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isconsii epartmentofindustry, PRIVATE SEWAGE SYSTEM County:
La! and Human Relations INSPECTION REPORT ST . CROIX
Safety and Buildings Division
' (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village a Town no : State PI o..
MIKLA, JAMES A. X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
r
60w J-
/,60, 1 1 7T TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic d Benchmark %3
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet g 3S' ono, 7 r
TANK SETBACK INFORMATION St/ Ht Outlet c~ '
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >as Q ~a > L o NA Dt Bottom
Dosing NA Header/Man. 46,E r'
Aeration NA Dist. Pipe 9S .l0 -7
Holding Bot. System , 3, 0' qLl,
PUMP/ SIPHON INFORMATION Final Grade
_TZ-VT-171 717T
Manufacturer Demand 41' /0
Model Number GPM
TDH Lift Friction System TDH Ft
mead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 11-1 DIM N I N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER
INFORMATION Type O Model Number:
System -t.r.t=+° OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
V h Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Trench Center 1-90 Bed/ Trench Edges,~ -30 ` Topsoil E3 Yes ❑ No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Baldwin.18.29.16W, S 1/2, NW 1/4, Hwy. 63
Plan revision required? ❑ Yes 'No 7 S
Use other side for additional information Poll
SBD-6710 (R 05/91) Date I spector's Signature Cert. No.
ADDITIONAL COANTS AND SKETCH ,
SANITARY PERMIT NUMBER:
Safety and Buildings Division
W .,~...a
011LHlR SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave-
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. C~+o~
• See reverse side for instructions for completing this application State Sanitary Permit Number
(f
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]_ s /Z_ NolIq State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location l
tJ4w+ e5 75►. IQ /4_§;gp 1/4, S T N, R lei 4 (or (W)
Property Owner's Mailing Address Lot Number Block Number
0 god ~i ve.. W,4 wX
Cit , State / Zip Code Phone Number Subdivision Name or CSM Number
e 72 Nearest Road6 7
II. TYPE F BUILDING: (check one) ❑ State Owned Ity
Public 1 or 2 Family Dwelling - No. of bedrooms Ci Tolwn OF Q df u~i'~^- G/.S• fY J
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo -6 O Z - `d 4/0 - 000 - 000
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1- jgNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only - Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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. ft.) Proposed (sq_ ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
DO 750 r,7 5 0 OVA 95• ~ ~ Feet 5 Feet
VII. TANK Capacity
in Total # of Prefab. Site Fiber- Exper.
INFORMATION gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
Septic Tank or Holding Tank /Zoo 5Gr5 Z El 1:1 1:1 1:1 1:1
Lift Pump Tank /Siphon Chamber t(7 ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the"undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MPRSW NO.: Business Phone Number:
le olso>-~ l67-q 71:5 -481-.337$
Plumber's Address (Street, City, State, Zip Code):
liilzo ~ ; ~ f ~L/DO7
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (IndudesGroundwater ate Issued Is i g Agent g ture (No tamps)
Approved ❑ Owner Given Initial /g -'j x/VI Surcharge Fee)
Adverse Determination U ~J y
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division, Owner, Plumber
INSTRUCTIONS.
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3_ All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement- Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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SOIL AND SITE EVALUATION REPORT
,DI in accord with IL , Wis. Adm. Code
.arwa..n•.ww,.uuawJ COUNTY
Attach complete site plan on paper not less than 8 1/2 x 1io~h~s,in (z. Q ust include, but r'O
st c
not limited to vertical and horizontal reference point (ection and% .+1
"a[,s(o scale or PARCEL I.D
dimensioned, north arrow, and location and distant crest
APPLICANT INFORMATION-PLEASE PRIN "A~f INI6AION REVIEWED BY DATE
s
PROPERTY ANNER- , PROPfR4 LOCATION
JA✓>?~ S Go L NZJ 1/4 S W 1l4,S~8 T 29 N.R IZ, JV(
PROPERTYOWNER:'S MAILING ADORES
tAT BLO Y FBD.NAk4EOFICSM#
CITY, STATE ZIP CODE PHO ❑ VILLAGE f CRTOWN NEA EST ROAD
G=~o w r° l~ s (7r C~/ lo"o,
(4 New Construction Use P4 Residential / Number of bedrooms
j) Replacement ( ) Public or commercial describe
Code derived daily flow<g Y gpd Recommended design loading rate • 7 bed, gpd/9- -S -trench. gpd/ft2
Absorption area required 50 bed, ft2''37.5 trench, ft2 Maximum design loading rate bed, gpd/tt2 trench, gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations e r e ~e C e 4__0_X2
75
Parent material _ Sqn rf~ /p~,y) Flood plain elevation, if applicable N ft
S = Suitable for system CONVENTIONAL MONO PrGROUNOPRESSURE AT-GRADE SYSTEM FILL HOLDING TANK
U= Unsuitable fors stem ,9 S❑ U )Z~ S❑ U As ❑ U As ❑ U El S ,~'U ❑ S it U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft Consistence Bardary in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Roots
Bed Trend'
N 2 W,, e- 6 rri v as C P
• 5 • la
CLO
Ground e?C l,J a c4
elev. ,
9~ft. 2~--76 X7.5' 5~ 5 .S f"71 ° g
Depth to -
limiting
~ factor
7~
I
Remark's:
Boring #
0Y? e _
'OOC ICI v 'r w c-~'
Ground
elev.
