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HomeMy WebLinkAbout032-2138-60-000 n ■ s -0 n o � � } ■ � � � $ & - � «■ -0 A e z 0# @ 0 2 n , , o o < o )- « E ± E # * I - \ R 0 3 ® % R : § 2 CL k \ cr a \§ \ 2 G @ ; ' 2 § t \ E E §; & 0 E g @ � © 2 @ v � E ® E CL� C m' \ § _2 § k C ® I 0: f f \ k 2' n r■ CL ~ CL § % 0 0 o k' R I § § § k 0 o / LR �� \ } k \ k § " g z rr E & z � z / = a (D o > / % / § ±, CD f § . 44 = . cn � k \ / cn / \mod CL a 7 ƒ [ W k § / — k \ \ G ) ;CD 0. 0 ■ T m / # i E ■ / z kK �i z7 f0 ,{ � � � o\ƒ± 6207 § E# \ e m, ¥ = CL 0 % §E!@ EEb it 2 2{2 Dp i k , 3w { CD , m§§ /D® &9 2 � C, ■ ƒ w _< §\ w o \ § \ 2 � Parcel #: 032 - 2138 -60 -000 03/28/2008 08:14 AM PAGE 1 OF 1 Alt. Parcel #: 14.30.19.1223 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - RIVARD, JOHN H & TONI J JOHN H & TONI J RIVARD 1577 72ND ST NEW RICHMOND WI 54017 C = Sc P = Special Address(es): " = Districts: S hoot S Spe Property Primary Type Dist # Description " 1577 72ND ST SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 3.160 Plat: 08- 023 - ROCKAMORA SEC 14 T30N R19W N1/2 NW1 /4 LOT 12 Block/Condo Bldg: LOT 12 ROCKAMORA Tract(s): (Sec- Twn -Rng 401/4 1601/4) 14- 30N -19W NW Notes: Parcel History: Date Doc # Vol /Page Type 03/05/2002 672614 1847/174 WD 2008 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/24/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.160 48,800 150,900 199,700 NO Totals for 2008: General Property 3.160 48,800 150,900 199,700 Woodland 0.000 0 0 Totals for 2007: General Property 3.160 48,800 150,900 199,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 550 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division • • ` INSPECTION REPORT Sanitary Permit No: 404937 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village X Township Parcel Tax No: Rivard, John I Somerset Township 032 - 2138 -60 -000 CST BM Elev: h Insp. BM Elev: BM Description: V Q � USy`t , S#J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic I Ben chmark ` 3 � I Ov I Dosing A It oo Alt. BM ST�Co ao- 5 Aeration Bldg. Sewer •�/ Y Holding St/Ht Inlet s TANK SETBACK INFORMATION St/Ht Outlet S / q / r? TANK TO P , /L L / WELL BLDG. Vent to Air Intake ROAD Dt Inlet V / 1't Septic / nS / Dt Bottom Dosing Header /Mar !, • 23 10 Aeration Dist. P`1,77 _ / w ✓S v Holdip Bot. System f vle 3 PUMP /SIPHON INFORMATION Final Grade Manufacturer nd St Cover GPM 2. 106 Model N ber TDH Lift riction L System Head TDH t Forcemain Le , aejK Dist. to Well SOIL ABSORPTION SYSTEM �Gi w BEDITRENCH Width I WVI t '4 No. Of Trenches PIT DIM SIGNS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 1 SETBACK SYSTEM TO P/L 5 B4DG WELL LAKE /STREAM LEACHING Nawfac INFORMATION Type Of System: �� h / / CHA UN O [Model umber: 1 1 �r�_ 1� V 3 DISTRIBUTION SYSTEM C 16 .5"J-"td E66 D �h Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake X 3 1! N Pipe(s) Length D i Length Dia pacing SOIL COVER x ressure Systems Only xx Mound Or At -Grade Systems Only b$e eiv` �X Depth Over Depth Over xx Depth of xx Seeded /Sodded x Bed/Trench Center > �r Bed/Trench Edges Topsoil Yes k NN j x Mulched Yes [.41 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: // a Inspection #2: I l� Estates Location: 1577 72nd Street Somerset, WI 54025 (NE 1/4 NW 1/4 1 T30N R19W) Rockamo ra Lot 12 Parcel No: 14.30.19.1223 ,, j 1.) Alt BM Description = 1 •� F'� ULt.Q9- d ~�r'Ve MVt&a - ft S " ?I L + Wi SyS 2.) Bldg sewer length = ?�2� l �C�,� Y 36 ��SerVLLT``OrP1 ShOK fiva� �tof VIS /6l1.Gt = i C1t ur- �.Q,w Sv � - amount of cover I] QQ� ` �t o- Plan revision Required? /Yes No -- - - -� Use other side for additional information. - Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) Sarcty and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 _ isconsin Madison, WI 53707 - 7162 ite Addross De artment of Commerce P 3 O // �p Sat icoy ermit Number Application Sanitary Permit In accord with Comm 83,21, Wis. Adm. Code, personal into on oW �1r�v e ❑ Check If Revision nuy be used for xcond&ry purposes Privacy Law, I, Application Information - Please Print All Information Sate Plan I.D, Number Property Owner's Name ; ' Parcel Number Property Owner's Mailing Address 3T CP#ou( Property Location OOL04TY 'A yf S T N. R Ciry, State Lip Cale horse um r Lot Number Block N bee , • % ti' _ el, Subdivision Na me CSM Nurntrcr i ' �� �L Ll. Type of Building (check all that apply) ❑City 1 or 2 Famdy Dwelling - Number of Bedrooms ❑Villaga O Public /Connnercial - Describe Use _ wownshi ❑ State Owned Newest Road �p M. Type of Permit: (Check only one box on line A (ntunbering scheme for internal cue). Complete line B If applicable) A. 1,0 New 2 ❑ Replacement System 3 ❑ Replacement 7( Exis C3 Addition to For County U" S stem Tank Ord ' System Permit Number Date Issued { B. ❑ Check if Sanitary Permit Previously Ltsued I IV, Type of Permit: (Check all that apply)(numbering scheme is for internal use) '1 i 44 f0 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Comuucted Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment t 4 ❑ lJocirculating, 30 ❑ Other V. Dispersal/Treatment Area Information: s 3 AA C Design flow (glxl) Dispersal Area Dispersal Area oil Applicauun Percolation Rate System Elevation Final Grade �? E Required Proposed Jtaa(Gxis. /Days /Sy.Fr.) (Min,/Ir>ch) _ / '� E! no VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steil Fiber Plastic Gallons Gallons of Tanks Concrete Consuuctod Glass New Existing Tanks Tanks Septic or Holding Tank S Dosing Chamber VII. R" asibWty Statement I, the undersigned, a responsibility for installation of the POWTS shown on the attached plans. Plumber' ame (Print) . Plumbe 's Si MP/MPRS Number Business Pbone Number Plumber's Address (Strout, City, State, Zip Code) l s VIII. County /De artment Use Onl Approved ❑ Disapproved Sartsutry Permit Fee (includes Groundwater Date Issued Issuing Agent Sigasaro (No Stamps, Surcharge Fu) ❑ Owner Given initial Adverse � ._Deter rninatiun t 27 —i � T IX. Conditions of � Approval /Reasons f Di rr.� vv�*►� Au-b caoplek ptaua (to the Couatj oily) for the "so oo papa aot teas that it/3 s It toebas Is am SBD -6398 (R. 05101) 1 C1 T tl 3 I 1 7j 4T i kk�s _ j Au r __ __. __ __ _ __ __ � _ __ __ __ __ �_ _- ,� -.- __ WisconsjF!Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division o Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code { Tom Schmitt Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal refer peir'1t (�M), direction and St. C roix percent slope, scale or dimensions, north arrow lecation and alstance to nearest road. — Parcel I.D.# Part of 032 - 2049 -60 -0 & 032 - 2049 -70 -0 APPLICANT INFORMATION - PI mt alinformatiollt, viewed! B Date Personal information you provide may be used f r se' dary ' T4macy Law, s. Tb.04 (1) (m)). y �I 2 Property Owner Property Location Rivard, Harold And Belisle, R (�na A Y i Q Govt. Lot na NE 1/4 NW 1/4 S 14 T 30 N,R 19 W Property Owner's Mailing Address - Lo) # Block # Subd. Name or CSM# 812 150th Aver �aM L 12 na Rockamora City State ` ' ; 'Code City ] Village Town Nearest Road New Richmond WI 5 17, j 5 -246 -5 Somerset 1 160Th Ave E New Construction Use: Z Residen � edrooms 3 ❑Addition to existing building EJ Replacement 0 Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd/ft .6 trench, gpd/ft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate .5 bed, gpd/ft .6 tr ench, gpd/ftz Recommended infiltration surface elevation(s) Area 189.8 87.5' ft (as referred to site plan benchma6 Additional design / site consideration Area 1186.2'& 81.9' Parent material Pitted Glacial Drift Flood plai n elevation, if applicable na ft Sle for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank table for system ®S ❑ U ®S ❑ U ® , ❑ U ®S ❑ U ❑ S ®U ❑ S M U SOIL DESCRIPTION REPORT t u�60 Depth Dominant Color Mottles Structure