Loading...
HomeMy WebLinkAbout036-1085-60-000 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Coul: Croix INSPECTION REPORT t. GENERAL INFORMATION (ATTACH TO PERMIT) Sanit4jY4Q{ff No -: Pe {{rrrs��on�a��llipinffoo�rmation you provice may be used for secondary purposes [Privacy Lavv .15.04 {{ (1)(m)1. a1UIOTI, is ame: El City El Jtai1 Pfo ship State Plan ID No.: CST BM Elev.:. Insp. BM Elev.: BM Description: Lit ParceM1 0685-60-000 I L4 / / TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r L o �28) Benchmark ad, v v 0 /d'6 D _- — Aeration Bldg. Sewer 3 Hold N 1 Ht Inlet S,S� 9y y'/ TANK SETBACK INFORMATION 61 Ht Outlet y TANK TO P/ L WELL BLDG. Air I to ntake ROAD / ir Septic (do �� 3 NA D _ r- --- NA Header / Man. G, / 3 �( A i A Dist. Pipe i y 3. �L Holding% Bot. System Z yG r2 - 6Y l2. PUMP/ SIPHON INFORMATION Final Grade S 0 L Manu — - -- --- Demand O WN — Model Number'" M TDH Lift Friction Syste TDH F Forcemain Length Dia. H Dist. To SOIL ABSORPTION SYSTEM BED / T4W Width Length No. Of Trenches P No. Of Pits Inside Dia. id_ Depth DIMENSIONS + s 2 DIMEN I SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA anuacturer: SETBACK CH ER INFORMATION Type of UNIT _ um er: System: (�h. >�, 3 DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 1_5L Dia. Length 3,C Dia. _6�L Spacing 7, 3 2 8 Z Z 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/Tr nch Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc. Xnspection #1: 9 //L /o�) Inspection #2: Location: 1637 Highway 64, New Richmond, WI 54017 (NE 1/4 NW 1/4 33 T31N R17W) - 333117517 l.) Alt BM Description= ((s f) h4% /, Of / 06,dee- 'o6(P S,�Sy�� l�a5 16- '-rel S(;y44y, 2.) Bldg sewer length= 6 ( 0 r.,, k64 ex;s >< Y� S f w,`>u � �o�.wy s- - amount of cover = Plan revision required? ❑ Yes No Use other side for additional informs on. _ p SBD - 6710 (R.3/97) Da4 Inspect .gnature Cert. No. k ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - t A I I p � � @ p 3 3 g i� f , K F f . a p � � t i e � Sanitary Permit App ication Safety & Buildings Division In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. ` See reverse side for instructions for completing this application PO Box 7302 �SCOfIS Personal information you provide may b m fpr 8ceadan purposes Madison. WI 53707 -730^ Department of Commerce (privacy Law. s. 0(,,; (Submit completed form to county if r state owne< Attach complete plans (to the county copy only) r t syste on ag per t3t than 8 -1/2 x 1 I inches in size. County State Sanitary Perm' Number '(S eck i evious plj Lion State Plan 1. D. Number s're V-0 A 3 - I. Application Information - Please Print all Information Location: Property Owner Name , ' R i t�' { / ✓� , - i Property Location G t`e Ti. � 114 l I /4 &?3 T N. or Property Owner's Mailing Address A c � Z �hN� Lot Number Block Number City, State Zip Code Ph et L, ` Subdivision Name or CSM Number ���s� -UcJ Olt (7iS )5Y9 -G6D/ II Type of Building: (check one) ❑ City O 1 or 2 Family Dwelling —No. of Bedrooms: ❑ Village ❑ Public /Commercial (describe use): X Town of O State -owned S 7 ✓ v7 — ,V.,/,/ III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road Waal G ' A) 1. 