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• • ST. CROIX COUNTY ZONING DEPARTMENTS
AS BUILT SANITARY REPORT ~Owner yI Af Al- PP Prope
rty Address 13 ?13 I AIA(City/State /~Q U C-, TO Af ~/0 Legal Description:
Lot Block 7 Subdivision/CSM # ~
, PIN # _ 0 'Dd4
f - t/4 ALe t/4, Sec. 12, TAN-R~Qy W, Town of 5;r
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer ill ga Size ST/PC/ aQ / Setback fr om: House I. ~a"We112q=P/L 3.2
Pump manufacturer ZDELZ E2 Model /D
Alarm location lec, ss &
(UOLDING TANKS ONLY)
Setbac cs. S . _ _ Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: at--AfL,1,1 Width _3 Length 2 -5"'- Number of Trenches Z
Setback from: House d Well &-5- P/L 6_ Vent to fresh air intake 192'
ELEVATIONS:
~ .r
Description of benchmark La ST,4fiE SUJ cyan Elevation g g,0,6
Description of alternate benchmark WoZ o o r- Y,-,o l Ac o y -V//t p Elevation 9,5-- 78
Building Sewer F11,72 ST/HT Inlet . 9 ST Outlet D PC Inlet fQ 6
PC Bottom _ 2/,,2A Header/Manifold Top of ST/PC Manhole Cover
( )
Distribution Lines 51Y-3-3 (2) FY-33
Bottom of System (1) U00 (2) 9 -06 ( )
Final Grade (1)~ 7 (2) AL ' 7 ( )
Date of installation I 9 Permit number 3 3 ,ff ~L2 State plan number IVA
Plumber's curn ature - License number 0 !4f Date / 457
Inspector
Complete plot plan
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.
PLAN VIEW
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INDICATE NORTH ARROW
afety r of Commerce
Safety and Buildings Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT
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)].
Permit Holder's Name: ❑ City ❑ Village 0 Town of: State Plan ID No.:
CANOPY, KEVIN ST. JOSEPH
CST BM Ell-e-v.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9900192
TYPE MANUFACTURER CAPACITY TION BS HI FS ELEV.
Septic W"ks load Benc mark
Dosing Vbm
Aeration Bldg. Sewer 90-
Holding t IKf Inlet Z eP1
TANK SETBACK INFORMATIONt Outlet p
Vent to , O fts•
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet ~S 2-
p, u
Septic 2 r 39 11 AIA NA Dt Bottom -1
Dosing / r NA Header / Man. Jyv, :3 9( y YZ
Aeration NA Dist. Pipe g Y 3 .
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 5
Manufacturer P Demand 5 DZ
Model Number fcs~~PM C s
TDH Lift Lrictiory. System TDHf;Z3Ft (p
Forcemai n Length S 3 Dia. Z r~ Dist. To weu
SOIL ABSORPTION SYSTEM
BED N.CA Width Len., No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM bisr6N s DIMENSIONS
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING IVlanu fi,-_
INFORMATION Type O CHAMBER Moe umber:
System: h -ft 30 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipes x Hole Size x Hole Spacing Vent To Air Intake
4-160
Length Dia. 7 Length ;k Dia. Spacing s / 1 /1 1 441
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 El I` ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 27.30.20.582,NW,NE 1393 MAIN STREET
'39'
CZ) 4A ZA Lee, i sv 1
U ifItye,41401 I- +0*
Plan revision required? ❑ Yes [g,"No
Use other side for additional information. (o Z
SBD-6710 (R.3/97) Date Inspector's Signa re No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
F
3
4 Y
E
F
{
x
i
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l
Ais~onsin Safety and Buildings Division
SANITARY PERMIT APPLICATION Zoo E. Washington Ave.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. ST C (20 (':74
• See reverse side for instructions for completing this application State Sanitary Permit Number SM ~ -7
The information you provide may be used by other government agency programs ❑ Check if revision to previouslication
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Propert Owner Name Property Location
/4 ~F 1/4, S T Q , N, R E (or)(10
n Propert Owner s Mailing Address Lot Number Block Number
r
Cit State Zip Code Phone Number Subdivision Name or CSM Number
it v 8 ( -C
MC-7-0 At W, AIIA
11. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ❑ village Town OF . 0 Iy Aay.
