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HomeMy WebLinkAbout040-1229-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun Safety and Buildings Division INSPECTION REPORT fit. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitnjy ?r tNo.: Personal information you provice may be used for secondary purposes [Privacy Law .15.04 (1)(m)]. [ Parl son , mit Holder's Name: C] City E] lLiT TovKn State Plan ID No.: Dan l YY 311 T BM Insgp.pBpMG' Ellev.: BM Description: Parcel 4 ►� 9 -90 -000 8 0 • I loo • 10 1 '_[�pq I" fever t 114V TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark qqb 98�• a �� 8. fi5) Dosi ng t' BM Aeration Bldg. Sewer Holding St /Ht Inlet 3 `Ca qq 3 3s , TANK SETBACK INFORMATION St/ Ht Outlet 3.:�o cm 3,oS' TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Air I �- Septic 30 9 ' NA Dt Bottom Dosing NA Header / Man. Aeration NA ;o -ass- o� ,o. 145:9' F Holding Bot. System c i �� �• 15 PUMP/ SIPHON INFORMATION Final Grade b e ' qgq. /s ' Manufa Demand St cover 0 C - �S ' Model Number GPM TDH Lift Fr' ' n SY TDH Ft ss Forcem Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM (3 e� e�� ( 3 ' 9 RENO Width Le th ! No.O Trenches PIT -11 6- of Pits Inside Dia. Liquid Depth DIMENSIONS 3 V(• DIMEN I N SYSTEM TO P / L BLD WELL LAKE / STREAM LEACHING Manufa rer: SETBACK CHAMBER l INFORMATION Type Of .' ! Model Number: n System: l� >zO "15 C �� — OR UNIT DISTRIBUTION SYSTEM Header! Manifold p Distribution Pi �xH le pacing Vent To Air Intake Length Dia. Length i . 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 ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: :x- / - I In speefirin Location: 339 Soo Line Road, Hudson, WI 54016 (NW 1/4 SE 1/4 16 T28N R19W) - 16.28.19.1129 Glover Station Addn IV -Lot 64 1.) Alt BM Description = 2.) Bldg sewer length = 21.0 - amount of cover = ? Plan revision required? ❑ Yes No Use other side for additional information. ao 3- SBD -6710 (R.3/97) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: „ a ,.,.qa a r_ E z m i E i 3 # 3 a a c 3 S ...# m m _ e A .� e...� 3 S s t e. ........ ... es € f y € i c A sa J. . �v xee i i a_ I 4 # a a P # a = E .... .,. _.I ! �...�., _ .. ,.m.m.�. .... e s s F t 4 [ � x 3 t F a 3 e 6 .:... , 1 me } S - 33? S LAN&- e p. Vi sconsin Safety and Buildings Division SANITARY PERMIT AP:P RATION , , 2 01 W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 83.05 S A{irrf: Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the Sys , Ot 1e4 County than 8 1/2 x 11 inches in size. J • See reverse side for instructions for completing this applic %IN ' ` r stateSd'pitary Permit Num er Personal information you provide may be used for secondary purposes w'��� ❑ Ch it revision to previous application [Privacy Law, s. 15.04 (1) (m)). � State- Ian I.D. Number I. APPLICATI N INFORMATION - PLEASE PRINT ALL Ib Prope Owner Name Fitoa 4 S T a�5 , N, R ` M) W O r� Propert Owner's Mailing Address Lot Nu ber Block Number s . N City, State Z t1cocle Phone Number S�i ision N me or CS Nu `ber ^ I N S�{ ( ) C t 1 II. P F BUILDING: (check one) ❑ State Owned Iti Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms sa T own of 1 S cL III BUILDING SE: (If building type is public, check all that apply) F Tax Number(s) -29. 