1ZLNew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Num (s) System Tank Only Existing System 03 e) B) Permit Number Dete4mved ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) N.Non- ressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland P g ❑ Pressurized In- ground ❑ Holding Tank O Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dispersal/Treatment Area Information: Z 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4, Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed ✓ Rate (Gals. /day /sq. ft.) (Min. /inch) n � p �] Elevation O O 9�/ p / d tB `' / lJ • O (" 9 7 ✓ o VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersigned, assume responsibility Lnr installation of the POWTS show the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): P PRS No. Business Phone Number ! Plumber's Address (Street, City, State, Zip Code) S 7 VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) S Determination Z Z S 0 0 ?/ 3 0 0 � IX. / of Approval /Reasons for Disa Z ohtd rr ccc �//�/��ot * /0.- d � 191 Ahle V'atC'�i.`r. y 5 ✓(t ..s.rnt��t�d7" /vv a l � . ++ S. � -4 15 a /tf - eeS oK �r(S . nLus < 0( OCGyaiCG4� �y am. /y oteMiek' Or &4ri 4/k" S�Gi Hrr7 ' C ah/ y C� f '�O � / 1nt 7`4 ✓ht. o�pClla../ - �arti /v� h• Y'GSr`�tq[°� S lltdLL� CXrS � 61. Ni O/'aAr`s.gi ?,Y V gCref dWAAe r 1 y A, J6Kh6oO If9 SBD -6398 (R. 07/00) S33 7li 1N17 lYO �S 0 0 � M'sY e. sh f � * Wisconsin Department of Commerce SOIL EVALUATION REPORT Page l of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal referen I t B�ll , ion and Parcel I.D. percent slope, scale or dimensions, north arrow, an `b c t§ arest road. Q �p QQd Please print all in ion. .�.�'"' Reviewed b Date Personal information you provide maybe used for se na purpoE�w, s. 1 64�( (m)). Property Owner , t om ; ( Pro ovation %I A �0 govt. Let 1/4 1/4 S3 T S1 N R E (or) Property Owner's Mailing Address _s. ' Lot Block # Subd. Name or CSM# I 1 � 1 G _OtJ�hAG UFO 1 c, City State Zip Code Ph r E) Village 0 Town Nearest Road U 0f ( 715 - ✓� (o (� New Construction Use: Residential / Number of bedrooms 4 7" — Code derived design flow rate Gtic GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable General comments and recommendations: all - e /�co• 9Z • �d '/U S z 69' _75 ` 51 F1, - string Boring # f-1 � Is pit Ground surface elev. 9y D" ft. Depth to limiting factor Ki S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2 I 0 -1g. /0 -- SL Am qh i e vn -�' CS 1v� • q Z c — Z 3 g-A� ' 0 7 , 5"Vz 5 1 16 — , z .10 L sr Boring #I Boring 9 Ground surfaceelev. ft. Depth to limiting factor 7� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 w\ r L' cj I V-F r I p- !6 r -e _ ,�✓ 7 Va .. * Effluent #1 = BOO > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) /Signature CST Number a vn Sc mac A 'W- =- �� 2S 3 34 Address Date Evaluation Conducts Telephone Number /l a ff S7 SokvvrS -a reiro Z g - 4 - C ) C) 7/1577e ly? * oo i r. Property Owner && 4 Parcel ID # Page _� of�_ F-31 Boring # ❑ Boring [�.it Ground surface elev. 9 6 ft. Depth to limiting factor —' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I `Eff#2 o- Ia. - 5 L no ( 1 U� �✓ C S , t, z.q F—I Boring # E) 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 GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. 