HomeMy WebLinkAbout032-1017-95-200 I
Wisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 370201
Permit Holder's Name: ❑ City ❑ Village ❑ X Town of: State Plan ID No.:
Somerset Townshi
CST B Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
90 32 .0. L YF 6 Z. 032 - 1017 -95 -200
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic L ZoD Benchmark gs 9 0 .3 2
Dosing Alt. BM 5:90 9; 9's
Aeration Bldg. Sewer .3`f' 011.54'
Holding St /Ht Inlet
TANK SETBACK INFORMATION St /Ht Outlet 13,0 go.Zo'
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic > SO ' >' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe '
Holding Bot. System o ' s-
2.6 B�.Z
PUMP/ SIPHON INFORMATION Final Grade s g,4 90.29
Manua er emand St cover
Model Number GPM
TDH Lift L riction etem TDH Ft
Fo emain Length Dia. Dist. To
SOIL ABSORPTION SYSTEM IZ C� a -E-r
TRENCH Width Len g, th No.. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME -/ a. DIMEN 1 N
SYSTEM TO P BLDG WELL LAKE /STREAM LEACHING Man fact rer:
SETBACK CHAMBER ���
INFORMATION Type Of w Model Number:
System: C-.11. fso > �� In OR UNIT
DISTRIBUTION SYSTEM Im°
Header/Manifold U Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r
Length e, Dia [a. Spacing 7 T
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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies; persons present, etc.) Inspection #1: 09//'1/OD Inspection #2: -f—/
Location: 285 230th Avenue, Somerset, WI 54025 (SE 1/4 SE 1/4 6 T31N R19W) - 06.31.19.87F
1.) Alt BM Description=
2.) Bldg sewer length= 2-19.0' ,
- amount of cover A-t
y rvv.�, i;-
` ) & j q-1m
Plan revision required? ❑ Yes "M No
Use other side for additional information. 1 0 - 5 Is 011
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: a
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Safety and Buildings Division
SANITARY PERMIT N 201 W. Washington Avenue
Wisconsin P O Box 7162
Department of Commerce In accord with Comm 83. o Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the on t�less`,, C&�my
than 8 1/2 x 11 inches in size. '
, le��, N1
• See reverse side for instructions for completing this ap ionr 5ta Sanitary Permit umber
Personal information you provide may be used for secondary purposes 1 eck if revision to previous application
[Privacy Law, s. 15.04 (1) (m)).
.�' a Plan Review Transaction Number
L APPLICATION INFORMATION -PLEASE PRINT ALL MATT
Property Owner Nom t �� /4 ,5 T , N, R E (Or)o
S
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
( )
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
Public 0 1 or 2 Family Dwelling - No. of bedrooms — ❑ Village Town OF t.
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers)
I
1 ❑ Apartment/ Condo 1
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. [[��{( New 2. F] Replacement 3. [] Replacement of q. E] Reconnection of 5. E] Repair of an
" stem System Tank Only Existing System Existinq 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. /i ch) 7^/ 9a?.a 8 Ele ation 9j, j5l Feet -o Feet
Capacit
VII. TANK in Ca allo Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank -- El ❑ El 1-1 1-1 ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for insta ation of the onsite sewage system shown on the attached plans.
Plumber's ame: rint Plumber's igna r : (No sta ) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Stre t, Cit State, Zip C de):
_ s _
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved nitary Permit Fee (includes Groundwater ate I ssued Issuing Agent Signature (No Stamps)
Approved E] Owner Given Initial Surcharge Fee)
Adverse Determinations va�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.12199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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- 3151.
To be complete and accurate this sanitary permit application must include:
1. Properly owner's name and mailing address. Provide the legal description and parcel tax nurriber(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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 Foss; 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 Wiscorsin 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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Wisconsin Department of ommerce ML AND STE EVALUkON
Division of Safety and Buildings Page ! of
Bureau of Integrated Services in accordance with &:09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in �l must County
include, but not limited to: vertical and horizontal reference point ( Ore'ction end ` ' st (3,t Y Co
percent slope, scale or dimensions, north arrow, and location and istce to neatestrpacl.' Parcel I.D. #
- 14 — acs o o
APPLICANT INFORMATION - Please print all infortmation. 4 Reviewed by Date
Personal information you provide may be used for secondary purposes (P&4�y Law, s. 15.04(11 3
Property Owner "motion
i Q ,� �� 1 Q / Govt. Lot ,/1/4 S E 1 /4,S T 3 ,N,R E (o W
Property Owner's Mailing Address t # Subd. Name or CS M#
City State Zip Code Phone Number
❑ City ❑Village Town Nearest Road
+ e I Wtj 5 Y0A S ( 5 ) 9 Y -38a o ?a r+ I .r,. .736" Avr. .
