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020-1062-80-100
rY o a I -0 ° o 03e°a p °� h W O o N o U O. co `o a) c c v N W I � Q) a) E a z z° E c o c � c c L m 0 CL LL. a >, ° a o aoi m 0 3 a _ Q 2 G Q 0 o > � M 3 M u o w iri z in 3 E E z _ o _ o c € o E o 0 v z a m a m 0) N H fn C7 d c p O Z a C C y U U T O O + w E O 15 f" r a) 1 p N m N S E N N 7 0) > >-0 M 7 O N •� N C o v a c N c 7 c •� d v ; _ 2 0 3 a o p w - a o a o N c p c p o c m c 0 Y c O O C O N c - 0 z H D Z m= N z co c c N Cl) Cl) E c H E 0 C N d N c H 0 o O G O a G a a rn m Z j NN t ( j 0 fn fQ f _> > co333 a� I m��3 a= Z •N 0 aaa. aaa IL o rn rn O 3 c) y fA J V C O) z C O) O) cn 0 M C 0 � M m C m p) > d Q z to > of Q z cn m o ° O M a c co y c 00 CO C N CD �.+ C� 0 M 3 C C 0 V a O O CD CD op cc V w ED �� N o N o E c �� C O) y O N N N N O D N a N n O) F1 O' N� O Y C tt11'')) L C14 cn 7 p N O (n O 1 O C') O in E i U • O �' o N 2 Co ch O z 5 z Co o z to Cd w w IL a 3 c. `a `m • CL d . 0 d c N m e `Iv E 3 r- 0 ; 'o y , o m '.3 0 '.4 �1 A Ua2 000 OU) r DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 1dW y , ST'7 4 , Sec. 2 3, T29 -1119 S ta t e a Pl ned) .Number: Town of Hudson CONVENTIONAL El ALTERATIVE is R ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME'OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: ?_l Zane Bollom Rt, Hudson, T 7 1 C BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: P RE-IF. PT EV.: / I CST REF.JrNELEV.: Name of Plumber: _ MP /MPRSW No.: County: Sanitary Permit umber: 83 SEPTIC TANK/ ?� �5 ' ©� ('� S �'' MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLE J=V.: WARNING LABEL LOCKING COV r PROVIDED: PROVIDED: & C, L UPG- .S 1 aq 91 , 9O. 9� YES ❑ NO ❑ YES NO BEDDING: 1 r'DIA.: MATL.: HIGHWAT R NUMBER OF ROAD: PROPERTY WEL BUILDING: VENT TOF ESH (. 1 O i / C 'C ALARM: FEET FROM LINE: I AIR INLET ❑YES 0 ❑YES ❑ NO NEAREST —* R: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NU PROPERTY WELL: I BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM AIR INLET: PUMP ON AND OFF ) ❑ YES ❑ NO NEAREST --* SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL A w or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: N DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID ! TRENCHES: MATERIAL - -- -- DEPTH: DIMENSIONS GRAVEL DEPTH 1 F11_1_ DEPTH DISTR. PIPE DISTR. PIPE j DISTR. PIPE M�TERIA :NO STR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: [1'��O„1(,� FEET FROM LINE: r AIR INLET: r NEAREST MOUND SYSTEM: 8, Mound site plowed perpen icular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/ BED DEPTH OVER TRENCH /BED DEPTHS IL: SODDED: SEEDED MULCHED: CENTER: EDGES: S ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: N0. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIP . _._ FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO DISTR. DISTR. PIPE DI IBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CO SPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO 1 ❑ YES ❑ PERMANENT MARKERS: OBSERVATION WELLS: 5AREST MBER OF PROPERTY WELL: ( COMMENTS: / [--]YES ET FROM LINE: ❑ NO ❑ YES ❑ NO -� (�.�„��� ✓ Gu ��r �s2P a%� �j(,L�, �/t�+° it��� ° , , Zk - -�I- oirt�E� C?7��G� -�-� �' Cn � -�c,< �,c�' , . :a ) �l 3 din C 'r Sketch System on et in county file for audit. Reverse Side. SIGN LIFE: TIT SBD -6710 (R. 06/88) �' ` C'�ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1 5`,016 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Za e -23 vl /vim Gv '/4 SGT/ t /4, S 22 T Z9, N, R /Y N (or) nW PROPERTY OWNER'S MAILING ADDRESS LOT # A1,4 BLOCK # A// Iff .5 SSz 7 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER .5 386 Check one CITY NEAREST ROAD II. TYPE OF BUILDING ( ) ❑State Owned ❑VILLAGE ❑ Public 01 or 2 Fam. Dwelling - # of bedrooms ' PAI ICEI TAX NU BERG �— III. BUILDING USE: (If building type is public, check all that apply) 13 — 2? —/ 9— 239 1 ❑ Apt/Condo 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. TY OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. Yom` New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill 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. /inch) ELEVATION _}50 e, 15 e z.