1 t7 , 112 1 f Apartment/ Condo © -' 1 - [ Z 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ...... System ________ System_____________ Tank Only______________ Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 E] In-Ground Pressure 42 E] Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14 E] � System -In -Fill 3 g ' 4 &k VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate Syt@p1 rev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevatio (D 0_0 Feet 9Wy Feet acl VII. TANK in Ca gallons Total # of Prefab. Site Fiber- Exper_ INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st acted Steel glass Plastic App Tanks Tanks Septic Tank JdW&mT T+- <Qr-S 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i tion of the onsite sewage system shown on the attached plans. PI u ber's Name: (Prin PI ber's Sig (lature: o Stamps) MP /MPRSW No.: Business Phone Number: L C) 5 3 IS - Plumber's Address (S treet,�y, State ip Code): � w t Lo--r 0 l I M IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) pproved [] Owner Given Initial Surcharge Fee) 4 Adverse Determination �' I A" 'd,� X. CONDITIONS OF APP AL / REASONS FOR DI PPROVAL r n t t ( t v_ `�� r,n`I'� S s SBD -6398 (R. 4199) DISTRIBUTION: final to C unty, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 4•• r, 5. Onsite sewage systems must be "properly ai` fained.`The septic tank(s) must be pumped by a`licerised pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266 -3151. �.1 To be complete and accurate this sanitary permit application must include: 1 . I. Property owner's name and mailing add__ ress. Provide the legal description and parcel tax number(s) of where the system istobe'installe`d. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, et5.,), address and phone number. Plumber must sign application form. -• IX. County/ Department Use Only. X. County / Department Use Only. Co plete pla 3ecifications not smaller ttti 8 1/2 x 11 in�#ie muXt;be subrp o the county. The Z s must include the following: A) plot plan, drawn to scSre or with com�lete dimensions;Jocafian of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pymp rr !Wand pump manufacturer; D) cross section of the soil absorption system if required by the county; E)' test dat Eft 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCiARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) or a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. AnT R wa r� 1 r�so,1 N V s r \ /y s 1(.0 Tai tv ei �Q d m N s s119 1 0 � �e y^""Cd� d� C�T 4 lash s�;c. �s 'orsj .3 8 _rn 48 "4L 1 4 rN a I� t� i I _ Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page \ of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR `4aA W0 ode r -..,. COUNTY Attach complete site plan on paper not less than 81/2 x 11 inch 48'We Plaaa,)Mu�nclude Taut PARCEL I.D. # not limited to vertical and horizontal reference point (BM }, direct r4sd °I° i f'Spe; male or � dimensioned, north arrow, and location and distance to neares roa, C 0 " IZ24 �0 - i R IEWED BY DATE APPLICANT INFORMATION- PLEASE PRINT ALL INF ATIC! ,t, PROPERTY OWNER: - P P tOCATI ' W L` ° u 5 1 /4,S b T Z8 .N,R 1 Q E( W PROPERTY OWNER'S MAILING ADDRESS s _ -=; QGK# NAME OR CSM # V S 7", f ISUBID. 