HomeMy WebLinkAbout038-1192-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 429983 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)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Aherns, Richard I Star Prairie Township 038 - 1192 -40 -000
CST BM Elev: Insp. BM Elev: I BM Description: nn Sectionrrown /Range /Map No:
cs-kk A 4t'o , *n ,& a 63 cr" 11.31.18.992
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
� �r4•b�
Septic Benchmark t
VJC —�K.S w'& �3 • S� `t`t 9(e - *6
Dosing Alt. 43M O g3 • fi 5
Aeration Bldg. Sewer 1
Holding St/Ht Inlet
3.8 �S• SUHt Outlet �'s
�
TANK SETBACK INFORMATION y 1 q$ - •`fI
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , I S 1 / f Dt Bottom
Dosing 1 c'7C) Header /Man.
Aeration Dist. Pipe (a.
oo
.o
Holding Bot. System
v 33 2 .7-
Final Grade /
PUMP /SIPHON INFORMATION 3•S$ %'00
Manufacturer Demand St Cover 1.16-+ 9 ;� • 9 J r
Model Num
TDH Lift PilbfiqZZ System Head TDH Ft
Forcemairi Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM Jo P.0
868 RENO Width ' Length r No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ?, G &.w
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufactu er 11 C
INFORMATION CHAMBER OR - \ . — 3'
Type Of System: qr UNIT Model Number:
t-tvA • Z3 2 b
DISTRIBUTIQtj SYSTEM L
Header /M@ni� tt Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pip s) f
Length Dia �' _ Lang Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of odd ed xx Mulched
xx Seeded /S
Bed(rrench Center Bed/Trench Edges Topsoil T L. U Yes No 0 Yes No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1�, S )� 2 �3 Inspection #2:
Location: 1290 220th Ave S rie, 154_ _026 (SE 1/4 SE 1/4 11 T31 R1 8W) Huntington Meadows Lot 8 Parcel No: 11.31.18.992
1.) Alt BM Description
2.) Bldg sewer length t n
- amount ovcover� u•I:" •. � Z n�C� 0 at�0� �R.M.e „ Q�Al1S = lJ ? .gym '
A
A
P revision Required? Fa Yes No
Use other side for additional information.
• ��� � _
P te, A I nse ctors Signature Cert. No.
SBD -6710 (R.3/97) ,� M �"L.
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Divisi+rn Sanitary Permit No:
. INSPECTION REPORT 429983 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)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Aherns, Richard I Star Prairie Township 038 - 1192 -40 -000
CST BM Elev: Insp. BM Elev: BM Descdptioni Section/Town /Range /Map No:
4'6 .� °i O , o co Ak v. f IQJ C M& 11.31.18.992
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � `Tvt Bench rk ,;Fi 3 1 41
Dosing Alt. B + 0 11
Aeration Bldg. Sewer 2 2, 1
Holding St/Ht Inlet 3 , 1O 1
TANK SETBACK INFORMATION St/Ht Outlet 1-Z 0
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' 115" 3b ' — Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe �2
/Aliv O
Holding Bot. S em i 3 d,
PUMP /SIPHON INFORMATI Fin a Gr d� e h
Manufac er Demand St over f Ll
I M
Model Numbe
TDH Lift Fric i s System Head T Ft
Forc ain Length Dia. Dist. to Well r
SOIL SORPTION SYSTEM C1 l)
R N H Width I I Length No. j0f Trenches PIT IMENSI NS No. Of its Inside Dia. Liquid Depth
DIM '2 2
SETBACK SYSTE ✓ M TO P/L BLDG 1 WELL LAKE/ REAM LEACHING afa `de .
INFORMATION CHAMBER OR l
Type Of S stem:
v ' v UNIT Model Number: 1 r
DISTRIB la I TI M �* f /t. �
Header /Manifo 1 1 Distrib ion x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) --%. too 8
L 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 ] No [j Yes No
COM T cl co d' crepencies, persons present, etc.) Inspection #1 - 3 Inspection #2: _r___ '
Loti o 290 220th Ave Star Prairie, W1 54026 ((SE 1/4 SE 1/4 11 T31N R18W) Huntington Meadows Lot 8 Parcel No: 11.31.18.992
1.) Alt BM Description =
2.) Bldg sewer length =
amount of cover
Plan revision Required? n Yes >No �I LIA
Use other side for additional information. _.._ ___ _ _—_�
SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No.
I Z9 0 2-20
Sanitary Permit Application 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
1*scons Personal information ma ou p rovide be used for second p urposes Madison, WI 53707 -7302
Department of Commerce y p y p
[Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
state owned.)
Attach complete p lans (to t h e cou nty copy only) f t h e system, on paper not less than 8 - 1/2 x 11 inches in size.
County --- ' — Stat7 Sanitary Permit Number ❑ sion to previous application State Plan I. D. Number
4 12 1 1 K?
