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Home My WebLink About26-0500CS- 001,D6 r G BAYFIELD COUNTY SANITARY PERMIT APPLICATION Zoning District Lakes Class I. APPLICATION INFORMATION Soil Test County 1 L O� b o (Please Print All Information) No: _ I Permit No: O"D Property Owner's Name: PQ+4IC d -M le CovvM County: Bayfield Address of Property: fry, (d Property Location: t�, y I'tt KO• WS f l% pp�� 56 % 51 '/., S Oq T50 N. R O'' E (or)Q Property Owners Mailing Address: u +sf,2a Township: Gov. Lot #: we t iein ave A _ field Cittyy, St to I Zip Code Phone Number Lot # Block #: CSM #: CSM Doc # Subdivision Name St Azvl Mu S 0 II. TYPE OF BUILDING: (Check One) ❑ State Owned ❑ Tax ID#: 04'-OO'a'SO -o3 cc' -GAO -(0000 Public (Explain the use/purpose ) I S y H 1 or 2 Family Dwelling - No. of Bedrooms _/ j Ill. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) ❑ New ❑ Replacement County Private Interceptor Li! FHEU 4laay ❑ Reconnection ❑ Repair ❑ Revision " ❑ Transfer of Owner (List Previous Owner be B) ❑ A Sanitary Permit was previously issued. Previous Permit Number. Date Issued: 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 Required (Sq.Ft.) Proposed (Sq. Ft.) (Gals. / Day / Sq.Ft.) (Min. Inch) Elev.(Feet) Elev. (Feet) VI. TANK Capacity i er INFORMATION: In Gallons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Constructed Steel S - rh Plastic 2026 Exper. App New Existing Tanks Tanks r`l Septic Tank or Holding Tank Bayfield Co. Lift Pump Tank/ Sao _� 3 � J I �S ` Siphon Chamber VII. RESPONSIBILITY STATEMENT: I the undersigned, assuma responsibility for installation of the onsite sewa ow the attached plans. Owner's Name(s): (Print) Ifapplying for Section c above Si e(s): o Stamps _42wner's G Plum er' Name: (Print) if applying for Section A or B) above u er's ' nat o ) MP/MP W No: v�i eu Baal Plumber's Address: (Street, City State, Zip Code)Wosb Home Phone: 3ll6 d eiv0ti &-wove Pd 7eS- 3 a37 Business Phone: 7/5375-a37S (vt c' T/ VIII.. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit/Transfer Fee: I Date Issued: I Iss"'rr- A--rt'sSinnaature / D///atte:' _ Approved ❑ Owner De a Initial / lit' Adverse Determination IX. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: on reverse Lot Line 4'Prop-e�-Y lrue T Sad' �a. 3 fl C 4 o Cl n Oho Bat tfb6e '°I c? -� r x well X�4 3 sa t �A F Sb e, n s jJovklti O Sot W .___2t \M L_-.---4---------' Pve l tie "' 15O"k t55 /g5o5plif Qu/� oev Name of Frontage Road 14 R4 ) 1. Name the frontage road and use as a guideline, fill in the lot dimensions and indicate North (N). 2. Show the approximate location and size of the building. IMPORTANT DETAILED PLOT PLAN 3. Show the location of the well, septic tank and drain field. IS NECESSARY, FOLLOW STEPS 1-7 (a -o) COMPLETELY 4. Show the location of any lake, river, stream or pond if applicable. 5. Show the approximate location of other existing structures. RECEIVED 6. Show the approximate location of any wetlands or slopes over 20 percent. SEP 0 2 2026 7. Show dimensions in feet on the following: Bayfield Co. Planning and Zoning Agency a. Building to all lot lines i. Privy to building b Building to centerline of road j. Privy to lake, river, stream or pond c. Building to lake, river, stream or pond k. Drain field to closest lot line d. Septic / holding tank to closest lot line I. Drain field to building e. Septic/holding tank to building m. Drain field to well f. Septic / holding tank to well n. Drain field to lake, river, stream or pond g. Septic / holding tank to lake, river, stream or pond o. Well to building h. Privy to closest lot line Submit To: Bayfield County Zoning Department, PO Box 58, Washburn, WI 54891 u/forms/sanitary/bayfieldcou ntysan itaryapplication Revise: June 2018 Proofed by: I Industry Services Division 1400 E Washington Ave County �+ ' 11 )Yr P.O.ox 7162 anitary Permit Number (to be filled in by Co.) $ t „-.