HomeMy WebLinkAbout030-1009-60-000 f �
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
488064 0
(ATTACH TO PERMIT)
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name:
City Village X Township
Parcel Tax No:
Orf, Robert I St. Joseph, Town of 030 - 1009 -60 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
J60 Qry\ - 1 03.29.19.47A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark �f
/4)0 3. 43 163.43 / Cc)
Dosing Alt. BM
Goo d �w L, (,Db i� 1 C 3.35 oT
P a 5 Bldg. Sewer ,7
b
Holding Q St/Ht Inlet
ll.zb 91, z3
�
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO WELL BLDG. Vent to Air Intake ROAD DtInlet _
Septic 2-7 27' — Dt Bottom t -7� $t '
Dosing $ I 2 j Z 1 Header /Man. 7.51 am 8
Aeration Dist. Pipe 475".5
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover ,\ d 4 _ 6�•s� 3.35 /60 •�$
zo �. \�2f GPM i deM T Y'
Model Number G
TDH Lift Friction Lori System ead TD4
9 .10 1 Forcemain Length � Z �D SS ia. N Dist. to Well 70-0
5t `� Z
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenc PIT DIME S�V ION No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 �L{ 'r �� —�
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR �
Type Of System
1 33 � S' Al n UNIT Model Number. J ,
DISTRIBUTION SYSTEM / [ /(94 -A. / _ Vf
Header /Manifo� I' '/ Distribution x Hole Size x Hole Spacing Vent to A' Int
�F Pipe(s) \ \ 3 f o ►�.
Length Length Dia \ Spacing ` , �°✓`
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over . Depth Over xx Depth of eded /Sodded xx Mulched
Bed/Trench Center C, 3 Bed/Trench Edges To xx Se
psoil \ Yes No Yes x ' No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / L / C> C>- ( 4> Inspection #2: / /
Location: 1174 County Road IHudson, WI 54016 (SE 1/4 NW 1/4 3 T29N R1 9W) NA Lot / / Parcel No: 03.29.19.47A
1.) Alt BM Description= F. I 1 �` Co it . -
Gt��a �•�GrC. ova
2.) Bldg sewer length = 4
- amount of cover = � i T �Jw� V b
1? GnJ�-
Plan revision Required? Yes No
Use other side for additional information. (0
Date Insepctor's S' nature Cert. No.
L SBD -6710 (R.3/97)
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Safety and Buildings Division copy
201 W. Washington Ave., P.O. Box 7162 St. Croix
Madison, WI 53707 — 7162 Sanitary P ermit Nu mber (to be filled in by Co.)
cOnsin
Department of Commerce (608) 266 - 3151 0(}
Sanitary Permit i tion s Pin I.D. Number
In accord with Comm 83.2 1, Wis. Adm. Code, 1 ' ormation ide Project Address (if different than mailing address)
may be used for secondary pu vacy w, s
L Application Information — Please P fo tin 1174 Co. Hwy. I
Property Owner's Name - Parcel #: Pending Lot # Block #
030 - 1009- 60 -000, Na Na
Robert C. & Shirley M. Orf COUNTY . 4
Property Owner's Mailing Address Property Location
603 River Road SE v,, NW Ii,, Section 3.
City, State Zip Code Phone Number
T 29 N; R 19 W
Hudson, WI 54016 (715) 386 -2244
IL Type of Building (check all that apply)
X 1 or 2 Family Dwelling - Number of Bedrooms 3
❑ Public/Commercial - Describe Use Na — existing 30.90 acre parcel
❑ State Owned - Describe Use ❑City ❑ Village XTownship of St. Joseph
IIL Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New S X Replac ement s yste m ytee ❑ Treatmerrt/Holding Tank Replacement Only ❑Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New last Previous Permit Number and Date Issued
Before Expiration Plumber owner
IV. rype of POWTS stem: Check all that a I
X Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area InformationvIliree trenches @ 3'X 64', forty eight (48 total -16 per trench) "Quick 4" Infiltrator Chambers at 19.1
ft. /chamber + 3 r end caps = 934.20 sq. ft EISA
Design Flaw (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
450 gpd 0.5 gpd sq. ft. 900.0 sq ft 934.20 sq ft EISA 94.00'
VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units L.J P S ���l Z Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank 1,000 _ 1,000 1 Wieser Concrete X
Combination ST/PC
Aerobic Treatment Unit
- T
Dosin Chamber 500 " X00 V Wieser Concrete
4
VIL Responsibility Staten t- I, the undo—sign assume responslygy for instalation of the POWTS shown on the attached plans.
Plumber's Name (Print) N 's S' tune MP/MPRS Number Business Phone Number
James K. Thompson #30021 (715) 248 -7767
Plumber's Address (Street, City, State, Zip"Code)
340 Paulson Lake Lane, Osceola, WI 54020
VIQ. County/Department Use Onl
Rrl moved � � Sanitary Permit Fee (includes Date Issued Issuin Agent Si (No Stamps)
Groundwat rcharge Fee)
❑ Own van Reason o 'al �� Z�
IX. Conditions pprov Rmlams � �•'' G � � (�^ 0
SYSTEM OWNER; J C�
r 1 Septic tank, effluent filter and &6 p Cb&k
dispersal cell must all be serviced / maintained 1 t
as per management plan provided by plumber.
2. All setback requirements must be maintained
I ode /ordinances.
as per applicab e c
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Wisconsin Department of Commerce SOIL EVALUATION REPORT p age 1 of 3
Division of Safety and Buildings i rdance with Comm 85, Wis. Adm. Code A.C.E. Sal &Site Evaluations
County
Attach complete s *e�rficmal not less tha x 11 inches in size. Plan must St. Croix
include, but not lima nd a reference point (BM), direction and
percent slope, scale or dime ' , rth arrow, and location and distance to nearest road. Parcel I.D.
030 - 1009 -60 -000
eas pi in > B Date
Personal information you p rovide ay be used for secondary purposes (PrTvacl Law, s. 15.04 (1) (m)). F 69 ,0 'ZW
Property Owner J `- 0 200 Property Location
Bob Orf Govt. Lot SE 19 NW 1/4 S 3 T 29 N R 19 W
Property Owner's Mailing Addrew ST. CROIX COUNTY Lot # Block # Subd. Name or CSM# rn1
603 River Road �S urc.1-
City State Zip Code Phone Number _j City J Village $01 Town Ndarest Road
Hudson I WI 1 54016 1 (715) 386 -2244 St.Joseph 1 1174 Co. Hwy. I
New Construction Use: 01 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
NJ Replacement J Public or commercial - Describe:
Parent material Glacial outivash Flood plain elevation, if applicable na
General comments
and recommendations: Site suitable for replacement conventional POWTS @ 0.5 gpd/sq.ft. Install three trenches at 93.00' using 16
Infiltrator "Quick 4" chambers per trench (48 total).
Boring # --� Boring > 120" in. Soil
�( Pit Ground Surface elev. 99.01 ft. Depth to limiting factor App lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2
1 0 -10 1Oyr3/3 none sil 2fsbk mvfr es 2vf,f 0.6 0.8
2 10 - 25 1Oyr5/4 none sil 2fsbk mvfr cw 1vf,f 0.6 0.8
r
3 25 -54 10yr5/6 none Ifs,ls,s Osg ml aw AHcontains
0
4 54 1Oyr5/4 none s Osg ml aw 6
\,,� 5 63-74 1 Oyr5 /4 none s & Ifs Osg ml aw 0
to
6 74 -120 10yr5/4 none s Osg ml - .6
r 43 — consists of an unsorted mix of 7.5yr4/6 Ifs & Osg 10yr5/6 Is & S. Horizon contains < 50% elluvial limestone fragments ns � 2" irregular bands of 7.5yr4/4 Ifs. Loading
rate of horizon reduced to reflect reduced permea a
Boring # Boring
Pit Ground Surface elev. 99.23 ft. >123" in. Soil Application Rate
#i Depth to limiting factor APpI
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -12 1Oyr3/3 none sil 2fsbk mvfr cs 2fmc 0.6 0.8
2 12 -32 1Oyr5/4 none lts Osg ml cw 2fm,1c 0.5 1.0
k2 �
3 32-49 1Oyr5/4 none sil 2msbk mfr cw 1fm 0.6 0.8
P, 4 49_92 1Oyr5/6 none s & gr. Osg dl aw 1vf 0.7 1.6
b 5 92 -123 1 Oyr5/6 none s & gr. Osg dl - - 0.7 1.6
Horizon #4 con ' s appprox. % gravel & 25% cobbles. H#5 contains approx. 20% gravel.
* Effluent #1 = BOD ? 30 < 220 mg/L and SS >30 < 150 g/L a it #2 = BOD < 30 mg/L and TSS <30 mg/L
CST Name (Please Print) ignature: CST Number
James K. Thompson �---- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson lake Lane, Osceola, 1/272006 715 - 248 -7767
Property Owner Bob Of Parcel ID # 030 - 1009 -60 -000 Page 2 of 3
[ Boring # Boring
wf Pit Ground Surface elev. 97.90 ft. Depth to limiting factor > 119" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -12 1Oyr3/3 none sil 2fsbk mvfr cs 2fm,1c 0.6 0.8
2 12 -37 1Oyr5/4 none sil 2fsbk ml cw 2fm 0.6 0.8
3 37 -84 1Oyr4/4 none gr. is 2msbk mfr cw 1fm 0.5 1.0
4 84 -119 10yr5/6 none s Osg dl - - 0.7 1.6
Horizon #3 contains approx. 25% gravel & 25% cobbles, and contains discontinuous, irregular inclusions of 7.5yr4/4 Ifs. Loading rate adjusted to reflect
reduced permeability of horizon associated with inclusions. _
F Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
❑ Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
' Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <_30 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777.
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30��
Dose Tank Information Locking cover with warning
label and locking device and
sealed watertight
Electrical as per NEC 300 and
Comm 16.28 WAC 4 in. min.
Disconnect
Tank component is properly vented Alternate outlet
location
Forcemain diameter
Wieser Concrete Manufacturer 2 in.
Cap acityl 603.36 Gallons
Volume 16.76 gal /inch A
Weep hole or anti -
Dimension Inches Gallons B siphon device
A 18.00 301.69
B 2.00 33.52 C P ump off e levation (ft)
C 5.00 83.79 1 88.42
D 11.00 184.36 D
Total 1 36.001 603.36
D ose tank elevation (ft)
3" Bedding un er tank. 87.50
Alarm Manuafacturer LevelArm
Alarm Model Number DLV
Pump Manufacturer jZoeller
Pump Model Number 153
Pump Must Deliver I 32.95 gpm at 14.47 ft TDH
Orf 3 bedroom Dose Conventional
Pump Chamber Calculations
1. Force Main:
Diameter 2"
Length 40'
Flow rate 33.00 alg /min.
Friction loss 1.03'
(40')(2.58ft./100ft.) = 1.032 ft.
2. Total dynamic head:
Min. supply pressure 0.00'
Vertical lift 9.50'
friction loss 1.03'
Total dynamic head = 10.53'
3. Pump selection:
Manufacturer: Zoeller
Model number: BN 53
Pump will discharge approx. 33.0 gpm @ 10.53' TDH
4. Dose chamber:
Manufacturer & capacity: Wieser WLP 1000 /600 MR Combination ST/PC
Liquid depth: 36 00" na 16.76-gal./inch ( 603.36 gal. actual)
Sizing:
A) One day holding capacity: 18.00" = 301.68 gal.
B) Alarm setting: 2.00" = 33.52 gal.
C) Dose volume: 5.00" = 83.80 gal.
(450ga1.X20% Design flow) + (.164X40) = 96.56 gal. Max. Dose
D) Reserve storage: 11.00" = 184.36 gal.
TOTAL 36.0" = 603.36 gal.
W cc W HEAD CAPACITY CURVE 6v4
I- U-
2 "53 -55" SERIES 4
• 25
e
TOTAL DYNAMIC HEAD/ I 4N
FLOW PER MINUTE
EFFLUENT AND DEWATERING o
CAPACITY +
p 20 HEAD UNITS/MIN 1'k -
I Q 6 FEET METERS GAL LTRS 4% 11'/2 NPT
= 5 1.52 43 163 •
V 10 3.05 34 129
15 4.57 19 72 1
Q 1 5 19.25 5.87 1 0 0
Z 4
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t— 2
5
9
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US
GALLONS 10 20 30 40 50 3%
-
LITERS
� so 33.o��,s°
FLOW PER MINUTE ± dr3�e ro-e.
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Piggyback Mercury Float Switches • Available with special cord lengths of 15
available.
25, 35 and 50'.
• Variable level long cycle systems • Alarm systems available.
available. • Duplex systems available.
Standard cord length - automatic 9 fL
Standard cord length - non-automatic Ic 15 ft
SELECTION GUIDE
M53/55 SERIES Control Selection 1. Integral float operated mechanical switch. no external control required.
Model Volts -Ph Mode Am Sk,, ex Duplex 2 Sk gkp deangkmercuryfloatawitchordoublepiggyboamerwryflo at
M53/55 115 1 Auto 8A 1 or 1 lx 7 switch. Refer to FM04T7_
N53155 115 1 Non 8.0 2 or 2 & 6 3 or — 4& 5 3. Mechanical alternator 10.0072 or 10-0075.
D53/55 230 1 Auto 4.0 1 or 1 &7 — 4. See FM- 712 for correct model of Electrical ANamator. - E-PW.
E53 /55 230 1 Non 4.0 2 d12 & 6 3 or 4 & 5 5. sensor mercury float switch 10- 0225 used a saamtmiacthsta .wtthE- Pak(3)or(4)
goat syuuem_
53 Series - WL23 lbs. -.3 H.P. 55 Series - Wt. 25 lbs. -.3 H.P. & Four (a) hole - .I- Pak.) unction boy. f orwatsrtightc onnectionorwlre"simplexor
duplex operation. P/N 10 -0002
7. Two (2) hole "J~. )unction box. for watertight connection orWioe. PM 10-0003.
Faintarmationonaddhianal Zoekrpmducts-WWeatalopgtCOmbinahMStarter FM0514: - CAUTION
Piggyback Metcory Float Switches. FM0477; Electrical Atte -alor. FM048Q Mechankal Attema- AN Installation of controls, prolectlon devices and wiMg should be done by a qualified
W F 0 95 AlarmP+dra00.FMOS13 Strtp/$ewagegasins FMWQ7;andSGnplexContrpl licensedelectriclan AN electrical and safe tycodmshouldtx roNowedlnaddMontothe
most rceent National Electrk Code ( NEC) and #w Occupational safety and Health Act
(OSHA)_,
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of 9 g every Zoeller pump.
M AM TO. P.O. 8a7K 163#
LWhvi k, KY40256-0347
778 -
Z Z7Z-(jff - ff OI (50 SNP TO.. s28o aa,t um tans M Manufacturers of ... L��. KY40216
® 2) 2731. 1(800) 928-PUMP O
FAX (50) 774 -3624 QUALITY /�Ud/P9 �A'CE ���J
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Conventional Septic System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD- 10705 -P (N.01 101). All local and/or state rules pertaining to system
maintenance and maintenance reporting shall be complied with.
Septic Tank
Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank
that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be
serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water
tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of
service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater
than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division.
Pump Tank
The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to
verify proper operation.
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface
within and above the system and will promote frost penetration during cold weather months. Cold weather installations
(October - March) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of a diversion valve. Valve to be
switched diverting effluent from dispersal cell currently in use to resting cell on a two -year cycle coinciding with septic tank
inspection and maintenance.
Continaency Plan
If the tic tank or of its co become defective the tank or component shall be repaired or replaced to keep the
� a com �
will system in proper operating condition. Excessive ponding within the dispersal cell be eliminated by instailing a new soil
absorption cell to bring the system into proper operating condition.
Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715)
248 -7767 or the St Croix County Zoning Department at (715) 3864680.
ST. CROIX COUNTY
• SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Rgy. -r'
Mailing Address S�,
Property Address 7 /7 / (fQ . �7 )O _
'
/ / (Verification required from Planning & Zoning Department for new construction.)
City /State AL Ste, c.)l SyO Parcel Identification Number 030 &V f- 66- 4:=
LEGAL DESCRIPTION
Property Location SE t/a , i'J� '/a , Sec. 3 , T 2-2 N R /� W, Town of c9-- SeJo�
Subdivision /7 , Lot #
Certified Survey Map # 44 , Volume — Page # --
Warranty Deed # ,� SS 77 7 , Volume /Z , Page #
Spec house yes no Lot lines identifiable yes ' no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 3
—W &/ 1 3 0 1 D L
SIGNAT OF APPLICANTS) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
REV. 08/05
555774 74 VOL 1223PACE,rj�S
Clowmmt Number
_ WA MNTY DEED
e•a.e boa. t.e: @.%7.1fi12rl Wt@. ateea.
_.
W toga ;1= G!S'i'c i'3 G: FIDE
Hats IXIM. made by Robert C Orf and Shirlev M Orf C"KIX Co., %V1
husband and wife as marital survivorship proyerty � PAWS
FEB 19 1997
GRANTO oonw and 114ff nts the progeny described below to • St. Croix 1t 4:15 P.
___
CoMtY - G NTEIfor of
u V I Clt. ►k ji,t:r vt Ub X-
1 '�} .•. ' _"' It � ... „� _�. - ...a .- __..- . -.r._�
Any person named in this dead may matte an appeal from the amount of
owro —stion within six months after the date of recording of this deed w fret forth
M "2.0SMW Vllisoonsin Statutes. For the purpose of any such appeal, the amount This space is reserved for recording data
of canperwtion stated on the deed shall be treated as the award, and the date the
deed is recorded sl be treated " the date of taking and the data of evaluation. Return to
Timbers- S°lissen Land Specialists,Inc.
Other persons having an iMSrost of record in the property. P.O. Box 207 Hudson, WI 54016 -0207
Lpa) 0 ee 10 0don This Mlle rat) homestead property.
r
Parcel Idendfication Numbw/Tax Kay Number
oat
9 1 041119
a . vu
Legal description is at
........ .11h
Six" L' a � P _
f,
D .'
vyC� t.
X. S � C r
�e N
r ame)
tsan.rw state of Wisconsin )
' r
) so.
r ,_
� Ndown at y )
n the above date, r County
was acknowledged before me
by the named per@ is).
,. Irkd Noma)
atary NaMe. d MnacwW
M NNary Pub6a, ahp yY�e�ir�
NMt Namal Data Cammraian Expirew
t Ip 8939 -03 -00 This instrument was drafted by St. Croix County Parcel No. 9
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