GPDO Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ConsistencE Boundary Roots Bed I Trench 1 1 0 -5 10yr3/3 none sil 2mgr mfr cs 2m .5 .6 A 100 2 5 -19 1Oyr4 /4 none 1 2fsbk mfr gw if .5 .6 S Ground 3 19 -45 10yr5/6 none grsl 2msbk mfr gw if .5 .6 5 elev 94.14 ft 4 45 -90 1 Oyr4 /6 none grls Osg ml - - -- - - - - -- .7 .8 , Depth to limiting factor >90" Remarks: �sRflsr� �i 1 0 -11 10yr3/2 none sill 2mgr mfr cs if .5 .6 �2 2 11 -33 1 Oyr4 /4 none 1 2msbk mfr gw 1 f .5 .6 Ground 3 33 -41 10yr5 /6 fSl grsl 2msbk mfr gw - - - - -- .5 .6 5 elev 92.13 It 4 41 -84 1Oyr4 /6 none grls Osg ml - - -- - - - -- .7 .8 Depth to limiting factor >84" Remarks: CST Name (Please Print) Signature: �—� Telephone No. Thomas J. Schmitt 715 -549 -6651 Address Tom Schmitt Date CST Number Ref # 586 Valley View Trail, Somerset, WI 54025 5/9/00 227429 1006 PROPERT *OWNER: Rivard Harold And Belisle, Roland SOIL DESCRIPTION REPORT tool Page 2 of 3 PARCEL I.D.# Part 6[032-2049-60-0 & 032 - 2049 -70 -0 Tom Schmitt Depth Dominant Color Mottles Structure GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistence Boundary Roots Bed Trench AR � 3 1 0 -7 10yr3 /2 none 1 2mgr mfr cs 2m .5 .6 S to 2 7 -18 1Oyr4/6 none 1 2fsbk mfr gw if .5 .6 s Ground elev 3 18 -25 7.5yr4/6 none is Osg ml gw if .7 .8- 89.67 ft 4 25 -96 7.5yr4/4 none sl 2msbk mfr - - -- - - - - -- .5 .6 S Depth to limiting factor > 96" LL Remarks: 1 0 -16 10yr3 /2 none 1 Ifpl mfr cs 2m .4 .5 �{ 2 16 - l Oyr4 /4 none l 2msbk mfr cs 1 f .5 .6 , S Ground m3p 10yr6 /6 elev 3 40 -49 1Oyr4/4 7.5yr4/6 sl 2msbk mfr cs - - - - -- .5 .6 86.38 ft 4 49 -96 7.5yr4/4 none grls Osg ml - - -- - - - - -- .7 .8 Depth to limiting factor >96" 513. S 9'f.8 Remarks: The mottling in this bore is less than 1' thick overlying a coarser textured soil greater than 3' thick, making it possible to install a conventional system in the coarser textured soil below the molt me. S I 0 -10 10yr3 /3 none 1 2fsbk mfr cs 2m .5 .6 . S 2 10 -30 7.5yr4/4 none sl 2msbk mfr gw if .5 .6 Ground elev 3 30 -43 7.5yr44 none Is osg ml gw if .7 .8 . �- 86.85 ft 4 43 -55 1 Oyr4 /6 none ms Osg ml gw - - - - -- .7 .8 Depth to 5 5 - 6 5yr414 none grsl 2msbk mfr - - -- - - - - -- .5 .6 limiting factor >96" cr� Remarks: aL i ,. h Ground elev Depth to limiting factor Remarks! i S L� i _i I I I. ' l i Sr ao c l o it Idd I � I f - i1,.A4_j Pell V - - - - - o - meet' �7✓ �'"� -- — _ - -- -- _ - - f Ccd,f�- ta-�._._ : I , I I I i I I I j I I I I I I I I ; t I I , 1 I : i r I r I I 1 , r I - I I I I ' I : I 1 I I , r I I I I , j • , r -- - --- I I r I I I r , : I I I I , i I I I I I { t _ I i_ I I I I , r I r I ! I } t : I ; I ' I I I ! I r I ' t I r L I j , I I I i I � I I I I I I I t 1 f : r r t ! I I• 1 : r ' I I _ 1 I I I I I I I l I I I I , , I I I I r, I ; I I : I r I POWTS OWNER'S MANUAL 8Z MANAGEMENT PLAN Page _1__ of FiLE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer — S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA, Effluent Filter Model ❑ NA Number of Commercial Units NA Pump Tank Capacity gal 3 NA Estimated now (average) gal /day Pump Tank Manufacturer M NA Design now (peak), (Estimated x 1.5) gal /day Pump Manufacturer NA Soil Application Rate gal /day /ft' Pump Model JZ NA e, 9 Influent/Effluent Quality Monthly average* Pretreatment Unit ,Z NA Fats, Oil ex Grease (FOG) 530 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODs) 5220 mg /L ❑ Mechanical Aeration ❑ Wetland Total Susp Solids (TSS) 5150 mg/L 0 Disinfealon ❑ Other: Manufacturer Pretreated Effluent Quality ❑ NA Monthly average ** Dispersal Cell(s) Biochemical Oxygen Demand (BODs) .530 mg/L J9 In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ❑ Mound Fecal Collform (geometric mean) s 10' cfu/ 100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size !A inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months ,E year(s) (Maximum 3 yrs. ) Pump out contents of tank(s) When combined sludge and scum equals one -third ()i) of tank volume Inspect dispersal cell(s) At least once every ❑months Z'year(s) ( Ma)imum 3 yrs.) Clean effluent filter At least once every �s ❑ months Oyear(s) Inspect pump, pump controls at:alarm At least once every ❑ months ❑ year(s) ETNA Flush laterals and pressure test At least once every ❑ months ❑ year(s) 0 NA Other At least once every ❑ months ❑ year(s) gNA Other At least once every ❑ months ❑ year(s) NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Maste Plumber; Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. 