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Home My WebLink About26-130Swr Department of Safety County Bayfield �/ S� �3 & Professional Services, Services Division SanitaryPermit Number (to be filled in by Co.) D Industry 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 66545 Hart Lake Rd purposesin accordance with the Privacy Law, s. 15.04(1 xm), Stats. Property Owner's Name EN ERED Parcel # Derek E. & Emily M. Johnson 04-024-2-47-08-22-2 00-323-17000 PropertyOwner's Mailing Address Property Location a 0 a3 66535 Hart Lake Rd Govt. Lot 22 City, State Zip Code Phone Number Iron River, WI 54847 - y. v., Section T 47 N R 08 Eo Lot ii 17 ®lor2 Family Dwelling —Number of Bedrooms 3 Subdivision Name Plat of Ellenwood El k# R VED ❑ City of ❑ PubliclCommercial—Describe Use ❑ State Owned —Describe Use ,U 1dYlfagyvf CSM Number Al Iron River 2 Town of µ Di�tY"'�9a`�', ,�9y�(�hrtick:Srtfitr ❑ New System ® Replacement System ❑ Other Modification to Existing System (explain) ❑ Additional Pretreatment Unit (explain) A. B. ❑ Holding Tank ® In -Ground ❑ At -Grade ❑ Mound 0 Individual Site Design ❑ Other Type (explain) (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued Expiration y % Design Flow (gpd) Design Soil Application Ratc(gpd/st) Dispersal Area Required (sf) Dispersal Area Proposed (at) I System Elevation 450 0.7 642.9 646.6 J_100'&98' Capacity in Gallons Total Gallons 4 of Units Manufacturer e Tank Information $ New Tanks Exiettng Tanks cG m is vHi c, r7 a Septic or Holding Tank 1000 - 1000 1- Wieser X Dosing Chamber 600 — 600 1 Wieser X Plumber's Name (Print) Plum is Si ature MP/MPRS Number Business Phone Number �/— e PI ber's Address (Street. City, State, Zip Code) er a h kL 5561 I Op'pt-ved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denifll Conditions of Approval/Reasons for Disapproval A -a ched c aid Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size SBD-6398 (R. 03/22) RECEIVED ,c TMr�rrr AUG 042026 �, Wisconsin Department of Safety & Professional Services (t Division of Industry Services �r Bayfield Co. SOIL EVALUATION REPUIngendzonrn°q4e Page 1 of 3 TEST #io7-?(. `_ O�'10 in accordance with SPS 365, Wis. Adm. Code County Bayfleld Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limped to vertical and horizontal reference point (BM), direction and percent slope. Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 04024-2.47-08-22-2 00-323.17000 Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). ril //O Property Owner Property Location ❑ ❑ Derek E. & Emily M. Johnson Govt. Lot Y. r s 22 T 47 N R 08 E (or) Wp Property Owner's Mailing Address j Site Address or CSM and Lot #: 66545 Hart Lake Rd 66535 Hart Lake Rd City, State, Zip I Phone Number ❑ city ❑ Village ® ioc I Nearest Road Iron River, WI 54847 I1 1 I Iron River Hart Lake Rd ❑ New Construction Use: ® Residenlial/Numberofbedrooms 3 ❑ Replacement ❑ Public or commercial —Describe: Parent material 0utwash Sands (Rubicon-Sayner complex) General comments and recommendations: Boring # ❑Boring ®Pit Ground surface elev. 104.4 ft. Code derived designflow rate 450 GPD Flood Plan elevation if applicable N/A ft. Depth to limiting factor 96 in, / elev. 96_4 ft. Soil Anelicatinn Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/FP •Eff#1 Eff#2 1 0-3 10YR 2/2 — s Osg ml as 2vf 0.7 1.6 2 3-18 10YR 4/6 — s Osg ml gw 3m13f/3vf 0.7 1.6 3 18-41 10YR 5/4 — s 0sg ml cw 2m/1f 0.7 1.6 4 41-96 1 0YR 6/4 — s Osg ml — — 0.7 1.6 Horizon 4 has ban Is of lam Ilse 2❑ Boring # ❑Boring ®Pit Ground surface elev.101.1 ft. Depth to limiting factor 96 in. / elev. 93.1 ft. Soil Aoolication Rate Horizon Depth In. Dominant Color Munsell Redox Description Du. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' •Eff#1 -Eff#2 1 0-3 1 0YR 2/2 — Is 0sg ml aw 2vf 0.7 1.6 2 3-14 7.5YR414 — Is Osg ml gw lm/1f 0.7 1.6 3 14-36 1 0YR 4/4 — $ Osg ml gw 2mtmnf 0.7 1.6 4 36-52 1 0YR 4/6 — S osg ml gw lm 0.7 1.6 5 52-96 1 0YR 6/4 — $ Osg ml — If 0.7 1.6 Horizon 5 has bans of lam Ilae CST Name (Please Print) Signatures - CST Number Keith Wiley 654921 Address I Date EaluatIon Conducted Telephone Number 11623 E Larson Dr. Lake Nebagamon, WI 54849 7/19/2026 218-451-2611 Effluent #1 = BOD > 30 S 220 mg/L and TSS > 30 Si 50 mg/L - Effluent #2 = BOD, s 30 mg/L and TSS S 30 mg/L SBD-8330 (R03/22) Page 2 of 3 Boring # ❑ Boring 101.1 ® Pit Ground surface elev.it. Depth to limiting factor 96 in. / elev. 93_1 ft Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPO/Ft' •Etf#1 Eff#2 1 0-7 1 0YR 2/2 — s Osg ml as m2f/1vf 0.7 1.6 2 7-18 7.5YR 4/4 — s Osg ml cw iwmt f 0.7 1.6 3 18-42 10YR 5/4 — S Osg ml gw 1m/1f 0.7 1.6 4 42-96 10YR 6/4 — s Osg ml — — 0.7 1.6 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. / elev._IL Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' 'Eft#1 *Eft#2 Ptai ilngand Zoni ❑ Boring # ❑ Boring ❑ Pit Ground surface elev._ft. Depth to limiting factor_In. / elev._ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPO/Ft' 'Eff#1 'EB#2 " Effluent #1 = BOO' 30 5 220 mg/Land TSS > 30 5150 mg/i.. * Effluent #2 = BOD, 5 30mg/Land TSS 5 30mg/L Johnson (3 bedroom) Soil Report Plot Plan North 105' 103' 101' 99' Septic tank & drainfield to be abandoned per SPS 383.33 w C Scale 1:40 17.4% O L co W s W = ®Well e x Bench Mark = Duplex nail w/orange disc in 14" DBH pine tree Elev= 100.0' NOTES: Derek E. & Emily M. Johnson 66545 Hart Lake Rd PLAT OF ELLENWOOD LOT 17 IN DOC 2021R-587599 S22 T47N R08W Town of Iron River 04-024-2-47-08-22-2 00-323-17000 3.120 acres Garage - Property lines not shown > 50' from tested area - Lake Millicent elev z 60' CST 119900002 -SP Page 3 of 3 �k E. & Emily M. Johnson 66545 Hart Lake Rd .2-47-08-22-2 00-323-17000 Douglas Plat of Ellenwood Lot 17 22 47 8 Property Owners Name Property Address Tax Parcel Number County Legal Description Section Town Range Page Index 1 Property Information 2 Data Entry Recerveb 3 Plot Plan 4 Drainfield Cross -Section AUG 26 2026 5 Tank Information Pbnn as b� and 6 Maintenance Plan ZoningA 7 Contingency Plan Keith Wiley Designer Name RECEIVE:O Designer Signature AUG 26 202A D2388PSS Designer License Numpx ZIIKJ d Zoning Agency 218-451-2611 Designer Phone Number 7/30/26 Date KEITH WILEY D 2388 PSS ESKO MINNESOTA Page 1 of 7 In -Ground of sorption Version ay 2022-2027 Component Manual Used 3 Number of Bedrooms 17.4 Percent Slope (%) 96 Depth to Soil Limiting Factor (in.) 0.7 In Situ soil application rate 300 Estimated Wastewater Flow (gpd) 450 Design Wastewater Flow (gpd) 2 Number of System Elevations 100 Proposed System Elevation #1 98 Proposed System Elevation #2 Proposed System Elevation #3 104.5 Original Grade #1 104.5 Finished Grade #1 101.1 Original Grade #2 101.1 Finished Grade #2 Original Grade #3 Finished Grade #3 Wieser 1000/600 Combo tank or pump tank Pol lok PL -525 Effluent Filter RECEIVED AUG 262a? Baia Co. Planning and Zoning Agency Infiltrator Quick4 Plus Standard I Chamber Type 12 Height of Chamber (in.) 20 sq.ft. per chamber(ESIA) 3.3 sq.ft. per pair of end caps (EISA) 4 laying length of chamber(ft) 1.5 length of endcap(ft.) 34 Chamber width(in.) 2 Rows of Chambers 3 Distance Between Cells (ft.) 16 Number of chambers