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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344650 Permit Holder's Name: [_1 City ❑ Village $] Town of: State Plan ID No.: Lundb erg, Mark I Town of Hammond CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 018- 1054 -30 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. Towel SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 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 ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2004 Highway 12, Baldwin, WI (SW1 /4, SW1 /4, Section 24 T29N -R17W) - 24.29.17.377B Plan revision required? ❑ Yes ❑ No Use other side for additional information. I I F SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e a a mm c i a e .. m E € E d 7 I 3 `:. ..,, e ..«.... ... �.._ _. ; .... .....,.,,: e, a. ,....,. ,,., ,. a ,,.._ ... ... ...,. .�.. .. .. �.. _ ... ...... € .... � 3 s ... e ».�..®...:...; s e f � i r d I i .. �.m .-... .;......... .. -a.... e ..,.. . s- . e .. ....., ... s .. - x 3 g �. �_ _ _ fi i c s E eu ......m..... to ...., t ... .. .�... ., _ _. .. _ ti f r a 3 e� w .. ....... a , Ea .e a g w f # � x 8 w ` p I S # ..,. .,. e .... ... A .M . ... ...... .... e.m me a .. �. a x, d �x z .. —. ....,. .. ... ,.,, _...., w.,...e.e...... ., .....�,,...— .- ....M. Safety and Buildings Division Vi scons i n SANITARY PERMIT ON 2 01 W. Washington Avenue In accord with ILHR 83 / P O Box 7302 Department of Commerce �,r, Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the m, on DOA#n ot lest'_ ounty , than 81/2 x 11 inches in size. • See reverse side for instructions for completing this a tio4 1,fir to Sanitary Permit Number Personal information you provide may be used for secondary purposes 3T CP 99 ! Check if revi co previous application [Privacy Law, s. 15.04 (1) (m)]. IpM J tate Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT A RNP/� ,rte Propert wrier Nam c on b y p i 1/4,Sa( TJ ,N,R E(or W Property Owner's Mai ing Address Lot umber Block Number I Cit State Zip Code Phone Number Subdivision Name or CSM Number Li v Z (�iS)6ssy- 77 IL TYPE OF BUILDING: (check one) ❑ State Owned !t Nearest Ro ams Public 1 or 2 Family Dwelling,- No. of bedroom Town OF III BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 2�. ,1-7 . S"11 1 ❑ Apartment / Condo l 1 loi�v —�— 0 000 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) Y Existing a , A) 1 ❑ New 2 ❑ Replacement 3 � Replacement of 4 E] Reconnection of SRepair of an System ________S�rstem _____________ Tank Only______________ Existing System ________ sSystem B) A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Distribution Experimental Other 11 Seepage Bed f �lo 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench n'• S � % 22 E] In-Ground Pressure 42 ❑ Pit Privy [] A1 13 Seepage Pit k C* "1�' 43 ❑ Vault Privy 14 ❑ System -In -Fill b 1afbo o 'S VI. ABSORPTION SYSTEM INFORMATION: 1_ Gallons Per Day 2. Absorp. Area 3_ Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed s ,!) (Gals/d / . ft.) (Min. /inch) Elevation 5-0 A- )° Feet . r�'Feet VII. TANK in gallo Ca ut ns Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tank Tanks Septic Tank or Holding Tank / - 6 ) � 0 ❑ 1:1 E] 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I t e undersigned, assume respon ' ilit stallation of the onsite sewage system shown on the attached plans. 09111156 is Name: (Print) nature: (No Stamps) Business Phone Number: Plumber's Address eet, City, State, Zip Code): L IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate ssu Issu� g Ag nt ignature (No Stamps) [Approved [:]Owner Surcharge Fee) _ f Owner Given Initial /��(�� j�S{ Adverse Determination 77 — 11 4V=e� X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Codewill be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. 4 To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system isto be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. 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. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 fora; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. -Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page J__ of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and t �- percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # CO o - 3o -6od APPLICANT INFORMATION - Please print all information. Hle)oeweq by Dat Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location m Q r L_ V r �j G r Govt. Lot 5L3 1/4$1 J 1 /4,S T a(f ,N,R E (o W Property Owner's Mailing Address Lot # Block# 7. Name or CSM# apO4 R w I la city tate Zip ode Phone Number ty p o e ❑City ❑Village Town Nearest Road wi f I 1 5 yoo ( /5) (o%,V-31771 LL pT rf_Jv a VA New Construction Use: Residential / Number of bedrooms .3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/ft trench, gpd/ft AjZsorption area required bed, ft 2__ __trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft r ` 4 'nfiltration surface elevation(s) _ . 3 3 it (as referred to site plan benchmark) Additional design/site considerations Parent material 'a G.� Q c.:�c L O %JItw Q S LN Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S El 64 S El 64S ❑ U 1 0s ❑ U ❑ S O U ❑ S Q U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure GPD/ ft Bo # P BOing Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 ay 1 u R Ground 9 elev. ft. Yb 7 S y (R' Y ,S Depth to �_ 7 : , limiting facto in. 1• Remarks: Boring # he _. e., V to f C} It Ground 1I ig elev. ft. • • Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address 'T k Date CST Number _'i -17 Qa17 26 5 y c4 L,, SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Du. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. ft. Depth to limiting ; factor in. ' Remarks: Boring # Ground elev. n. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. tt. Depth to limiting factor in. Remarks: Boring # Ground elev. n. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) .1tYla,r k Lv '�5 pa C,. ; C) II T 09N , P, Sw 1 /� �ta'Iq etc, ay, !70 k y0 Na 6 ) , 7e- lo t f [1.�0..•�d1.. bDr• w� al a� i r Nom 1 � a 3 o 7 h vs h i j i i .. } i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address (Verificatioa required from Planning Department for new coastructioa) City /State ell �,;v C J Parcel Identification Number e&j 30 — 040 LEGAL DESCRXPTTON Properly Location (. ) %�,Z %., Sec. T-2yN RAW, Town of Subdivision Lot # Certified Survey Map # Volume . Page # Warranty Deed Volume Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑. no SYSTEM °MAINTENANCE consists bv roperu=wdmabt==Wofymscpticsyst=couldr=I tmits tobaadtewastes.Pmpermakew"nce pumping out the septic tank every three ye= or sooner if needed by a Iicensed pamper. what you pat into the system can affeathe 5mctim of the septic twk a htatmeat stage in the v&sW d>sposai- sYstan- - IU PrOPWY owner agrees to submit to SL Croix Zoning Dcga ftnent a catiscation fQM16 sigwd by gu.owaac and by. a P J yznaP1> umbe oralk= cdp= 4 =vai*gthat(l)&eoa- itowastewaterd ix=lsystem is is Pcvpec operating condition an(/or (2) after inspectioa and purnping f ry ), one septictankris iess than W dill of sludge. V%T" dw Undersigned bave read the above requkcments and agree to maintain fire ate ri set for&, hencin, - as set by the Department of Commerce and the P • 8e disposal system with t e t ific aids �� � Your septic Department of Natural Resources State of Wisconsin.. Ceitificatioa system has been maintained must be completed and renamed to the SL Groix.Cocaity Zoning Office vvithia 30 der f the there year iration date. M TURF APPLICANT / 1 71 DATE OWNER. CEItTI1tICAZ')<ON I (we) oatify that all statements on this form are true to the best of my (our) lmowledge. I (we) am (are) the owner(s) of ropeity d a ve, by virtue of a warranty decd recorded in Register of Deeds Office. SIGMA APPIICANT / / DATE « « « « «« Any information that is mis- represcatod may result in the unitary permit beiag revoked by the Zoning DepartmcnL ss Include with this application: a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed �b . . ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the /y /���� residence located at: 6 t i /,, �� /� Sec. ALT T_j C N, R W, Town of �( y A St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate 0 t or length of time: Oy gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known) : __A//,4 Age of T k (if known). (S gnat e 17 (Name) Pleas Print � ( itle) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I ce'rtify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code ex ( cept r inspection opening over outlet baffle) . Name r Signature <*ellr— MP /MPRS DOCUMENT NO. WARRANTY DEED T, SPACE RESERVED FOR RECORDING DATA i STATE BAR OF WISCONSIN FORM 2-1982 49427G 990 481 _ REGISTER S U ICE J]er -- and-- BatbaxaA .Miller_,__a /k /a_Barbara ST• CROL E�•,Wf Ann __Mil lex,___Huaband__and -Wife _ as__Joint- _Tenants_ -__. _ Reed for Record - - - -- - - -- - - - -- -- -- - - - -- - - - -- ------- - - - - -- - JAN 2 2 1993 � conveys and warrants to Mark__E.__. Lundberg __and__Sandra-- K.._______ ---------- -• - --- - - - -- - - - ---- ------------------ y - - - - - -- at to : R . M + ii max - al -- _--_- -'- !I Register of Deeds ;I I' -------------------------------------- ;. __ __ __ _______ _________ ___ ___ ____ _ _- __- _______ RETURN TO _ __________________ __________ __ ____ _______________ .__._ .- -_ __ ;i -Or - Six -- - ._._.... Count , j the following described real estate in --------- _ ............ � - t•. y - -, State of Wisconsin: Ta Parcel No- - - - - - -- ---------------- - - - - -- ;! The South Two hundred eighteen (218) feet of the West One Hun red Sixty -Five (165) feet of the Southwest Quarter of the Southwest Quarter (SWJSWJ) of Section Twenty -Four (24), Township Twenty -Nine (29) North, of Range Seventeen (17) West. Except portion sold to Highway Department. i • fi r- . I •A �� j �j I' it II I, 1 i I! �i This ---- 3s - - - --- - -- ----------- homestead :property. Ii i i (is) (is not) Exception to warranties: Easements, restrictions, and rights -of -way of record, if any I �{ Dated this ---------- 15 th- ----- •--- -- - - -- - -- - - -- - -- day of -- - -• - -- January ------------- - - - - - __ ---------- .. - - - -, 19.93.... I ' I! � --- - - - - -- - - - - --- (SEAL) j - - - - - -- (SEAL)_. �_ --------------------------------------------------------- * - Ronald W. Miller --------------- ------------ - - - - -- ----------------------------- I ' - - - - -- (SEAL). fi.G�t. / %L(.ryt ------- - - - - -- - - - - -- (SEAL) j! A u * _--_--_-_._---_--_-__--- _---- __- __-- ___- ____----- - - - - -_ + - - Barbara /Miller,_ a(k / Ann Miller if i AUTHENTICATION ACKNOWLEDGMENT �i Signature (s) _____________________ ----------------------------- _--------- STATE OF WISCONSIN ss. l ------------------------- - - - - -- ------------------------------------------ - - - - -- ST.CROIX ---- -- -- --- ---- ------- ----- -- - - - --- --County. authenticated this ________day of___________________________ 19_re me this _____ 15th ___ Personally came befo ----------- day of it }.� 19.93__- the above named __ Ronald__W___Miller_ and _Baxbax j -- --------- - - ---------------------- - ------------------------------------ - - - - -- .-Barbara--Ann--Miller ---------------------------- ------- - - - - -- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- ------------------------------ --------- --- --- -- -- ----- •-- - -- ---- authorized by § 706.06, Wis. Stats.) to me known to be the person __________ who executed the f Sing instrumprit and acknpw�edge the same. THIS INSTRUMENT WAS DRAFTED BY ° "• +.� Leo A. Beskar, At= torney �' �``. - -- - l ---- - - - - -- -------------------------------------------- --------------------------------------------------------- -------------------- - - - - -- - - -- ' :_••• I Rodli, Beskar & Boles, S.C. h �5 '•. "�?* : •J`�'�) - St_.OrA1X __._. ---- River— Falls - -W1 -- 54022--------- - - - - -- � i - -- -,i :Nptary Public - ____Count Y, Wis. (Signatures may be authenticated or ackno`wledge4 : Beth U }i?�' IjCommission is permanent. (If not, state expiration are not necessary.) o �- +t .date : �ICtary M- Hic,5E le of I'Vistrnsin 19 ) C' My C +ttn rl ;r IQ <irl *Names of persona signing in any capacity should be typed 0 r�jyi7t d b signatures. WARRANTY DEED ST "a7�ii OF WISCONSIN Wisconsin Legal Blank Co., Inc. ' FORM No. 2 — 1982 Milwaukee, Wisconsin t n N 0 0 Cl) 0 $ '9 0 7 r 7 3 o 3 (D (D n A 'O K M 1 K N � .0' 4t C .