- • 7 2 0 Feet 93. Feet VII. TANK CAPACITY Site in lls Total # of Prefab. Fiber- Exper. a on INFORMATION New is Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdino Tank /ODO /dOU ee s LJ Lift Pump Tank/Siphon Chamber 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 Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Da /e E 4 � Z Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssu Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ owner Given Initial / ` S— Adverse Dete rmination ` Z _ X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i i APPLICATION FOR SANITARY PERMIT r STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ----------------------------------------/--------------------------------------- Owner of property z4✓26 TBO1/O Location of property 1/4 S� 1/4, Section -3 , T Z N -R W Township tYG/G�'so�'7 Mailing address Address of site �jy Dap Subdivision name /�efeS b �ouYJ(�3 Lot number Previous owner of property �e��rn� �4�0 [>l9Z7< Total size of parcel zD G J AG ✓°r°S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes X No Volume - 7 7d and Page Number - as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. #Z fr1le ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Documen No. / Awiv?� gnature of Owner Signature of Co -Owner (If Applicable) 3 / ,W - O 3 - /C) e �6 9 g Date of Signature Date of Signature 'rte .. I� ~ c ..DOCUMENT NO. STATE BAIT OF WISCONSIN FORK 1 1!!t 1M /f f ►aCt atrsiiree f� 1isleaslMe WARRANTY DEED 425118 v�: �v �,c 5' �, - _ - - - -_ - _ =- : ae>�sTERS o� This Deed made between -- ''°dens l • Land Bank of- -__.__ �. CA�OlX GO., WtS. St. Paul P 0 Box i�9 Ri r Fall WI -;4022• - -_• _._......_ -• r ,• JJ ppc��rd #4 3 t ....... . ........... ...•_.... ...... .. -- ... ...... .- ..- ._......._ .....- ........_..._....... r' of Ao A.D 19i8 .......................... ..._..- ....._....._.- .. .-...... ........._..............- ....., Grantor, Zang R. Bollom and J tx,r-iri L. Boilom 8:30 M.. and.................• ..___...._........_............ .-.-...._................ ........._..._................. .. - --.. .......................................... .. ....... ..... .. ........... .... ............. ... .... .. . .•• -- iJM '' ....... ........ tlisf a .......... -.. - ..... ... ..... .......... Grantee, Witnesseth That the said Grantor, for a valuable consideration...... F Twent ei thousand and x'100 `$2r',Mo.00) _ -- �� - .....__- .i -... _A .. . ..... ............ . .. ... ... -._ -.. - - - - -- -__ - -- - ��.- ................._.... RiiY�N TO conveys to Grantee the following described real estate in _.......'- •.. CrUlx County, State of Wisconsin: _ A �- _�rc_el of land located in the NWT <,f the �W4 and in the i _41 of the NWL of Section < T29N, R1�)W, Township of Hud- Tax�,ar� _ w ,, • (I son St. Croix Co., WI, more ful ly described as follows: bogiming a ft bafTier"' "• ^. ctior. i, T ?N, R.. Thence NO °r,.' "1 alork, ',he t line of the :�Jc �f' t1,F PJW of said seetiaJ a distance of ?17.00'; Thence X9°46 4 " E 1284,1,2'; "hence S56°09'18"E 54.. ?' to the NE G�T12r Of t)7e I of the S1J? of said Secticr 23: Thence SO °04 t?? "r! a; the Fast line of :aid fk of the SW; a digtanoe of'�+3.32'; Thence S89 °56'40 "W 13''.61' to a point on the West line of said . "M1!.', of the S1rtI Ther e % "�. alarm mid line a distance of 649.03' to the Point of beatmirlg. Contains 20.61 Acres subject to [telly Road rir)t- of-way over the westerly :3 feet thereof. Also subject to any and all easements, ri�rt- of -i,ays or conveyances of record. ', p� S "a ' iR j� + Jj i Y ' t r� Il I This ._.._... IS ... ............. homestead property. j (is) (is uut) Together with X111 and singular the hereditaments and appurtenances thereunto belonging; !� �. And ....Fed�raJ...t.�nd_.Bank..o_f. �,t.