HomeMy WebLinkAbout042-1086-20-100 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner � db3 g 5 .
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Pro Address
Property ,
City / State
U u�s N »c syo c•
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Legal Description:
Lot �_ Block Subdivision/CSM # \J5 h \10 13 7 g
5: Sec , T_-al N -R1 W, Town of w orxco PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer
W c R �_S Size ST/PC a fib/ Setback from: House Well Wr; N P/L j O } -
Pump manufacturer Mode
Alarm location
(HOLDING ANKS ONL
Setbacks: Service road air intake Water
Meter location
Al on
SOIL ABSORPTION S
GbWVeN ioNp
Type of system: Itkl orQ Width 3 Length �� Number of Trenches a
Setback from: House Well ofi �,, P/I, UO + Vent to fresh air intake y
ELEVATIONS
Description of benchmark Q �' T� p I d P V C_ ° RQ Elevation O
Description of alternate benchmark Elevation
Building Sewer ! ST/HT Inlet '' ST Outlet �° 3 PC Inlet —
PC Bottom Header/Manifold g yS Top of ST/PC Manhole Cover �� S
Distribution Lines () () ( )
X3,5 0 B�
Bottom of System () ( ) ( )
Final Grade
Date of installation Z- /WA Permit number 3Sj 7Z State plan number
g �—VLA Plu mber's signature License number Z�) _c) Date
Inspector �kV 1 �''�� rL�
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
G
a - 3x75 I a,Nc�,e1
t8'
1 3'
1xWic ? o �,a,
6'
13�D(ZW`1
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
,Safety and Buildings Division
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)1. 353229
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
Hokeness, Jon i Town of Warren
CST BM Elev.: Insp. BM Elev. BM Description: ( Parcel Tax No.:
:0 I C V A - 0 1Z p endin g
t?v if P c, s Ii
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_
Septic on Benchmark
Dosing Alt. BM 0#
.03
Aeration Bldg. Sewer
Holding St/ Ht inlet ✓', 4 9,5 9
TANK SETBACK INFORMATION St/ Ht Outlet 6, oZ $5-,(63
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom ----
Dosing NA Header / Man.
Aeration A 'Dist. Pipe
A .(o �O
.Go
Holding Q 7 Bot. System 2-
PUMP/ SIPHON INFORMATION Final Grade �. I V ,,10
Manufacturer nd St cover q g , D
Model N tuber GPM
TDH I Lift Ion System TDH Ft
Force mai Length m H Dist. ToweII
SOI PTION SYSTEM 2ecf.� �o
RENCH ) Width L No f renches PIT No. Of Pits Inside Dia, Liquid Depth
iM DIMEN I N
LEACHING Manua u r: 5'4k,"
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM r -
INFORMATION Type Of , _ CHAMBER M del Numb
System: r 7� OR UNIT U
DISTRIBUTION SYSTEM
Header / old u Distributio s x Hole 5i Hole Spacin Vent To Air Intake
Lengt Dia. Length Dia. Spacing J -/
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 t .11 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspec ion #I: lZ /I /R9 Inspection #2: 4--i
Location: 907 Alex Lane, Hudso ( 114 P 1/4 Section 31 T29N - R18W) - 31.29.18._
1.) Alt BM Description= � �`�� - }, S E cewtel,
`
�
2.) Bldg sewer length = 'I • v
"G - amount of cover = (g
Plan revision required? ❑ Yes No
Use other side for additional information. 03 1 Z Z
op
SBD -6710 (R.3/97) �D�t 4 (� we �� ,_ Inspector's Signature Cert. No
� �u.� Ve0[
SANITARY PERMIT APPLICATION 20; E and hi nlgngs Division
AisConsin In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, Wf 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. St C
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check i revision to pree� irapplication
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property�acaN f 1/a 1/4 �� Namg eN Q Location ,
1/4, a, S 3' T a � N, R B E (or
Property Owne 's Ma I ng cidress Lot Number Block Number
� 9� st, 90
City Tate Zip Coe Pho a Number Subdivision Na a or CS N tuber
o (115) - 71 s Q 3G7
11. TYPE OF BUILDING: (check one) ❑ State Owned V [] 't earestRoo
Public 1 or 2 Family Dwelling - No. of bedrooms j Tow OF tr�Ql3
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ,(�
1 ❑Apartment/ Condo Q Ya _ /�" g d_ l b o
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 Wew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
�Tystem ____System _____________ Tank Only_______,______ Existing System _________ExistingSystem
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 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit f f 43 ❑ Vault Privy
14 ❑ System -In -Fill K
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.) Prop ed_(sRR ft.) (Gals/ y /sq. ft.) (Min 'nch) Q Eleva
3'
V U S�V p3 S Feet 167.5 Feet
VII. TANK
Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION New E xisting Gallons Tanks Manufacturer's Name Concr t st Con ed steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank ( _ o2�V ❑ 1:11 ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑
VIII. 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' nature: (N Stamps) MP /MPRSW No.: Business Phone Number:
Plum e 's Ad ress treet, Cit State, Zip Cod
� � 6 - DJ V 5 u1
IX. COUNTY / D ARTMENT USE ONLY
❑ Disapproved Sa Mary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
�
14 Approved ❑ Surcharge Fee) Owner Given Initial /
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: •— �,�
5'8044 (FLT WISl DISTRIBUTION: Original to Count one copy To: safely & suddinga Division, owner. rhrnber
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`Weiwisiri Department of Commerce SOIL AND SITEXVALUATION Page I of 3
-A' wo of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
AC.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8Y x 11 inches in size. Plan must County -
include, but not lirrated to vertical and horizontal reference point (W), direction and St. Croix
percent slope, scale or di nernsions, north arrow, and location and distance to nearest road. Parcel I.D.#
APPLICANT INFORIIAATION - Pkese OWU ev+ed B 042 - 1086- 20 -1DOat
Personal information you provide may be used for 4-pu S��YA4Y . s. 15.04 (1) (m)). y
t
Property Omer +� Property Location
Jon Hokeness C0❑ r ,� ovt. Lot SW 1/4 NW 1/4 S 31 T 29 N,R 18 W
Property Owner's Mailing Address Lit # Block # Subd. Name or CSM#
771 Kal St. t (1i`° /s 2 VSM Vol. 13, Pg. 3678
City State Code P$3on City ❑ Village ZTown Nearest Road
Hudson WI 16. 74br X7724 Warren Alex Lane
❑ New Construction Use: ❑ eS` till ! Nam r 4 ❑Addition to existing building
❑ Replacement ❑ Pu or 1prr�l
Code Derived daily stow 600 gpd ---' Recommended design loading rate .7 bed, gpd/fF .8 trench, gpd/ftz
Absorp area required 857 tom, ftz 750 trerich, f" Maximum design loading rate .7 bed, gpdff •8 trench, gpd/ft
Recommended infiltration surface elevation(s) 83.50' ft (as referred to site plan benchmark)
Additional design / site considerations Install trenches using high capacity infihrAors. Site evaluated by Adam Schumaker to be used as replacement
Parent material Glacial outwash Flood ain elevation, if applicable NA It
S- - Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable f o r s y s t e m ®S ❑ u ® S ❑ u ® S ❑ u ® S ❑ u L I S ®u ❑ S ® u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD
Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Trench
1 1 0 -3 1Otr4/2 None sl 2fcr mvfr cs 2f,m,c 0.5 i 0.6
2 3 -31 10yr3 /4 None A 2fsbk dsh gs 2fin,lc 0.5 0.6
Ground 3 31 -46 10yr4 14 None sit 2 m sb k dsh aw I%m. 0.5 0.6
elev --
87.67 It 4 46 -84 1 Oyr4 /6 None s Osg dl gs I f 0.7 0.8
Depth to 5 84 -112 10yr5/6 None s Osg dl - 0.7 0.8
limiting - -�
factor
>11r - - - --
Remarks:
2 1 0 - 1Otr 4/2 None is Osg — dl cs 2fm,c 0.7 0.8
2 7 -20 10yr3/4 N one Is Osg dl gs 2fin,lc 0.7 0.8
Ground 3 20 -41 1Oyr4 /4 None sl 2msbk dsh cw I%M 0.5 0.6
elev
87.74' ft 4 41 -102 10yr5 /6 None s Osg dl - - 0.7 0.8
Depth to
limiting �0
factDr
>102'
Remarks:
CST Name (Please Print) Sign re: Telephone No.
James K. Thompson 715- 248 -7767
Address A.C.E. Soil & Site Evalu 'ons Date CST Number Ref #
340 Paulson Lake Lane, Osceola, W1 54020 10/29/99 3602 1121
PROPERTY0%V M ionHokenm SOIL DESCRIPTION REPORT „2, page 2 Of 3
�, PARCEL LDJ 042- 1086-20 -10 A.C.E. Soil & Site Evaluatioms
Depth Dominant Color Mottles Structure GPDIft
Honzon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. E sistence Boundary Roots
Bed Trench
3 1 0 -5 10tr4/2 None Is Ogg dl cs 2f m,c 0.7 0.8
2 5 -12 10yr3 /4 None Is Ogg dt gs 2fm,1c 0.7 i 0
Ground
elev 3 12 -32 1Oyr4 /6 None S &gr. Ogg dl cw if &m 0.5 0.6
89.57' 4 32 -111 10yr5 /6 None S Ogg dl - - 0.7 0.8
Depth to
limiting _ _ --
factor
>111'
Remarks:
Ground
elev
Depth to -
limiting
factor
Remarks:
Ground - - — -- -- - - -- - - - -- — --
elev
Depth to
limiting
factor
i
Remarks:
Ground
elev — — -
Depth to
limiting
factor
Remarks:
p�. Z5 vq�'j
Ci P
♦ El a da�on
Q System �,-U .n
CaK•E.re.e 5e, &, Adam
Or nax'sow eaal"" ," 5 Ll.u ►v�a e/ used �m—
f}dar► -� e7leie A0 60.'
• 82 Area
o�
ToP ar A!' Age.
P;,ae E/e o- bg. 37. ' h
r
Own zf boo
melon h�o/SenPSS Cat 2 �F d6M ✓a /3, A . 367f
77/
�u o(Sor?, ,., /• T . Off' [.aa.r�en, S� . L'.rOir W., �.Jl.
54!0/6
27V37
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
i Wis. Adm. Code
Bureau of Integr Services In accordance with s 3:Q9
„
Cqunty
Attach complete site plan on paper not less than 8 1/2 x 11 inches in ize,: must
include, but not limited to: vertical and horizontal reference point ( difection �,, S4 . CrUI
percent slope, scale or dimensions, north arrow, and location and istal1ce to ned 44t zbad.jj Parcel I.D. #
APPLICANT INFORMATION - Please rint all info ” Wjon.
P Reviewe b Date
Personal information you provide may be used for secondary purposes (Priv ytaw, s. 15.04
Property Owner I ' f{t6ation
1 L y 5 V Govt. Lot- 1/4 1/4,S3/ T z q ,N,R 18 E (or)
Property Owner's Mailing Address tot # 8 Subd. Name or CSM#
35 3 Amu i lee �� s oe �G
City State Zip Code Phone Number
❑ City n Village Eg- Town Nearest Road
1U. r) I W 1 I S`161b 1 ( )6`I9-(e731 Orrf cuoe�el� Fr
fI New Construction Use: residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 660 gpd Recommended design loading rate bed, gpd /ft trench, gpd /ft
Absorption area required f 53 bed, ft -7, trench, ft2 Maximum design loading rate • 7 bed, gpd /fie trench, gpd /ft
Recommended infiltration surface elevation(s) q `/ ft (as referred to site plan benchmark)
Additional design /site considerations .41 Cl v. 80.30
Parent material 6z, (Qc;Q I 61,e _�42 Flood plain elevation, if applicable
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system [al S El ®"S ❑ U RS ❑ U RTS ❑ U ❑ S 2 U ❑ S ® U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft
Boring Texture Consistence Boundary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
64 v r3 Z - 5L inQ b rn ir 6 I •Ll . s
IL �v r W 5 OS nit CS J 1
Ground
elev.
9!L_9 ft.
Depth to
limiting
factor
120 in. Sti.S 9%
Remarks:
Boring #
Ground
elev.
9 SO ft.
Depth to
limiting
factor
12J in. Remarks:
CST Name (Please Print) Signature Telephone No.
C- er L 71 S 2-g7-`
Address Date CST Number
46 der o erseA q -15 -94 zs a
P f" SOIL DESCRIPTION REPORT
PROPERTY OWNER -
Page 2 of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 !YI Z
10 r3 JL — 5L- Irnabk (n � r
10 '41q — S' 1 l mabk rrt�r- c5 - 2 .3
Ground 3 /� - 1,3J 1 -I/4) — (Y15 OSC4 1 M( C-
�1
elev.
T 10 ff.
Depth to
limiting ;
factor
J o in. `7
ue
Remarks:
Boring #
0 - 4 10 r l L- I rM k rrl -t'►- C 5 �-1 • s
..........................
y � ]1'1.5 D rnj CIS
..........................
Ground
elev.
9y.Gd ft. ,
Depth to
limiting
factor
IZ$' 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 # U ( 10 r S / 2 - 5L m ah k `f S
Ground
elev.
9 fS0 ft.
Depth to ;
limiting
factor
zb in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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s toALS
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address / A e/4 , 62
Property Address A lex L c- �
(Verification required from Planning Department for new construction)
City /State L eAl Parcel Identification Number
LEGAL DESCRIPTION
Property Location-��O %4, % a, Sec.-3/ , T N -R�ff W, Town of f'l .
Subdivision ° , Lot # �.
Certified Survey Map # 77 , Volume 13 , Page #
Warranty Deed # (o ���
ty , Volume , Page #
Spec house ❑ yes no Lot lines identifiableXyes ❑ 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 hys been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year Wirao&h date.
<�_._ — ZI / /
SIGN AP LICANT DATE
OWNER CERTIFICATION
I (we) certify tha 11 sta meats on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pro scribed a ve, virtue of a warranty deed recorded in Register of Deeds Office. c�
S:IGN11 O 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
STATE BAR OF WISCONSIN FORM 2 - 1998 613634
WARRANTY DEED KATHLEEN H. WALSH
n/ PA�G REGISTER OF DEEDS
V01.. 111... 146
Document Number 9 563 ST. CROIX CO., WI
____...IIII
RECEIVED FOR RECORD
This Deed, made between RTCHAR) O STQjjT and 11 -10 -1999 10:00 AM
JAN PT STOUT husband and wi
WARRANTY DEED
Grantor, EXEMPT #
-- - — CERT COPY FEE:
and j0N R. HOKENESS and JULE�r: v^ic£Pd£ COPY FEE:
TRANSFER h usband r RECORDING FE 1000
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in —t—c • X County, State of Wisconsin:
llecording Area
Located in part of SW 1/4 of NW 1/4, Sec . 31 , Name and Return Address
T29N, R18W, Town of Warren, St. CRoix
Jon & Julie Hokeness
County, more fully described as Lot 2 of 771 Kaly Rd.
CSM recorded June 20, 1999, in Vol. 13 of Hudson, WI 54016
Certified Survey Maps, page 3678, as
Document No. 605977 -78.
0'-1 Z -- ! u % LD -Zo
Parcet Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this day of )A Qv e DC..I j 9 _ •
Richard 0. Stout (SEAL) j anet
(SEAL)
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this day of Personally came before me this <� day of
' 1999 , the above named
- -Richard 0. Stout and Janet P.
* -o to '' NOTARY PU BL I C
IC
TITLE: MEMBER STATE BAR OF WISCONSIN RT,4TF OF `T'IS CONS'N to
(If not, me known to be XURWIN4 the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout
1353 Awatukee Tr_
Hudson, Wi . 54016 Notary ublic, State of W co sin
My c mmi is permanent. (If not, state expi�r ttiioynr� date:
(Signatures may be authenticated or acknowledged. Both are not T ' ^�"�� •)
necessary.)
* Names of persons signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis.
CKUTHM
(1- 9 V, Co M
G05977 SLCI*COm
ro c z II° °
w w z r r a r BEARINGS ARE REFERENCED TO THE
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"]D ouas�. red Wisconsin Land Surveyor, hereby certify that by the direction of Richard and Janet
apt We $' and mapped a part of the SW1 /4 of the 111/4 of Section 31, T29N, R18W, Town of
arren, St. Croix County, Wisconsin; described as follows:
Beginning at the West quarter corner of said Section 31; thence N01 along the west line of said NW1 /4,
703.09 feet; thence 187 457.00 feet to the point of curvature of an 80.00 foot radius curve, concave
southwesterly, whose central angle measures 132 whose chord bears S26 and measures 146.48 feet;
thence southeasterly along the arc of said curve 185.07 feet; thence S64 271.48 feet; thence S01
459.87 feet; thence S89 197.68 feet; thence S89 171.93 feet; thence 888 396.35 feet to the
point of beg nnina Above described parcel contains 11.361 acres or 494,874 Sq. Ft. and is subject to all
easements, restrictions and covenants of record.
I also certify that this Certified Survey Kap is a correctly dimensioned representation to scale of the exterior
boundary surveyed and described; that I have fully complied with the provisions of Chapter 236.34 of the Wisconsin
Statutes and the Land Subdivision Ordinance of the County of St. Croix and the Town of Warren in surveying and
mapping same.
W/S
Douglas J. Zahler �'V DOUGLAS J �
Registered Land Surveyor oo 7AHLER a
S 6 N Land Surveying * 3 -2145
212 Walnut St. HUDSON,
Hudson, WI 54016 WiS.
5
OW1ER S CERTIFICATE OF DEDICATION
As owners, we hereby certify that we caused the land described on this Certified Survey Map to be surveyed, divided,
mapped and dedicated as represented on this map. We also certify that this Certified Survey map is required by St.
Croix County Ordinance to be submitted to the following for approval or objection: St. Croix County Planning, Zoning
and Parks Committee and the Town of Warren.
WITNESS the hand and seal of said owner this g day of _ 19`� 9
In the presence of:
�S
Richard 0. Stout J net P. Stout
State of Wisconsin ) SS
County of St. Croix) �u Re �
Personally came before me this4?�ay of 19
the above named Richa 0. Stout and Janet P. Stout, to me kno o be the persons who executed the foregoing
in u nt and owl Bed a same. c�yF9
Notary Pu ic, / Wisconsin.
Ky Commission expires a 0 3
TOWN OF WARREN CERTIFICATE
I hereb certify that this Certified Survey Map is approved by the Warren Town Board.
Clerk U Date
w 1 s subject to State, Count and Township laws rules and regulations (i.e.
Hach parcel shown on this map ( i s �e t S te , y p g
wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St.
Croix County Zoning Office and the Town of Warren for advice.
Vol. 13 Page 3678