9Y-Z n.
Depth to - -
limiting
factor
Remarks:
CST Name:-Please Print Phone:
-74/P ~,lu Con
7is' 42? 3 37, _
Address
FZ 0 122a- ,!n
Si nalure Date: CST Number:
Depth Dominant Color Mottles Structure G
Boring # I~orizo in. Munsell ~ Texture Consistence Barry Roots
Qu. Sz.I,UnL c4lor Gr. Sz. Sh• ,Bed Trend
.o
f c)-/Z ,5 /(-,'o ,7 e- s' ,zC s 72 V C W CG #5
Ground
e ev
~•I'frt.
I
Depth to
limiting
actor
gG
Remark's:
Boring #
$jppyyi. Sr/
0.~'>]S OL::WL
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
f.•p L•':b
Ground
elev.
n.
Depth to
limiting
factor
Remark:
Boring #
:r-Y :•.r:•:
Ground
elev.
1t.
Depth to
limiting i
factor
Remarks:
DILHR vv•` .,>.~...I i " " v""in accord with ILHR 815, Wis. Adm. Code
' , COUNTY
Attach complete site plan on paper not less ~(I< s in size. Plan must include, but C
not limited to vertical and horizo ntal refe 9 X
dimensioned, north arrow. and locatio min istanWo nears % Of slope, scale or PARCELI.0.+1
APPLICANT INFORMATION-PL PR~VWFOR N REVIEWEDBY DATE
PROPERTY OWNER
( 195
PROPERTY LOCATION I'.
GOVT. LOT 114
,N,R E (a
~J 114,S T -57 PROPERTY 7WNEYS MAILING ADDRE S SW 43
.2.6 le? LOT1rA BL K N SUBO. NAME OR CSM it
CITY, STATE ZIP CODE PHONE NUMBER
L. oCr/v,'/% 4)i. (715)49 `Z 417 ❑CITY ❑VILIAGE OWN NEAREST ROAD
7k
a 1 o~w,'r~ 63
j>(]'New Construction Use,K Residential / Number of bedrooms
I I Replacement I I Public or commercial describe
Code derived daily flow60 gpd Recommended design loading rate tom. Absorption area required _ _ bed, 112 9Pw trench, gpd/ft2
_ trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd ?
Recommended infiltration surface elevation(s) It as referred to site plan benchmark)
Additional desigrr/site consider ations
r.. 5
Parent material
Flood plain elevation, if ii~icable it
S =Suitable for system COWS U MOUND ❑ U a U ssuRE a S o~U SYSTEM IN FlLL HOLDING TANK
U= Unsuitable fa system ❑ S U ❑ S X U
SOIL DESCRIPTION REPORT
Depth Dominant Color
Boring # Horizon Mottles Texture Structure Consistence GPD/ft
in. Munsell Ou. Sz. ConL Color Y Roots
Gr. Sz. Sh. Bed ITrerxf
- 1 a -7 7- S 3
sE f>]31 lZ- /Vone- S s~ MV Q5 3
Z_ 7 -3 f 75
YR 77
Ground 3 31-'10 75 5fd
elev.
G5 •71-9
93-1711. ya 7 7,s'yk~ c/
Depth to
limiting
factor
i
Remark's:
Boring # /
-wR 7,S'YR7 Non s. 3
Al Z g-33 7 5y~e
N
Ground ~~A1- S~ 7 5 /YJV~
elev.
r5 ry. $a g 14/`~ y s~ fc s✓~'~ • I.5
Depth to
limiting -
(actor
so ~
I
Remarks:
CST Name:-Please Print
Lr~le E, 1~u~SAr~ _ Phone: 6g 4- 3,378
Andress - ?/S-
Zo ea
Si~nalure
Date CST Numboc
Depth Dominant Color Mottles Structure G D/Ill
Boring >J Horizo Texture Consistence 8ouidary Roots
in. Munsell Qu. Sz. 6nL Color Gr. Sz. Sh. Bed @Truy;
ME 0-7 7"
-2.I y N~~ s ,hs .q .o at,-) Z Lp
Ground 3 ZI- 95 7,.,5ryR , 017c, S~V, r GGt~ Z ~ • ~ ' ' 8
elev.