�_.P�u:. ....... _ .... . ........... .... _ _:.- ._..- .......................... +! warrants that the title is goud, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the sarne. 1 p Dated this ......... .. .. 24T(+_....- ._............_- day of .... -. PRI.� _ __. ._.... 18 87.. i (SEAL) ..r / � ? fi - r (S�.) ......._ .... ........ ....... THOMAS L, DE ONE, u IN" • . .. . . ..... ............ .... . . ... . ........ ..... ........... • ..- _.- ._..... - -. -. . -.... ..... .. ---- •- • - - - - -- t ... ........ . .( SEAL) _._ ....- ......_- ... ...s"- '.:f.► . AUTHENTICATION ACKNOW LED G"JIT r 1 0 " STATE OF W1STEUNS1N �✓ -••-..__..__........._...•..--. ..---- •---- __.- .•.._.__..._ -• -• -- • - -• -- Sz,.- .�RQIX -.... y. - � - _.._..._Count -.� j authenticated this __......day of .... ........ .. .. ......... .. 19 -_...- ersonally came before me tt .� H..,:�iMF of ; II ,,PP I � R { � i •-- • ... .......... .--- ....._ ......_..--- - - -••- i�. j .- .- .... -. _- - - - - -- - - .. - - -_- _• -• -• - •-- .... - -- - -- TITLE: MEMBER STATE BAR OF WISCONSIN _- - - -• -. - - -_ --.,---- • ............................. (!f not. •...... .... ... ...... .. .. -.... - ...........-__-• .. t �� authorized by § 706.06, Wis. Stats.) ? � + to me known to be the person ... - .._ - . who e ' tl1 el ` f foregoin trument and acknowi ge the earn& THIS INSTRUMENT WAS I R..PTEO BV r .. n j ..... ._..__. . Notary Ptil,lic DIEAC �q1a. 91� Cortttuission L >ermanen (lf not, state (Signatures may be authenticated or acknow:cd:;ed. Both ' t' -ire not necessary.) J UNE ]0 .:"� - - - -- -- date: ....... �... . -....- .. .+.� •Namws wafts sitni c in any rn; "Ay ,h-Od be t5ve7 <:r p' '.1 n1 JfJUY Ill -Ir slgnaWrCS- n P g a �n a ST C'- 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a H OWNER /BUYER ROUTE /BOX NUMBER � � / I ��,X 552 7 Fire Number CITY /STATE W,',�_s? , � /�� j�Q /�i ZIP PROPERTY LOCATION: �4, sw 1 4, Section Z3 , T Z9 N, R /9 W, Town of /�u�f6h , St. Croix County, Subdivision /y/�fs �' 13 aN/f!�> , Lot number AIX Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, b,y a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents m_ y be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 E I /WE, the undersigned, have read the above requirements and agree cn to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart - v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DA •r / -90 St. Croix County Zoning Office P.O. Box, 98- Hammond, WI 54015 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. U PAR_�M OF REPORT ON SOIL BORINGS AND S AFETY &BUILDINGS IidI�USTRY, G DIVISION i!ABOR AND PERCOLATION TESTS (115) MADISON WBOX I 3707 HUMAN RELATIONS (H63.0911) & Chapter 145.045) —_ F ----- -.... - - - -- -- LOCATION $E(:TION: - — - *ti IUWNSf W MUNICIPALITY: LOTNO.:BLK.NO.: SUBDIVISIO T- fV 1 / � 1 / Z3 _ — MA TES �(ixX! As COUNTY: OWNER'S BUYER'S NAME: — K LING ADDR SS: / r - �7-cenIy ZAN P)OLL01`1�, - 1�T - 7 P11X a S4 0 /� USE DATES OBSERVATIONS MADE NO. REDRMS.: COMMFIii(;IAL. D PO F`,( filf TION: - MrbM�'rT6 S: PERCOLATION N TE' TS: Residence l _. --- l , New �_�Replace M AeCfl rc; ycx��'. �"ll�tt -�`6 SottS - v KfdARAT- - R S- Site suitable for system Um Site unsuitable for system `mil B - :�rLTTt t O S TC��' M U�.�� IN•GROUNDO URE:S Sl'� I A K:RE v��r rohlAL ( t OU If Percolation Tests are NOT required DES��I I GN RATE: / II any portion of the, tested area is in the /� - -� tinder s.H63.09(5)(b), indicate: L I L A . o S I Flondplain, indicate Floodplain elevation: Ly A `� __...._�.--- - - - - -- ------ P RV1 - fLE riE;yCtifP) TOWS -- -- - . BORING TOTAL DEPTH TO GROU NDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBS EST. HIGHFS TO BED IF OBSERVED (SEE ABBRV. ON BACK.) zS B� -Ts 2o" Bea S L 23~$RN MS iG* Coy B- 2 .b 9� S' _ ' ; r i9��t�Qnf �rL l9" Ak,4(,SrfC7� Co1vt /`1oI�L_ > 8 G 7 -!�" r l B- / A 7 g _ J) >� — IS �$�trTS f3 �g2NStL C IZ "1� B- 4 7-47- 94 4- > 7.47- ��? ° BcL r� , " fS S6 "6Q,^46te scab B- !`t r !