6 Lrj\ ) ei ST"W L[ PrD01770N CITY, STATE ZIP CODE PHONE NUMBER ILLAGE ®TOWN NEAREST ROAD R.LULIZ. PtL,t.5,k I S oLZ. (7 IS) 1 -1 IS - B 1 6 (k] New Construction Use.N Residential /Number of bedrooms S/ [ ] Additign to existing building j ] Replacement [ ] Public or commercial describe Code derived daily lbw 6-4 4C , gpd Recommended design loading rate -- — bed, gpf:W 0.5 trench, gpd/ft Absorption area required - bed, 9 kZOO trench, ft Maxfimurn design loading rate o - q bed, gpolft u - S trench, gpd 0 Recommended infiltration surface elevation(s) S " Mc`t W PkGe 3 ft (as referred to site plan benchmark) Additional design /site considerations 3 'M ►1 "2 UztC 4 S' w t 1S fv % a0' LA' a . Parentmaterial SMim ey l•- owe% 0 Flood plain elevation, if applicable N- ft S = St>iWe for System H�ONAL MOUND g0ROLIID PRESS'l1RE AT -GRADE SYSTEM W FLL HOLDING TANK U= Unsftitable for tem �I S❑ U W S ❑ U 0 S ❑ U ®S ❑ U ❑ 5 ®U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz, Coat Color Texture Gr. Sz. Sh. Botrxdary Roots Bed fends 0_6 10 3lZ - 30 Z Sb m�H C S - o.S 0,6 R. Z b - Lo 2 316 s l l ZS�k �+► F►- C o. S 0.1. Ground 3 \4 -ZZ - Sylz ly g) zwl S e-S elev. q -o ft. y zz_7g -S7C� �� - 1 s oVn Y17Ufh _ o•�! o.S Depth to limiting factor 77i� Remarks: Boring # o -t0 t o� R 3 !Z - s t I Z-'�s �k may, e.5 _ C, o. 6 Z z 10 _2y \1311 tssh �S — o .so.� 4 a 3 Zy -sb - x•syc� 3J _ S ] lw,sbrl rn�� �,," - o.y o.S Ground elev. SO-73s - 7. S ytZ VA � s c� sg .►- I - o• s n. L 9 82. , l ft Depth to limiting factor _T 7 85 Remarks: T Name—Plea Print Phone: Arthur L. �Je erer 715- 425 -0165 ress: egerer Soil Testing & Design Service - P.O. Box 74 River Fa11s,WI 54022 Signature: q_ 3 0 Z- 6 Date: 1_130 -- 9S CST Num 0 0 5 7 6 PROPERTY OWNER Z4 — C.WJ L-rZ- SOIL DESCRIPTION REPORT Page of 3` PARCEL I.D. # y Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxfi 0 10 4 IZ 3 - S i 2 `F Avz m' c! S 0-S n. 6 9 -LI) 1k�`lR 3/3 si 2.�s�k w�f�. cw o. o. Ground l� `iR 3!` - s - L a ble 'M 0 . S L) elev. °i $6.8 ft. S YR Y�vIlk p •q n.S Depth to limiting factor > 80 Remarks: Boring # , �, ) 0 -8 YO"l 3l Z S 11 Z`( Sdk wl S Z \Mit- -C S — o. S o• 6 Ground o.S elev. S `-) R Y/6 q K - 1 ft. i Depth to i limiting 1 factor ! ? - LS" i i Remarks: Boring # "V6 »:i> 1I2 — St) o•S1 o:6 Sil Z`fsbh YA i�- cS — o•s 0.6 Ground c — o.S'o. b elev. L/ 3L •$e S VP 3! � S J � c S bit 1*1 'FH o • �,( o • $ °i 11 s ft. Depth to ep RUC of M limiting factor I Remarks: Boring # �a $ i Ground i elev. ft. Depth to limiting factor i Remarks: SBD- 8330(8.05/92) PLOT PLAN Page of 3 y SCALE 1 "= qr3 ' Los- 6 Z yo3.8 9 LoT 6y Lr °►6Zi S X987 0 � s J % ' d /o 8•S S O• o O � Lt.9.841 LL.eu . NOTE: House to be at least 25' from trenc Well to be at least 50' from trenches. NOTE TO INSTALLER: pipe' Place 1st trench along the 988.5 contour as shown. Place additional trenches at least 6' apart and 30" deep at the upslope edge. Determine trench 0 elevations at the time of construction. 61 e ' y x•' r� 3SO •oo. LO eprn htiv S e �e Soo ( 715 > 425 —nl Ls _ M00576 CST Signature Date Signed Telephone No. CST # %sconsin Department of Industry SOIL AND SITE EVALUATION REPORT age \ of 3 Labor and Human Relations m /ision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ' ST- C--R -o 1 X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. • not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. D BY DATE APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWE PROPERTY OWNER: PROPERTY LOCATION C . 