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Wisconsin Department of Commerce County:
Safety and 'Building Division PRIVATE SEWAGE SYSTEM St. Croix
INSPECTION REPORT Sanitary Permit No:
384297 0
GEN�. 'AL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal ii ,ormation 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:
Fern, Rodney St. Joseph Township 030 - 2053 -40 -000
CST BM Elev: Insp. BM Elev: BM Description:
O 4 L // v c-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
-iL- I Illl; e QC�U 2 .33 102.13 lVa
Alt. BM
S `+° + W e o S' 9 G. 3�p
Aeration Bldg. Sewer #I
9.9 �z Y3
Holding St/Ht Inlet * I
10.9 9,y3
TANK SETBACK INFORMATION St /Ht Outlet o 1 2 3
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ( 7
z S , Z3 RattnM
SD r �� i Header /Man. 13_ } V I Z
Aeration Dist. Pipe 13, 1 P 'P
of ' Bot. System 1 y Q Y3
Final Grade
PUMP /SIPHON INFORMATION
nufacturer Demand St Cover
M
Model Number r
\ gl 9 • GW eY !Q Frew. hOkS� �r7. 9l. J
TD ift Friction Loss Head TDH Ft 70. 3
Forcemain Length Dia. Dist. to We 4 04le # Z
l2. zo QD. !3
SOIL ABSORPTION SYSTEM i Z L s a
BED H Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMEWMNS 3f 76-/
SETBACK SYSTEM TO P/L JBLDG IWELL ILAKEISTREAM G Manu ac urer.
INFORMATION HAM OR Type Of System: C r
-� UNIT Mods Number.
6- Z f
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size I x Hole Spacing Vent to Air Intake
t� a Pi r + r
Length Z 4 p pes) Dia ( Length �J Dia Spacing — AA
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil 9 p 0 Yes No �z Yes � No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:t/ 3 Inspection #2:
Location: 1363 & 1365 State Street Ho WI 54082 (SE 1/4 NW 1/4 27 T30N R20W) Village Plat of / Parcel No: 27.30.20.530
1.) Alt BM Description= � Cic oKcr Sib 4y f R"a-fe dooms 3 �O�scrvctf a. p,Pes (p+ �� 6e
JI3
2.) Bldg sewer length = y,
- amount of cover =� a iw
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Plan revision Required? C Yes lam No (i
Use other side for additional information. a �._
SBD -6710 (R.3/97) Date !iF sepctor s Signet ur Cert. No.
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06 er ment of Com►morce
S' Pertuit Number
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44XN(m - "WAtwed InGrouad ufl Mound 47 Q sow Piittn So Corstrul rd W ed 4nd
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NOTES: SS w ULL -
1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install 4" observation pipes with a
3. Septic tanksto be goo approved caps. ( 10 required).
o gallon capacity manufactured by
M l0►�LSTLi�V C'lZ(g7- W�ZP<gL Lis Z 1hi►z S �ZE�3 p
4. Bench marker Ste �t3ov�
5. Divert surface water around system to prevent .
ponding,at the uphill side.
Safety and Buildings
4003 N KINNEY COULEE RD
LACROSSE WI 54601 -1831
Visconsi TDD #: (608) 264 -8777
www.commerce.state.wi.us/sb
'y ` www.wisconsin.gov
Department of Commerce t �` _ -`
Scott McCallum, Governor
} r Brenda J. Blanchard, Secretary
March 26, 2001
CUST ID No.691727 ATTN. POWTS Inspector
ARTHUR L WEGERER ZONING OFFICE
421 N MAIN ST ST CROIX COUNTY SPIA
PO BOX 74 1101 CARMICHAEL RD
RIVER FALLS WI 54022 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 03/26/2003 Identification Numbers
Transaction ID No. 631603
Site ID No. 627720
SITE: Please refer to both identification numbers,
SITE ID: 627720, RODNEY FERN above, in all correspondence with the agency,
ST CROIX COUNTY, TOWN OF SAINT JOSEPH; 1363 STATE ST
SE1 /4, NW1 /4, S27, T30N, R20W
FOR:
DESCRIPTION: TWO (THREE BEDROOM HOME) ON CONVENTIONAL SOIL ABSORPTION SYSTEM
OBJECT TYPE: POWT SYSTEM REGULATED OBJECT ID NO.: 785754
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Conventional Soil Absorption Component Manual for Private Onsite Wastewater Systems" SBD- 10567 -P
(R.6/99).