-�' 10,4 SaL 8- PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IAl6'MES AF1'E RSWELLING IN1E -MIN. P Rl - j _ PE:RIQ _� -_ PERINCH P - r 3 31 t4c>q C 99.3r 3 �z >z > <3 P- z 2.7`6 140W 9 7Y 3 s Q 74 —T 2 P_ - A r r 04- i- t r PLOT PLAN: Show locations of percolati W, , orings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• rontal and vertical elevation reference points n It their location on the plot Plan. Show the surface elevation at all borings and the direction ar d percent of land slope. �ENCHM AID k _ r- fPl kL !nJ t k�[ J r A$oVK - 6RovN SYSTEM ELEVATION /. F�,My r_�� J�� I oN ►oo.oa . 7olk, T 11 ALTE�RNATC 5y6TErt l:t.%�ATIoN B- 4 �= ..V,( � St t`Ti o i 2g4' ± Tc, J • d ® SGAL KELLY tea \. 'C ;vST �M f�9 S ITS LOC -ATt PV (" 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): — TESTS WERE COMPLETED ON: ADDRESS: CERTIF'CATION NUMB 1PHONE NUMBER (optional): d 07 SEC �N o S -, 1 .1 u� . V ��# ��, C _ 3� 3f5 4 690 -- - -_ -- CST SIG ATURE: DISTRIBUTION: Orypnal and one copy u, Local AnNsnruy, Ihnherty i)wner an l :i :a i -:!m, DII HIi -SRD -6395 (it, 02 111 9 ) OVI'fi . O Ld LA I�vrM so L � Q �Z � Z I� t � Zane Bo /lo m Ala. R7` §' Box J527 a 10 0 io l� o • /D' ---{{ CPILAII v � Pi � po o �� � • �g "�/ � / � l� ' t � � •7 � 9 'J .o OZ i� �� JV op c9 JJ� -- vaJ QpO�pA Aa I 1 �'�pe y; � I 1— — — — sec Z3 zz5 S IC • o. (� NIJi ScJ i d� 3 II r3 n mP 6 z9 Cs 3 /3 Wisconsin Department of Industry SOIL AND SITE EVALUATION Page of Labo, and Human Relations Division of Safety and Buildings mzcoq' an , ' h s. ILHR 83.09, Wis. Y" County Attach complete site plan on paper not less than 8 1g2 is 11" inche�in . Pldh tnpst y`(�j :.- include, but not limited to: vertical and horizontal pefer"Ca poin �Ot�; �'{e ion'apd percent slope, scale or dimensions, north arrow, ;chid (6cation and dist'91 p nea sla�ad. parcel I.D. # bZ © • /067 /a CD APPLICANT INFORMATION - Please print all inhwl r la Revie by e Personal information you provide may be used for secon \ ry t) purpobdyl4aw. s. 15.04 Prope Owner �.` v rty Location /r�� �j0l�D�•1 .'., , .w— ~"� vt. Lot ALAI 1/4J� 1 /4,S T N,R E (or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 937 ,C%4cY Address State Zip Code Phone Number / Nearest Road d 0 ✓ l S�f�� ( ,f6) 97/� ❑City [:1 Village Town ELL � ❑mm New Construction Use: esidential / Number of bedrooms 3 Addition to existing building 0-rfeplacement ❑ Public or commercial - Describe: Code derived daily flow 7 � gpd d design loading rate bed, gpd1ft trench, gpd/11 Absorption area required trench, tt aximum des* n loa i to bed, gpd/tt gpd /ft Recommended infiltration surface elevat *on / /lA* W - • 3 ft (as referre to site plan benchmark Additional design/site considerations 9.e1 %A) s' ' / 10/4f Parent material 7 L C OjJ.�1� LJ Flood plain elevation, if applicable ft S = Suitable for system Conve 'oval Mou In -Grou ressure AT -Gr System in Fill Holding Tank U= Unsuitable for system s❑ u B El u s❑ u C� ❑ U ❑ s u ❑ s u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench n - 7 T - 7 o 2 l Z- - / sk Cv . Z :. 3 v // 3 �0 ye ` - ,BIZ_ Zf �^ �l s - Ground 3 /Oy 51 S v ' .lJ c elev. `7'*� Depth to limiting factor } f ij Remarks: Boring # 2- L SQL 2fS S 017 A0YX Z Z �•3 /OY/Z � SSG z S�' rl, � S / 7' Ground elev. ��. W it. ; Depth to limiting factor w' 0 in. Remarks: CST Name (Please Print) Signature Telephone No. 1R OGET - 7 - Zt'� -i3 i G �-T� 71 S' • 3 (fG • ool0 Address Date CST Number Ulbrtcht 8 Associates �3. f•� 2cfal� Piriva Sewage Consultants 665 O'Neil Rd. Hudson, Wis. 54016 rV7 &rf -- 77 ORIGINAL 7/ - ,e 4! S2 2 do lle' —1 SOIL DESCRIPTION REPORT PROPERTY OWNER Page Z of PARCEL LD.fr 1920 • /��- SO • / dam ' o �-O -/0 2 - D • /da Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground O K elev. ,-24 ft Depth to limiting factor 60 Remarks: Boring # z Ground elev. 