in first row 16 Number of chambers in second row Number of chambers in third row 32 Proposed Number of Chambers Used 642.9 Minimum Distribution Cell Area Required (sq.ft.) 646.6 Distribution Cell Area Proposed (sq.ft.) Page 2 of 7 Johnson (3 bedroom) Lift to Gravity In -Ground Plot Plan North 105• 103' 101' 99, Septic tank & drainfield to be abandoned per SPS 383.33 Wieser W1000/600 -MR precast nk w/ polylok 525 filter & Goulds EPO4 pump Scale 1:40 I Two rows of 16 Infiltrator Quick4 Plus Standard chambers 2•• forcemain ASTM D1785 DF 1 17.4% ~ •. ®Well 3 bedroom house NOTES: % Bench Mark = Duplex nail w/orange disc in 14" DBH pine tree Elev = 100.0' Derek E. & Emily M. Johnson 66545 Hart Lake Rd PLAT OF ELLENWOOD LOT 17 IN DOC 2021R-587599 S22 T47N R08W Town of Iron River 04-024-2-47-08-22-2 00-323-17000 3.120 acres Garage - Prope7ty lines not shown > 50' from tested area - Lake Millicent elev z 60' - All vent, observation & conveyance pipes 4" ASTM D1785 or code equivalent Page 3 of 7 Cross. Section of a Two Cell In Ground Component Using Leaching Chambers Observation/Vent Pipes 4.50 Finished Grade — "— Finshed-G�ade 101.10 Slope 17% Ce eperation // mat h ,y ,i/l .''" op final Grade 191.00 of Chamber ti � - � , : � �%p of Chamber 99.00 em Elevation - �s.. System Elevation 98.00 Treatrhent .find �Dispersal Zone ";' Limiting Factor Observation/Vent pipes to be constucted and capped with approved materials for the particular use. RECEIVED and Zoning Ageiy 67 feet 67 feet AUO 28 hayfield ilnp and Za Observation / Vent Pipes to be located at the ends of the distribution cells. Page 4 of 7 4" Sch. 40 Vent >or=to12" Above Final Grade Inlet - Baffle Approved Manhole Covers With Warning Labels and Locking Device / 4" Min. Above Final Grade Weather Proof Junction Box Electric per NEC 300 & COMM. . 16.28 WAC LAIternate Outlet Location ii jI pproved • 4" Sleeve II2 inch forcemain Poiylok PL -525 I Ill'"" A eep Hole or Anti Siphon Device Wieser 1000/600 C 7.6 Vertical Difference Between Pump Off and Inlet to Chamber 55 Length of Forcemain(ft.) Inches Gallons 2 Forcemain Diameter (in.) 1.39 Friction Factor per 100ft. 0.76 Friction Loss 8.36 Total Dynamic Head A 28.8 340.4 B 2 23.6 C 8.2 97.0 D 12.0 141.8 TOTAL 51.0 602.8 5 Number of Doses per Day 88 Gallons per Dose (Not to exceed 20% of Daily Design Flow) 8.97 Volume of Forcemain Backflow 96.97 Total Dose Volume 600 Pump Tank Capacity (Gallons) 11.82 Pump Tank Volume (Gallons / Inch) 51 Liquid Level (in) O4 Pump Type METERS ER SG Tank Alert 1 8 r u G 4 0 0 z 4 6 8 10 1z mn caw►t 1 Page 5 of 7 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 6 of 7 FILE INFORMATION owner Derek & Emily Johnson Permit # nFSIr'N PARAMETERS Number of Bedrooms 3 ❑ NA Number of Public Facility Units ® NA Estimated (average) flow 300 al/da Design (peak) flow = (Estimated x 1.5) 450 gavday In Situ Soil Application Rate 0.7 gavdayift2 Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG), 530 mg/L Biochemical Oxygen Demand (BODs) 5920 mg/L O NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ® NA Fecal Coliform (geometric mean) 510° cfu/100ml Maximum Effluent Particle Size '4 in dia. O NA Other: ® NA 'Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frslp9h0Ynd Zoning Agency Inspect condition of tank(s) At least once every: 3 ❑ months (Maximum 3 years) ® ear s O NA Pump out contents of tank(s) 2 When combined sludge and scum equals one-third (Yu) of tank volume ❑ NA ❑ When the high water alarm is activated Inspect dispersal call(s) At least once every: every:(Maximum 3 year ❑ month(s)3 years) ® O