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per Comm 84 product approval conditions.
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Slats.
• The existing POWTS must be properly abandoned.
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the
initial installation of the POWTS in accordance with an approved management plan shall be conducted by a
person who holds a registration issued by the department as a registered POWTS maintainer.
ARTHUR L WEGERER Page 2 3/26/01
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely, DATE RECEIVED 03/23/2001
FEE REQUIRED $ 175.00
FEE RECEIVED $ 175.00
Charles L. Bratz BALANCE DUE $ 0.00
POWTS Plan reviewer II — Integrated Services
(608)- 789 -7893, Mon. - Fri. 7:45 AM to 4:30 PM
cbratz@conunerce.state.wi.us WiSMART !code: 7633
Safety and Buildings
4003 N KINNEY COULEE RD
LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
www.commerce.state.wi.us /sb
Vhsconsin �� www.wisconsin.gov
Department of Commerce
? , Scott McCallum, Governor
�1 `. Brenda J. Blanchard, Secretary
�Y
March 26, 2001'
CUST ID No.691727 A17N: POWTS Inspector
ARTHUR L WEGERER ZONING OFFICE
421 N MAIN ST ST CROIX COUNTY SPIA
PO BOX 74 1101 CARMICHAEL RD
RIVER FALLS WI 54022 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 03/26/2003 Identification Numbers
Transaction ID No. 631603
Site ID No. 627720
SITE• Please refer to both identification numbers,
SITE ID: 627720, RODNEY FERN above, in all correspondence with the agency.
ST CROIX COUNTY, TOWN OF SAINT JOSEPH; 1363 STATE ST
SE 1/4, NW 1/4, S27, T30N, R20W
FOR:
DESCRIPTION: TWO (THREE BEDROOM HOME) ON CONVENTIONAL SOIL ABSORPTION SYSTEM
OBJECT TYPE: POWT SYSTEM REGULATED OBJECT ID NO.: 785754
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Conventional Soil Absorption Component Manual for Private Onsite Wastewater Systems" SBD- 10567 -P
(R.6/99).
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per Comm 84 product approval conditions.
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Slats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Slats.
• The existing POWTS must be properly abandoned.
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the
initial installation of the POWTS in accordance with an approved management plan shall be conducted by a
person who holds a registration issued by the department as a registered POWTS maintainer.
i
r.
ARTHUR L WEGERER Page 2 3/26/01
• The current owner, and each subsequent owner, shall receive a co of this letter including instructions relating
q PY g g
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /instal lation/operation.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely, DATE RECEIVED 03/23/2001
FEE REQUIRED $ 175.00
��` ✓ ✓ ✓ �� L FEE RECEIVED $ 175.00
Charles L. Bratz BALANCE DUE $ 0.00
POWTS Plan reviewer 11— Integrated Services
(608)- 789 -7893, Mon. - Fri. 7:45 AM to 4:30 PM
cbratz @commerce.state.wi.us WiSMART code: 7633
t 4
TITLE SHEET Page I of S
Conventional soil absorption system for
2- 3 bedroom homes on one a
p reel of land.
This lan has as been re ared in Soil Absorption Compo Manual c SBD- 10567- P t (Rt6�99� nventional
Located in - the SE 114 of the NW 114 of Section Z - 7 , T 3o N, R 20 W
Town of _ ST. 3pS �f} `3
T'. C1ZU X County, ".Wisconsin.
