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HomeMy WebLinkAbout020-1334-20-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT f Owner SA 41 M 4 F R:q! Address .ate x ' /Z-/ ` A i s City /State f f'a 0 ► e? �4 uJ! r y r / � ST C O U N TY ��- , ` `, crurvrY � CNING CFFICI: , Legal Description: Lot Z 'Z- Block Subdivision/CSM # ZA(41- w Vz tDoe A, te 14" '/4 S J '/. Nf–, Sec. ;KZ, T 7? N -R Town of y p 5 ®av' PIN # z o SEPTIC AN DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 1,11E 15 ER, SizeAT c & Setback from: House Well 74 P/L Pump manufacturer — Morel -- Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: TIWA 1 Width Length Q Number of Trenches Z— Setback from: House - 7ea • Well PAL 17 * Vent to fresh air intake 1 Z� ELEVATIONS Description of benchmark ! � � o I .S'Ocj 47 NLr el- �6 Elevation Description of alternate benchmark T� P of Z t o " k: Elevation !7 , , z • 13 Z p Building Sewer , ST/HT Inlet `i 1 AD -` , ST Outlet ' 1 1 � PC Inlet PC Bottom Header/Manifold'�Y- - Z - 5 Top of ST/PC Manhole Cover Distribution Lines 1 71 t 0 c r (f 4 Otw Ce,, — ? d c70. 7y Bottom of System Final Grade Date of installation � / ermit number 07 & 41 State plan number Plumber's si tur Li cense number ate 1 Inspector Complete plot plan NOTICE Please provide the following: • A lan view sketch showing everything within 100 feet of the s P g � g stem. Y • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW � L � Fir � 79 C). � y w \ \ e 1 c +fir f 4 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count INSPECTION REPORT ` Ceo 'X 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)]. 8 b �I Permit H Ider's Name: ❑ City ❑ Village � Town of: State Plan ID No.: 4.m , / /&✓ a --� CST BM Elev Insp. BM Elev.: BM Description: Parcel Tax No.: 10 ' le ,-4 1 L't &I !° 133 zA'nClic TANK INFORMATION ELEVATION DATA jj�jg��o3p TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic V\1 j Benchm k J C', ?> 1011 9C. -t/ Dosi ng Alt. I&y1 q' -.88 Aeration Bldg. Sewer '2.5 q2• /Z, Holding &D4 Inlet TANK SETBACK INFORMATION IN ®W Outlet TANKTO P/L WELL BLDG. Ai I ntake ROAD Dt Inlet y„� e tl C - 70 - L - 3' Z( NA Dt Bottom A- Dosing NA Header/ Man. j p. v7 1-0457' 7 1 ps Ae tion NA Dist. Pipe Holding Bot. System j P T7. 75" PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand & y�" "76.2 Model ber GPM TDH Li Friction yStem TDH Ft Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length I No. Of Trenches PIT No. O i s Insi Liquid Depth D IMENSIONS �� Z DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK INFORMATION TypeO CHAMBER I'� ` – 7 D' 1 I OR UNIT Mo System DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake Length Dia. Length ! Dia. A�_ Spacing / I A5VK L0 TMI ') 1 D SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over ,/ Depth Over xx Depth Of xx xx Mulched Bed/ Trench Center Bed /Trench Edges ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LG - 7 Re..1 M R p/8_ &LAe I•� AU. &- ISAY 1 a-C S1JiAj � o y n s t cwner o� ��a,�� . LOfZZ 7� I�,���,tGvvl,f� Wl.� L✓aS Id�tvh} -�� • I�lv� �', v►a � 5��1 �8 Plan revision required? ❑ Yes N No Use other side for additional information. Cj 1 15 ' I �� g94; SBD -6710 (R.3/97) Date Inspector's Yignature h oii�onsin Safety and Buildings Division S ANITARY PERMIT APPLICATION 2 01 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 112 x 11 inches in size. C ✓v� X • See reverse side for instructions for completing this application State sanitary Permit Number 3a7 <t/ / Personal information you provide may be used for secondary purposes JRfCheck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. & It '7 1Qn/ i1 aple Z_a/7e State Plan I.D. Number I. APPLICATION INFORM -PLEASE PRINT ALL INF RMATI N Property Owner Na a l Property Location b +�''Y�t f L IL..-n u )1 is 1/4, S °Z? T Z! r N r R ? E( W Property Owr's Mailing Address Lot Number Block Number City State Zip Code Phone Number Subdivision Name or CSM Numb (.3XQ Z-?� X304 Np iC 4!e x YP F B LDING: (check one) ❑ State Owned ❑ It� Nearest Road ❑ VII age i/i> Sa N p� D Public 1 or 2 Family Dwelling - No. of bedrooms own OF 1� III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) � I ? 1 7/_ 2 1 E] Apartment/ Condo oza- r3� 7 tt�� 2 []Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 Q Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 Q Church/School 8 Q Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 13 Q Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. 