NA Clean effluent filter At least once every: 3 ❑ mon (s) ® ear s)) ❑ NA Inspect pump, pump controls & alarm At least once every: 3 ❑ month(s) ® year(s) DNA Flush laterals and pressure test At least once every: ❑ month(s) O year(s) ® NA Other: At least once every: O yemon) th(s) 2 NA Other: 2 NA SYSTEM SPECIFICATIONS Tank Manufacturer Wieser O NA 2 Septic O Dose O Holding vol. 1000 gal Tank Manufacturer Wieser O NA ❑ Septic ® Dose O Holding vol. 600 gal Effluent Fitter Manufacturer Polylok 0 NA Effluent Filter Model 525 Pump Manufacturer Goulds 0 NA Pump Model EPO4 Pretreatment Unit 2 NA ❑ Sand/Gravel Filter 0 Peat Fitter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection O Other: Manufacturer Dispersal Cell(s) O NA 2 In -Ground (gravity) 0 In -Ground (pressurized) ❑ At -Grade 0 Mound O Drip -Line ❑ Other: Other: RECEIVED 2 NA Other: ® NA ra MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (14) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (12/02) Page 7 of .71 — START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result In the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. g The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorptionmay place following IR$Ae "r g rp systems be reconstructed in removal of the e' infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> AUG 2 Pi Zn7li SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RBSWXonESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. Planning and Zoiing Agency ADDITIONAL COMMENTS POWTS INSTALLER Name Phone p,_ 33- cf(tod POWTS MAINTAINER Name 774et %; Phone f _ &0Z) SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name AJ -vi -5 c �P' ameBayfield County Zoning Phone _ S — hone715-373-6138 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies In compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. BAYFIELD COUNTY Derek & Emily Johnson CHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent 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.) • Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 2 Original Plot Plan (383.22(2)2. 3. & 4.a) • Cross Section, Over -Head Profile of the System and Schematic of Tank from Manufacturer ® Pump Tank Diagram, Alarm and Pump Curve (when applicable) Sd Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) 2 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) 0 Fee (Make Check Payable to Bayfleld County Zoning) (383.21(2)(c)7) 0 2 Complete Sets of Plans (383.22(2)(2.) (Note: Sanitary Application and Maintenance Agreements are to be attached to all copies) 2 Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) ❑ State Plan Review (when applicable) 0 Copy of Warranty/Quit Claim Deed (Optional) Sanitary ADDlication: (Include the following Information) 0 I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) 2 Project Address or Road Name where driveway is/will come off of) 0 II Type of Building 2 III Type of Permit 0 IV Type of POWTS System 2 V Dispersal / Treatment Area Information 0 VI Tank Information W VII Responsibility Statement (Plumber's Information) 9 *Date Stamp* Plot Plan: (To Scale or To Dimension) 0 Signature and Plumber Information 2 Surface Elevation of Body of Water 0 Direction and Percent Land Slope 0 Tank and Filter Information and Location 2 Wetlands / Navigable Bodies of Water 2 Absorption Area (Proposed and Existing) 0 Bench Mark (Location, Elevation and Description) 0 Component Manual Version i 2 (Owners Phone Number) RECENEC AUG 26 ppyF Piann'IV and ZZO. Agency 21 Address Number and Road 0 North Arrow 21 Contour Lines {d Structures and Driveways 