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 # 4 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) w 1 o c N � kA �Z M 1� IS T oo y LA y 0 1t f� • 9£S£ abed £l'OA c �/ CO e1C1 w $ W +` r. F? a z m0� +cx $ O 2 a Q D 25 WmWZ �r c- s�iz � aQ = p 0 M Y O o '° m F= F - OW Y D Z W W U W ZI- O w v)W Q W N ONO"o= �° Z CLz � ° Z Z Z p —I tN U 1 W °� Z ? v zi h � SONdI 0311d1dNf1 W L) CL LLI w CL o J LLJ J g CL N om, V4:� � z w � vi Q 0 Z C�1 Z m w O Z ` t Z w X . X o0 0 O�`. .o TMS 3HI 30 4 /TMN 3HI 30 3NI� iSV3 Q 0 `O O a w Z (M„LZ,b0.00S) 126'£49 3 „62,20.00S `, 3NI ONIISIX3 •• �D t w Ci Ln o r � \♦ / 3 3 O Q� Z L ' i L Q FIF UJ Z Z OD L� L Cl Fa-1 ' o o a 3 U W 3 3 � W W•W , co r i O O Ce N O V Hi W W ~ H O � -I �I oI `” Z �` x �- O cD W a J J �° w C3 O w W CO °° F-- w "D w OD \� Z i M� �' z ' c U rin II wi 03 --c J Qd Q0� N0.1 r, w l v W 0 I Ora �D M .�-� Cl) N U' ^ O i d 1 U i Co' 0\ t0 - ^ Z I O �/] r� Q_• , I 0:) Lf� Q 3 LLJ 1 of CD 0 + o O I Co ON 1.� OD OD I N lb Q O W Z O) i J i J I ON 0 ON Z i w 1 W CC) Frri Q a W A p3 Cr) y �' a l W O N Q r` � rr Q z' �, W ci W Li 4- I M I J -- ei w e"s � r� of N v> cn vii � d :� S v Q w o W �0 U I n.l � w ►- � o O A Ems, ¢ � o o �.� Qw l'n� c�'� 1 W O ¢ oe ¢ �ri M 0 Y z ? [�, c cow co `fI I ( F- ¢ pv, �Wo W CD V ai Q (1) Cl) J 1.0 J wA m o ... . ........ .v .................... X3,, '06 0 co ° o , 0. OON 88'849 M Z 3,1-9,21.00S M 4 /TMN 3H1 30 3NI� IS3M � ,86'S9E ,OS'68Z IZ'89£ Z8'08Z L8'9002 ,60'64 „L 3 M�21.00N 3 „TS,40.00N (M „LS,4i.00N) z 04 4 /TMS 3Hi 30 3NI iS3M �. w N w Nur OUZ �— ^ 00 C) v CD C5 0 LO z cn z Z 3 N SON dl O311V'ldNn B 7 N y 661 b kt�y '3„ 15,40.00N 2JV38 Ol 03VV11SSb 'cZ 6 0��� 1 �� 4 N01103S 30 4/ LMN 3HI 30 3NI IS3M 3HI Ol 030N383338 388 SON18d38 � cS V d7 ZOL -86 'ON 80f NOSA010 13VHOIVI 1.8 031JV8(3 lQvinb1SNl SIHl 7 AINniw 8 S,80)LIA nS xioao is ZZ06RS I 8661 L I AON ` Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanita 320223 -: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: pp Cit El Villag Town of: State Plan ID No.: 13OLLOM, ZANE HUD ON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020 - 1062 -80 -100 TANK INFORMATION ELEVATION DATA A9800411 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Mode 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 E] Yes 11 No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 23.29.19.'239 ,NW,SW 837 KELLY ROAD Plan revision required? ❑ Yes ❑ No T] Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No Safety and Buildings Division Vsconsin SANITARY PERMIT APPLICATION P o �Washin Ave. In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 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. ! ,j , } , C ( ^,. • See reverse side for instructions for completing this application State Sanitary Permit N umber The information you provide may be used by other government agency programs ❑ Check if revision to previous application IPrivacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location ►.1 t- o w. N4J14 1/4, S �3 T 'Zfj , N, R E (or) W Propert Owner's Mailing Address Lot Number Block Number `c� v _l l,,. 7Z L ,,� City Stat Zip Code Phone Number Subdivision a or CSM Number �� wdsc5,.l b _ �}C� 1 1 (3w.) 19A d ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road ❑ Village Public or 2 Family Dwelling - No_ of bedrooms_ Town OF � ..l K 111. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) 020 o — /Od 1 ❑ Apartment/ Condo V V62 — Eva - 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2_ ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.�'Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure ,..� 42 ❑ Pit Privy 13 ❑Seepage Pit /-Caen- I ��r�t' 43❑ Vault Privy 14 ❑ System -In -Fill 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. /inch) Elevation 4-szD I &A4S -7 q (v 136 Feet 7cf, Zaeet pac VII. TANK Ca tt in s allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steet glass Plastic App New Exist in structed Tanks Tanks Septic Tank or Holding Tank GV /200 I ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. 