9 Zln- ys~67 S' 4 C Z 7,5ygs sc/ b °Z • 3
Depth to
limiting
factor
Remarks:
Boring N 3
l O-C. 7,5YP ~I/o s,~ ,21y) S /Y) v L- 105 3~ • $ ~ ~
z 6-13 7,5 y y q /lo ~~ms /71?V C, QGJ •5 -b
3 13-ZS s/ / 6 C cJ 2-~' • 4 •
Ground
elm ft. 4 Z8-'y1 5Y V /Uo» e, sc / / C W • 2 -3
YK, P /I, el 5'
Depth to
limiting
factor
Remarks:
Boring #
7.,'ye 3L won si f Ivs 1;12V as 3~ _•5 •C
s:<z
S r B5 Z 7"Z3 7, 5 ye /V o s. .2 r~'J S Jam? ✓ ow
Z_~ • 5
3 z- s-39 75 YR qty A,),, 4 c ~ 2-~' - • 5
Ground
elev. 'q 38 70 5 y c z 75 5 SC~ • Z
Depth to
limiting
Remarks:
Boring if
V e- 15,;l L-K t7?
Ground' ~~-~►5 7 5 y 1 v GW
elev. '4 15-f4 .5,vg 51IR
Depth to I - -
limiting
factor - - - -
Remarks:
' e
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS 2,1
PROPERTY ADDRESS 9~/- ~ywy - /1~
(location of septic system) Please obtain from t e Planing Dept.
/
CITY/STATE
xz /V W
PROPERTY LOCATION Ad#? 1/4
1/4, Section Zq N-R~W
TOWN OF
ST. CROIX COUNTY, WI
SUBDIVISION
LOT NUMBER /y/a
CERTIFIEDSURVEY MAP VOLUMEPAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed um
the on-site wastewater disposal system is in proper operating condition and (2) a ere nspee~ on and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
1/We, the undersigned have read the above requirements and a
disposal system in accordance with the standards set forth, herein tsetl by the Wipsconsinsewage
DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year xpiration date.
SIGNED:
DA 2 7 G~'/ll'
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property UrG'ry) C
Location of property-ld6%;:1-1/4 Z w 1/4, Section `8 T
Townshi ~N-R ~ W
Township Mailing address 26/0 9-
0 .4
Address of site 9
~✓W G 3 v~ ` ~Gb~
Subdivision name
Other homes on Lot no.
property? Yes No
Previous owner of property
Total size of property ~p
Total size of parcel rt.s
Date parcel was created /b 6 5
Are all corners and lot lines identifiable? ✓ Yes
Is this No
property being developed for (spec house) ? Yes ✓
Volume ZZY-5 and Page Number_ No
as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DO
NUMBER AND THE SEAL OF THE REGISTER OFT DEEDS R. InVOLUME
addition PAGE
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am property described in this information ( form, b virtu r of the
warranty deed recorded in the office of the County a
Deeds as Document No. ter of
own the proposed site f he sewage, and disposalthatsystemI (we) presently
obtained an easement, to run the above described property, I (we)
for
construction of said system, and the same has been duly recordedtin
the office of the County Register of Deeds as Document No.
gnature of pplicant
c o
Date of Signature le9 -
Date f S~ nature
u DdL~UMENT NO. WARRANTY DEED
"CORDING INFORMATION
Vol_ REGISTER'S OFFICE
ST. CROIX CO., WI
Redd for Record
THIS DEED, made between GERALD E. KUSILEK AND VERONICA M. O CT 2 O 1995
KUSILEK, an undivided one-half interest to each, as tenants in common, Grantor, and
JAMES A. MIKLA AND CHRISTINE J. MIKLA, husband and wife as survivorship 'it 9:00
marital property, Grantee, w M
WITNESSETH, That the said Grantor, for one dollar and other valuable 4 .
ReqMwd Deeds
consideration conveys to Grantee the following described real estate in St. Croix County, State
of Wisconsin:
TURN T
Bakke Norman, S.C.
Baldwin, WI 54002
po~q A Tax Parcel No:
outh 1/2 of the Northwest Fractional 1/4 of Section 18, Township 29 North, Range 16 West
~ PT the So
uth 15 rods of the North 28 1/2 rods of the West 10 rods and
/CE
PT the North 13 1 /2 rods of the West 510 feet.
This is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging; and Grantor warrants that the title is good, indefeasible
in fee simple and free and clear of encumbrances except:
Easements, highways, utility rights and reservations of record, and will warrant and defend the same.
Dated this ~7}! day of October, 1995.
(SEAL)
* (SEAL)
*Gerald E. Kusilek
(SEAL) -e7).
(SEAL)
*Veronica M. Kusilek
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) of STATE OF WISCONSIN
}
} ss.
ST
}
authenticated this _ day of . CROIX COUNTY
19
Personally came before me this 6774 day of
*Thomas R. Schumacher October , 1995, the above named Gerald E. Kusilek
and Veronica M. Kusilek
TITLE MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) to
me known to be the person S who executed the foregoing instrument and
acknow ed ame.
THIS INSTRUMENT WAS DRAFTED BY:
BAKKE NORMAN, S.C. * ~JE+e~OEcSavE,t/
BALDWIN, WISCONSIN Notary Public, St. Croix County, Wisconsin
*Names of persons signing in any capacity should be typed or printed
below their signatures. My Commission is permanent. (If not, state expiration date:
19-__)
Notary Publit`State Of WtsWn*
My Commission Expires Marrrh 22, IWO
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