1:1 Prt Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ffz 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, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) r r• PAGE 3 OF NAMED4 j - c,-UZLOT# LEGAL DESCRIPTION.Af '40/,,S3 3T,3 /,N,R /7E (ori wo SCALE: 1 BM 1 ELEVATION /d0 ' BM 1 DESCRIPTION 1'IC�..` fv � � G r ��Q � BM 2 E LEVATION D ESCRIPTION hu n p c e r, t r pb ( C SYSTEM ELEVATION ALTERNATE ELEVATION j 7 . ,q/ C) CONTOUR ELEVATION A/ /r� few U � L fv � • (aq. Pte) • � Bent pr pos CA �. r y J SIGNATURE _ DATE T ST CROIX COUNTY SBPTIC TANK MAIMTBMANCR AC A SBMT AND 0WMBRSHIP CUTIFICATION FORM owmmuyor- r --�-- Ma,ltlttg Addrm Propaty Aft= lvediiatba miq bw fi= p own% t to sew conavuetioaj cRyade - ii.k ;:,, 4 , - 11 - - pswd IdaatiHaettat Ntaaba , © /6UZ.60-. acj ProperW Loudon K /-'W A, Sm T LN -R,..� Town Of. �''L.. SWxUvldon r --- .____�..�.._._..�._..�._, Lot # wumq► Deed # -, 141 Yalm pop # �!2 #poa ham CI ya P no Lot Um weeS w ya ai a� i�m�petaN�a!'�oatNpdooaddet raft lsle��mos8dl�.amsdiswMewPropec 000eteer et e�tbeseptlQlpRcfwq►�es�wts er eooe�, id'sesdatb7r �c�eeeNdp Wbst�o+ct�at �° � 4''m° aae ottt3i �eeatc�s.a eoMmeartsagA ih� �.� ' TLspropeagro�aar ow f srW SL 0* rmft s sadosd as tam, sped by dw o i m =07 � p�p�r me &mbm fsah wpw fted(I)dMembieaw- A"lbitt iek V ambSewAdom OWN MsAwb*@dfoamdp ,(jr= 0MASIL . �r ire LaNS'sad tine +bore tsdpea to mauls the pdrsla aenip dtepoe� � � tba eamds� wtdbal6,,oe setiyr Or DepegaseaRef4�a+eMraveesrdtb�e ��� faAe o!'l�eeoarts. a'lt lWym oWembmbMS dmaetbeooaepkbedealrea �o !!r t7oo�c C�omh► ZedaE Owe 3Q �" y 1 al DATS I (rns} eet�Q► dnt 4t atales�esli m tb6e !beta ante m da beet of my Ioa$ llarw � t taa (on) dw ow=K=) of to t by vmw its folffk qr deed gap M'deftf of Deeds t3�. � frAft � •.•••. AWimboaft do is W'iFerpR+rwdted t iR dLe easitaq► pamlt briap terelmad by the Zosiad " "" betw" wlib sk ammesttoou a itleM t1► deed t the or Dootte Qum" Acwat ey map il' totem= b =do in the wacmty decd W THIS IS A M DRANDUM TAX BILL:-ND NO : t;X RECEIPT ee•ii 'd s use.•ve INN • w �� O :mom ma C) �N { � a O O� c • > ° ul ca N �. ld $._ � OM � � a E ❑ ¢ a ZS .+ « IpD 9E � 1 ` - � ZZ 8 1.� mN na I tUq I �: p ; U3 a f' • < 3 r y O f Q, v J! LM ' W z O a �► : O 7 t't Ea i iL Q M++tOO�N ` ,-� V4 Off¢ � in 1 • � � E CC t . . • , A . . 13 t Q` 0` a 101 > •0 '0'0 N °z a m « « «O a M M < O m m N t tl i W 0• ZO+- +0�00I5 • m r� E� ° � - ma D CO to Z- "m K ° a � t!3 0� ... O � � a B� " '. 1� •� 0`Mct -� ++ my w a �- a n Cd V3 M tYi N N N W « t O Z' rn z LL T - 0- 0� �} K. W Z 1.. > N o Z W x UdtWit Ul O �O�t *f Q L) O OG t� c0 O 01 ti� M - O N N ++ r CO © p. m . ILL W •� C��ct—to 4 ct 4t'Q • O _" _1 O t O 5C "U3 it3M • N M N • 1 O A •� v " e-t N r. CJ 00 - 1 Win k M b U J CD '7 ta: > �1-w c <t`- o —In 0` O N E ►' 1 +-+A t!3 / On +' m M N CD r+ fr7 C7 M Q 3 , to M r ., «Q► « cif o O 43: M= i 0 3 10 0 W .; r e••� O Q a$ Q .� _ WOGO IA W MME, N a' a'o. W 0 W 4 - _ - WW W O , t O IN BE I1Qd•0'* '� N o « 4 >WYhCD 10 to 8 9 N qt "WuyM M Q. J HE391 >1 Z W Z LY.' �'.� v O W " N �' WUUO~ ZA3 -• �° 00 Z �X+r+ O PO `. 