2 Boring Locations 2 Property Lines 21 Well Locations 2 Leaal Descriptions Turn Over ► Cross -Section and Over Head Profile of the System: Surface and System Elevation • Position of Observation and Vent Pipes • Dimensions and Depths ffi Make, Model & Number of Chamber Units in each Cell ProoertV Information • How many systems will there be on this parcel of land? 1 ffi Has this property been split? no (Property Statement shows Property History) Fees: ig 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 0 Maintenance Agreements + $ 30.00 (checks made out to Reg of Deeds) RECEIVED AUG 262925 atamrn° aw aUry u/forms/checkllsCychecklistforsanitaryapps (10/2009);(®7/2011);(®2/2012)(®5/2/2012 -dc) Proofed by: Private Sewage System Maintenance Agreement DOCUMENT NUMBER s) Name 2026R-61 3621 Dare —k o-- Emtt-Y JOhAISOAJ DANIEL J.HEFFNER s) Mailing Address REGISTER OF DEEDS CJ r I - 1'. O_I BAYFIELD COUNTY. WI IP(QS3S' er L RECORDED d [)$ 011 09/03/2026 AT 1 2:08 PM Tax ID # RECORDING FEE: $30.00 vy-pay a VT os as vo-3)3 i 000 PAGES: 1 As owner, I (we) do hereby certify the private sewage system will be installed in accordance with the certified soil testers report and approved plans and specifications on file with Bayfeld 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) 1/4 of 1/4 Section aa.Township q iN. Range 8 W. Recording Area Additional Legal Description: /� Return To: Town of TRdni R,y't a (Acreage) Gov't Lot Planning and Zoning Department Lot /7 Block Subdivision Pc.4r OF- f t aeNwccd RECEIVED Lot_CSM#_ Vol._Page_ CSM Doc# ❑ In -ground gravity K In -ground dosed ❑ In -ground pressureF jwT t eR� ylstem: ❑ Mound ❑ At -grade Sewage System ❑ Other 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. 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 manufacturers 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 pending on the ground surface. Mounds. At -grade. and In -ground 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. Bayfleld 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 tents and conditions of the agreement shall be binding upon and inure to the benefit of all current and future owners of such property. Owner(s) Name(stPlease Print Dcr&k Subscribed and swom to before me on this date: 9- a4- a (O �w.l Jmb.nx,n Notarized Owners)-SI nature(s) Notary Public NOTARY PUBUC STATE OF WISCON My Commission Expires: 4-II-aoso Drafted by: Kizer (5' ntr / Date: `d —c' -/--a&, Proofed by: _ urfomis/sanitary/septicmaintenceagreement Revised July 2020 FAYFIELD 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: JOHNSON, DEREK E & EMILY M SS -00823 66535 HART LAKE RD IRON RIVER, WI 54847 Transaction Number: SS -00823-5554E Description Private Sewage System (Septic Tanks) ft 41! $400.00 Total: $400.00 Payment Amount: $400.00 Reference: 42274 Paid by: A G O'Brien, 4907 Lightning Dr, Hermantown MN Payment Type: Check Transaction Date: 9/15/2026 Receipt of payment does not guarantee eligibility of permit and is not proof of issuance of a permit. BAYFIELD COUNTY SANITARY PERMIT (#04)-26-130S STATE SANITARY PERMIT OWNER: DEREK E & EMILY M JOHNSON GOVT LOT: LOT: 17 BLK: SUBDIVISION: Plat Of Ellenwood 1/4 1/4 SEC: 22, T 47 N, R 8 W TOWNSHIP: Iron River SOIL TEST: 107-26 REPLACEMENT SYSTEM SYSTEM TYPE: Non -Pressurized In -Ground PLUMBER: Ag O EMILY MACGILLIVRAY DATE: 9/15/2026 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: # PM 1082 Condition: Properly Maintain System Per Recorded Agreement THIS PERMIT EXPIRES 9/15/2028 POST IN PLAIN VIEW MUST BE VISIBLE From ROAD FRONTING THE LOT DURING CONSTRUCTION