1�1 • Bt-t E PM 17 1J l S S C L Z Gefr-t6 g N W il4 1 /4,S I b T Z8 ,N,R 1 q E( W PROPERTY OWNER - S MAILING ADDRESS : % P — LOCK # SUBD. NAME OR CSM r LO N. wt t�tw g T. 1 GL6\)Lr\_t ,S"W 4 f' brio" CITY, STATE ZIP CODE PHONE NUMBER FICITY VILLAGE QrOWN NEAREST ROAD R L0-_ 3 1L PtLL$, S OL (71 cIZ.S- 4 t 61 pY I svo LIUIE D4 New Conshdon Use. N Residential / Number of bedrooms Additign b wdsting bLiking () Replacement () Public or commerdaf desaibe Code derived daily I, 6uo go Recommended design loading rah — = - bed, gpolft 0 . 5 trenA W W Absorption area retired - bed, ft 'Z-oa trench, 111 Mabmum design loafing rate o- I bed , o _ -S trerXk 9 Recornrnended infiltration surface elevation(s) %% >lluT W t>k6'e 3 ft (as referred to site plan WdwnaN Additional design /site considerations XZJeC.tt MaJb S' w I; h I r %4 8 0' LA ti 6 . Parent material ouet2 Sf' 'Zi4 W'VkA^S H _Flood plain elevation, l app6r" N •►� • i< S = Suitable for system I cmvwnm& I MOUND IN- GROUN1 PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TAW U = Unsuitatlie for sys tern - L 0 S 0 0 ❑ WS ❑ ®S ❑ ❑S Lou I O Rill SOIL DESCRIPTION REPORT Depth Dominant Color Moines Texture Structure Cor>slsflmw SorrUy Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rertdi 13 1 0 -6 to ix 3tz — sil Z sb W Z (, LoH V_ 316 .5; - L E 1M Clv - o. S u• b Ground S y2 jIy S) Zwt AK e- S _ o•S o -lam elev. ct _o ft. y ZZ_ 7$ - )- S VV_ '5 1 s � Yrt U f N _ o..�( o. .S Depth to limiting facfior - 7 Remarks: Boring # l _ - o -i.o s ' o. C 3 2- 1 4 - 3b S y 1 y s) 1 wt Sbh m I, Ground elev. so -85 S y iZ V A - o• S o. 6 ci ez. - f It De" to limiting factor Remarks: T Name: - Please Print Plane: Arthur L. 715 -4 2 5 -016 5 tde erer , egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 Sgnature: Date: CST Number: G q -30Z 6 1--30 -4 M00576 PROPERTY OWNER ZXt'_ — 3CWV - SOIL DESCRIPTION REPORT Page Lot 3 ' PARCELI.D. # Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon; in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trertch k sit z�3d wmi� ps o S (z q- V7 16 4 8 3/3 S l� Z.'� S�Et 1►n FI• CW Ground S l� Z,'F J1�k Yn elev. ai -% ft. 1 4 3'M y1 6 O• to -S I Depth to i limiting I factor Remarks: Boring # ; I Z S t , Z`(Z S �I� wi - Fu g _ o - S � a. L t, : . Y , z' g - Lo�ttz 3!� r � J Z � sbk w►�F►- � s u .s 0A 3 Ground z8 -6o 7 -SIR 31y — S I 1 c-Sbk CS .- o -Vi 0.5 , elev. •3 `-I R YA — `�S O Sg w, � � a. S i o -L g$4 - -1 ft. Depth to limiting factor Remarks: Boring # I Z — si) Z'FSbF� w� `F�, ag = o•S,o Z 9 -'20 \%3%I 3 !3 S1l o•S� o. 5 � Z `�sbh � �>- cs — L 3 Ground - M - mQ'4 316 � Sill ztS `6h Yh ` i,- cS — a.S o, b : ele L/ yQ 3! S csb1� �'FH v•�! i o.s Depth to ep OF H'1 limiting factor Remarks: Boring # I Ground elev. f t. Depth to limiting factor Remarks: SBD- 8330(8.05/92) PLOT PLAN Pa 3 of 3 SCALE 1,,= qr3 ' LoT 64 �^ Y03.89' Lt 6y t °►9Zi 0.2 S x°18? at ire r, '9 y e ' S EL9gq S 3 So• o � � �.qa� s 6S �1' ntr� of NOTE: House to be at least 25' from trenc Well to be at least 50' from trenches. ,� _erL, I $$,g$, OKI NOTE TO INSTALLER: t" moo—A 'Pipe Place 1st trench along the 988.5 contour as shown. Place additional trenches at least 6' apart and 30" deep at the upslope edge. Determine trench o elevations at the time of construction. o 0 o�•8q� e ' y 3S �•oo. LO �.P�''Cl bry Shkit.