INDEX
Page 1 of 5 TITLE SHEET
Page 2 of 5 SYSTEM MANAGEMENT PLAN ` 1 �
Page 3 of 5 PLOT PLAN
Page 4 of 5 PLAN VIEW-CROSS SECTION ww
Page 5 of 5 LEACH CHAMBER DETAIL �V
C
PREPARED FOR
!s
H CJv L'V�i, � WI 54O8Z
PREPARED BY
WEGER�R .SO = L. • TEST 2 htG
AND
DES = Gam! SERV S CE ���ma�eou�e�e
k�'' • ��
P.O. Box 74 421 N.Main St. .••.......
River " = .,'
er Falls, WI 54022
Phone 7 15 - 425 -0165 ART:J -� j
Fax 715- 425 -6864. ER`� t
�,' 0.015 a
ELL`Pl0i771,
T
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W I
COI"l�l S
APPROVED
M0F
JOB No. O I -O
I
Conventional Soil Absorption System Management Plan
Pursuant to Comm 83.54, Wis.Adm. Code Paoe Z- of
Seoti c Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, "=. The contents of the
septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and
outlet filter shall be assessed at least once every 3 years by inspection. 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 continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of
the tank. if the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise
the*owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in
the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required.
However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and
Buloings Division.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to
verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary.
Dispersal cells '
No trees or shrubs should be planted or allowed to grow on the component. Plantings may
be made around the 'perimeter and the component shall be seeded and mulched as necessary
to prevent erosion and to provide some protection from frost penetration. Traffic (other
than for vegetative maintenance) on the component is not allowed. Cold weather install-
ations require the component to be heavily mulched for frost protection.
Influent quality into the 4 system "may not exceed 220mg /L BODS, 150 mg /L TSS and
30 mg /L FOG. Influent flow may not exceed 'the maximum design flow specified in the permit
for this installation.
Observation pipes within the dispersal cell shall be for effluent ponding.
Ponding levels should be reported to the owner and any levels above 4 inches considered
as an impending hydraulic failure requiring additional, more frequent monitoring in
accordance with Comm 83.52 (2).
General
This system shall be operated in accordance with Comm 82 -84 Wis.Adm.Code and shall be
maintained in accordance with it's component manual SBD 10567- P(B.6/99)1 and local and
state rules pertaining to system maintenance and maintenance reporting..
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and
pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole 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 Unches in diameter shall
be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component.
Continaency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition.
If the dispersal cells fail.to accept wastewater, additional soil and site evaluation
may be required with plans being submitted to the Department of Commerce, Safety and
Buildings Division.
Questions about the operation or maintenance of this system should be directed to:
The County Zoning - Office at C[w LX
The system installer at `1 LS —3C -3� Z� SCl l�1 k.: 5z
The tank manufacturer at BOp - C? Z.SM (s:rs
The effluent filter manufacturer at BOO - S7l4Z zNnia
The leach chamber manufacturer at Boo - ZZ( - 4rc[36 ? _-R
PLOT PLAN
Scale 1 "=SO ' - Page 3 of S
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L
NOTES: 1 s T. w L'1,L - Cxs� �4
1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install 4" observation pipes with approved caps. ( 10 required).
3. Septic tanksto be �00 gallon capacity manufactured by
ML �,,ss .
O � TL'1'� P tZ w Zft'Stt C2 s z
4. Bench marker S t� 13oyL
. Divert surface water around system to prevent ponding at the uphill side.
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1019
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow 'on and distance to nearest road. Parcel I.D.
030 - 2053 -40 -000
Please pri a(t,ip i i n� • , e g Y Date
Personal information you provide �secon ary purp`( fiv Law, s. 15.04 (1) (m)). �
Property Owner p rr^rr� r� Property Location
Fern, Rodney __r 'A V IE ,` � Govt. Lot SE 1/4 NW 1/4 S 27 T 30 N R 20 W
Property Owner's Mailing Add ! ,L Nut Name or CSM#
1363 State St.
City State Zip Co COU umber — J City j Village ej Town Nearest Road
Saint Joseph I M:. 54=8 G (?1 -q 4 St.Jose h I State St.
