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HomeMy WebLinkAbout042-1055-40-000 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 /2, ou Q*t'.� A / �A- I zx INDICATE NORTH ARROW v Wistonsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety. and�3uildings Division INSPECTION REPORT IX GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryEelrnitlVDZ Personal information you provice may be used for secondary purposes (Privacy La s.15.04 (1)(m)). 3 44 44 u6 �� Per t{pl '�N'9 B ERT ❑ Cit�,,�J,a v ❑ Town of: State Plan ID No.: CST B Insp. BM Elev -: BM Description: wWtatc 1V Parcel 7864102:- 1055 -40 -000 l� + TANK INFORMATION ?- 17 -f 1 ELEVATION ATA TYPE MANUFACTURER CAPACITY. STATION BS HI I FS ELEV. Septic Benchmark W. 1 rE n� .'ti Aeration Bldg. Sewer H ng St/Ht Inlet TANK SETBACK INFORMATIONJ! Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt irl Septic OU Y"�Di t NA D in A Header / Man. A Ion NA Dist. Pipe a IeNf 1� h•L �Q� Holding Bot. System I�w to /iZ' 4�s� PUMP/ SIPHON INFORMATION Final Grade H -mot r Manufacturer m nd p 25i 0a Itie- Model u GPM TDH Li L ric S stem TDH Ft orcemain Length Dia. owell SOIL ABSORPTION SYSTEM BED R NCH Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liq h DIME - DI MEN N G Manuf r: SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM 'INFORMATION Type O System: !r S 3 ( /Ov t OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length � Dia. Spacing Z - 4Z Z Z �7 J SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over De th Over xx Depth Of xx Seeded /Sodded xx Mulched ep P Bed /Trench Center Bed / Trench Edges Topsoil ❑Yes ❑ No E] Yes [] No cy COMMENTS: (Include code discrepancies, persons present, etc.) s �� �- y r LOCATION: WARREN 20.29.18.306C,NW,NW 1063 HIGHWAY 12 - LOT 1 V 'r4r ltd 5 1% ( R3A1f ut� Pow �6� 5 Gt/Clrt 'S �c oo�•r �rta�s 4 .� '�C, Plan revision required? ❑ Yes [ Use other side for additional information. ca1_a71n io qu0-7% Date spector's Sigqg Cert. No. X KY `' 3� OL z p Safety and Buildings Division e.•��r�., SANITARY PERMIT APPLICATION Bureau of Building Water Systems 2011 Washington Ave. In accord with ILHR 83.05 fWis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the s ?rti, on less Ccitpty than 81/2 x 11 inches in size. • See reverse side for instructions for completing this appy a4pn pt i;' t* '. State Sanitary Permit Number t: r , ,Ix - jY-Y(' z Z The information you provide maybe used by other government agency pro ra Q.tf,jj • ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. \\ { °Y ".F Flatolan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL I ATIO Property Owner m ._1_ 1 A(roperty, 166ifajic �j—f- #i /4, S ,{ �j T �, , N, R g E (or Property Own r sMailingAddress Lot Number Block Number D 2 City, S to Zip Code Phone Number Subdivision Name or CSM Number���g/ II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Ro d ❑ Village 2 Public [] 1 or 2 Family D welling - No. of bedrooms wn OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) Zv Z F (,P & C 1 ❑ Apartment/ Condo e J( 2 —! e57, —Al 0 ^ 00 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 E] New 2 Replacement 3. ❑ Replacement of q E] Reconnection of 5 ❑ Repair of an System System Tank Only______________ Existing System - --------- Existing System B) A Sanitary Permit was previously issued. Permit Number y� Z. L Date Issued �? ` V. TYPE OF SYSTEM: (Check only one) ' Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ S epage Bed 21 E] Mound 30 E] Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill ( _ - 3 X VI. ABSORPTION SYSTEM INFOR ATI N: 49•s // IN t+G- , m 7' 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System E(�v. 7. Final�Grade � 0 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) ?b o5' Elevation el 4 1 i F(J3 Q , Feet Feet Capacit VII. TANK in allons Total # of Prefab. Site Fiber- Exper INFORMATION g allon s Tanks Manufacturer's Name Concrete Co Steel glass Plastic App New Existing strutted Tanks Tanks eptic T or+4aklia9Tank �QOQ Lif 1 tuber ❑ ❑ ❑ ❑ I ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's S gnature: (No Stamps) MP /MVyiyo8 B;ui ness Phone Number: .F C_A1/ /` � . 7 —33 ,2 2 P lumber's Address (Stre t, city, state, Z�ode): � � O 5>7 t t.lJ Q IX. COUNTY DE PARTMENT USE O NLY ,,�� ��11 F1 Disapproved Sanitary. Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) PtA roved Surcharge Fee) T pp ❑Owner Given Initial Adverse Determination - j X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVALti/ SHD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber JIM t Safety and Buildings Division tIll�ii "� tee+ SANITARY Bureau of Building Water Systems �� ■■.,r.r. PERMIT L M 201 E. Washington Ave. In accord with ILHR 8 �Idm. Co P.O. Box 7969 0 0 ` Madison, WI 53707-7969 • Attach complete plans (to the county copy only) forth s m, orMt lesYS`� : unty than 8 112 x 11 inches in size. 1 • See reverse side for instructions for completing this ap II 1 t)O4 P ? , i. St to Sanitary Permit Number Sz cRGlx 3 The information you provide may be used by other government agency p tp{r ms Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. �. " NI�IGCJFF /CE tate Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL AT �' Property O ner amQ r p n f!, O s 1/4, S :A !: N, R g E (or)Q/ Property Owner's Mailing Ad r ss Lot Number, { be r City, ate Zip Code Phone Number Subdivision Name or CSM Number Ti. TYPE OF BULL NG: (check one) E] State Owned ❑ tit �� l / V Nea oad E] Public 1 or 2 Famil Dwellin - No. of bedrooms V onn of al- aw"krA /2 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) . - 2A . VT 1 ❑ Apartment/ Condo (5 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. ktd"`eplacement 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 ❑ S age Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 eepage Trench' 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit f ° " 43 ❑ Vault Privy 14 ❑ System -In -Fill f ' ; k 5 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 nn Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation -Y,57 0 1 5 1 3 yQ 1 Feet 9? . 75 Feet VII. TANK Capacity in gallon Total # Of Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete con- Steel glass App. New Existin strutted Tanksl Tanks Septic Tank 0r4taLca4ZQl`0k_ /o ©o Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system h wn on the attached plans. Plumber's Name: (Print) Plumb is Signature: (No Stamps) MBusiness Phone Number: Alufb I t s = 7AY9` -332 (Stree , ity, State, Zip Code): w ?�" 3 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued IssuiA A ent Sig attire (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination a' �D wl X. CONDITIONS OF APPROVAL / REASONS FOR ISAPPROVAL: S9D -6398 (R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Ruilrlings nivi ion, Owner, Plumber 8 ei, F, kx Pit /V y ;PV. 7,29 l 9�, 7 N N � �a 1 7.5 i -PaE1 „ C c Jo- 6,e S coo n h 0 (A `7 - - J�-, g y' A Lie SCALE l” _ (} Tom Nelson BM L a / BM 2 -�.,� s G n ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I �hav/"e inspected the septic tank presently serving the Ab f't /o/iY S ' residence located at: (� ;, �/ Section �70 , T_1$N, R _tg , Town of W 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 fr absorption system? Yes V No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ) DOD 0 Construction: Prefab Concrete Steel Other Manufacturer: (If known): Age of Tank (If known) : j // 7 g (Signat re) (Name) Please print (Title) (License Number) -4 -99 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 certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). r Name �/\�� gnature L 24� P /MPRS �} Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Environmenta BY Desiga Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION - PI p&)t-all.information. R e Personal information you provide may be used yedgndary Pub (Privacy .haw. s. 15.04 (1) (m)). Property Owner 7 Property Location Folks, Bob� Govt. Lot NW 1/4 D W 1/4 S 20 T 29 N,R 19 W Property Owner's Making Address Lot # Block # Subd. Name or CSM# 1063 Hwy 12 a 1 City V zip - u ayr ; [� City ❑ Village ®Town Nearest Road Roberts ' 3 '4 ' ' J Warren STH 12 v ® New Construction Use: , ;, , '�W4 drooms 3 ❑Addition to existing building El Replacement El of mrb4 ' ribe Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpdr 8 trench, gpdhF Absorption area required 643 bed, flz 563 trench, ft Maximum design loading rate .7 bed, gpd/fF .8 tr ench, gpd/ft Recommended infiltration surface elevation(s) 94.25' ft (as referred to site plan benchmar Additional design / site consideration t Parentmalerial loess over Glacial OatWash Fl la in elevation, 'If licable NA ft ble for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank itable for system NS El U ® S❑ U ❑ S ®U N S U ❑ S NU CS z U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/fl? Boring# Horizon in. Munsell Qu. Sz. Cont Color Texture Gr Sz. Sh. Consistence Roots Bed ! Trench .............. 1 1 0 -10 10yr4 /3 - sil 2msbk mfr as 2f .5 .6 2 10 -25 7.5yr4/6 - Is 2msbk mvfr as if .7 .8 Ground 3 25 -74 7.5yr5/6 - gs Osg ml cw - .7 .8 elev 97.95 ft 4 74 -86 7.5yr6/4 - s Osg ml cvv - .7 .8 Depth to limiting factor CA >86 Remarks: 1 0 -12 10yr3/2 - sil 2msbk mfr as 2f 5 i 6 2 12 -29 10yr3 /3 - sil 2msbk mfr as if .5 ! .6 Ground 3 29 -36 7.5yr4/6 - is 2msbk mvfr as - .7 .8 elev 96.75 ft 4 36 -45 7.5yr5 /6 - s Osg ml cw - .7 .8 Depth to 5 45 -52 7.5yr4/4 - is 2msbk mvfr cw - 7 i 8 limiting 6 52 -88 7.5 6/6 - s Os mt - - .7 .8 factor yr 8 >88 Remarks: CST Name (Please Print) Signature: Telephone No. Thomas C. Nelson 715 - 246 -2454 Address Environmental By Design Date 6,6 5'C CST Number Ref# 1432 120th Street, New Richmond, WI 54017 —'404X ff227387 252 r - - P17OPERTY OWNER: Folks Bob SOIL DESCRIPTION REPORT Page 2 of 3 PARC LLD 1 E .# Environments By Design Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ! Trench 3 1 0 -10 10yr3 /2 - A 2msbk mfr as 2f 5 6 2 10 -29 10yr3 /3 - sil 2msbk mfr as if .5 .6 Ground elev 3 29 -39 7.5yr4/6 - Is 2msbk mvfr as - 7 ; .8 99.32 ft 4 39 -65 7.5yr5/6 - cs Osg ml ew - 7 8 Depth to 5 65 -98 7.5yr5/6 _ s Osg ml - - 7 8 limiting factor Remarks: Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor Remarks: [MV iPOKAfR7AL i 1432 120'' STREET. NEW RICHMOND, M ISCONSIN 715 -24o -2454 Tom Nelsor, Ceriitird Sud Tester `!27+87--- AvOstered Swittarhm sRt_io'.71 3 K#* 4K} K} KFK♦# k;## 44fiM #m #u #K #K4�. ♦ #1 # # #�s # # # >� #M3 K44 K� }kK� # #� #4KK# c I L i i i ! 15 Ci Z3 =1, 1 � SCALE l "' = �) , Tom Nelson JBNI { �± l �<<► �7..� .. ,� ; BM 2 ..� I x6W4 Department of Commerce SOIL AND SITE EVALUATION Pace 1 of 3 'Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Ental By Design Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Paroel I.D.# APPLICANT INFORMATION - Please print aff information. .. Personal inforrnation you provide may be used for secondary Purposes (Privacy Law. s. 15.04 (1) (m)). R Date � U Property Owner Property Location Folks Bob Govt Lot NW 1/4 NW 1/4 S 20 T 29 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1063 HNIT 12 1 City State Zip Code PhoneNumber ❑ City ❑ Vfllape ®Town Nearest Road Roberts W1 54023 Wamen 1 STH 12 ® New Construction ❑ Residential / Number of bedrooms 3 ❑Addition to existing building ❑ Replacement Use. . ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpdfif 8 trench, gpd/ft? Absorption area required 643 bed, ftz 563 trench, fts Maximum design loading rate .7 bed, gpd/ft2 .8 tr ench, gpdfiF Recommended infiltration surface elevation(s) 94.25' ft (as referred to site plan benchmar Additional design / site consideration Parent material Loess Over Glacial OutWash Flood plain elevation, if applicable NA It S Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill bolding Tank U= Unsuitable for system NS 0 U 0 S❑ U I ❑ S IN U E S❑ U ❑ S NU ❑ S N U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Rood GPDAIR Borin 9# in. MunseN Qu. Sz. Cont Color Gr. Sz Sh. Bed Trench 1 y 1 0 -10 1Oyr4/3 - sil 2msbk mfr as 2f .5 .6 2 10 -25 7.5yr4/6 - Is 2msbk mvfr as if .7 .8 Ground 3 25 -74 7.5yr5/6 - gs Osg ml cw - 7 8 elev 97.95 ft 4 74 -86 7.5yr6/4 - s Osg ml cw - .7 .8 Depth to limiting factor >86 Remarks: 2 1 0 -12 1Oyr3/2 - sil 2msbk mfr as 2f .5 i .6 2 12 -29 10yr3/3 - sil 2msbk mfr as if .5 .6 Ground 3 29 -36 7.5yr4/6 - is 2msbk mvfr as - .7 .8 elev 96.75 ft 4 3645 7.5yr5/6 - s Osg ml cw - .7 .8 Depth to 5 45 -52 7.5yr4/4 - is 2msbk mvfr cw - .7 .8 limiting 6 52 -88 7.5 /6 - s Os m1 - - .7 .8 factor y� 8 >88 Remarks: CST Name (Please Print) Signature: Telephone No. Thomas C. Nelson �� �` 715- 246 -2454 Address Environmental By Design Date = CST Number Ref # 1432 120th Street, New Richmond, W1 54017 27387 252 PROPERO OWNER: Folks, sob SOIL DESCRIPTION REPORT zsz Page 2 of 3 PARCEL I.D.# Environmental By Design Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/ff? in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ! Trench 3 1 0 -10 IOyr3 /2 - sil 2msbk mfr as 2f 5 ; 6 2 10 -29 10yr3 /3 - A 2msbk mfr as if .5 i .6 Ground elev 3 29 -39 7.5yr4/6 - is 2msbk mvfr as - .7 .8 99.32 ft 4 39 -65 7.5yr5/6 - cs Osg ml cw - 7 i 8 Depth to 5 65 -98 7.5yr5/6 - s Osg ml - - 7 i 8 limiting factor >98 Remarks: Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor Remarks. Ground elev Depth to limiting factor Remarks: r [KVf 0[51 l 432120' STREET, NEW RICHMOND, WISCONSIN 715- 246 -2454 Tom Nelson Certified Soil Tester 227387 --- Registered Sanitarian SR00713 ********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** T ) h i I I I 15a 13 ,7.5 zg � + / i 3 b eJ Coo n —;; Z9 y3� SCAL I" _ A0 ! e Tom Nelson BMi ap 0o ie�n 0k.+ Vic' `. +c ta A 5 ��Ct ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 190 h Ff�fi Mailing Address Property Address (Verification required fr m Planning Department for new construction) my -- j ©S�S =y —000 City /State lQ od l= t - �S UJ.� Parcel Identification Number LEGAL DESCRIPTION Property Location L V V %, y 4. Sec. _ • T_2� N -R W, Town of l, G' N Subdivision Lot # . Certified Survey Map # D �� 5 j Volume Page # 15 - 2 3 Warranty Deed # _ y D :z �2 �o Volume 7 / Page # Spec house 0 yes [- no Lot lines identifiable E Y es C1 no SUS ' M :MAIlMNANCE Improper use and maintenance of your septic systemcould result in its premat=fanure to handle wastes. Propanmh =ante 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 heart stage in the waste disposal_ system. The property owner agrees to submit to St. Croix 7ming Department a certification form, signed by the owner. and by a master phm9x=.jom=ymanpImnbe4 restrictedplumberoralicensedpungwvcrifyingdw (1) the on- ate wastewaterdisposalsystem is in proper operating condition and/or (2) after inspection and pumping.(if necessary), the septic-tank is less than 113 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. &AA4 w 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. g'i9�g SIGNATURE 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 1 DOCUMENT NO. STATE HAR OF WISCONSIN rORM 1 --19ft rHU s#act Rtt"*Vte "a RaCORetNe 6A TA r' WARRANTY DEED' "01"eit3 OFFICE This I) Deed, mt<de b -2ween .................. .......... .....Y..... . . $ Richard John Hayhurst T „ E 3T. CROIX CO., WIS. �4 and Deborah -. -- ......... Hayhurst ............................. " Rsr'd fw Rewd this 7th .... ....................................... a June A.D. 19 5 ...... ....• .................. ................ ......... .................. •--- ........ K Granter, i ---- -- an�I.:.. Roke. r. t.•. W..... ka��cs ...ac�..A.eb.xa...J..._.o�,k$ - 11:25 A ... ...................... ................. •---- •- •...... ................ -- • -• -•• •.... * Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... ........... - ...... . ............................ .. _ conveys to Grantee the following described real estate in ... $t.._.- Cr0_].X......... ' County, State of Wisconsin: �i Part of the Northwest Quarter of the Northeast `— - - Quarter of Section 20, Township 29 North, Range Tax Parcel No: ... __ ........ _. ........ 18 West described as Lot 1 of a Certified Survey Map R filed in the Office of Register of Deeds for St. Croix County, Wisconsin on June 5, 1985, in Vol. 6 of Certified Survey Maps, Page 1528 as Document Number 402481. f f This ..._LS...- • .............. horlestead property. 100 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; A Richard -- Jo n -- Hayhurst.. and Deborah Grace Warrants that the title is good, indefeasible in ee simple end free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend the same. Dated this -- - --- ---- ------------- • -- day of ... •- - June -.... - 19..85._. f f ...... •. ..... -------- ------ ------- (SEAL) 4RI _: _.. ---- - ------- ....(SEAL) ------ ------- ••- •--- •- - - - - -- - _----- - --------- - - - - -. , HAR JO HAYH RST (SEAL) }'.... = CllurSEAL) --- ----- - -- ----- --- --------- - - - - -- I . ' ........ -- - - - - -- - - -- DEBORAH GRACE HAYHURST- - -.... _- - -- AUTHENTICATION ACKNOWLEDGMENT Signatures) __ Rich .rd..dD1n--- Ha- yhurs.t....... STATE OF WISCONSIN and Deborah Grace Hayhurst -• ................................. ••--- -• - -•- --- ------------------ - - ---- ----------- -- ------------------ - - -- -- -county. authenticated this _ . 11ne--- ..... 19.. .8 Personally came before me this -• .. ............day of - - ------- 19 ........ the above named - ----- •--- - - -•-- .. .... ................... .......... *..SA•1 Ly CAR. L-------- -------------------- - - - - -- ------ TITLE: U - IMBER STATE BAR OF WISCONSIN (If not •.. •- -- -- ---• ----- -------- .......... ................ authoriz^d by E 706.08, Wis. Stats.) to me known to he the person -- --------- Who executed the foregoing instrument and acknowledge the same. THIS iNSTRVMENT WAS UP.AFIE.J BY HEYWOOD, CARI & MURRAY ._ .. -. - - - -- - -- - - - - -- - -- - i, ©. - - - -Bo :, -- 219- ,•- Jiud4� , o r . -W1 - -- --- ....... Notary Public -. --- ----- County, Wis. (= ignat may he authenticated car acknuwWged. Poth My - Commission is permanent i[f not, state expiration i are not i.- cessnry.) date: -_ - -- •Nun+ of persons sitning to any - -r—iy shou6: he t, ;aM ar printed bek— their signat;: rte. VVAAR"' °" DEED STATE BAR OF WISC(`.*SIV 1VE- —in Leval B ;auk Co. Li— FORM No. t -190 milwaukee Wia. d ...,_ �.... .. �. ... ..s.:� ,. �'��•. fixes -.- t. .. - = ?'�Sas. . rxk -'' - - i 0 Z4M CERTIFIED SURVEY MAP Located in the NW 1/4 of the NE1/4 of Section 20, T29N, R18W , Town of Warren, St. Croix County, Wisconsin Surveyed for: Richard Hayhurst Rt. #1 Roberts, WI 54023 NORTH LINE OF THE NE 1/4 SECTION 20 U.S. HIGHWAY ° 5_5 39 E 1112t1 _ S89 _ 379.98' 540.44' M N I /4CORNER_ _ S89 ° 5539 "E S89 0 55'39 "E — NE CORNER 8 SECTION 20 275.76 264.6 T29N, RISW POINT OF BEGINNING 2 I HOUSE 217507 SO. FT 21656. . FT EXCLUDING RIGHT -OF -WAY EXCLUDING RIGHT -OF -WAY 226605 SO. FT. 225301 SQ. FT. INCLUDING RIGHT -OF -WAY INCLUDING RIGHT -OF -WAY N W xw I- -- U. M 0 60 W � 0 . Ki ' OD co _ O � o OD FILED W a O I. = W Wr- ar JUN. 5 9985 o W o - g 3 °w � a o� a N �- o bddw of bosh N ti O It Of* �If, 4Q6 O - W O O p N ZN O W Q Z W IL O � W N g LEGEND W c� Z COUNTY SECTION MONUMENT ? ct W 0 I "X 24" ROUND IRON PIPE WW 1 WE113HING 1.68 LSS /LIN. FT. SET m Z. 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