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 2_71. 30. -2-0 , S$
1 ❑ Apartment/ Condo O O - D -SO- 00 2
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. ;K Replacement 3. ❑ Replacement of 4. Q Reconnection of 5. Q Repair of an
System________System_____________TankOnly______________ Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one) C9 ~ C ~ te-t .
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 (Seepage Trench 22 ❑ In-Ground Pressure / 42 ❑ Pit Privy
13 Q Seepage Pit e X `7 43 Fault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION-
70:77)
1. Gallons Per Day 2_ Absorp. Area 3. Absorp. A ea 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
0 .0 .1-5,00 Feet O Feet
Capacft
-
VII. TANK
in gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
e Ic Tank or ng Tank (f QQ~ ` ❑ ❑ ❑ ❑ ❑
tftP,,pTank/,~iA,,era-m_bejr 0001 1 O r ' ❑ ❑ ❑ ❑ ❑
VItr-RIESPONSIR1111 STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu a 's Signature: (No Stam P/MPR Business Phone Number:
of 17 -
JAI oz:g~ ; 2 Y"
Plumber's Address (Street, City, State, Zip Code):
S O
IX. CO NTY/ DEPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing tSi ature No Stamps)
approved Surcharge fee)
pp Q Owner Given Initial"' r 1
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 IRA 1196) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
i
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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
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.
C 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, lotAonof 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 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
Wiscon,Siri Department of Commerce SOIL AND SITE EVALUATION
bivfsion of Safety and Buildings Page __L_ of
Pureau of Integrated Services in accordance, 6} 11 ; 09, Wis. Adm. Code
Attach,complete site plan on paper not less than 8 1/2 x 11 inp s iI size. lan*st County
include, but not limited to: vertical and horizontal reference ~ajFltBM), dirQ~n C~ rD 1rX
percent slope, scale or dimensions, north arrow, and locatio1n ap8 distance to n~A oad. Parcel I.D. #
APPLICANT INFORMATION - Please print all'I,W~ rmatiojt '-HCNk€ ~ 9 Reviewed by Date
Personal information you provide maybe used for secondary purpose (Pfi~cy '1_64 1QfC t) (m)). 0~7 tJ AA le -7, ) c cf
_w' 7
Property Owner -rarurty
I{ ~n~YW /
/Y1 C_ y) ~ : ~r 1/4 =1/4,S .7 7 T3® N,R ?0 4W W
Property Owner's Mailing Address r ( #--Block# Subd. Name or CSM#
13V .51, 1
Cityt/ ` State Zip Code Phone Number El City El Village Town Nearest Road
/7OUt / L✓.z S'Yob!? (~/f`) 5 9'69x3 ? N.,Ir
❑ New Construction Use: Residential / Number of bedrooms- Addition to existing building
Replacement
/~y~ ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate - S bed, gpd/fit . trench, gpd/ft2
Absorption area required bed, ft27Mtrench, ft2 Maximum design loading rate - bed, gpd/tt2 - 4trench, gpd/ft2
Recommended infiltration surface elevation(s) 9~r o0 It (as referred to site plan benchmark)
Additional design/ site considerations f
Parent material dG i Flood plain elevation, if applicable /Yn ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ®S ❑ U ®S ❑ u 0S ❑ U 5i-S ❑ U IJ s ❑ U ❑ S 19 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g in. Munsell C lu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
o-,I7, ' 11-Y ~scL lrzsd k M Pv- w
Ground 3 s =S8 7i _Y14 S/~ L S ,?,I S4 41
l~J .S~ 6
elev.
"ft.
Depth to
limiting ;
factor
Remarks:
Boring #
Ground 51 96 f L.S D
9 eOKft.
Depth to t.
limiting
faotQr
A-Lin. Remarks:
CST Name (Please Print) Signature Telephone No.
7T~a 2/S 5`V9_e S7/
Address 00, Date CST Number
/~/le l/~✓ ~ru.' ~rse~ L✓1 T ,VD1 f~ ~9'/~ 122 7
, SOIL DESCRIPTION REPORT
PROPERTY OWNER Ca p C~7/ Page of
PARCEL LD.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
a / 2119 Ts~/L /rte k m~- IP
Ground .3
(i e,
Depth to
limiting
lactor in.
Remarks:
ks:
Boring #
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 #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD-8330 (R. 07/96)
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• PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VE WT CAP
M"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING
T
JUNCTIOM BOX MANHOLE COVER
~ 25' FROM DOOR, 12•MIU.
WINDOW OR FRESH I
AIR INTAKE I
CvRADC I M• MIN.
I
7- COWDUIT
11~
. PROVIDE ) - IN LE T AIRTIGHT SEAL i I I I
I I I i APPROVED JONI
APPROVED JOIMT A I I ( W/C.I. PIPE
W/C.I. PIPE k
I II LxTENDING 3'
EXTENDING 3' ALARM
ONTO 50610 &OIL I I ONTO SOLID 6011
0 I I
10
I OW
C I I
LLCV.._^ FT. PUMP
OFF
D
CONCRETE CLOCK
3" APPRO
R15ER EXIT PERMITTED DULY IF TAWK MAMUFACTURCR H^S SUCH APPROVAL gEppl
SEPTIC f 5PCC.IFIC. ATIOPIS
DOSE
TANK MANUFACTURER: WUMBER OF DOSES: PER DA4
TANK 51ZE : GALLONS DOSE VOLUME
ALARM MANUFACTURER: ~LJlY/r ALE/ INCLUDING BACKFLOW f~~• _-GALLONS
MOOCL WUMBER: CAPACITIES: A=IUCHES OR 3 Lj!: GALLONS
SWITCH TyPE• CR U 8= INCNES OR G+LLOWS
PUMP MANUFACTURER: Z-2 L6 C.INCHES OR CALLOLI5
MODEL NUMBER: /r,'YIQ D. /INCHES OR GALLOWS
SWITCH TYPE: MOTE: PUMP AMD ALARM ARC TO OE
MINIMUM DISCHARGE RATE ?j~ yy GPM INSTALLED OW SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND, DISTRIBUTIOW PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . FLET
FT. I IoW FACTOR.. FEET
+ 60.0- FEET OF FORCE MAIN X ~ o rcFRCT ~
TOTAL D*JMAMIC HEAD FEET
/NS/D6 Q/A
INTERLIAL D LWSIOWt OF TAWK: Me%==~I ;V#i _ -80iLIQUID DEPTH 3_
SICTWED: LICLOSE NUMBER: .1'217 ZZ DATE: S Zy ~i
ri
HEAD CAPACITY CURVE
W EFFLUENT MODELS
- - - A CAUTION Model 18514185 should
nnl I m enb~nl 1 14' Inoa Ihnn 11) 1"01 1 D"
40 ISU
38 125-
120-
36 91
34 110-
32 105
00
30-
21-
go
186,
26 85 4186
24 80 165.
4165
22.
70
i
1? 20-
18 60_ 163, - -
4163 114
a 4189
50
14 45-
2 40-
140, 88,
35 4140 4188
10
30 185, \
8 137 4185
25- /
8 20 .r/
4 15
10 t4'
5 -
53,57 98
0
U.S. GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160
LITERS 80 160 240 320 400 480 560 640
0 FLOW PER MINUTE 009922
TOTAL DYNAMIC HEAD/
FLOW PER MINUTE
EFFLUENT AND DEWATERING
MODEL 53,55, 98 137 140, 161, 16 165, 185, 186, 188, 189, 191
4140 4161 4163 4165 4185 4186 4188 4789
. LTRS. GAL. LTRS. GAL. LTRS. CAL. LTRS. CAL. LTRS. . LTRS. GAL. LTRS. GAL. LTRS. CAL. URS. GAL. LTRS.