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 to 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 observadon 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 nodflcadon of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one -third (1i) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at Intervals of 12 months or less shall be performed by a cerdfled POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemical, that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a sentage servidng opera prior to use Pile °( System start up shall not occur when soil condlti m are from at else Inflltrativt surface, During power outages pump tanks may RII above normal hlghwater levels. When power Is restored the txceu wastewate will hr discharged to the dispersal cells) In one large dose, overloading the cells) and may result In the backup or surface discharge tai effluent. To avoid this situation have the contents of the pump tank removed by a Sepup Servking Operator prior to roto power to the effluent pump or contact a Plumber or POW75 Malntalner to assist In manually operating the pump contro:> ;u restore ncrmal levels within the pump wnk. Do not drive or park vehicles over unks and dispersal cells. Do not drive or park ever, or otherwlse dUwrb or compact, the grew within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater marn may Improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; clg4rett.e butu; condoms; cotton swabs; degreasers; dental Ross; diapers; dlssnfectanu; let; foundation drain isump pump) water; fruit and vegetable peelings; gasoline; grease; herblcldw; meat scraps; madicatium; oil, palntlnst croducts; oesticldes sanitary nookins: tampons; and water softener brl r A13ANDONEMENT When the POWTS falls and /or Is permanently taken out of service the following sups shall be taken to Insure that the system is properly and safely abandoned In compllanee with ch. Comm 83.33, Wlscoruln Adminlatrative Codes • All piping to links and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and plu shall be removed and properiy dlspos*d of by a Sepuge Servicing Operator, • Atler pumping, all tanks and plu shall be exuvatxd and removed or their covers removed and the void space nii(d w;,r coil, gi avel or another Inert solid mdterlal. CONTINGENCY PLAN If the POWTS falls anct cannot tN repaired the following measures have been, or must be taken, to provide a code compliant replacement system, A sultable replacement area has been evaluated and may be utlllred for the location of a replacement will absorption system. The replacement area should be protkcted from disturbance and compactlon and should not be InMnge4 upon : requlred setbacks from existing and proposed svucwre, lot fines and wells. Fallure to protect the replacement area wii: result In the need for a new soil and site evaluation to establish a sultable replacement ana. Replacement syswnss rnust comply with the rules In effect at that drne. O A su►table replacement area b not available due W setback and /or soil limltatlons. Barring advances In POWTS technolo;, a holding link may be Installed as a last resort to replace the failed POWTS, 0 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 w locate a suitable replacement area. If no replacement area Is available a holding tans: m. be Installed as a last resort to repl+ce the failed POWTS. 0 Mound and at- grade soil absorption sysums may be reconstructed In place following removal of the biomat at the Inflluaelvt wrface. Rtr<onsvvalosu of such systems must comply with the rules In effect at that time. < < WARNING > > 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 RESULT, RESCUE OF A PERSON FROM TKL INTERIOR OF A TANK MAY Of DIFFICULT OR IMPl1ttIR1 IF ADDITIONAL COMMENTS POWTS INS'T'ALL POWTS MAINTAINER Name 7 Na me Phone 3 r phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name /�ency ___ Phony ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer 0 P1 1 1� a nd Mailing Address 2 ISL, \ t New R I r,Vimo , W/ S g vi Property Address (Verification required from Planning Department for new construction) ZZ z D0 City /State Sdyl/�/ S� / GG�i Parcel Identification Number - z 13 v LE GAL DESCRIPTION Property Location '!a, AL(Z.) ' %a, Sec. _Z� T - N -RAW, Town of Subdivision d pg , Lot #. Certified Survey Map # , Volume , Page # Warranty Deed # e� lfz , Volume )q, .Z Page # / 7y Spec house O yes [9 no Lot lines identifiable lXyes O no SYSTEM MAINTENANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, 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 Zoning Office within 30 days of the three year expiration date. � 4 &� SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION 1 (we) 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. z ,24p/ 02 SIGNATURE F APPLICANT DATE * * * * ** Any 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 vo! 1847PAf,1.174 STATE BAR OF WISCONSIN FORM 2 • 1999 KATHLEEN H. MA LSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., MI This Deed, made between Harold IC Rivard and Roland J. Belisle RECEIVED FOR RECORD — ___..._._._.__.....__. 03 -05 -2002 9:40 AN A_ WARRANTY DEED Grantor, and John H. Rivard and Toni J. Rivard, husband and wife, EXEMPT # REC FEE: 11.00 - — TRANS FEE: 99.00 COPY FEE: CERT COPY FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 12, Rockamora, Town of Somerset, St. Croix County, Wisconsin. Name and Return Address KRISTINA OGLAND ESTREEN & OGLAND 304 Locust Hudson, WI 54016 032 - 2138 - 60-000 Parcel Identification Number (PIN) y — This is not homestead property. Oli) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of February 2002 • • � K. Rivard Q� _ • • Roland J. Belisle AUTHENTICATION ACKNOWLEDGMENT Signature(s) Harold K. Rivard and Rola J. Belisle - STATE OF WISCONSIN ) ) ss. County ) _ K •". authenticatgd is -day of February 2002 Personally came before me this .. _day of r the above named + I'stirt6 O nd — TIT1�F IMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. au 706.06 Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY + A ttorney Kristina Oglan _ Notary Public, State of Wisconsin Huds Wl 54016 My Commission is permanent. (1f not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ') + Names of persons signing in any capacity must be typed or printed below their signature. information Prora•• Company. Fong du Loc. W1 8008562021 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2.1999 := W N.YY.t. =4wo.,) p I 3 11 A CRES r ,Z / N �_ N .3 �o �// MINIMUM FFE. OF 500.3 y o I + - �- - - - -- S 89'17'39" E 612.48' - - - - - _ N 410 202.18' co In • 04 MINIMUM F.F.E. OF 500.3 7 g•02� co 0 i LOT 10 N I N 136, 549 S0. FT. N Z 3.14 ACRES cq I S 8917'39' E 614.95' 3 ' I ;i I I Q =1: w t o o f L O T 11 I �. w I i C I ' � ���s• 137, 098 50. FT. I I I r lv \�00! ♦ !V ti / �F J. 15 ACRES N CNI y ' AD MINIMUM F.F.E. OF 507.4 I I _ - - - -- - - -- 4 S 8- - -- 245.61 - - - - -- I I: cvo, :� i• - M/N /MUM F.F.E. OF 5074 a1 M ° g fn z y ` ° z 3 3' 3. N �N \ t:w.L. r l`�! LOT 12 ` i I `J 137, 650 SO. FT N i i I •�i �'s '" � ' . _j 3.16 ACRES � W 55 "E A 89.95' i \ I / 619.90' SOUTH LINE OF THE NE 1/4 OF THE NW 1/4 66.00' . - - - -- N8917 - 39 "W 1185.91' - - - - -- -- So�Gt i BE UNPLATTED_ LANDS fi r,., TOP OF FOUND