11Wwtbefs Name: (Print) ,P1uw1►erlSignature: (No Stamps) o.: Business Phone Number: P (Address (Street, it , State, Zip Code): 6Z q1! S I wd bOAJ �v L IX. COUNTY / DEPARTMENT USE ONLY =[[]]Ownere(Given oved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A nt Si nature ps) Approve Initial / %/�(� Surcharge Fee) q Determination C/ - �l/1� / 09�� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ,� �-'�►,�� ST. CROIX COUNTY WISCONSIN ZONING OFFICE N N N N N N N ■ ■ ■.� ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: '-Z cA -4 -<_ "� 1I nn. Address: Day time phone: ( 3W,� A L+ j C� Parcel I . D. off' /vim 2 - 6 - i c, u ii 2u / ( G Z — SQ Legal Description of property: tjw + 5LJ ;, Sec. Z3 , T. 7A N. , R.LGJ__W. , Tn. of n��.[ , St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this residence (is /is not) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. signature: Date / 5/97 v Wisconsin Department of Industry SOIL AND SITE EVALUATION Page of 3 Labor and Human Relations Division of Safety and Buildings in accordance with S. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ��• /1_ _ (_`� Include, but not limited to: vertical and horizontal reference point (BM), direction and north arrow, and location and distance to nearest road. Parcel I.D. # 0 • 0 • S • !dv percent slope, scale or dimensions, no d,Z / �O� P P. oz.0• ioGZ. 0 — • ldt� APPLICANT INFORMATION - Please print all Information Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Prop= Property Location E 13 ollel Govt. Lot /VIA/ 1/45 1/4,S T 2 ` ,N,R // E (o►) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 9 3 - 7 1 Nearest Road cl State Zip Code Phone Number / W1. is ty ❑ city El Town LL,. ty � ❑ New Construction use: esidential / Number of bedrooms Addition to existing building _ 0-ife-p-lacement ❑ Public or commercial - Describe: Code derived daily flow _ gpd Recommended design loading rate bed, glade trench, gpd /ft Absorption area required _ &M_ bed, ft S�3 trench, ft Maximum des* n loading rate . bed, gpd /fl gpd/ft Recommended infiltration surface elevation(s) - 1 SYST a /�G • 3 ft (as referred to site plan benchmark) Additional design /site considerations cntt %-V Parent material SL f " C Q '' LJ Flood plain elevation, if applicable ft S = Suitable for system Conve nai Mou In -Grou ressure A Gr System in Fill Holding Tank U= unsuitable for system S❑ u R El u s❑ u 51 S❑ u ❑ s u S D SOIL DESCRIPTION REPORT Horizon D Dominant Color Mottles Structure Consistence Bound Roots GPD /ft2 Boring # P Texture ry Bed , Trench In. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Tf 51,t 2 Z 1 Ground 3 LL /0Yt 5/ & d 5a • `" elev. l •�ft , Depth to limiting factor 7 f lj Remarks: Boring # � 0 •lI /D ,/� ZlZ --' s�L ZfS S S ..,G Z ioY/t L ? . 3 , V4 L0 Ground elev. Depth to limiting factor a in. Remarks: CST Name (Please Print) Signature .� Telephone No. o Q �I2T" ������ ���'S Address Date CST Number Ulbricht 8 Associates 23 • �� 2 Y� v to Sewage Consultants WS O'Neil Rd. Hudson, Wis. 54018 7Z for a 90NOVOW i�ep is 0 - P Y l t UFPARJIV OF REPORT ON SOIL BORINGS AND S AFETY &BUILDINGS If OUSTFiY, DIVISION •ABOR AND PERCOLATION TESTS (115) MADISON WI 79 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SEc.TION: "1UWN, °iF LP ML1NIl:IPAL11 Y: LOT NO.: BLK. NO.: SUBDIVISION NAME NW V > >1 z3 uD sUti — M�Tt_s COUNTY: OWNER'S BUYER'S NAME: , MAII. ADDR Ste - / I / AN - P- hE fQPA ; A C- j� X_� _t!1 _L 1�T_�_ �1k � 7 / S 2 'i / aSP u US - DATES OBSERVATIONS MADE _ - - -- NO. REf)RMS,: COMMFH? 1/11. r)FSCRIf fI : Pf�1=(C�T57= $�RIPTTU S: PE MOLATION TS: — 1 New �- i Ro lace `r II.. M w1 [ 4R.