I. Application Information - Pl ease Print all Information Locati
Property Owner Name Property Location
2 4' { r � ` f MAY 14 2003 `7: 1/4, - 1/4, S & T ,N, 1C 4 ( 1 '
Property Owner's Mailing Address Lot Number Block Num
ST. CROIX couU J7-
ZONING OFFICE '
City, State Zip Code Phone Number in Name or CSM Number
II. Type of Building: (check one) S ,. C,�.; fit s) ❑ City
� 1 or 2 Family Dwelling - No. of Bedrooms:
❑Village
❑Public /Commercial (describe use):_ 5 7KTown of ,
❑ State - Owned
t / Nearest Road /
a+ � / Parcel Tax Number(s)
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 7
A) L FB.New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. FTAddition to
System System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
P(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 Inform
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed 6��f Z Rate (Gals. /day /sq. ft.) (Min. /inch) j y -- / = 9.2, 3 Elevation
j b /
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
y ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (print) Plumbe ' i nature (no stamps): MP/MPRS No. Business Phone Number
r `
Plum Address (Street, City, State, Zip Code
IX. Coun /Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee) 225 r -
Determination
X. Co ditions of Approval /Reasons for Disapproval: �, �.�f
PAAa
gT y
I
SBD -6398 (R. 07/00)
/��f PLOT
PROJECT �� G /jam �G+P1� 5 ADD ��� �G h G( /"/ r[ r
la. Lr 114 /T Nl `'�' Tc?wN �, �,QUNTY X
MFRS Byron Bird Jr . 2205 DATE S G� BEDROOM 7
CONVENTIONAL XXX A -Grade CONVENTIONAL LIFT HOLDING TANK �—
MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE Q LOAD RATE 7 ABSORPTION AREA /�� z # of chambers
BENCHMA V.R.P. rr s / ; 3 �/ —�G� ASSUME ELEVATION T�IO 1100'
❑ BOREHOLE • WELL
/' f
Vent SYSTEM ELEVATION
AT, Sidewinder High
Of Capacity Leaching
Cove Chamber with 17.2
t ^2 per chamber Grade, at System
Long 34" Elevation
ir
r- 7 2,5
>rJ
O
r-
PLOT PLANT /
PROJECT G.I�t 6 (��`�YI 5 ADDRESS
1/4 r 1145 /T N/ W T - WN �Z. COUNTY 1
� . SLR � � . � 5f r� �
_!� BEDROOM
MFRS Byron Bird Jr. 2205 DATE
CONVENTIONAL XXX A -Grade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE Q LOAD RATE 7 ABSORPTION AREA # of chambers
IL BENC$MA V.R.P. ASSUME ELEVATION 100'
❑ BOREHOLE WELL g; 'l A .
Vent SYSTEM ELEVATION
> 12" Sidewinder High
o f
Capacity Leaching
Cove Chamber with 17.2
6" t ^ 2 per chamber Grade at System
Long 34 " Elevation
P, f^
J 1T
i
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Buresy of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
O t - Attach complete site plan on paper not less than 8 1 /2 x 11 inches in siz . flaa Count
include, but not limited to: vertical and horizontal reference point (BM ' e'bHon and (/✓'p
percent slope, scale or dimensions, north arrow, and location and di nss to near,A road.
•. � Parcel I.D. #
APPLICANT INFORMATION - Please print all informs ton. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privaiky taw, s. 15.04 (m)).
Property Owner PT y'Lo
catiori
Govt`L��f /4,S/ T N,R
Property Owner's Mailing Address Lot # Block#`` &bd. Name or CSM#
Ci j �tate Zip Code Phone Number ❑ City ❑ vilipw Town Nearest Road
New Construction Use: Residential / Number of bedrooms Addition to existing building
S Replacement ❑ Public or commercial - Describe:
Code derived daily flow ez� gpd Recommended design loading rate bed, gpd /ft 2 - trench, gpd /ft
Absorption area required bed, ft ft Maximum design loading rate ` 7 bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable
ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S El �S ❑ U Ss ❑ U J ❑ U ❑ S kLu ❑ S .RU
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
„:.:<:: ��
' (c y
Ground "ope - iz -
Depth to
limiting 0 12.3
fac or
- in. 50- 4114 '�(
,z Remarks:
Boring #
0. 0
Ground $ t r
ft.
Dt ;pth to �� ,�
limiting
factor,
in. Remarks:
CSZNam (P lease Print) Signature Telephone No.
Ad j Date CST Number
i
r
1.
PROPERTY OWNER �u - t �f7 SOIL DESCRIPTION REPORT Page of
PARCEL I.D.# �v -
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground "t
'OF
�ft• '
Depth to
limiting y
factor
-� ��in.
Gf. Z- Remarks:
Boring #
Ground '
elev.