New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
l� �y Q
Code derived daily flow / 5 f) gpd Recommended design loading rate . / bed, gpd/ft o v trench, gpd/ft
Absorption area required _ bed, 2 At trench, ft Maximum design loading rate bed, gpd/ t gpd
L ! 1 trench, /ft
Recommended infiltration surface eleva 3,�f 5 �"r• �, �.. i�� fi, a ! ` (as referred to site plan benchmark)
Additional design /site considerations v"�`i' $ �'fii �, ��.QQ � � y ! �• — 1 M �1�♦ r`A '�"Q�' �► e t A , 4. y -
t+ r
Parent material Q. � ►�.? C4 V� Flood plain elevation, if applicable e5; 4-P f
LU: Suit able for system Conventional Mound 3, one In- Ground Pressure AT -Grade System in Fill Holding Tank
Unsuitable for system % S El U EA S ❑ U y [� S S❑ U U
SOIL DESCRIPTION REP T
Boring # Horizon Depth Dominant Color Mottles Texture Structure nsistence oundary Roots G
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
f I o -5 aw z 5 L P. �w F
Is
G 7.5 � . (�, __ t r� k3 1 r 6 '. e 6
9 Eft. 45.3 7 .5 ` S -' m L C. e,J ti3 r
Depth to 32-y - )s �P— to -S d.. M L r-7 ,
t.c3
limiting qD-50 7, 5 `t � y - L 5 ..
f a ctor
in. 7, 54 61 L 7 : i
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Remarks:►
Boring #
i 0-L, I DI R ht S t_ Qv- la M Fr 95 a F 1 S , 6
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IN
449 7.5 V Y o 1 %)F
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Ground % 40/ $ 0 4. --� ''• ► i
53 ey3ft.
Depth to
limiting
factor t .�C. { r 6
lam' in. Remarks: . 9 r.' `- � `'"` �*� �!- r� •�.v"
CST Name (Please Print) Signature Telephone No.
fit. �, -c-;� Y8 -35 f?V
Address -i Date CST Number
- a _ A 0 00 a
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At SOIL DESCRIPTION REPORT
PROPERTY OWNER r®► QR ` C , Page t of
PARCEL I.D.# D 17 _ -� D- 0 0 0
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
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Ground I'1' ?.�j K yJ = � +F6b� t tl 5 C w `? {- , . S
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Depth to
3b• - 7 .54 KS - S - M L
limiting „ 92 < )
teL ptor
Remarks: `i t + �J Ta I� t"` a, 0 tq ,a, y ..
Boring #
O)VA 6 2 hA Fe'
544 k �r '4 w 4 S ' •(o
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elev.
Depth to 08
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factor
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Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # O -5 q [0 ` rn a -5 .(V
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Depth to 9 ' y
limiting qp
factor
L ID - ' n. Remarks:
O r' f� w` �.1 L
Boring #
z
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elev.
ft.
Depth to
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' Remarks:
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ST CROIX COUNTY _ J I
SEPTIC "TANK MAINTENANCE AGREEMEN
AND
OWNERSHIP CERTIFICATION FORM 2Ra�
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State ,lrnr�, —sa1� lti` Parcel Identification Number 16/7 - ;i9 -4010,0
LE GAI, DESCRIPTION
Property Location, 5S, '/,, . ,E 'A, Sec. _�, T -R Town of
Subdivision — , Lot #.
Certified Survey Map # Volume Page #
Warranty Deed # (02 S , Volume 5� t i , Page # _�- 0
Spec house ❑ yes ;1 no Lot lines identifiable LE yes ❑ no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix 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 andlor (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 maintaimcd must he completed and returned to the St. Croix County Zoning Office within 30
days f the three ye r expiration date.