�,denr.e_ ! __ X - p MAecf! � 7 /'7r��t: -N c}Y? , I`'c'�a'��� -r6 Solt_s � xCZ u�Kfdn4� �O R ATI NG ` : S- Sife for s U= Site u 1 ((► nsuitable for system _ `-•/ � - .,/ITThk ' S N M U S CC U ING 3 C � u RE:rYSI s Elu LIFIGT �IU :RECp NVE�/T!0►VAL ( i t ) If Percolation Tests are NOT required DESIGN RATE: II any portion of the• testod area is ^/ in the under s.H63,0915)(b), indicate: ( Z ld, S S I Floodplain, indicate Floodplain elevation: ' V A P ROFILE Lic= ;;f.;tiiPi TOWS BORING TOTAL PTH TO R UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH - M. ELEVATION - OBS EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,) z , 4k1.TS Zo" &W& L 23"'IBRN MS +Gt Coy - B 1 �c.Do 92 2( f�(ot�l: >E3 .OU _ 7g'� P,Qw &) Sq. 6P_ 2 b7 9 �C - -- f `�`6k A SQL l9" 8ka Cs t67p C' CnM B �o r✓ L > 2 6 7 - , ; r 8 d S-i 6t (6 6 ), 3 CoC' eA M - C5 } Ci' �'Cc h B- 3 1 9 _ I�oN ><; 1 — 1 LTS 13 BeNSILsC8aNMsi6e /2 B- 4 74 Z 94 4 NON > 7.4 i� (��r r� t � 56 "8aN1t`1S46I -� C" I B ^ — - - -- p ! t i ? � 13'' $>tN ' L il" t�QNS 1`GC oo /3.54 n(�I.rL > O.00 r%1s -4f" Je J B• , PERCOLATION TESTS TEST DEPTH WATER IN I4OLE TEST TIME DROP IN WATER LEVEL -INCHES RATE MINUTES NUMB IkM*4E AFTE SWE LLING I NTERVAL. -MIN. PERIO — _ - P .RIQ 1 -_ PER INCH P. 2 7.7`6 tY ON L 9 7X P- . n o',1 t U 3 > 2 7 2 �p PLOT PLAN: Show locations of percolati - t , orings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- , ontal and vertical elevation reference poit)ts n It their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. tco4cf0i AIZk _`. ' 44L i„) F �" j 1' A(sovt; 4ROOn4`�' SYSTEM ELEVATION /_ LLE 4A I UN ►oo.oa . ZoIk T I 4 ALTEkNAT C Syc -ri L f t:11A ? Io N �- 7 t -ro J / A ® / / BALL' KECLV F� 3 AL-IrRNATe I / Jc'3O 19 ' /T1: L OC.A - rI t7V aN PE\(EtQS C 1, the undersigned, hereby certify that the soil tests reported on this form wore made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge, and belief, NAME (print): TESTS WERE COMPLETED ON: V .)uN e'ON W ADDRESS: — CEIF'CI ATION NUMBER: PHONE NUMREIi(nptionall: d07 >t` GUNL of -- - -3` �FS� 4 0FSO CST SIG ATURE: DISTRIBUTION: 0,,41m al and om copy to Loc;,I Amlun,iy, I',olmt ty Ownot nml S -1 1 :•,u ,, DII HP- $1lftfi:if5 W 0 /1 17) ()VI' it 0 S ir �d N I� r LA s 11�9�� n, N '1 4 r � 1vo11��� 311 .. ` z z ' Z Igo i r r— - ,f zone Bo llo m Na. R 5' L30X 6 7 // 2� k� O \ � O • prof qj Pi {louse pror /y)� Pepe — — — Sec . 23 z z5 s; f� I NtWi 5IJ 3 II 73 Ca I m P GG Z9 Cs 3103 Plly ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer `Z c w �� n vv,_ Mailing Address c3 �I ,e )1 �/ / d Properly Address (Vedficatioa required from Planning Department for new construction) City/State _ - Iv�� Sera IN I Parcel Identification Number ba- JO(.2-SO vzv- /oG2- 00 - eao LEGAL DESCRIPTXON Properly Location N LJ % V4, Sec. ,L T2Q N-Rj _W, Town of Subdivision Lot # Ceded Suxvey Map # Volume . Page # Warranty Deed Volume 1 - 1 Page #. 6 75 — Spec house 0 yes no . Lot lines identifiable 0 yes ❑. no 8YS�1AIl�N11�Tt 1q PwPw== 4 =zwen=ceOfy=&CFaCSydCM ooald =s*iaitsp c�etohaadleRrastcs.Pmperata Ocaamoc Consists of pampiag outdo septic ft* evmy ftw y= or som ec. if beaded by a Yiowsedp=4= What you pat.iato dne system effi �e •boa of tlbe septic taatc m See �stedisposaisysbem. .. - - - T PmPertY' agnxs to sabrait to St: Quiz Zk ft Departmentx .man faun. signer by the -ow=nerdby. a P 7 Y P dplambaoriUcmwdp =VwvcffykgtfZat( -ed6 astcavatrrdrsjwsa16yz6Cd, n in Pr"Pa oPaating eon& ion and/or (Z) after cn nerd f¢ ), the septic ft&is icss d an w dull of shrdge. Uwr- tC Wd=igwd1=c rad &c above tnVk==ft sod agree to aaaiatain &. pr Aft sewage deposal syswm with the standards at ford, h=ia.as set by 6c Department of O mmetne nerd do Department of tuft l Res =es; State of Wisconsin.. won thatY w systemlmbocamaiobinodmartbecompleteda ndretumedtodeSt .(�roix.CormtyZoning-Office days- of tine three year expiration date, ?M( � AIIPUC � AANT DATE ORmER I ( CE _TINI<CA.TION we) certify dint all stat=cnts on dais form are true to the best of my (our) loaowlcdM I (we) am (are) the owners) of the property dmnibed above by virtue of a wunnty deed =coded in Rogista of Dodds Office, TUBE OF lIPPT,iCANT DATE s « « «sa Any information that is cols era. +a. -� �Y t�tlt is the unitary pemrit being r�wolred by the Zoning Department. «* Indude with this application: a tumpod wuranty dead from the Regista of Dodds office a copy of the certified v=cy map if rcfcmcc is made in the warranty dead i * DOCUMENT NO. STATE BAR OF 1VISCONSIN FOIt11 1— 19$2 T.16 SPACC R!5!N'110 'OR N[COFO.NG owiw • WARRANTY DEED 7`�6PA ^,.575 , cs� :�tvTtR� Oc�iCE i ' ' his Deed, n.ade between r e der I tr d Rank of i (. Mix Co., ti is, 5t.•- Pau1,...P..0....Box 1)9 Riv r hall t l ..c�. 31C+r R:v�rd !!:, 30th .... .... ..... ....... ............................... ........... ..... r a Aprii A J. 1' ? ........................,- . ......- ........................ Grantor, : 8:30 , and.. -.. ra.rie R. Bgl om nd ..a + ;tx,rth...L. BoI I cm..._..... �__ n. .. ... .......... ......................... ............................... ............ ............ ht V al Jc•. +. ................................................................... ............................... Grantee, Witnesseth That the said Grantor, for a valuable consideration ..... Tw „nty_ i�ht thousand and rR,I10_0 ($"8, 000.0!) ) - -- - - -- — .................... St. Croix........ �CruNNTo conveys to t,rantee the followinP described real estate in ............... . .... County, State of Wisconsin: A parcel of land located in the NW4 of the SW4 and in the Ba0- /Obi- So_/oo SW4 of the NW' of Section 23, T29N, R1)W, Township of Hud- .Tax Parce �o: 0.1 /D(o .3 - n! :Ao son, St. Croix Co., WE, more fully described as fol BFi;innD u� a•. �e ,r r it of SecGicin 23, 112 Rl9W; Thence 14.')0021:i "E aLonT, the W iest line cf the _cWG of frP (Z 3a id ,ec`ion a distance of 30. Thence 339 ° 46' _ `4 "E L?84.62' ; Thence Sib 1 09' 1l3 "E 54.13' to the I IE c,xt>er of the P+k(4 of the `U'4 of said Sec ticn 23; Trip :e 30 along the Fast lire of _ =aid '�U of the 3W. a distance of 643.32 Tht�!nce S89 1 56 1 40 "W 1327.61' to a point on the West line of said %L' the M.; hFr�e NO°14'57'14 along said line a list uxce of 64,.03' to the point of beginning• Ccmt.ains ,.bl Acr _s vib ieot to ''.el'_ Road right -cf- -way over the westerly 33 feet thereof. Also subject to any and all eax ents, r,4it- of -ways ,x conveyances of record. This ......... ............ homestead property. �l (is) (is uuL) I` Together with all and singular the hereditaments and appurtenances thereunto belonging; And �.!.. -P31,I4..- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ,I 1 li and will warrant and defend the same. I I Q APRIL_ 7 !i Dated this ._ - - - - - - - 29 TH... - -.. ._. ....... -. day of ._.. `. .._ ................ I9._:.'.... , j __ ............. ........ ....................__. ....._(SEAL) I ^a' '... ), ff/ Y'.....(SEA[) THOMAS L. PELow, V. DMIN. jl - - ---- - -• - -- - - - .............. ............ .........._..............(SEAL) ....... .......... .............. --------- -- :'(SEAL) I� _--------- ------- - --- -- ---- ............... -- ....... • ....--- - -- -.. ------ -------- .'.`,•� _ �l AUTHENTICATI0ri ACKNOWLEDGI'__A lT }- i I O Signature(s) STATE OF WISICO SIN ✓ c •--- ----------- ------ --------- ------ - ------ ---------- .�L..- .CF County. � ' I authenticated this -------- day of— --------- ...... .... -- -> I9 ------ ors- rally came before me � - - -- -day of hjs .�Q.T.. P n `` H °R I� thp a amed I L F ...DMIN. i HOMAS.- L- - - -- ' E..ONG �.. -�' ' ' - - -- ----- ...-- - ..... . ... ............. ...... . ............ ............... 'j TITLE: MEMBER STATE BAI. OF WISCONSIN ................ ..................... 1 If not, ........ ................................................. 1 authorized by ; i0 .OG, Wis. St:yts..' to me kno«'n to be the person ... ......... who executed the f_oregoin - trument and aeknowl ge the sar..e. THIS Iti RJYE JT ti4S CRAFTED f3Y I -.. _.. y --- ----- --------- ...... I ....... I .. .... _ do • -c Public T IERC Count•, Wis. iSi� ; nature m: :e aotncnticatc,l or acknonl- ds;ed. Beth M.x Cornn:i,sion is perrl.in k cn !f not, state expiration are not rece- ;ar,.) .JUNE In O P date: ... - - -- -- it "� *Names or Dersocs s.gn,ng in any capac!ty sh be typed or prir.'.d t cir '..w na t� :�s.