Depth to y
limiting
factor
in.
i' Remarks:
Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Boring # �� r
Ground i
6epth to so - Y
limiting
fact
�<- in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
r
Soil Test Plot Plan
Project Name , Byron d Jr.
Address � o S
CSTa X02 v S
Lot SubdivIsIon -4�Date
N /R W -,- Township
I3oring O Well PL' Property Line County
BNI or VRP Assume Elevation 1 't �. wo , �• 5��c•E'��
System Elevation� *HRP
f Ri
6
G_
��V
U V
I
�
Scale 1/4" = 10 1~t. When Dimensions aren't stated
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tank Capacity a l ❑ NA
Permit # 2 q °1 (►, -3 Septic Tank Manufacturer G e/1175 ❑ NA
DESIGN PARAMETERS b Effluent Filter Manufacturer `� - ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) L` al /da Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) <Z� gal/day Pump Manufacturer ❑ NA
Soil Application Rate g al/day/ft 2 Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspend Soli (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L t4n-Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ N Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑
year(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ ear(s) 13 month(s)
arl 1(s) (Maximum 3 years) 13 NA
Y
Clean effluent filter At least once every: !)❑ month (s) ❑ NA
� ❑year(s)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
❑ month(s) Other: At least once every: ❑ year(s)
[3 NA
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master 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 observation 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 notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y 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 chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
Page of
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 chemicals
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 septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
repilaSigement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil 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 wells. 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 time.
❑ 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 failed 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 holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative 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 rY. Name ,: /6i C��� , C y
Phone �; Phone
SEPTAGE SERVICING OPERATOR LOCAL REGULATORY AUTHORITY
Name ��� y ,_ . �� Name ri' /� c
Phone �-{'� Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d)&(f) and 83.540 ), (2) & (3), Wisconsin Administrative Code.
I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
WNERSHIP, CEFTIFICATION FORM
Owner /Buyer / �G. ✓ /
Mailing Address
Property Address �q Z 2z A u--e, '
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number �' /� " y —ee-en
LE GAL DESCRIPTION
Property Location Jw� ' /4, 5� '/4, Sec. _Z1, T -R W, Town of 4e�4 L
Subdivision ti u >n 1� KaadD U) S- , Lot # D
Certified Survey Map # , Volume – Page #
Warranty Deed # Volume o / - — Page #
Spec house ❑ yes 4 no Lot lines identifiable A 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 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.
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (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.
SIGNA = TURE 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
0b/1212td83 09.30 17152466886 S C S ANK PAGE 0 /Ul
STATl3 J)AJi OF WISCONSIN Ytll1M •L • Jy9!1
KATHLEEN !I. WALRi
WA RRANTY DEED RCG15'I•t~k OF D: M)f
Docu:nmei Number ST. CROON M. I wt
bt EMVIV'lrq 'r'uA RECORD
Thin D+sad, made betwoon Ciuy A. Fdia,
• �.;�dFT d
Grantor, and Wahard R. Ahdru ® a stalk perrfon. "" SAP ., Pee; 11.
TR�9S irrn 97.
%,rwl ' FL•"E t
cc FU
dralubpor '
Gmutar, for a valuablo consWbrrulon, convays to Ozuuttaa the
followJag 4cwllbod roal camto In Si. Croix _ ` County,
Stato of'Wixonsln (if more space is needed, ploao atuch addeddurd)]
Lot , Plot of H mminhton Meudom In the Ta %vn oi" 5tur Pralrle. St. Croix ftapidhrg/uxa
County, wisoonsln. Numia acid Itaxo Addrmer
ft'If 4 JA 14 i¢ikt,l.
a�C OA K
fG wx 4-
Pew al w oN D, vi I t:;Li 0 17
I'eru:l lderiSGcatloo NrcnLor (PIN)
'I'bio Is not homm=d praptrty.
E,jteppt�ptL9 to wACCBttI'IU9: l.rlleltteutts, eatrlttianar aqd rights�gf way oi'r000rd if airy.
Dated this day o f_ March
* clauk gain _
,�u7 4��� "YCCA'xlUw sCKNOWLEDGMENT
6lgnature(a) Clay 4. l�diu STATE OF WISCONSIN )
su.
�. County
outhGnd I4 ' day ri1'_n'l++rl H� 20n9
limntr,natlly o ®o1a beaforq ilyd tlsis _,_„_ d4Y of
thr above numki4
w KAffuna 01C add _.. _...r
TITLE: R1C�,IVIb1 it `rA`T)r BAR OP WISCON mo kn�owrt co be the arBun(dy who executod the fbroaoina
(Ifni, ,._— �. instrument w►d uuk-- �dga4 thti mamo.
audsorized by j 706.06, W is. S'MT.5.? .