New Construction Use: r► Aesi entiioi?'F(utnl�t edrooms 6 Code derived design flow rate 900 GPD
V1 Replacement _I Pub�r l - Describe:
Parent material Outwash Plain Flood plain elevation, if applicable NA
General comments
and recommendations: Recommendation - Conventional System. 0.5 GPD /sgft rating. Possible system elevation90.13'.
(Note) Be sure to maintain 50' setback from all wells.
Boring # I Boring
VJ Pit Ground Surface elev. 94.75 ft. Depth to limiting factor >129 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflt'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3/2 none sl 2msbk mvfr gw 2m .5 9 �
2 8 -36 10yr5 /3 none sil 2csbk mvfr gw if .5
3 36 -60 7.5yr4/4 none grls imsbk mfi cw - - - - -- .7 �� ✓
4 60 -129 7.5yr4/6 none grls imsbk mvfr - - -- - - - - -- .7 4,2
rz3
F2 ] Boring # _j Boring
Lo/J Pit Ground Surface elev. 93.13 ft. Depth to limiting factor >120 in. Soil Application Rate
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 -10 10yr3 /2 none I 2fsbk mvfr gw if .5 ✓ .8 �/
2 10 -26 10yr4 /4 none grsl lfsbk mvfr gw - - - - -- .4 . 4 1
3 26-48 7.5yr4/4 none grls imsbk mfr gw - - - - -- .7 i "
4 48 -120 7.5yr4/4 none Is Osg ml - - -- - - - - -- .7 ✓ �io(
* Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD S30 mg/L and TSS < 30 mg /L
CST Name (Please Print) Signature: ✓ CST Number
Thomas 3. Schmitt V 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
Somerset, WI 54025 9/15/00 715- 549 -6651
Property Owner Fern, Rodney Parcel ID # 030 - 2053 -40 -000 Page 2 of 3
3] Boring # Boring
✓j Pit Ground Surface elev. 94.30 ft. Depth to limiting factor . > 128 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 -9 10yr3 /1 none I 2fsbk mvfr Cw if .5 ✓ .8 ✓
2 9 -37 10yr4 /4 none S4 lmsbk mfr Cw 2m .4 ✓ .6
3 37 -51 5yr4/4 none grsl 2msbk mfi Cw - - - - -- . 5 ✓ .9 ✓
4 51 -128 7.5yr4/4 none grsl 2msbk mfr - - -- - - - - -- .5 ✓ .9
F-1 Boring # _j 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
F-1 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
* Effluent #1 = BOD 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. »lease contact the dennrtment at 60R -266-3151 or TTY 608-264 -9777.
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I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/BuyerviJ n
Mailing Address W 21 " r
Prop Address 13 b e 5
(Verification required from Planning Department for new construction)
City /State
u Parcel Identification Number 6 �2
�.�o teN
L EGAL DESCRIPTIQ�[
Property Location _---'/4,
rtY �
p L %, Sec. A 7 . T 3 d N -R, 9S W, Town of
Lot #
Subdivision
Certified Survey Map # - Volume -. Page #
Warranty Deed # Volume Page #
Spec house ❑ yes 2L no Lot lines identifiable ❑ yes ,Rf no
�r�►_� l�+rAtxTENANCE
Improper use and maintenanceof your septic system could result in its premature failure W 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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
lumber, restricted lumber or a licensed pumper verifying that (1) the on-she wastewaterdisposal system
is in r oper , operating ond np p if necessa the septic tank is less than 1/3 full of sludge.
is is proper operating condition and/or (2) after inspection and pumping (� �'Y),
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with die standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certificati
30
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning OM
days the three yoar cbwation date. /1�
SIGNATURE P ICANT
DATE
93ME CE,BMICATION
I (we) certify that all statements on this form are t rue
recorded best of M ( our)
Deeds Offices. I (we) am (are) the owner(s) of
r ove, by virtue of a warranty deed Regis J)
DATE
« «« ««« A information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. « « « « *«
«« Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
STATE BAR OF WISCONSIN FORM I — 19.
556008 WA RR VOL i r •� N•rY DEED
m �,rt5. �
DOCUMENT NO. "~
_ 1 _..--- •--- _..... __ _._ _ tl FIEGISTWS OFFiCT
1 ST CROM C TY 1 WI
l :
This Decd maJc between —Hairy E!ern an d -
- Glor- ia- -G. Fern, xrshan� and_ F 2 6 1997
VLfe
>, ,Grantor, 9:30 A. M
�! and - -- Rodney R. Fern, Single____.__.._� i; � ft
IL
;� — ReytsW of Da
1.
Grantee, �?
1• WII;DCSSI;ih, - That the said Grantor, for a valuahlc consideratian THIS SPACE nEstnvED FOH 11EC000ING DATA _�_ ,i
�� . —...__ —_— ...._ -.__ _ .. . :.. ......... _..... ___ _ _. I• A AND ET 14M A00 / ( 'SS
conveys to Grantcc the following descrihcd real estate in
Ciunly, State of Wiscon 1 13 06 �' .e. 4tx` /QD
I
I (Parcel Idee :ifiration Number)
Lot 8, in Block "2" of the Village of Houlton, which is
more particularly described as: Commencing at a point in
Section 27, Township 30,Range 20, 1,579 feet,South,and
290 feet West , from the quarter post between Sections 22
and 27: thence South 284 feet and 9 inches; thence West
100 feet; thence North 211 feet and 9 inches; thence i
I in a direct Nortneasterly line, the place of beginning,
St. Croix County, Wisconsin.
WNSFER '
This ---- _ is- homestead ro rt iII
P {x Y• 1
(is) (is not)
Togctbct with all and singular the hcrcditamcnts and appurtenances thereunto belonging;
And — — — -- --- I
warrants that the title is gout, indefeasible in fee simple and free and clear of encumbrances except
1 '
and will warrant anti defend the same.
Dated this —_. 5th — day of — February
L41 (SEAL) (SEAL)
-- Harvey -- Fe •
1
(SEAL) (SEAL)
, WTnENTICATION ACKNOWLEDGMENT
` Minnesota
I1 Si`naturc(s) —__ STATE OF)WUW" =
�� R8IDat3
Count 5
authenticated this day of _ , 19_ Personally came before me this ._ day of
► —^
Febr 19 -93 the above named
�1 Harvey Fern -a-A
a3 in is G. Sores
i� TITLE: MEMBER STA - rE BAR OF WISCONSIN and - Wife
It (ir not,
authorized by g706.06, ' <Vis Slats.) to rite known to be the person who executed the
i.
1 roresoing vistrumeakand ac cwledgc thesyne. I THIS INSTRUMCNT WAS DRACTED BV `
121A-w-ale 4N
1' Jeffrey Nycklemoe,__
�y Attorney At Law • nich 1 e Cre a • .Harx Pn ___� —_
- -- _------ •---- __ -- -- Notary Public ,�.m County, Wis.
(Signatures may to authcntieared or acknowledged. Dexh arc not My col.- mission is permanent. (if not, state expira;.ion date:
i necessary.)
�: - �'�Id'QL G7tEfiFWiRE _ _-
• Namr� id Irrvw.. �.punp m .mc .atu.iw aMnit,l he lvrw .. Pdaca hk6w I:, it siKnamtca. f�'�_.__ (7�(
A CaOXLRWMN
•• WAItRh`ry twvtr SPATE. nnn OF WISCO, IN Eloft 1 /3vxw
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