SI NNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are tntc to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pr perry described above, by virtue of a warranty deed recorded in Register of Deeds Office.
A IGATURE OF 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
VOL 1511 PAGE 220 '
STATE BAR OF WISCONSIN FORM 3 - 1998 63115
KATHLEEN H. WALSH
Document Number QUIT CLAIM DEED REGISTER OF DEEDS
ST. CROIX CO., WI
William W. Hase a and Opal H. Haase, husband and wife, quit - claims to RECEIVED FOR RECORD
Jason O. Haase and Rose M. Haase, husband and wife as survivorship 05-16 -2000 2:00 PM
marital property, the following described real estate in St. Croix County, QUIT CLAIM DEED
State of Wisconsin: EXEMPT 1 A
CERT COPY FEE:
COPY FEE:
TRANSFER FEE:
RECORDING FEE: 10.00
PAGES: 1
Record
Name and Return Address
Judith A. Remington
REMINGTON LAW OFFICES
P.O. Box 177
New Richmond, WI 54017
PIN: Part of M- 1017.70-000
This is not horneatead property.
Part of the Southeast Quarter of the Southeast Quarter (SE14 of SETA) of Section Six (6), Township Thirty -one
(31) North, Range Nineteen (19) West described as follows: Lot 1 of Certified Survey Map filed April 27, 2000, in
Volume 14 at page 3834 as Document No. 621946.
Dated this# #day of May, 2000.
I
• • WILLIAM W. HAASE
" OPAL H. HAASE
AUTHENTICATION ACKNOWLEDGMENT
Signamre(s) STATE OF WISCONSIN )
authenticated this _ day of ) ss.
ST. CROIX COUNTY )
Personally came before me this Ay of May, 20110, the
TITLE: MEMBER STATE BAR OF WISCONSIN above named William W. Haase and Opal H. Haase, husband
(If riot, and wife, to me known to be the persoa(s) who executed the
authorized by ' 706.06, Wis. Stars.) foregoing instrument and acknowledge the same.
TWS INSTRUMENT WAS DRAFTED By //
Judith A A. Remington Public, State of Wisconsin.
REMINGTON LAW OFFICES My Commission is permanent.
P.O. Box 177 (If not, state expiration date: % c): '- QUe)1 )
New Richmond, WI 54017
Telephone: (715) 746 -3422
STEPNAIIpE A. OESg11D
(Signaalres may be authenticated or ackwwledged. Both are not NobI)/ PuD8aSto of Whc mttin
-r y' )
.Names of persons signing in any capacity should be typed or printed below their signatures.
QUIT CLAM DEED STATE BAR OF WISCONSIN
FORM No. 3.1996
Inlomullon Prosessimak company Fond du Lac. Wisconsin 900{5-12021
'i�I ROt1ALD F. T� C
�,Q,W! 41�0N t
S-1 1 F'(.,
ANIPI' Y,
wlq� ' w 6 1946
l7 T
% °� o ° Wx' ERTIFIED SURVEY
MAP
Locohnd in Part of the Soulhnost Quarter of the Southou -0 Q%jnrter of Seetlon 6, Township 31 North,
Rongn 19 werl, Town of 5oilrmn01, SL Crnlx County, Wlnr.onnin.
Prepared for and at the railuesl of:
OWNER:
William Ilaase FASF 111 CORNER
324 2,5011) Avenur, 5F_C110N 6 -31 -1y S0U711r -. ';7* CORNER
Sarnersnl, WI 54026 (FOUNT) 7 " IRON 1 5fG110N 6 -J1 -19
Drafted by: r 11. Dodgn A1.1 1M. CO. MON.)