4.U3 zMO W i- OG DG i `• •� M N FH _ h_Zz WC3 UI <CO33C.F- F O " Ml_ I WP 1- -0OWM" DOCUMENT NO WA DEED TMIS SPACE RESERVED /OR RLCCRGING DATA STATE BAR OF WISCONSIN FORM 2- --1982 1023 t 621 . PAt. t£GIaTER'S OfFiCE S7. CROIX C0.,1M i ROGER V. JOF.':SON and DEBRAH JOHNSON, Rac•dfbrRe" ....2sliand irife . .. ...... .. . ..................._.. i'u .._... ........ . .. ............. ............................... .. ... JUL 2 T 1993 .._ ... .... I ... ..... .._ nXV1b . WAhhROYP . A . ND . _Ji1LI)v__ . ' at ,- 9' 1 � conveys nd r t .-.. V �k�,��fl�F, husband aiic3-- ri.�e .. ..... . . .. .. .......... ........................... ................... ............ _..... ... .......... . __•___- __.__.- I ./1. ............................................. ........................ ....... ..... ...... I .......... _.... __. RETURN TO - -. - . ...... ...... ....-... ...................... .... ... . __... ------ . -------- ........... .............. . the following described real estate in St• Croix .. -- ..County, — f State of Wisconsin: Tax Parcel No ............................... N1 /2 of NW1 /4 of Section 33- T31N -R17W, St, Croix County, Wisconsin. * * TOGETHER WITH AND SUBJECT TO an easement for ingress and egress over and across the east 66 feet of the N1 /2 of NW1 /4 of the above described section to and from State Highway 64. 4� If a road is built upon said easement, all maintenance, constructio iI and improvement costs shall be the sole expense of the Grantors. Grantors may use the existing driveway located on the above described property for access to the S1 /2 of NW1 /4 of the above described section as long as the S1 /2 of NW1 /4 is used for agricultural purposes. * *This easement reserved to Grantors across the East 66 feet of the property shall be appurtenant to and run with the land-owned by Grantors in said Sec. 33- T31N -R17W, being the S1/2 of the NW1 /4 and the N1/2 of the SWi /4. ` I This .- ...... is----•---- ----._ homestead property. • (is) (is nog) EW Exception to warranties: easements, restrictions and rights -of -way of record, if any. Dated this --- - .. ... .. ... .. .... ...... day of - -- .... - - -- 4 _ ---------- (SEAL) - � (SEAL) Roger V. rohnson Debrah Johns - - ••---- - - - - -_ --- - - - -_- - - - - -- - - - - - -- ' ---- - - - - - - _ _._ . - ---- - - - - ... .. ....... .......(SEAL) -- - . ......... .... ............. - - - -• -- -- ---- -- - - -- - - -- -(SEAL • ------------ - ---- ---- --- ------ - -- - -- AUTHENTICATION ACKNOWLEDGMENT Sicnature(s) ............................. ............................... STATE OF WISCONSIN -----------•---- •-- •----- ••--- •-- •-- •- - - -••. •- •- ••------ ------- ••- ••-- • - - - -- St. Croix -- ----- --- --- --- --- --- --- -- ------ authenticated this -------- day of ........................... 19 ...... Julfersonally came before me tie! __"- _lam_.._ -day of 19 -------- the above named 0 Roger - - r. - John - g iy -- and - De br - son ----------------------------------------- ....... ------------- -_ - - -- - - - -- - ••- • - - - -- - - - - - -- - •--- - - - - -- ••- - - - - -- ------- - - - - -- ------- • ..... .... TITLE: MEMBER STATE BAR OF WISCONSIN (If not, .................................... --------------------------------------------------------- authorised by 1 706.06, Wis. Stats.) to me known to be the person ._!i._.----- who executed the e ing ms rent and Qnowledge the same. THIS 1 STRUMENT WAS IDRA EO SV Rrstina Oglan� ' - nors �. t;to�eneg a#� F�a .... Alice J N►y Pt�� -. -. -- - - - - -- -- ------ ••- -- - - - - -- -- -- - I --- -- - --- - ----- ............................. - -•-- -- - - -- .................... Notary Public . S-- . Cr-- s t (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state exp on are not necessary.) date: -- --- - ----•- 1� C f .1 -Nacres of peril. +� mIxn ,,g Ii m anj e:p 1ty aF. :_ld he t)P• "S ., p,mt�l b- thwi e1F.nat.ar— I� S?ATIK BAR OV 7WVFCU?IS! -N Wisconsin omega! Blank Co - , Inc FOH�f Ne. '/. –.. I99l Ms;n- a• -.k8 ?. F This )ft4??u+ti tJf tf?jd i Doc. No. e Rntal U Ere; • E �l�g4, y S n-d r wrts�tt -stry. DiLHR iis� �.� acr !� a °� l-4nt of MV ` , ftations safety a & ST IMU LAT ION 0.8a f 797 h &cfton,j 53707 TYPE Pf OR NT USING 1KACX ate (MI 2WO67 alit- - stew - SUeaY Addrt;s R ecording lnftxmat onn (Leave BirF SSc) Street Addre�: Omf- County: 1 State a zip Code: at fwd NumbW of VAR 6 11`7 an A j Seller's Tett:phone Number (include area cods): of RmvW tltrdt Pr (may attach separate %• A/ _ � ! / ,� 9t �v S 33 .,^7 SeMion i01.1Y2 (4) and (6), Wis. Slats., requires that a properly nutlorl` he lr ed Certificate of Compliance, Stipulation or waiver accomparri tarster documents at tm+e of recordation. This process is further explained in chapter VIR 67.08 and 67.10, Wisconsin Administrative Code. Receipt of a CordlicaM of Coenplisnce from a currency licensed inspector is proof of conformance with ei srgy conservation standards of ILHR 57.05. In lieu of the Certificate of Compliance, ft purchaser may accept responsW; ty for future conformance with either a Stipulation or Waives. The purchaser of a residential rental building shaft present this property validated Stipulation to the %gisler of Deeds at the time the frander Is to be horded This in - ales iha budding is subject to the Rental Was&* iz~ Rubs, and that the new owner will briny a into compliance with energy standards w" OW (1) VEAA following the transfer. }.Tb The purchaser(s) show tbmpbta all en down ttrrough the Stipulation Agreerrert to include purchaser's sigoatureladdress bWk The Stipulation must tt n submitted to DI-HR in Madison or to agent for vallidalion (contact DIL.HR for location of nearest 011HR Agenq. When subadttirg for validation W r DILHR send all copies of completed form pine filing lie. Do not send castr, make check payable to DARK, and wad to: DAM Rental 3 f Weetherization Program. P.O.4ox 7971. Madison, W 53707. After validation. copes will he returned to purchaser unless anot'w party is dosigneted in wrabrg. 7M 41391IM;ige6 6ffJNfE The purchaser of a budding with 4 units or loss who intends to owner- occupy, but is unable to do so within e0 day; of the bansfm due to en tatt3 n «awe, is req „tsao to talcs out a Stouistion. MHR wiff cancel die Stipulation after confirming that owner has occupied one of the units. Whither nob'ficatlon to DB.HR of owrsr- occupancy is required. DKAR will confirm cancellation in writing. Wevic �,.a t VWM or Wo ■ t s STIPULATION AGREEMENT preyfwx « w.Isar he ewmft ease far lrtt Cry (in accordance with ILi td 67.08(3), KAR 87.13(4) and Wisconsin Statutes 101.122) ,® � t ONE (7) V A Ae bells> !w trbase des�ed redder el mAifi 6a ildba brta , ON— wRA aner�r ooewarraloa altaAtlyds et tit f�syt4ar i7 wo Ww iso De dab of a Rees Id Purchoser's s ue; 8 Zip Code: Pu s Telephone code): /C r oe s O/C /S E? '_ Y r Date validated: Expirawn Date (add one (1) y� to J ❑ oa HR Daft vaNdatedj: �] Dot agent [� for ed AfuniCipeN1Y July 27 , 199 3 Auth. or Tax Rev. it A -55 —� 0 July 2T, 1994 Print Official s Name: s fora inter �l fe? Transfer Authorization; ( Number From Stamp Here: � J ea 0 onrsell sy m me: 3 Croix eglster of Deeds S+ 4 9 2 3 0 _ _• `, - TRANSFER OF ST '• if the above described residential rental building(s) is transferred within one year of the valdation data of this Stipulation and before the resider” ranlaf baaldfng has been certified as being in compliance with ILHR 87, the new purchaser must sign below and forward a copy of ails document to DILHR By OW 91 .balm. ft new purchaser accepts the rbmp8ance responsibi ity to this Stipulation,11MAE VAIQUWAW COOS C06111101JAMM ACME 11110 1=11111MAIM DAW 411111111 LiSM VVWW r of the property adler expiration date is not valid without conformance to tha energy sheruherds, New chaser's St reet Telephone iVurntler (Mndu a uaa oorlt*. i SSD- 7115 (R. 08M) copy Distribution: VIRato--For Recordation: Yepow• -OiLHR Green -OKM PUk -B6%*) ' r wR '� rt. , • ... k.. r� • rs i Y r x ` t .t i. i � e�, _�, a •� r ,�� s r.4 a, STA PAR OF W[3(O S Y 0 K r o GlllT CLAIM DEED Mina 512 Roger V. Johnson anI Jebrah Johnson, husband and wife G , ST. CROlXc W1 ........... - -- Paced forP.:)�rd Gait cliims to Qavic�.,T. Waldroff .and Julie" A. Waldroff, _ .__. MAR 3 1994 husbalxf AC)41 W£e.,. _. _.. 10:45 C� �A�. at the following described real estate in ....... .. St... Croix ................. County, E State of Wisconsin: ALiURY TO Tax Parcel No: -. The Grantors herein relinquish all right, title and interest they have inand to use of t the existing driveway located on the N1 /2 of NWl /4 of Section 33- T31N -1117W. a This ....... is,- not ...... .. homestead property. g IM (is not) Dated this +7l.... day of - - -- -- (SEAL) L/ (SEAL) -------- _._..._- ---- -- ----- - - - -- -- -- - • .._.._ Roger V. ohnson -•- -------------- - -- .._.._ --- (SEAL) L16C4'id/t �rF?" . "�""�- ti ........ ........... Gebrah Johnson AUTHENTICATION ACKNOWLEDGMENT Signatures) -------------------- ------ --- ._ ..... STATE OF WISCONSIN �= St. Croix Sa. ...... . .......... _County. authenticated this -------- day ot ....... -ti Personally came before me this ..''�1..----..day of ---- -- ---- ------- 19% _. the above named ..... Roger -V.- .Johnson - and- Debrah- Johnson. y� _k husband and wife TITLE MEMBER STATE BAR YSF I5�QN 1 S / :'f - - ---- - - -- ------------------ - - - - -- - - -- (If not, - ?.. 1 „ri -•- /. ,I .v. is authorized by § 706.06, Wis. Stets 1 r _ ............. ._ to me known to be the person .g . - who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED SY •` "`"� -� ` � tisla.9glacid c.�w±e.5.._R.:..M.r! - - - -- - -. -- - -- Attorne at law 0 ..- ..- -. Q�sw .._ ................ . .. . . . . . .. Notary tic ..S.I_.( ! r: (Signatures may be authenticated or acknowledged. L,th 'My Commission is permanent.lIf not, state expiration are not necessary.) date: QUIT CLAIM DEED STATP n.AR OF WISCONSIN K "•se.i,airt Lae :1 n'wnlr 1'u. ine. FORM No. 3 — 1982 liiiwauk•e, R'... Sanitary Permit App ication Safety & Buildings Division In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 Vvi seonsin Personal information you provide may fb r an' purposes Madison. WI 53707 -730'' Department of commerce (Submit completed form to county if r [Privacy Law, s. 0 ( 2 state owner Attach com lete plans (to the county copy only r vsteg6on er t�R than 8 - 1/2 x 1 I inches in size. County State Sanitary Permi Number , eck i evious p ' tion State Plan 1. D. Number S I/'o �C 3 q I. Application Information - Please Print all Information Location: Property Owner Name r c _, 1 C 1 � Property Location Sr N� 6 r c� ,e 114 0 114. &3Y T3l ,N. Rj or Property Owner's Mailing Address E , Z ptatNG / Lot Number Block Number City, State Zip Code Phzine a Subdivision Name or CSM Number GJ al G I ( ; " S II Type of Building: (check one) ❑ City ❑ 1 or 2 Family Dwelling -No. of Bedrooms: ❑ Village ❑ Public/Commercial (describe use): bl.Town of ❑ State - owned - 7 - a Aj7_VrlJ III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road rS/ G A) 1. JaNew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Num (s) System Tank Onlv Existing System B) Permit Number Dateiasned ❑ A Sani= Permit was previously issued �1'i I • 11• S IV. Type of POWT System: (Check all that apply) B_Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At - grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dispersal/Treatment Area Information: Z 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application S. Percolation Rate b. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) n � p �) �� Elevation oo ✓ � 9" ✓ , 7 ✓ �- 9`/ 80 VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII Responsibility Statement I, t1:e undersigned, assume res on ibility for installation of the POWTS sho wn4p the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): P PRS No. Business Phone Number _V .2 7 Plumber's Address (Street, City, State, Zip Code) r � VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) z , �P.pproved ❑ Owner Given Initial Adverse Surcharge Fee) I Determination 4 2- Z S- �d eh— 3 O U � IX. �� Conditions )j of Approval /Reasons for Diss pr / o val: Z ohc a «� / � f eaat v %� �tr�^c C 6 K `Ft�inYf 1 ,* 0 At 71,171.p -, r //5 ✓eLiu.�nt.cC�RTit�►1// [ � Z•, 1 5 A ✓esre1e^eeS ok flf�'s 10✓✓,o<�`y pnu Ze 616,,o,_eW .6 Q or At 1 W4k4 5�6/a� "><r'�ah7Ly C 1 * , 4 / ik es �a �Gie Ta ✓n. pOCdetl�jar._. /U• ��� YGSr�egf� &OY ex.s{ 6" 4, 2Y0 •c CrGf 6wjAr T py CO'' J6"6,, 1r /9V SBD -6398 (R. 07/00) C7 r � .r: ;r I r: z i S° C4- � IV- CNQ -� to o I`^ a rte. i a w; I F. a . 4 t : . a � 3 Z! �- p ! L I y Aft d 3 h r -.Y d 4 i 0 M I + LIJ V Z N 1t •4. E '^ H t M L E • i rP , y� i r � N I r t �r r Y• N LO L il l 'rte _ -- b90/ 0E£I Z6'bZEI Ol t-1. I M l 9 - �I N9 �- ( d mss° 3� eq V� 9E 9j w . � f c 4 { L ' c \ In co CD- n� a 3 „Y 3