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Wisconsin Department of Health and Sooial Services
Plb, 067 3/70 Division of Health
M / IL/ SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY 7
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY W ;TM SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Cheek Ones
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP' ")
C. IS LOCAL PERPIIT REQUIRED FOR THIS WORK? � _ YES NO L/ ? PERMIT NUMBER
D. SEPTIC TANK CAPACITY 1 Gallons NEW INSTALLATION - REPLACEMENT ADDITION
MATERIALSa Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: /
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence � Coan:ercial Industrial Other
Specify
Number of Persons to be Accommodated .-) -- Number of Bedrooms _`)
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatio Potato Peeler YES % NO
Other (Specify)
G. MASTER PLUMBER MAKING, INSTALLATION
Name: !i %7 -s:'! r't �/� Addressa License Numbers
r
Signature of Applicant: I r �'. ,. - -� -� MP 3
Address: --
g, (T be C pleted by Issuing Agent) y�
Date of Application 1 7 0 Fee Paid
Permit Issued (date �1 ✓2 n D Permit Number vP IPI_
Agent (Name) Fors)
Town, V111age, City, ounty, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.00 for each cup. 'ia Lanz and the third copy
of the permit (canar)) to the Division of Health. Checks an.. money orders should be made payable ts.
the Division of Health.
Do not write in space below — FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) (gee Cor,L9s.)
FEE RECEIVED VALID. No. d � � C7 n PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
sarcic TANK raarsrr No.
R Y P 0 R T O N S O I L P L R C 0 L A T I 0 N T E S T
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLUMBING SECTION
P.O.Box 309, Madison, xis. 53701
Pursuant to H 62.20, xis. Administrative Code
P E R C O L A T I O N T T S T
Test Depth _... Ckiaraoter of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second so Next to Last To Fall
1st Netted Overnight in Minutes Last Period Last Period Period On& Inch
Example
P • 0 36" Top Soil 10" Cla 26" 25 Ye or No 30 1 7 2 1 2 1 2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below Pro osed Abso tion S stem
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inohes Observed Estimated Observedl Estimated Character of Soil with Thickness in Inches
Example
B - 0 72" 72" Black Top Soil 12 C&M jL6 Sand 18 Gravel 24"
? ?. e ll " tj �� Vic•° ,�� �<r
�Z ° r5 � - ` .l C)
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCYt
RESIDENCES Number of Bedrooms OTHER (Specify) Number of Persons
FOO WASTE GRINDERS You Nu Y Dishwashers Yes No �� Automatic Clothes Washert Yes No �
E FFLUENT DISPOSAL SYSTEM: NEW Y EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feeh� Trench Width Depth __� Number of Linea
Seepage Beds Length Width Depth Tile Size No. Linea
Seepage Pits Inside Diameter _ Liquid Depth I
I the undersigned, hereby oertify that the percolation tests reported nn this form were made by me or under my super-
vision in accord with the prccecures and method specified in Chapter H 02.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME _ ( Y i i - . 7 � : — e � . L^ ` ! TITLE
(Typo o r Print) J
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE '7- 4 � C= ;� T; SIGNATURE
"UNMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715- 962 -3121
800 - 962 - 5227
FAX- 715 - 962 -4030
ST. CROIX COUNTY GOVERNMENT REPORT NO.*. 45330/01 PAGE 1
CENTER REPORT DATE. 7 /23/93
1101 CARMICHAEL ROAD DATE RECEIVED*. 7/20/93
HUDSON, WI 54016
ATTN*. THOMAS C. NELSON
OWNER*. Kevin Amys
LOCATION*. 1148 Co. Hwy, H, New Richmond
COLLECTOR*. Jim Thomson
DATE COLLECTED: 7 -19 -93
TIME COLLECTEPf 1:00pm
SOURCE OF SAMPLE: Outside tap
DATE ANALYZED*.7 -20-93
TIME ANALYZED*.2*.00pm
COLIFORM,MFCC*. 0 /100 ml
INTERPRETATION*. Bacteriologically SAFE
NITRATE -N*. { 1 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria /100 ml
Nitrate - Nitrogen: mg /L
12
�L�ryE� tJ
Bpi Si cgol^
COUNTY
LAB TECHNICIAN*. Pam Gane C11NC3Q�FiCE
OF. \NOEVENAEHr 1
�' to WI Approved Lab No. 19
V y
y`' < Means "LESS THAN" detectable Level Approved bye
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
.w
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
� 911 FOURTH STREET •HUDSON, WI 54016
- (715) 386 -4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $1 ❑ Septic 25.00
❑ Water (Nitrate & Bacteria) 35.00 (Visual inspection
Owner: WI 4/WM � Re ested by: i ll
Address • - �Cti ,�`ess
City & State: ma>• , City & St. ,
Zip Code: Zip Code:
Telephone N°: ejZi) 2-!hL 3g3s' Telephone N°: ( )/
Property address (Fire N & Street)
Location: , ;, Sec. , T '? N, R W, Town of
St. Croix Co. , WI. Tax A - -` Parcel ID N
House 4o o r:� Realty i Lock Box Combo:
water sample tap location: tv
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM*
Is the dwelling currently occupied? ,-Yes ❑ No
If vacant, date last occupied:
Septic system installed by: Year:
Septic tank last serviced b : 9 n" Date:
Previous Owner's Name(s): r
Have any of the following been observed? 12 1
❑Y ;N Slow drainage from house.