� 3 (n O O N q O A (7 O N m O ( O n j O • 0 a C A d 3 O O (00 d O. .� '~ n Cl) m o z n cn m 0 0 0 0 °- 0- N (D 0) Q CD N O A 00 (b p O O O CD N n n C 7 Oo �1 (J7 N (D p O O O O ~ l\ O O V N (fl N N (0 O � w un < D a D m a N (D to G - (D N CA p w c 0 G) (O O z. .O. .. O O � N O O in `"' CT N T CD N O f0 O N 0 0 0 N r a' n. I it CL) '' � tl 0 0 0 0 0 0 0 CL 00 Lo cn O N N N j 3 E N N y 3 O Ln or A cn O _ (D _ �1 (p � fD (O fD .. O_ Q lr � d N O N d N N 3 0) 3 d 3 d °' (D _ (D _ N C L N Z D O CD z Z o N a N O =. O D .-_�. 7 O Z D z 0 CL 0 X11 O O N N w C) 0 00 0. (D O y (D CD N • CD 0 N N N .. = O co C �t ��. 3 (D C (D d 3 w a d �� 0 A Z n din = C: C 7 p z O CL 0o v w T m °D M a a z 00 3 °o c 3 � m g CD tll m fll A CD N O IT 3 > N d i 'C2 (D (D O Q N I O S j CD I0) C CD A7 C O R Z () �. N O �7 O O x co A CD cn w C m F (D 0 t0 _ aCD N O 3 ? N CD d . 3 CD O tv cr N N N CD `r a A 0 {� 3 00 „0 CD CD O' w 0 0 iA O 4 00 O i O i .,� S ST. CROIX COUNTY ZONING DEPARTME .' AS BUILT SANITARY REPORT Owner . Property Address _ - S � 9 r C it y /State ,a ,. c cl � Legal Description: Lot _ ?" Block Subdivision/CSM # 2 � r '/a ,� ' /a, Sec. ,Z�, ' PIN N -R_W, Town of #` SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House Well P2 Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: �j /� Width _ Length _ Number of Trenches _ Setback from: House -'e Well '7s P/L / ©, Vent to fresh air intake 57� ELEVATIONS Description of benchmark Elevation � -- Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) ( ) ( ) Bottom of System O ge -;/7 O _ �'• C ( ) Final Grade () %'-? () ( ) Date of installation ?, &&,199 Per it number ?V — 9 State plan number Plumber's signature License number Date Inspector L Complete plot plan � X NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. I PLAN VIEW Sle- I G 3 G Of /7'6 4St I 4 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Sr. CM IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 344509 Per Hto1d Name: ATRICK El Cit[] Village Town of: State Plan ID No.: W , jJDSON CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: Z 66 1 d G S// - (� 020- 1133 -80 -000 TANK INFORMATION -�Iq ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic = . D Benchmark 6 � o Dosing L cl v or Aeration Bldg. Sewer Holding �/ Ht Inlet ` TANK SETBACK INFORMATION 6)I Ht Outlet TANK TO P/ L WELL BLDG. Air i to ntake ROAD Air Septic /Q NA D osing A Header /Man. Aeratio NA Dist. Pipe 7- Holding Bot. System *� , X PUMP/ SIPHON INFORMATION Final Grade Z Manufacturer mand Mo r G TD—HI TD Lift Fri S stem TDH F Loss d Forcemain Length Dia. Dist. SOIL ABSORPTION SYSTEM c , BED H widt Len , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth IM Z DIMENSION Ma fa SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC �u� ber: gr SETBACK H AM BER INFORMATION Type o / `_ Mo el N System: D V O l DISTRIBUTION SYSTEM Header/Mani Id Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. AM Spacing �Q!� / r /v ± Q / 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.) LOCATION: HUDSON 18.29.19.648,SE,SE 921 WILLOW RIDGE ROAD 6 ualue 3' 1 0 6 640<6 0 -a &V :5 / 64•e' wo S Plan revision required? ❑ Yes ❑ No Use other side for additional information. �� G SBD -6710 (R.3/97) Date Inspector' nature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E E ; t ..€ a .. .... . ...... .. t , a t � L a a 3 t I r # a �m e ym a -+ t E # , , »a S } s$ j ffi i D � � , a � S E a _ F S , », ,,— E F t „� t i { mm , �W „e r Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue *IscoAdn In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 3gq.Sa°/ Personal information you provide may be used for secondary purposes ❑ Check it revision to pre sous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Prop y Owner Name Property Location 1 /a TX 1 /4, S T , N, R E (or�N Property Owne 's w iling A res , Lot Number Block Number I 1? r .� City, S e Zip Code Phone Number S ubdivisio n N e o CSM N ber II. TYPE OF BUILDING: (check one) ❑ State Owned t� Neare Ro d 2Z,247A L T ( l age Public 1 or 2 Famil Dwellin - No. of bedrooms wn OF 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) W. SA 111. & 4 1 ❑ Apartment/ Condo w�i�s — 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. tK Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ System -------- System ------------- Tank Only______________ Existing System _________ExtsttnaSystem 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 12JR Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 1A 1 43 ❑ Vault Privy 14 ❑ System -In -Fill 31 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min /* ch) Elevation Feet Feet VII TANK Capacit gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks tic Tank o ❑ El 1:1 1:1 1:1 Lift Pump Tank /Siphon Chamber t ❑ I ❑ I ❑ ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for in tallation of the onsite sewage system shown on the attached plans. Plumbe s Na e: (Rri ) Plumb 's S n urG ( t ps) MP /MPRSW No.: Business Phone Number: r U b s Addres ( tree , City, St te, Zip Co O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater R;; Iss Issuing Agent Signature (No Stamps) EI� Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit 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 besubmitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 - 3151, To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed.' II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 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, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) crass section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. I 2? //w v_ �o I , 3p j 3 ac' 36 V. I I I ff��iJ GL/fLS� /� �2a 30� �! Fy IN W isconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page / of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 7 include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # I _ APPLICANT INFORMATION - Please print all information Review by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 41 ✓ Govt. Lot 1/4s 1/4,S T N,R E (ord Property bwriees Mailing Address Lot # Block# Subd. Nam or CSM# yi City State Zip Code Phone Number ❑ City El Village 0 Town Nearest oad ❑ New Construction Use: ® Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow _ gpd Recommended design loading rate , Zbed, gpd/ft gpd/ft Absorption area required bed, ft trench, ft2 Maximum design loading rate ,Zbed, gpd/ft2 trench, gpd/ft Recommended infiltration surface elevation(s) 1 5s, ell I ft (as referred to site plan benchmark) Additional design /site onsiderations Parent material Flood plain elevation, if applicable ft r S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S U W-S ❑ U 0 S ❑ U ®S ❑ U ❑ S t U ❑ S J9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots ::; Bed ,Trench s a ZAJ Ground A0 Y Depth to limiting n(i factor • ��,ZL_in. Remarks: Boring # F u Ground — • elev t Depth to limiting factor 2ZZ in. Remarks: CST Name (PI se Print) Si atu / Telephone No. Address �� 1 Date CST Number i SOIL DESCRIPTION REPORT PROPERTY OWNER A — Page of PARCEL I.D.# _/ /, 3R AL- 6,xk s Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench IV 41 S Ground J , elev. Depth to limiting factor 0 Remarks: Boring # I � ' Y Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; 13 Ground elev. � ft. Depth to limiting factor in. Remarks: Boring # z i Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9198) ST. CROIX COUNTY ZONING,OFFICE, CERTIFICATION STATEMENT 1 FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ;i��( �,�,¢i1� �� residence located at: 1 /4 1/4, Sec. s /R , Tlz--aN, R_ W, Town of / Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No,"� (if no, skip - next line) Approximate volume or length of time: gallons minutes Capacity: /BOO Construction: Prefab Concrete Steel Other Manufacurer ( if known) : Age of nk ( i f k wn) : (Signature) (Name) lease Print (Title) (LI Number) z +. (Date) Farm to be completed by licensed plumber (x.145.06, Wisconsin Statutes) ' or Licensed Disposer (NR 113 Wisconsin Administrative Code) f — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — u Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, is. Adm. Code (except for inspectio opening over outlet baffle). Name - Signatur - MP /MPRS 5/88 S I' CROIX COUNTY SEPTIC T, MAINTENAi'4CE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ � / V 1 Mailing Address �l L"I d V.✓ Jr — Property Address __s�90�e_ _. (Verification required from Planning Dep artment for new construction) _ City /State Parcel Identificnlion Number — LEGAL DESCRIPTION Property Location � r /4 /4 , S, ', Sec. � , �_ N -R1 /awe') , Town of _ • 1? Y Subdivision _11 ,e _ ,Lot Certified Survey Map # Volume , Page # _ Warranty Deed # �j I�4�'r/ , Volume , Page # >, Spec house © yesX no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Prope: maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed purnper. What you put info 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 ( ner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that(]) the on -site was Le water di posal system is in proper operating condition and/or (2) after inspe,: Lion and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1 /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 Commer,.e and the Department of Natural Resources, Statc 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. T6_1 SIGNATURE OF APPI.ICANT� DATE OWNER CERTIFICATION I (we) certi that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) G.e owner(s) of ,the property descri d bove, by irtue of a warranty deed recorded in Register of Deeds Office. SI A R OF APPLICANT DA L * * * * ** 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 fn,m the Register of Deeds off a copy of the certified survey map if reference is made in the warranty deed - 1 • // AS BUILT SANITARY SYSTEM REPORT TOWNSHIP AA2 . T / _ZJN, R /L 4 j. ADDRESS ST. CR OIX COUNTY, WISCONSIN. DIVISION / , LOT_,Yj LOT SIZE , PLAN VIEW -Distances b dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Well E -� I � i i i --� z � I In ri - a S CALF ".TIC TANK (KS) 4L4V GR._� i � CONCRETE_y STEEL N0. cdf rings on cover Depth DRY WELL _NCHES NO. of - -- width length area no. of lines __ width lj length area_ depth to top of pipe ,.:;r,EGATE RATE � AREA REQUIRED & P < 90 ©` AREA AS BUILT y /Y =iaimer: The inspection of this system by St. Croix County does not imply complete .- A.liance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for tem operation. However, if failure is noted the County will make ever effort to _ermine cause of failure. '''ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST `INSP OR DATED PLUMBER ON JOB LICENSE NUMBER 33 6 3JP RS z REPORT OF INSPECTION_INDIVIDUAL SEWAGE SYSTEM • San.itany Penm.it State Septic G _ NAME � � L' '� rawna hip � St. Croix County location Section J SEPTIC TANK Size gattonz. Number o5 Compantmenta 1 D.i.atance Fnom: W et it. 12% on greaten scope < ,2_Q 6t Bu.itd.ing it. Wettands fit. H.ighwaten `__ it. DISPOSAL SYSTEM D.iatance Fnom: Wet 12% on greaten Atope bt. Bu.itd.ing it. Wettands F t. H.ighwaten it. FIELD DIMENSIONS: Wi o j tre nch it. D epth o b no ck ' b etow tite 5 Z Length of each .Line — � it. Depth o4 rock oven t,ite Number of tineh 3 Depth o4 t.ite below grade .in. q, Totat .length o j Z ines it. Sto pe o6 trench .in pen 100 it. D.i.btance, between tinez Depth to be.dnock ' Totat ab.d onbt.ion anea jt Depth to groundwater fit. S G Requ.ined area 5,�o it2 Type of Coven: Papers n Straw PIT DIMENSIONS: G Number o4 p.it's I Gnavet around p.it.5 yea no Out,6ide d.iameten it. Depth below .inlet fit. 2 Total abzonbt.ion an it A Area ne ed it2 INSPECTED B TIT APPROVE /r� ,DATE — 19 7 REJECTED , DATE 197 I J EH 1.15 • 4 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH _ - P.O. BOX 309 MADISON, WISCONSIN 53701 /p REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: �G' /4,- SE' /4, Section 1L, T-2?N, R/5_� IV (or) WT,wnship or Municipality /�7 / u J SdN Lot No. `�, Block No. r`�% X �� �� County ! S UbdiviSion Name Owner's Name: �►^,`cK � f // Mailing Address: g/� Ze d h Sy`% v u it, ,. S . TYKE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 1�7_- PERCOLATI ON TESTS S-- 3-72 SOIL MAP SHEET S 7 SOIL TYPE J RX V0 A - trA t — ��►15/rt �- �' /'Px PERCOLATION TESTS TEST I DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED" SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN P 1 fig" 5�,e jre 1), 14 / - P °Z qg" _< e &re- 0,4'14 / A10 3 f0 (O (D. • P-3 i ye" 90 r e- & A A /y /1/d -3 � � 6 's SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B_ r�, +cam, o .. s 36" B- � C6,� ,clo,,<< 796•, (, «tS, 3,2 " SAC, S'$" S +ter, y 6 „ / 6 „ i o s c „ � B- s- � yob 6„ r1LoK� 7Y6�� `, rtS, r/, Jr" S'f► Gr. G,- PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locationand square feet of suitable areas. Indicate number of square feetZ absorption area needed for building type and occupancy. /-gy Zk'Ob Sk A " •`f,OLC �'� �� Sys Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. I- fJeP /,>tee,dr�; a C1' rm se I \ t N 03 Ba x i / rc, - \ c • l�� � d e _ v s u � _ � � re ,� l e. _ ,S c t lo rz / so N .� `le zAt94YA y I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with t procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Q S r p� a, Certification No. Address /44r'o Name of installer if known e 1 CST Signature COPY A —LOCAL AUTHORITY State and County State Permit PLB B Permit Application Per 't # PP County � - for Private Domestic Sewage Systems Count *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: GGU 5 le-Si tR' elLie B. LOCATION: S E ' ' /<, Sec ion Le , T,; T N, Rj!7 & (or) 0 Lot# _ City _ Subdivision Name, nearest road, lake or landmark Blk# Village w I e Towns C. TYPE OF OCCOPAN Y: Commercial *Industrial *Other (specify) *Variance Single family ( Duplex No. of Bedroom !� No. of Persons D. TYPE OF APPLIANCES: Dishwasher ( YES NO Food / Waste Grinder YES ,< NO # of Bathrooms --Q-- Automatic Washer R YES NO Other (specify) 14 00 E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation a( Addition_ Replacement Prefab Concrete x *Poured in Place Steel Other (specify) _ F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) :5 3) , 5 Total Absorb Area 0 q. ft. New Addition Replacement *Fill System �2U r�'.1 /Pgu.rred Seepage Trench: No. n . Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width Depth A, Tile Depth _3(v No. of Lines 3 Seepage Pit: Inside diameter Liquid D� Tile Size Percent slope of land - /ate } A L.Jej y Distance from critical slope I, the undersigned, do hereby certify that the information / I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tes�, NAME ► Jr ' er C.S.T. and other information obtained from (owner /builder). Plumber's Signatu MP /MPRSW# 47 , -P Phone Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). E - W11111 e _. v A F s 3'�'� $� �Q, j , , , , Do Not Write in Space Below FOR DEPARTMENT USE 9NLY _ Date of Application .'S - - Fees Paid: State la -� Con y X Date Permit Issued /Rejected (date) =/� Issuing Agent Name _ d Inspection Yes No Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/11/76 VOL 1 V)9 F41 1:5 t5 1� -11 -3 C) --1 -4 Document Number QUIT CLAIM DEED 7:iL-L' ','I H-� Wf'i �rl r 1) L PATRICK R CRAWLEY and MARY J CRAWLEY husband and wife quit-claims to PATRICK R CRAWLEY and MARY J CRAWLEY husband and wife. as survivorship marital property E the ollowing described real estata in St. Croix County, State of Wisconsin. T4AHSFER :E7: RE'AR.DHG - (Parcel Identification Number) 020- 1133 -40 -000 Recording Area nd±LtuyAddress PATRICK R. & MARY 1. CRAWLEY This is horricstead propetly. 921 WILLOW RIDGE ROAD i U DSON WI 54016 1 LOT 39, WILLOW RIDGE 2ND ADDITION TO TOWN OF HUDSON. PATR' R CRAWLE * MAARYJ R�A W'L Y AUTHENTICATION ACKNOWLEDGMENT Signature(/) R- Cra STATE OF Wisconsin 10 C r-W 1w COUNTY OF St. Croix it Personally came before me this day of 199 authent ed day of th- above named PATRICK R CRAWLEY - 4 "00MEMW MARY J CRAWLEY to m-- mown tc be the pe who executed the foregoing instrument signature and acknowledge the same. type or print name signature r'71-17- MEMBER STATE BAR OF WISCONSIN type or print name Notary Public County, (If not, avthorized by'706.06, Wis. Slats.) My comm tssion is permanent. (If not, state expiration da! THIS INSTRUMENT WAS DRAFTED By es of persons signing in any capac0y, s! -uld De typed 0(printeo Robert F. Wall V'LA TTED LANDS iB r 1 BIZ ��� j� _ ?T7. I►2 /73.�►Z °" 6\ 00 N LAK E O y \ \\ ro �- a 9 ti y ,� � w c di 4 �y S a N d £ Cu LU N�e49AlaE 1 O N .p a iaszl3z � O 0 � � •ze " `� � ' to � I 3g9 9� `� E W �` a i7.s•��; ?37. �O C C I o o ✓V,, 0 0 w o ts