�t �, z p 500 g q- d_ J - -45 ( 715 42.5 —n1rs 1100576 CST Signature Date Signed Telephone No. CST # ° ° °° hA,A' �� �0 �( 0 Cl I � ' n � f � m a C y� m ' L ^t J O (n n 9 i � r j S - f _m o N' 10 cc' zr I ^' m co cn x =r CD = (o m - n i r-- p N 0 CL co' w x a , 3 3 2 •o � c �. C1 - -, (D I 0 = C 0 n s C7 =-�. ;T CD .-. - 0 W (L) O N, O p t - p (DD 1 N � (j) Q( A j N x S (� a ( w (C) x w Q (n m n > 0) °° w -• �' o a 1 i n �• _ <' x (0 (DC0 w Invert 11'- -- t � 0 I ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ' C) �0. A r— Mailing Address I to S 9 S� Q A l' Property Address 33 S6 L I ^Q (Verification required from Planning Department for new construction) City /State Parcel Identification Number t*) �{D LEGAL DESCRIPTION Property Location '' /4, SJ� '/4, Sec. G, T,L<N -R 7W, Town of Subdivision _ Gt oU .4P o— SteA Z J,1`t QA i L tb v� , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # i y '] 1 , Volume 1 '�f `�C� , Page # S 3 L Spec house ❑ yes 1�1 no Lot lines identifiable " 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 f e three year expi tion date. 1 ( S ATURE OF APPLICANT DATE OWNER CERTIFICATION (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 pro described ab ve, virtue of a warranty deed recorded in Register of Deeds Office. S16UTURE 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 MAR -23 - 2000 THU 09;23 AM RAY N. WELTER HEATING FAX N0. 612 825 2303 P. 02 io STATE Br,, ,l� WISCONSIN FORM 1 - 1 � CE, 1L $47'9 WARRANTY DEED KATHLF -EN H. WALSH qq (� REGISTER 01 "' DEEDS DOCUMENT NO. 1'I';..t490PAGE534 ST. CROIX GO., WI RECEIVED FOR RECORD This Deed, madc hctwccn Dennis R and Sandra C. 02 -17 -2000 9. 45 AN Schultz Revocabl Trust llennJI a R • . -Schultz and WARRANT'( DEED �2 annra (' Schultz llStees 'oath wj tb fu11 0 � EXEMPT Ii of Ra 1 p or tm LLCiitg Grantor, CERT COPY FEE: ind Daniel R. and Ju . a A. Ca rl _ Eon Wife COPY FEE: as survivors p marital party TRANSFER FEE: 154.50 RECORDING FEE: 10.00 RAGES: Wittll'StiCLh, That the said Crantur, htr a valunhlC Cpthidvralion xmveys to Grantee tile following described real estate in St. n ,ounty, State of Wisconsin, THIS SPACE RESERVED FOR RECORDING DATA .Lot 64 Glover Station Fourth Addition NAME ANDnETURNnDDAESS �j. Towns of Troy ATTN, Mortgage Dept - First National Ba x fib River Falls River f=alls, Wl 54422 040 - 1 T an -90 -000 Part:e Icatton Number This is not .,,, prnperty. js (ls wi Together with all and singular the hered"ments and appurtenances thcrcunto belonging: And Dennis R. and Sandra C. Schultz Revo a 1e T u t arrltnis that the title is good, indefeasible in fee sirrlple and free and clear of encumbrances except easements and restrictions of record and will warrant and, defend the same, nd will warrant and defend the sa d this day of February J 9000 (SEAL) (SEAL) Denn s R. Schult (SEAL) Sandra C. Schultz .� AUTHENTICATION ACIW0Wi.E0CM1.NT gnature(s) __ STATE OF WISCONSIN, sb. County. personally came before me: this day of itheaticated Ihis day of _ .,. ... It) LDruArY It 9000 , , the above named -- — - Sandr C. Sc u 'TL.E: MEMBER STATE BAR OF WISCONSIN � fari g to me known to be the person 4 m (If 3101, ' iJ -- audiorized by 6 706,06. Wis. Stats.) imlmmn t rnd a knn. I,'fn• th• aim. 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