❑Y1 Sewage Back - up into dwelling.
❑Y ON Sewage discharge to ground surface
road ditch or body of water.
❑Y N Slow drainage from the dwelling. cm
❑Y KN Foul odors.
Other comments relative to system operation:
r
I certify that the above information is complete and true to the
best of my knowledge. d
OWNERS SIGNATURE: DATE: L
"Qs�n
D a r
I
1
y ;
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
t
I N
TO BE COMPLETED BY INSPECTION 4CEN
System design & /or permit on file? ❑Yes RNd
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system Welow grd ❑At -Grd OMound
Approx. size 'X ❑Gravity ODose OPressurized
Ft . 2 OBed OTrench [Dry 'Well
❑Holding Tank 00utfall pipe
OBSERVED DEFICIENCIES 00ther OUnknown
Septic tank
m Setbacks: ❑House 17 ❑Well ❑Prop. line 00ther
Dose tank
Setbacks: OHouse �OWe11A0Prbp. l'ne 00ther
❑Locking cover OWarni g label - J' � OPump /Floats "
OAlarm�- OElec. wiring Y�
Soil Absorption System
o Setbacks: PHouse OWel1 OProp. line 00ther
OPonding: ❑Discharge: Or AI
General comments: S a7
d LZ
ayt
5 acne
p INSPECTORS SKETCH OF LOCA3I
N
A
3 a z 5 Inspector
Title
ryl�
i
ST. CROIX COUNTY
r WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
�
11 Carmichael Road Hudson
- 01 � W
, I 5401
- - (715) 386 -4680
July 21, 1993
Kevin Amys
1148 Co. Hwy. H
New Richmond, WI 54017
Dear Mr. Amys:
An inspection of the septic system serving your home located at the
above address, was conducted on July 19, 1993. At the same time a
water sample was obtained in order to test for the presence of
Coliform bacteria and Nitrate contamination. This inspection was
based upon a surface inspection of said system and did not involve
any excavating or chemical analysis. Accordingly, there may be
hidden defects in the system not discoverable by this inspection.
Our records do not date back to the time this system was installed,
so it is impossible to determine exactly what the system consists
of or how many square feet of drainage area there may be. At the
time of the inspection, the septic system appeared to. be
functioning, but not at full capacity. It was noted that sewage
effluent was ponded within the drywell indicating that the system
may be approaching failure. Given these factors it is very
difficult to estimate the useful life remaining in the system and
I cannot guarantee or warrant that this system will continue to
function properly in the future. I cannot predict how long this
system will continue to accept sewage effluent nor how soon the
system will fail completely. In an effort to prolong the system's
life as long as possible, I recommend that steps be taken to
minimize the wastewater flow from the house which enters the
system. For example, repair any leaking water fixtures and /or
replace them with water conserving fixtures, reduce time spent in
the shower, wash clothes and dishes only when there is a full load,
use a washing machine with a suds saver feature, etc. I would also
recommend that you have the septic tank pumped at a minimum of once
every three years.
Based on page 3 of the S.C.S. Soil Survey Manual of St. Croix Co.,
the size and topography of the property, and field findings of soil
conditions in the immediate area, it appears that when the septic
system is replaced a holding tank will be necessary.
It was also noted that there may be deficiencies in sytem setbacks
as required by current code. This constitutes a violation of WI.
Administrative Code s.ILHR 83.10(1) relates to a deficient setback
requirement. Dimensional standards such as setbacks, septic tank
capacity, drainfield size, etc., are "grandfathered ". So long as
the system is functioning properly, which means that it is
disposing the sewage effluent as well as treating it, we will not
condemn the system.
Should have any questions or concerns that I can clarify for you,
please feel free to contact me at this office between the hours of
8:00 am.- 5:00 pm., Monday - Friday.
Since ely,
mes K. Thompson
Assistant Zoning Administrator
cc: Earl Rose
file
r
Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 420652 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)]. 7 of 3 = Trv-46. IP
Permit Holder's Name: City Village X Township Parcel Tax No:
Am s, Kevin I Star Prairie Township 038 - 1016 -70 -000
CST BM Elev: Insp. BM Elev: Descri tion:
BM
TANK INFORMATION V ELEVATION DAT
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
!Ho:lding S t
C't'T 3� 3a • 10
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aer Dist. Pipe
olding 30 •(. /L �Spf I a Bot. System
z
„O oo, 0, W. t�•qd. V4, 4*,,k Final Grade
PUMP/ PHi.,..N O MA ION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain Lengt Dia. I Dist. to well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No Of Trenches PIT DIME NS No. Of Pits Inside Dia. ep
DIMENSIONS
SETBACK SYSTEM TO BLDG IWELL LAKE /STREAM LEACH anufacturer:
INFORMATION Type Of Syste CH OR
UNIT Model Num
DISTRIBUTION SYSTEM ou-
Header /Manifold Distribution x Hole e x Hole Spaci Vent to Air Intake
s
Len Dia Length Dia Spacing
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 M No ng Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection # [ 24 Inspection #2:
Location: 1148 Cty Rd H Star Prairie, WI 54026 (Government Lot 5 3 T31N R18W) NA Lot Parcel No: 03.31.18.52
1.) Alt BM Description = &/A .
2.) Bldg sewer length = 1 31
- amount of cover = I 91 t .
Plan revision Required? L Yes X No r
Use other side for additional information. 'L _
SBD -6710 (R.3/97) Date ; �Insepcto s Sig ure Cert. No.
Safety and Buildings Division County
t
` 111F 201 W. Washington Ave., P.O. Box 7082 ���}�
�sconsin Madison, WI 53707 — 7082 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 261 -6546 U &
Sanitary Permit Armlication State Plan I.D. Numbe /
In accord with Comm 83.2 1, Wis. Adm. Code, pets nal in tis'yi ottlidD �f1 /�S• �• b 27 01 3
maybe used for secondary purposes Priv Law, sl5.04(1)(m) Project Address (if different than mailing address)
I. Application Information — Please Print All Informati in JAN 1 6 2003 • p q cv�y, Ry
Pro Sl . CROIX COUNTY'
Owner's Name Parcel # Lot # Block #
Z
ZOMNG OFFICE
Property Owner's Mailing Address Pro ation
7 yam"
� 4 , L o f S'
., ' /�, Sec
City, State Zip Code Phone Number
rrcle
II. T pe of Building (check all that apply) „ r 5 11 T N; 12 E C40117 �c✓. 17
1 or 2 Family Dwelling - Number of Bedrooms -3 Subdivision Name CVO CSM Number
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use ❑City ❑Villao VWship of
r
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
❑ New System acement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that appl
❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of unable soil El Mound < 24 in. of suitable soil El At-Grade El Single Pass Sand Filter ❑
Constructed Wetland El Pressurized In- Ground ding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank -
Aerobic Treatment Unit r/
� � v
Dosing Chamber I I f
VII. Responsibility Statement - I, the undersigned, u sponsibility for installation of the POWTS shown on the attached plans.
Plumbe N ame (Print) Plumber's S' t MP/MPRS Number Business Phone Number /
Plumber's Address (Street, City, S te, Zi
VII oun /De artment Use Onl
Approved El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued -suing ent Signature mps)
Surcharge Fee) UD
El Owner Given Reason for Denial Ul7 Q C
IX. Conditions f Appro vaVR�for Disapproval �
3.G�t
Ar L5
Att ch complete plans (to the County only) or thAyst66 vA 1#pey not less than 81 x Ii inches in s'
— Y' O 14 - VNz
SBD -6398 (R. 08/02)
HOLDING TANK SERVICING CONTRACT
Contract Date
/ •-- 2 -03 This contract is made between the
Holding Tank Owner(s) Name(s) and Pumper's Nam
I �
�v, n Av —,--4
We ackno A d gene i stall ion of (a) holding tank(s) on the following prop rty: (Provide legal descriptions:)
1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the
pumping agreement requ:.eu in Comm 83.52(1)(c)1. Wis. Adm. Code and the approved Holding Tank
Component Manual. This agreement will also be filed with the St. Croix County Zoning Department.
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper
to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner
agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the
pumping equipment. The owner further agrees to pay the purnper for all charges incurred in servicing the
holding tank(s) as mutually agreed upon by the owfier and pumper.
3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to
the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further
agrees to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volume in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a
change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a
new service contract with local governmental unit and the County named above within ten (10) business
days from the date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on this date:
we_ V/ e 0 oZ o o3
' Today's Date
Pumper's Name (Print) Pumper's Signature ary Public Signature
Pumpees Registration Number y ° o
O y ti
r
f ?: a . • ry
�/ i 1
0
r
d
Safety and Buildings
\ * _1 10541N RANCH ROAD
HAYWARD WI 54843
�� TDD #: (608) 77
www.commerce.state.wi.us/sb
www.wisconsin.gov
Department of Commerce
James Doyle, Governor
Corry L. Nettles, Secretary
January 14, 2003
CUST ID No.226900 ATTN: POWTS Inspector
SHAUN R BIRD ZONING OFFICE
BIRD PLUMBING, INC ST CROIX COUNTY SPIA
1008 192 ND AVE 1101 CARMICHAEL RD
NEW RICHMOND WI 54017 HUDSON WI 54016
CONDITIONAL APPROVAL `
PLAN APPROVAL EXPIRES: 01/14/2005 Identification Numbers
Transaction ID No. 827013
SITE: Site ID No. 654848
Kevin Amys Please refer to both identification numbers,
11 Cm_ _. H------ above, in all correspondence with the agency.
Town of Star Prairie
St Croix County Government t(s) 1, S3, 31N, R1W
FOR: Replacement holding tank, 3 be sidence
Object Type: POWT System Regulated Object ID No.: 887811
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes : 01:
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. -----
E Ct >R
The following conditions shall be met during construction or installation and prior to occupancy or use:
General Approval Conditions
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Holding Tank Component Manual, SBD- 10571 -P (R.6/99)"
• In the event this holding tank malfunctions so as to create a health hazard, the property owner must follow the
contingency plan as described in the approved plans. In addition, the owner must insure that the operation,
maintenance and monitoring duties as described the Holding Tank Component Manual are complied with. A
copy o is m ormation must be given to the+owner upon completion of e probe
Review Notes
• Manhole c over or service port to be no more than 25' fro service r oad or drive p er Holding Tank Manual,
Table 1.
Reminders
• A meter shall be installed by a properly licensed plumber on the waters stem that adequately measures the
amount of water used by the structure, excluding hose bibs and wall hydrants, which o not isc arge into e
sanitary system.
• Anchor tank as necessary to negate buoyant forces per COMM 83.43(8)(8).
• Materials shall conform to the requirements of COMM 84.
4P • Abandon failing system per CO 83.33. —
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.
SHAUN R BIRD Page 2 1/14/03
4
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.
• Note: County regulations concerning the prohibition of holding tanks may vary. Check with the local permit
issuing agency.
• Note: The servicing of POWTS holding and treatment components, including septic tanks and holding tanks, is
required to be performed by licensed pumpers under chs. NR 113 and NR 114.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the
installation, operati r main nance of the POWTS.
Sincer Fee Required $ 60.00
Fee Received $ 60.00
Balance Due $ 0.00
Patricia L Shandorf
POWTS Plan Reviewer, grated Services WISMART code: 7633
(715) 634 -7810, Fax: (715) 634-5150, M -F 7:45 am - 4:30 pm
pshandorf@commerce.state.wi.us
cc: Leroy G Jansky , Wastewater Specialist, (715) 726 -2544
Cover Page
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017
715 - 246 -4516
Date: 1/6/03
Owner: Kevin Amys
Location: Cty Rd H
System type: Holding Tank
Manuals Used: Holding Tank Manual version 1.0
10( co
iNG5
Page#
1. Cover Page ESPONDEN
2. Holding Tank Plot Plan 92--7o/-
3. Mound Cross Section
4 -6. Maintance and Contigency plan
7 -8. Soil test
Signature
License num 226900
1/6/03
I
PLOT PLAN
PROJECT Kevin Amvs ADDRESS 7540 Doualas Ave Racine Wi 53402
1/4 1 /4 S 3 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 1/6/03 BEDROOM 3
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK )00(
MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 3000 gallon LOAD RATE ABSORPTION AREA # of chambers
BENCHMARK V.R.P. N/A ASSUME ELEVATION 100 Filter 7ab �
❑ BOREHOLE O WELL *H. R. P. SW corner of property c:- j\'
SYSTEM ELEVATION none
Cedar Lake
cale = lit = 20'
00 Tank will not need
A
to be anchored
o according to soil
m test and is >10'
above lake level
r
5
CD
Property Line
Slope
Driveway is to act
Well as a service road ✓ Z S�r HT
0
Tank is to be properly
bedded and provided with
lockdown cover with
approved warning label
Existing 3
Bedroom
House
Old system is to be
umped and buried ,,-
3 Huffcutt HT
ul
B -1
D Cty Rd H
HOLDING TANK CROSS - SECTION
APO °ved Weather Proof
Cap Junction Box
Approved Locking Manhole Cover
4" C.i. With Warning Label Attached
Vent Pipe
Minims 12"
L �Finai Grade 4" Minim
( Approved Joint
r 18" Minimum
Water Tight
Seal High
SPECIFICATIONS Aiam Siiric .�1`"
TANK New Exi ti Approved Joir
_ Manu , at_
turer: w/ C.I. Pipe
Mind -C.I. Tank Size: lions � �.� Extending 3"
Plug � Onto Solid So
ALARM Manufacturer: S L
Model Number:
Switch Type :
NUMBER OF BEDROOMS
GALLONS PER DAY 6
3" of Bedding Under Tank j
i
i
Owner's Name •
Address: j- 0 7- -
Legal D sc p i on
owns h ip/Munic pal, ty:
County: <' ZZ
PLUMBER/DESIGNER
Signature:
License Number: 6 y
Date:
Maintenance and Contingency Plan
for a Holding Tank System
Maintanance:
1. Tank is to be pumped when alarm sounds off. Never turn alarm to silent. Upon sound
of alarm, limit usage until pumper arrives.
2. Owner agrees to use conservative water usage practices, i.e. water saving fixtures.
3. Owne will install a water meter for internal water usage use only.
4. In time owner will be able to monitor water usage and should be able to follow a routine
pumping schedule.
5. Tank is to be inspected at the time of each pumping for cracks or leaks in the tank.
6. Owner will save this plan.
Contingency:
1. If tank fails, replace tank. If alarm fails, replace alarm. All other components should be
replaced if necessary.
Phone Numbers:
Plumber: Shaun Bird 715 - 246 -4516
Pumper: Tom Mondor 715- 246 -5148
Zoning: St. Croix County Zoning 715 - 386 -4680
Shaun Bird #226900
1/06/03
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa ge -Of
FILE INFORMATION SYSTM SPECIFICATIONS
owner Capacity 7or or 0 ❑ NA
PeRnit "—�� ank Manufa ftM ❑ NA
DESIGN PARAMEtERS 6 went Filter Matwfeckmr NA
Number of Bedrooms O NA EffluentFftrModel
Number of Commerce Units Pump Tank Capacity ai NA
Estimated flow (awl) Pump Tank Manufactuw
Design flow (per. (Estlmat8d x 1 - 5) w C1 Pump Manufact
Sol Application Rate 1 au Pump Mods POW
InfluerNEf cent Cluaft ► • Prat Utz
Fats, ON & Grease (FOG) sac mig/L 0 Sandntgvol FEW ❑ Peat FNer
D Medutnical Aeration O Wetland
M Oxygen Demand (BWj 5220 mg/L p Disinfection ❑ Other.
Total Suspended Solids (TSS) 5150 Manufacturer
Pretreated Effluent OtOR Dispersal Cell(
Bbdm*; d Oxygen Demand (BOD 530 mg& 13 InVound (gravity) 17 In-ground (pressurized)
Total Suspended Solids (fSS) 530 mg/L 0 At -grade
Fecal Codform (geometric mean} 510' cfU/ 100mi t7
[ Maxlrrwm Effluent Particle Size K inch ditameter vmws typical for "Wstie t
•• V typical for P wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
At least once every "M months 13 year(s) (Maximum 3 yrs.)
inspect condition of tank(s)
Pump out contents of tank(s)
At least once every !7 months 17 year (s) (Maximum 3 yrs.)
At feast once every G months . 0 yeiar(s)
inspect pump. pump controls & alarm
At least once every 13 months s) It NA
At least once every O months ❑ year(s)
Other. At feast once every ❑ months O years) A
other: At least once every O months O year(s) ❑ NA
MAINTENANCE INSTRUCT l cab shad be made by a n bdiivkkad drying one of the following menses or
inspections of tal" and
dispersal Plumber Restricted Sennrer; POVYTS Inspector. POWTS Maintainer. Septage
cettficaitiOms: Masher Plumber: must include a visual Inspection of the tanks) to identify any missing or broken
g Operator. Tank inspections ar>d scum check for any back up
fit
hardware. maid aril cracks or leaks. measure the volume of combined sludge d check the effluent levels
of effluent on the ground surface• The dispersal ced(s) shad be vi of effluent on the
or and to check for any pig of effluent on the ground
surface• The poniduig
in the observation e a ooridition and requires the immediate
notification of the local regulatory au�ty-
9 surface may Indicate or more of the tank volume. the
When the combined accumulation of sludge and scum in any tank equals one rd ( of in accordance with ch. NR dsposed
entire contents of the tank shad be removed by a Septage Servicing Opera and
113. Wisconsin Administrative Code. rued POWTS components. pretreattment components: and any
The se rvk*ng of effluent filters. mechanical or a certified POWTS Maintainer.
OVw mahhtenaru� or monitoring at intervals of 12 months or less shad be pexfomned by event.
A s shall be, provided to the local regulatory authority within 10 days of c ompletion of any service
START UP AND OPERATION Pet pro ducts or other
ne
For w c0nSt action. PiW to use of the POWTS check treatment tanks) P con cen trations are
chemicals that may im a the treatment process and/or damage the dispersal( )- to use.
detected have the contents of the tank(s) removed by a septage servicing operator prior
• I
System start up shalt not occur when sod'conditions are frozen at the infitt ative surface. Page of
Dur9 power Wages pump tanks may 01 above normal highwater levels. When power is restored the exces
wastewater will be discharged to the dispersal ceff(s) in one large dose. overloading the cell(s) and may rest in the
backup or surface disci arge of al"a To avoid this situation have the contents of the pump tank removed by a
Septage Servicing Operator pdorW restoring power to the effluent pump or contact a Pkwdm r or POWTS Maintainer to
j assist In manually operating the pump controls to restore normal levels within the pump tank
Do not drive or park vehicles over tanks NW dispersal cells. Do not drive or park over. or otherwise disturb or compact,
the area w d n 35 feet down slope of any mound or at -grade sob absorption area
Reduction or•affinination of the following fnxn the wastewater stream may improve the pekoe and prolong the life
the POWs a irabY w$ :ate butts: condoms; cotton swabs; degwsers; dental fioss; ;
disidectantw fat; faaida m drain (sutrtp pump) water; fruit and vMetd e p herbicides: meat
scraps: medirallow, of 00ft p p sanitary napkins; tampow water sourer brine.
ABANDONOMENT
When the POWTS falls and/or Is permanently taken Ott of service the following steps shall 1p taken to krstxe that the
system Is properly and safely abandoned In compliance with ch. Comm 83.33, Wisconsin Administrative Code:
• All piping to tar ft and pits shall be disconnected and the abandoned pipe openings sealed,
• The contents of all tanks and pits shat be reproved and properly disposed of by a Sepfsge Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed arrd the void space
filed with sob. gravel or another Inert sold material.
CONTINGENCY PLAN
if the POWTS fats and cannot be repaired the following measures have been, or must be taken. to provide a code
compliant replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a mph sal
absorption system. The replacement area should be protected from disturbance and compaction and should not
be infringed upon by required setbacks from existing and proposed structure. lot lines and wets. Failure to
protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable
replacement area. Replacement systems must comply with the rules in effect at that tine.
A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be Installed as a last resort to replace the fated POWTS.
❑ 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 to locate a suitable replacement area. if no replacement area is available a -
holling tank may be instated as a last resort to replace the fated POWTS.
❑ Mound and at -grade sot absorption systems may be reconstructed in place follow" removal of the bomat at
the infttrative surface. Reconstructions 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 THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name 4 5 Name ! ,- --.-
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPET LOCAL REGULATORY AUTHORITY
Name / ._ ) /Y1 Agency ; 1� .
Phone - J
Phone _ b - ( , j 8
Thus dowmern was maned by tine stars a the green 1,810. Marquol hara Count► Z mho sm*atjw sgertdes. 1bb document meets
the m&drman miukerroift or dL Comm 8322MX1Xd)d.(f) and 83.54( (2) & p). Wisconsin Mrrdnis<raHae code. Use of this dmirne t does rat
guarantee the performance of the POWrS. GMW (fit)
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of
Division of Safety and Buildings ,odd ASS //y� , � A/
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must minty 6 "l D )
include, but not limited to: vertical and horizontal reference point (BM), direction and Prcel LD. 3 3
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Q
Please print all information. eview by Date
Personal information you provide may be usc J for se cy w . 15.04 (1) (m)). 3
Property Owner 1 - arty Location
/r
h y✓► ovt. Lot k 1/4 ��C1/4 s3 T ` N R /� E (or)
Property Owner's Mailing Address o Block # I Subd. Name or CSM#
City Sthfe Zip Cod ❑ City ❑ viII a 5ITown Nearest Road
BFI E
❑ New Construction Use: 24 Residential / Number of bedrooms Code derived design flow rate � GPD
(d Replacement / [I P or commercial - Describe:
Parent material 'i -t /rt 7 erra ceS Flood Plain elevation if applicable Ct ft.
General comments
and recommendations:
a Boring # ❑ Boring
pit Ground surface elev. ft. Depth to limiting factor O _ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
2 2 7. 5' l'z ` , 0 : E) eK A ✓l ct vim <v
F] Boring # [] Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Ef1#1 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mgA- ' Effluent #2 = BOD < 30 mg/- and TSS < 30 mg/L
CST Name (PleW Print L Signal CST
La tj 7 2SLf �57
Address n/ Date Evaluation Conducted Telephone Number
/ � GG vyror7� zt.� IeI7
Property Owner Parcel ID # Page of
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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 - Eff#2
F Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 •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 GPD/fF
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 - Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA- ` 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.
s6D -8330 (RAM)
a �, ✓► � �'���.r �rQiri
We e17
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QUIT CLAIM DEED
REGIS' E CrrICc
KEVIN AMY$. Wa KEVIN JAMES AMYS d JENNIFER AIM is bmby Wk 8'T. Wd *w eccr WI
an
&,a to KEVIN AMYS at JENNIIBR AMP tntrtee(@) at .n omw bud*$ r t�ttlt: 4 lbr Rccrd 1
mmoo(a) of the NEVIN AMPS REVOCABLE L.1VM TRUST dated FAmmy 21, MAR 9 1994
19%, ma folWwing dauibed rat soft io St. Crci: C=Wy, Stag at �iaccsis: 8 :30 A
` S
Tas pato@1 Nw
a
pad of oavanment Lot 6 5 0 . Secdm 3- 31 -18, damlW a & Wwa: C7oamenciaj at Joll laa W lion of aid Owaimat L.at "
• 3f' Bat 723 feet; dws
wilt W line of aid Oovemn at Lot 'S' 196.9 fat to N line of aid Cloudy Highway `H'; those@ Nw* 66. 33' Wet 100 feet b 3
the plan@ of batmiol.
All that hmd lyms betwroaa NEly live above dam pacd asd Sly abvadiye �Ldmbd"w"qm the Wly and Ely Use of
&an parcel a *m&d Nly to aid Sly abore`line dri&iar Labe.
no / S bomeatad property.
Dated this 28th day of FAhrn.ry, 1944.
AMPS
S
AGKNOWiFAGENOW
STATE OF 10MCMA )
4
pmaomlly coma burs ma dds 286 day of Fdwomy. 19% do above iemed KEVIN AMYS and JEN NWER AMYS to m
bows b be do panooa vim eri@ obd the forepom= meet and admawledpd the asma.
a
AOttALDILOT�EM nomad M. Odeo. Notary PWdw i
ttOTAR'f PUgtlGti80tE90TA � Cry. M➢ooeaob
HE�NEPN OOtJNT� camoiaaiaa spire October 29, 1991
GI CantrJslloe 601'M OR Y7 �
IW* ieahmoert was dn&d by
CMm A. Cowls. ATrOINEY -AT LAW
1324 W. Cld wad Avmte. Boa Cbwo. Vruw oin 54701
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>aMar 793 201 65 e3.8 PRAI'RI
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Nelson 39.4 l wvw w tz .� Meeds • t a k e C_uru . Bruce Alfred 375 M
Ridupl • . 7n &Cary Sbrc a • 64.4 & Mary & Alice
a
239.2 N e "h Part & e. lviv a IR Norman 80 cook z: Gaudy Larson Rtt 6M e n
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9 • 4o CC a • 4 •...n Nemeth 76.99 n.4 0.. w 77.4 • • 115.9 Farm
• +D Elk 46 &Joyce tcevk. a
• $ell 1eaa. 19. Wol 40 JAI) 108 m tlaow tl a •Scott 80 ! Harlan Marjor & 78 George & Inc ;
1 a°°tl • °o� a1z4 108 35 t2s Counter VehIS Dlmedel . Birkholz 155.9 `
m7 140.5 Brian & '.• Tnct 1a9 3 ida W&c Bemard 4
Monica Tracts 9. n •• M1s &S_ Rabat L.ob 53.6 Wallrich C Keith
w Patric, Joseph =; Mart & Patsy s.tsed old h a - Estates hk • Greenwood 7i1ov as
Gayle Du ggan Jbr1B Clarence &Price wto 40 Ian•e1 63 4o R toea�".aered 139.9 75A Ent etal 40 -
•C•aY1ue 133 Soden &Leona 100 Rivard �„ Las 20 60 David Rix asu .,Hired 1002 '�� • AIKe �•e+7 t3ankl
i N.7 i 4o Neumann H6M • Rw RM --tom � gp ryp! Sol, - T� . & g 50s
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i 90 71.4 Rivsrd Y I V • Cyntl . Folie T & ��. 4 3 16 Ruth 127.1 t T� 78.6 tt °' m 9 Steven 59 .4
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,
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2 53 Tlau •
u Wk159 WD6 PY` N.4 C 5
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Inc Gerald &
90 185.5 m k T BaCkeSTr • 335 K 9 Crlsty Francois • 1 po�t4',..... 633 •
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rate ° ]2.4 ;; Mym m • $0 y� � r Houle 7lS <
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800 Sez PACE 60 900 + CA 1000 110 " K
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- KATHLEEN H. MALSH
REGISTER OF DEEDS
ST. CROIX CO., NI
RECEIVED FOR RECORD
Document Number Document Title 01/16/2083 88:25AN
St. Croix County EXEMPT #
Holding Tank Agreement TRANS F EE: 13.00
COPY FEE:
tate Plan Transaction Number -1' D /:3—I CERT COPY FEE: PAGES: 2
Name — (Owner) lyped or printed
being duly sworn , states, under oath, that:
1. He /she is the owner /part owner of the follo arcel of ��;d, 1 cated in St.
Croix Coun Wisconsin, recurded in Volume Page = �Do , �ameiit -
Numb St. Croix County Register of Deeds Office: ee?�,,, rn, I
ti
A parcel of land locat d in the 4of a %, of Section
7 N -R W, Town of ,rc e 111- -� , St. Croix
County, Wisconsin, being duly described as follows (include lot no. and
subdivision/CSM or detailed legal description): ,5ee ,f/
Agreement Date: - 0a 3 I</ �ic (,[ Q P arcel Identification Number (PIN)
We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of
the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property
cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. Comm 83,
Wis. Adm. Code, or Ch. 145, Wis. Stats.
As an inducement to the county to issue a sanitary permit for the abode- described property, we agree to do the following:
1 . Owner agrees to conform to all applicable requirements of Ch. Comm 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have
the holding tank properly serviced in response to orders Issued by the governmental unit or the Department of Commerce to prevent or abate
a human health hazard as described in s. 254.59, Stats., the governmental unit (Town) may enter upon the property and service the tank or
cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current
services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats.
2. The owner agrees, pursuant to s. Comm 83.54 (2), and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure.
The water meter shall be Installed by a plumber authorized by the Department of Commerce to make such installations, with said installation
complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase,
installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter
the above - described property on a regular basis to read and /or Inspect tho water meter.
3. Owner agrees to pay all charges and costs Incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise
servicing and maintaining the holding tank In such a manner as to prevent or abate any human health hazard caused by the holding tank.
The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In
the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed
on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law.
4. The owner, agrees to contract with a person who Is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to
file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a
copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract.
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual
basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the
condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems
certifies that the property Is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm
83, Wis. Adm. Code. In addition, this agreement may ba cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement
to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the
agreement to be determined by reference to the property ;roheriB the holding tank is installed.
Owners} Name s) - Please Print _ Subscribed and sworn to before me on this date:
G Y l 1 ` I •�e e�ry6' .
No rized Owner' ignature(s) N ry Public .° gp� q ` ',�
C^� C N 0 t� �,, U�1 . y
A
a
Governmental Unit Official Name, Title - Please wt My Co fission Expires
7 6 �V /// A/ 0 -? ;" _-�- . -
Govemmen nit Official Signature Drafted b
f
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,midt QUIT CLAIM DEED U 2 1 1 1 P 6 i 0
REG1SIEWS C - *iC- 3
KEVIN AMYS, AW& KEVIN JAMBS AMPS ad JBNNIFBR AMPS do imreby quit ST. CROiX CO., WI
c1r:m to KEVIN AMYS or JENNIFER AMYS, trudes(s) or mroomw tnrtee(a) m Reed 1br Peterd
trades(`) of do KEVIN AMYS RBvoCABLE uvm TRusT dated Fwkwy 28, MAR 8 1994
1994, ffie Mowing down reel estate in St. Croix County, stye of Rraacaosi•:
s� s:3o ' • A.
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Ralunt in . i '�
Tax Parcel No:
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Part of Ooverameot Lot •S'. Section 3- 31 -18, desmlW as fellows: Commmeaciag at iateerscticn W liar of avid Ciowramr■t Lot
'S• and N lime of County Wgjmsy *H•; &ewe North 10.08' Bart 210.5 feet; demos South 43• 38' East 72.8 fact; thence s parallel
with W lies of Said C3ovsmn mt Lot 'S' 198.9 feet b N line of amid Coaaty Highway 'H'; d me a North 66 33' Weal 100 Beet to
the p1me of beginning.
All drat had lying between NEly line above de mlW parcel and Sly Awdim of Cedar Lab and between dw Wly and Ely Has of
above pored extended Nly to aid Sly shore line of Cedar Lab.
Tftiis i S per
Dated this 28th day of February, 1994.
AMYS
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AMNOWLEDG 23CUff
STATE OF ACVDG:.SOTA )
H>l2OMM COUNTY )
Personally cams before no dds 2ft day of February. 1994 do Shave nmaned KEVIN AMYS and ZNWM AMY3 to me
bows to be do persona wb awculed " fa io k areet and ado■awledged do Male.
bel I
ii80NAtD IOT.0 Rameld M. otter. Notary Public
NOTARY PUGL C"ESM
HErWNEPW COUNTY Ebmsq in County. Minnemoh
W Conrl"I m E*w Ott 2% Im MY oommiaian spires OckAm 29, 1998
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This instround was drafted by
Colleen A. Cowles, ATPOtNEY -A? LAW
1324 W. Claimna t Avmw, Em Cbire. Wisoaosis $4701