Tt 31S fr4STRUMENT WAS DRAY] ED 0Y
A "Pru.y 1r4rbilna telgnd Notary Public, state of wi hu ll
Auelsauu;WSts�dTii ` _ "„�_ My Conilrlis9lon is port )3nirnt. (UN 10C. BLOW oxpivdibla dace:
(Sipourrea amy be autitu Heated or wknow:edVd. Pour we not ce+;092Y .j _ ... ..�• - - -r l
Namur of poryuna nil hlHig In dray e400eity must bra iypt•d or primp! below & )IV 513110ture.
iy,►Syn.oUcn P�taadona'• GvnyrMi. i ��sg
1�AliRA:V7Y lU lv� ST^ NSIN
rAR( WISCO
P016<N • d, r ^ 5999
.I __. .........
CU 751 "5 8 SO. FT.
1 .00 ACRES
P .rcrased Dr
LOT ID
r
TOTAL AREA:
-�
65,1 80 SO. F
1,50 ACRES
8
0• ' 11 z0. FT. Ar 321
f 02
Y
sue``
LOT 0
TOTAL - VU .
7
iF .�• EE M :ram... °•.
V
r� - ap-
�a
r
� r
j I
i H��� I
I
Nw i w£ 1
i 1
Loeotod In pwe of t.. sava.a.L ooarc« d tl. SeuDnwt
.. —.. _.. _.. _. - +.. _.._ -_..J Nwft RwW IS Wm L T~ d!Ear poft SL Crek boon
I SwY MOP new*A Il Vak m 11 yaps 3113 Docorwd Nc
i i i RAgkNr d Oo�de Mlles
NW AF
ST
I sw
.._.._.._.._..J_.._..�- ate-- HUNnNGTON MEADO rt
NOT TO SOME SECro aF STAR PRARIE ST. CROX COUNTY, WSCONSIN FICE \
I I I
I I
1 MATT LANDS
i 1
1 ( I
AVM LW Dr w S1aVM 1/S OF PC 31 Ip OF me SF 7/� A� SLC1lAV 71
I I
1 ' - -- - --- -- S�W'34'E tt &61'
1 I I - - - - -- 27MW J:
j ' ^ W W tADE DRAMACE
c T SW'0a'34'E
S5SVrOrE 241.97
L� 2 \ LG? fl ' a W000 70. if.
n R 131 Acm PY SO, PONON0 EASOMMM"1 A.$A 1.7t ACRD
l . .•.. g
Lor Q r'' � ti 15.19 A 320.E
I ( 0
103,=2 W Z O R. 1 . �i .
it CIIt3 t
I {Fff at W mum I I
I I CSM YCl.U1E 11. PAGE 31 1j 28&4 1733{ .� aim SQ R.
131 mm '84'E 40.00' • St ''
8 • 33' 1 SS �' f NeC10'22'�
I ,I
- — — — — — — — — — — — — — — — n wr s I �,
I i Ul ACKS 1 I LdT a
1 , ' s1.w to. FL LOT
I I i i t st Ap[S 0t �
I I
1 ' 1 Lars .. «............ «..... «......... ............ «.«.....«« .... .....
I I I C5M YO11111E 11. PAGE 3113 �•« I • «�••••
1 1 i $ I
sv1IM 1A car I I 41tJIV owmeVr 1 I
1 � � ( 1 RQN. 22M AVE.
SER^ 11,17 -IC 1 I — _ _ _ _ J ___ ______ 2 N`W (MAN M CId K) Y F 0. ZZQM A , _ _ _ TO K Comm TO Tw Kw* � M �
---------- -rxrvaw mm A11: 2� 4 Lh A V E N U E h Nin
--- - - - - - ---- - - - - --
3OfAM LW A' W 3E 1/4 Or 3lCtgV A —
UNPIATM {Alas
ALL (NEAR lEA9lRFlA71TS NAYS tm1 MADE ro THE NEAREST QE (1)
THE NEAREST IVE � NO OO 1 �TNE VALUES 71 S1f O AM1 0
NO GtAON0 OR CONSTIUO11oN PMATTED UTNN THE POND t
EARL ST. CROIX COUNTY GLOBAL POSMONIG SYSTEN N[TSOUL MON MTS.
1St NOTE: THE PIM DKM ON TNN MAP AM S UUECr 10 SYA7F, OOUMIY AND 7000W LAWS3 RULES AND RENMTIONS" ItILAMI, MNW1 LOT 8TH ACCESS TO PAM
VEt1ERLY t1YERT OF 24' CW. 3W NORTNEALY OF THE SE CORNEA OF SEQ 11 - 1!2.70' ETC.} BOOM FURCHASM OR 0t%Q"W ANY PMCIL CONTACT ATE ST. Clt= COUNTY
20010 WIDE AND R! AFMOPIMTE TON WNW POR ADYK2: