the onsite sewage system shown on the Owner'sName(s): (Print) If applying for Section C above I Owner'sSignature(s): (No Stamps) Plumber's Name: (Print) Ifepplyingforsection/lora)above PI be o ps) sne MP/MPRSWNo: Douglas Manthey 230722 -PM Plumber's Address: (Street, City State, Zip Code) one: Business Phone: PO Box 196 Drummond, WI 54832 715-739-6868 VIII. COUNTY I DEPARTMENT USE ONLY I ❑ Disapproved Sanitary Permit/Transfer Fee: I Date Issued: Issui Ag is Signature! Date: Approved ❑ Owner Given Initial q / 9/?o '6 q Adverse Determination 1 jj IX. CONDITIONS OF APPROVAL! REASONS FOR DISAPPROVAL: Plot Plan on reverse side p�c RrbeCco, Gcrey ?);9s gtuw,. Tax TD; aiS(.0jj NE, NW, KELLY TN . 86yp)EZb Co., k/i SYsr AztV- 9G.zs Y -\l C-000cyotAre 2s ' o be y„ scLYU Qoc, -v,s(oick os Pct Ca�Ce RECEIVED SEP 032026 Sayfleld Co. Planning and Zoning Agency Gog.ei R• sl1L QoC'N6 Qe/ ) / - 99. zS Z- 94-zS' 3- 99.St' ¢- 98.00' s- /Gb•OO' 1 _ g8.7S, jl 7 — a.00 c'SRaw•v R -D 23o9Z2-PM M arty r� CAIIUITAOV OCQIIAIT AOOI IPATIAM R In accord with ILHR 83.05, Wis. Adm. Code COl1NTYYS STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than .7/ ') o ❑ 8'b x 11 inches in size. �� �/5 Check It revision to previous application —See reverse side for instructions for completing this application. 3 STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OL1ER PROPERTY LOCATION i/`5 1OeoL.L NE% N)yt/a, S 33 T 44, N, R S (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Kr. /, Box Z/4,4 — — CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 4?Aaa.' tf S1t'O 9/S 74f"41&z II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : X�/ NEAREST ROAD RD ❑ Public 91 or 2 Fam. Dwelling-# of bedrooms Ill. BUILDING USE: (If building type is public. check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 O Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 O Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) — E A) 1. New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an .D System System Tank Only Existing System Existing System B)El A Sanitary Permit was previously Issued. Permit# Dateiddt!Rrt 1` V. TYPE OF SYSTEM: (Check only one) SEP 0 3 20 Non -Pressurized Distribution Pressurized Distribution ExperimentalOther eayr�bning 1 11 ❑ Seepage Bed 21 El Mound 30 ❑ SpecifyTypOlanning and Zoning �Holding Tank 12 El Seepage Trench 22 ❑ In Ground 42 LI Pit Privy 13 ❑ Seepage Pit Pressure _ 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. R) PROPOSED (sq. ft.) (Gals/day/sq. f .) (MinJinch) ELEVATION 300 SLto flC . , 94•ZS Feet fl'Zr Feet VII. TANK INFORMATION... CAPACITY in alto, Total Gellona #of Tanks Manufacturer's Name Prefab. ncret Site Cot- Steal Fiber- glass Plastic Expert App. New stl Tanks Tanks shaded Septic Tanko 'IC 1,00 / 2S/A//SSeII Lin Pum TanklSl hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibilityfor Installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's posture: (No ) MP/MPRSW No.: Business Phone Number. 4,'o°Y �.csMUSs67V - - -- - 3938 7�S 79B-33sS Plumber's Address (Street, City, Slate, Zip Code): P.o..fS'ox,4o4 e4.g , All IX. COUNTYIDEPARTMENT USE ONLY ❑'Disapproved Sanitary Permit Fee (Includes cnjwamr Datease Issuing Agent Signature (No Stamps) lklApproved ❑ Owner Given Initial 6 -J8-9aa Dp.op 4• 0,LQd X. CONDITIONS OF APPROVAL/REASONS FOR DISAbPR6VAL- SBD-8398 (formerly PIb87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber c/4'flrs k q'OLL / bx 2 ) 4 A /`9 as oiv, l4 i nest N4 NW, 33, 44/ SW KELLY 7X'. 86YF)sLb Co., kit SYSTE7'l grt-• - 96,zs RECEIVED SEP 032076 Bayfield Co. Planning and Zoning Agency cV,QROWN w gs 4 VRP /oe' ©eo end a c GoieeH t S ;VG z%,eftve ,7y ®si - 99.25 Z- 99.25' 3- 99s -a ¢-' .00' S- /op•OD' 1. 7- 99.00 RD - v WELD. � 81 1 / 4 ANDRY RASMUSSEN & SONS, ING. Pig. r Htg . Concrete Septic Tanks Cable, Wis. 54821 Sellers # 211768 - Ph. 1t5-;93-3355 Master Plumber W= 3938 Wisconsin Department Of Industry, Labor and Human Relations P.O. Box 7969 Madison, WI 53707 CONVENTIONAL ❑AT -GRADE ❑ EXPERIMENTAL %NEW Permit Holder's Name: Permit Holder's Address: S Y856 Inspection Date: k fZoa a a,tS 3 '10 t..c . _ Bench Mark, escri e ii Different From Plan: Parcel Tax I.D. No. (Optional) Ref. Pt. Elev.: CST Ref. Pt. Elev.: 3i ZS Plumber's Name: MPIMPRSW No.: State Plan ID No. (If Assigned): Sanitary Permit Number: Ar'aQA (� 3936' /'i ! SPo ON SITE SEWAGE SYSTEM INSPECTION REPORT County: 64 yF1 rr cQ DIN -GROUND PRESSURE ❑MOUND ❑ REPLACEMENT ❑ RECONNECTION Safety & Buildings Division I,. ❑ HOLDING TANK \ ❑OTHER(SPECIFY) SEPTICTANK/HULDING TANK: rri Manua rer: j73An I Liquid Capacity: g00 I Tank Inlet Elev,: 7,4 I Tank Outlet Elev.: I �.G1 War i gg Label I P❑o Yesa❑No ONO Lo tng over Pro Bedding: 7 ❑ Yes ❑ No I Ve>tD: vent Mat'.:I �" ,/ \ Hi hWater Alarrn ❑ Y I NUMBER OF FEET FROM NEAREST- + R d: Property Line: Well: ,I I Building: /.2 Au Vent: nnclMr ruARARCO. Manu acturer: Bedding: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: HighWaterAlarm arm Warning Label Locking Cover Provided: Provided: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Gallons Per Cy e: Pump and ontros Operational: NUMBER Property Line: We Building: Air Vent: (difference FEET ump on ando ) Yes No Vent Installed: Vent Diameter: Vent Material: FORCE Length: Diameter: Material an Marking: VENT ❑ Yes ❑ No MAIN SOIL ABSORPTION SYSTEM. Check to soil moisture at Lee ceptn OT plowing or excavation. to son can oe,uueu lilt!) a wae, wn>v uaamn vnaIl aco>c u..... the soil is dry enough to continue.) DISTRIBUTION STSTEM: BED/TRENCH I Width: Length: I T I Nrenches: I Lateral Sparing: I r Cover Material: I I InsteDi.. PIT No. Pits:_ Liquid Depth: �, DIMENSIONS Z q L% 6 Gravel Beloyv Pipe Fill Above Pipe: I Inlet Elev.: En� Elev.:i Pipe Materiali No, Distr. Pipes:1 NUMBER O Property Line: We But ding: Air Vent: S 7./EM b, 0 VC PVG 2 M NEAREST—� jS� JS 725 Manifold Elev.: I Manifold Dia.: I Manifold Material: I No. Distr. Pipes: Distr. Pipe Dia.: ELEVATION AND DISTRIBUTION INFORMATION Hole Size: Hole Spacing: Drilled Correctly:I Permanent Markersi Observation WeIIs:I Pump Elev.: Vertical Lift Corresponds To Approved Plans: Dyes ONO ❑ Yes ❑ NO ❑ Yes ❑No ❑Yes ❑ No Mound site plowed perpendicular to Check the texture of the fill material for I PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ Yes ❑ No meets the criteria for medium sand. ELEVATIONS MEASURED. COMMENTS: (Sketch System On Reverse Side) Yes 0 No ❑ Yes 0 No SYsT, t6EV 9, a ❑ Yes 0 No Yes ❑ No I ❑ Yes ❑ No BED /Vol cnisP[E%c" 6r74J ,C;'." RECEIVED SEP 032026 Bayfield Co. Planning and Zoning Agency SBD-6710 (R. 0990) : Q=sue __ Sig ature. Title: (Keep a copy in your file for audit) B _t-YFIELD Bayfield County Planning & Zoning Department 117 E 5th Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-4010 Property Owner: Description Private Interceptor Submission Number: CS -00188 Transaction Number: CS-00188-4D7A5 Amount $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 5529 Paid by: A -Z Enterprises, Inc Payment Type: Check Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. Town, City, Village, State or Federal Permits May Also Be Required LAND USE - SANITARY - Private Interceptor SIGN - SPECIAL - CONDITIONAL - BOA - No. 26-0476 Tax ID: 21568 Issued To: CAREY, STEPHEN M & REBECCA A Location: S33 - T46N - R05W Town of KELLY Legal Description: NE NW 668 IN DOC 2026R-612335 BAYFIELD COUNTY PERMIT WEATHERIZE AND POST THIS PERMIT ON THE PREMISES DURING CONSTRUCTION Residential Structure in A-1 Zoning District For: Sanitation Permit — Private Interceptor [Previous Permit # 17150 (06118/1992)] (Disclaimer): Any future expansions or development would require additional permitting. Condition(s): You are responsible for complying with state and federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or modification of construction that violates the law or other penalties or costs. For more information, visit the department of natural resources wetlands identification web page or contact a department of natural resources service center (715) 685-2900. NOTE: This permit expires two years from date of issuance if the authorized construction work or land use has not begun. Changes in plans or specifications shall not be made without obtaining approval. This permit may be void or revoked if any of the application information is found to have been misrepresented, erroneous, or incomplete. Scott Roush, AZA Authorized Issuing Official September 09, 2026 This permit may be void or revoked if any performance conditions are not completed or if any prohibitory conditions are violated. Date