_ _ _ _ N00'34'02 "E 2579 --
f i1 S1• LINE OF' 11IF SF 114 -
L U T 1 f ��
TOTAL A RE A: �' I
a N U > i l ?oo
0 ► 1D / 164,764 SQ, FT. /3.78 ACRES
�'�;, AREA EXC. R - - I
o i3 o K1�TNLSEe o1OrfSN / / 141,529 SO. F1'./3.25 ACRES
" E -� v C SI.CroIxCo.,Wt 1/ /
a ;E PR m �� / UNPI_AT1_ED LANDS OF OWNER `vp, ��,
as i G � •- .__... " /// / •�� �•w. ar
' / / 500"34 358,49'
Ly
322.64"
N ? . / /'��, �'� 35.45'
E u U , � ; / 4 N� 5
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��' SOU 1N 114 CORNER- 04
si SE 6 -J1 -19
N (NO MONi1MENT S£T- -SEE
=� �9 »c siaEfr FA? wf IN£ ssES)
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County Section Corner Monument
A \ \ �/ j of Record
• Set 1 x 24 Iron Pipe weighing
\ I a minirnurn of 1,13 pounds per
linear foot.
\ �10 ` �\ I _ \ • • • • • •Building Setback Line
`.l��OS S ��`� \,� ` \ \ • (100' from R• -O -W)
�s � Denotes Utility Pole
1
W, 13p \ \ R_ Recorded As
JOB A00004
100 o 1 o0
Prepared by. -
A & E APPROVED GRAPHIC SCALE
LAND SURVEYING & CIVIL ENGINEERING ST. CROIX COUNTY SCALE IN FEET: 1 inch ffi 100 feet
Phone No, (715) 246 -4319 Planning Zoning and Parks Comff 6RINGS ARE REFERENCED '10 1HE EAST LINE OF THE
109.F-ost Third Street, P.O. Box 375 1/4 OF SECTION 6, TOWNSHIP 31 N., RANGE 19 W
New Richmond, WI 54017 AM 2 7 2000 WI- IICI-I IS ASSUMED '10 BEAR NOO 34'02 "E.
Sheet 1 of 2
It not recorded wimin 3u days of
approval date approval shall be
null and vold
VOLUME 14 PAGE 3934
CERTIFIED SURVEY MAP
Located In port of the Soullmost Quarter of the Southeast Quarter of Section 6, Town.rlrll> :51 North,
Range 19 West, Town of Sornereel, SL Croix County, Wisconsin.
SURVEYOR'S CERTIFICATE:
E:
I, Ronald F. Johnson, a Registered Wisconsin Land Surveyor, do hereby- certify that by
the direction of William Haase, I have surveyed, divided and mapped a parcel of land
located in part of the Southeast Quarter of the Southeast Quarter of Section 6, Township
31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin, described as
follows:
Commencing at the Southeast corner of said Section 6; thence, on an assumed bearing
along the south line of the Southeast Quarter of said Section 6, South 89 degrees 39
minutes 01 seconds West a distance of 466.27 feet; thence North 00 degrees 34 minutes
02 seconds Last a distance of 286.26 feet to the point of beginning of the parcel to be
described; thence North 66 degrees 26 minutes 12 seconds West a distance of 608.66 feet
to the centerline of Timber Road, a Town Road; thence, along said centerline, North 34
degrees 31 minutes 01 seconds East a distance of 59.30 feet; thence, continuing along last
said centerline, North 38 degrees 07 minutes 31 seconds East a distance ol'280.80 feet to
the centerline of230 Avenue, a Town Road; thence, along (lie centerline of230'
Avenue,'South 66 degrees 26 minutes 12 seconds Cast a distance of 386.74 feet; thence
South 00 degrees 34 minutes 02 seconds West a distance of 358.49 feet to the point of
beginning. Containing 164,764 square feet (3,78 acres). Subject to 230 Avenue (A
Town Road) along the most northerly line and Timber Road (A Town Road) along the
northwesterly line of (lie above described property. Also subject to all easements,
restrictions,. and covenants ofrecord.
I also certify that this map is a correct representation to scale of the exterior boundaries
surveyed and described, that I have complied with the provisions of Chapter 236.34 of
the Wisconsin State Statutes and the Subdivision Ordinance of the County of St. Croix
and the Town of Somerset in surveying and mapping the sAthe.
Ronald F. Johns --� Registered Wisconsin Land Surveyor No. 1186 bate
A & E Land Surveying & Civil Engineering
P.O. Box 325
New Richmond, W1 54017
OAF-
` VOLUME t.4 PAGE 3834
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