�-_�__ __._.. Madison, WI 53707-7162 J(g-lay 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 slate -owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy law, s. 15.04(1 m Slats. I. Application Information - Please Print All information _ Property Owners Name _ Parcel II 1. PQ+rick I iii(r`Ni1C Cot.t.rrneyu. E R� ---- x3'000-/aao0 Property Owner's Mailing Address Property Location Io8MD SherW Dr �� I ck Govt. [,at y,, y,, Section City, State I Zip Code Phone Number Berkley , CA- a47 (Circle on TW dr�N; R Eo_ _ II H. Type of Building (check all that apply) r� or 2 Family Dwelling— Number of Bedrooms Lo�0 Subdivision Name At Blocks ❑ Ihlblic/Commercial— Describe Use \ EP 2.12016 ❑ City of SS ❑ Slate Owned — Describe Use flay i ❑ Villag.1.am of •1� Ou2oning Dept. l/^�1� .'Town of CJI-F'{ e IA 1I1. Typo of Permit: (Check only one box on line A. Complete line B if applicable) RECE WED A.few System yep 0 Replacement System y 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. 0 Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit m tJued Before Expiration j Owner IV. Type of 1'OWTS S stem/Com onent/Deviee: (Check all that apply) Planning and Zon' ❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade b 'Mound≥ 24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain)—______________ 0 Pretreatment Device (explain) V. Dis ersal/Treatmcnt Area Information: i n P ) I Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (sf) System Elevation /Aa 1O.:37 V . T k Info Capacity in 'fool a of Manufacturer Gallons Gallons Units t? u New Tula I ExistinaTanks (J fl45 cn , Septic or Holding Tank 5 Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI 's Si a re MI'/MPRS Number Business Phone Number u n a-I+VA )1e. I 9 as 139 1!c 373-73x? Plum em's Address (Str et, City, Stale, Zip Code) 3ilbo BirCk 6v'0de I'�d Wastilc(,Lvn, WI 6f891 Vlll. Count /Dc artrnent Use Only ❑ Approved ❑ Disapproved Permit Fee I Dale Issued Issui gent Sign to ElOwner Given Reason for Denial $ StC) %al'p O'I IX. Conditions Approval/Reasons for Disapproval �of J/� Attach to complete plans for the system end submit to the County only on paper not less than 8 nix 11 inches in ire Reed for Issuance pro 9q ontq SBD-6398 (R. 08/14) AFIELD Bayfield County Planning & Zoning Department 117 E 5° Street P.O. Box 58 Washburn, WI 54891 Phone: 715-373-6138 Fax: 715-373-4010 Property Owner: Submission Number: CS -00186 Transaction Number. CS -00186-558A2 Description Amount Private Interceptor $50.00 Total: $50.00 Payment Amount: $50.00 Reference: 006832 Paid by: Cady Plumbing & HVAC LLC 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 - BAYFIELD COUNTY PERMIT WEATHERIZE AND POST THIS PERMIT ON THE PREMISES DURING CONSTRUCTION No. 26-0500 Tax ID: 4454 Issued To: COURNEYA TRUSTEES, PATRICK T & MICHELE L Location: S09 - T50N - R04W Town of BAYFIELD Legal Description: SE SW LESS STATE RESERVE IN DOC 2020R-584386 120 (MICHELE L COURNEYA TRUST DTD 09/03/2020) Residential Structure in F-1 Zoning District For: Sanitation Permit — Private Interceptor (I iii (laimoi ): Any future expansions of 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. This permit may be void or revoked if any performance conditions are not completed or if any prohibitory conditions are violated. Emily Macgillivray, AZA Authorized Issuing Official September 17, 2026 Date