FT. M. GAL. LTRS. GAL. LTRS. GAL CAL
5 1.52 43 163 72 273 93 352 91 344 100 379 61 231 61 231 58 220 145 549 145 549 45 170
10 3.05 34 129 61 231 79 299 84 318 93 352 61 229 61 231 58 220 140 530 140 530 45 170
15 4.57 19 72 45 170 64 242 76 288 85 322 60 227 61 231 58 220 134 507 135 511 45 170
20 6.10 25 95 36 136 68 257 79 299 59 223 60 227 58 220 128 484 131 496 45 170
25 7.62 8 30 59 223 70 265 57 216 59 223 58 220 122 462 125 473 45 170
30 9.14 49 185 62 235 55 206 58 220 85 322 58 220 116 439 120 454 45 170
40 12.19 21 79 45 170 46 172 55 206 70 265 58 220 104 394 109 413 45 170
50 15.24 20 76 33 125 50 189 51 193 58 220 90 341 97 367 45 170
60 18.29 15 57 39 148 32 121 58 220 71 269 85 322 45 170
70 21.34 23 87 9 34 52 197 51 193 69 261 45 1170,
80 24.38 10 38 45 170 28 106 51 193 45 170
90 27.43 31 117 2 8 34 129 45 170
100 30.48 16 60 17 64 tIIN7
110 32.00 4 15 120 36.58 130 39.62 LOCK VALVE: 19.25' 2}' 26' 46' S6' 66' 86.5' 73' 114' 91' 170' SSPMA
MEMBER
SUMP L L
AND SEWAGE
PUMP MFRS. ASSN.
I /
ST CROIX COUNTY
/ SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer IN /R V
Mullhig
Property Address /ZA /7Quc T p / 8 2
I/V ~T
(Verification ~~required from Planning Department for new construction)
City/State 06? C TDAL Parcel Identification Number. ® 30 - Z.D GO -S0 -ODO
LEGAL DESCRIPTION
Property Location AUL%4, §C '/4, Sec. LZ, T20 N-RAW, Town of ST~~ fj,Dy - .
Subdivision &A Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # ~=Q: Volume Page # 03
Spec house ❑ yes Ir no Lot lines identifiable [?Kyes ❑ 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.
Uwe, 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.
9
2i ~ L!::. ~ ~ /aZ2/
SIGNATURE OF APPLICAI DAIM
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.
S /.2
SIGNATURE OF APPLI A
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
~ '`)CUML-41 NC) WARRANTY DEED !i rT41i, SPA. :E RE ,E1:VED FOR RECOR1- DATA
STATE BAR OF WISCONSIN FORM 2-19931~
431'307 I iREGISTER'S OFFICE
5~,?~~~~ thl ST. CRUX CO., WI
Recd tnr Record
NORMAN C. JOHNSON and CORRINE A. JOHNSON, ; Dec. 29, 1987 jj
husba„d and wife as joint tenants it 11:20 A M
:on.-~• and %-.,rrants to KEIIIN L. CANOPY and
CONSTANCE J. CANOPY, husband and wife as,- Register of Deeds
survivorshipmarital oronert~, L!
it
-4 -n
:I
c "
tie „~lowi:t des-crihe,l real c+':,+.e in -
St.A Croix
o a r, t} , - - - - -
State ,r Wisconsin:
Tax Parcel No:.------._
Lot 28, Block "7" of the Plat of Village of Houlton, St. Croix County,
Wisconsin.
TOGETHER WITH AND SUBJECT TO any and all easements, covenants,
reservations and restrictions of record.
'i'RANS~
FEZ
is t,,,, I. r.,,•:
XXXXX
!'KC.r.L - arr::tt~a.
28th ~I- Dec m 7
I3-
:t-AI
yea[.
Corrine A. Johnson IT ~l
• Rob~ rt W. Mudge, att ey in
fact for Norman C. 6hnson
AUTHENTICATION AC KNOW LE DGMP NT
Signatri;) _ STATE OF IFISCON~1",
- >s.
- - St. Croix
R':~t;°3^.t:Cat Efj t11:J ]`l - r I~I - 281-h
ct -cane ; c, m
December ,y 847
` - - Robert W. Mudge attorney in fact
TITLE: MFNf"F.P TATS fl,;R i) XII.- (,A~i`; for Norman C. Johnson
f I` not
at~or. and Corrine A. Johnson
Attorney Robert W. "fudge--~=
GII.BEr"P, MCGE, POWCER & LUNDEEN
110 Second Straet, Hudso::, Wisconsin
lr,: nit .t.. . 1, •,.i 7)
ALICEJ.F1-EISG#~V H.
Mot?-+ Putric
Stan' I'IIS00(Isin