4New 2. Q Replacement 3, Q Replacement of 4. E] Reconnection of 5, Q Repair of an ______System ________System _____________ Tank Only______________ Existing System ________ Exlstln�S�fstem 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 Q Mound 30 [] Specify Type 41 E] Holding Tank 1 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit 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) EI vation '� q-38 SQ , $ ^° Feet '4 I 1 8r Feet ctt VII. TANK in Ca pa Site Total # of Prefab. Fiber- Exper. INFORMATION g allons Gallons an Manufacturers Name Concrete Con- Steel glass Plastic App Tanks Tank New Existin structed Septic Tank or Holding Tank /S Z El El ❑ E] 1 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 mps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 1 070 AUt-IT64, IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuin gent Signature (No Stamps) V.Approved Q Owner Given Initial Surcharge F ee) SICv Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.1 1/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber p"a o Safety and Buildings Division V•�L'■'■A SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 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. • See reverse side for instructions for completing this application State Sanitary Permit Number S01(p y I The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Nam Propert Location l �� / ' ,✓L ..®. t) /4 � 1 /4, 5 2 7 T .Z I , N , R,/ E( W Property Owner's Mailing Address Lot Number Block Number 2 30)( . 0- �, S'/ 2 7 -- City, State Zip Code Phone Number Subdivision Name or CSM Numbe ,og . TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit U Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town OF P ( 'P5 '_ � E If}PLA1. 111 BUILDIN USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 4::�> ?- 471— 1 33 `1 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. 19 New 2_ [] Replacement 3. E] Replacementof 4_ ❑ Reconnection of 5_ E] 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 5d Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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 ltlev. 7. Final Grade Re (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 9S. ff Elevation '` 7 - a 139 �St3 •8' —'" Feet 99 , Z. Feet VII. TANK Capacit INFORMATION in gall0 5 Total # of Prefab. Site Fiber- Plastic Exper Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Exist in strutted Tanks Tanks Septic Tank Q� ewnk— ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑ 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: Zo Sta ps) MP /MPRSWNo.: Business Phone Number: S L R 5 - 0 3S,bb 3 ��O' 9(0 I 'z._ . Plumber's Address (Street, City, State, Zip Code): a 79P vtrrfX- 9-1046 9044P v2 30 1 5 0 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) ® Approved ❑ Surcharge Fee) Owner Given Initial �,_ 9 -9$ Adverse Determination �� I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO -6398 (R. 05/94) DISTRIBUTION: Original to County, one copy To: Safety & Buildings Division, Owner, Plumber N Al 114 L c ?A D LA Mbe Iq 7 I;IA.P'.E LXxtir q S"Co4 4,F ll je F- v i s, no oe t v , I 62 a 04 ip ee IT I V C 44�k to RE MIA" 3 j, 5 I s w 3ac�o --- S o . y 7 iv 1 s6 � { 1 1 e, "Lj 1. N 7 37488 O3s L , - a 0 7 1 (1 N O U M - 7-4771 IN 1.Y�5-- --i<— 'A t�� I ' C l 0 IA 1 � I . I A G ' , , Uk c rq N Li kA fn LAIC, 0 i I � o � r - -�, �1 :(� p Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor.and Human Relations Page --I_ of �_ Divl$ion of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code a Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and % percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # ©�)D /0 Li - 0 APPLICANT INFORMATION - Please print a On. Reviewed by Date Personal information you provide may be used for seconds uvk! ' .04 (1) (m)). �` Property Owner operty Location Richard Stout .Lot SW 1/4 NE 1 /4,S 27 T 29 ,N,R 1 f[ (or)W Property Owner's Mailing Address ROT Block# Subd. Name or CSM# 1353 Awatukee Trail c >t I Badlands Prairie City State Zip Code _ • kPho Sri t City El Village ( Town Nearest Road Hudson WI 54016 X715 )5tt%. 1 `' udson Hill Farm Rd ® New Construction Use: ® Residential �111�mtlroledrob 3 — 4 Addition to existing building ❑ Replacement ❑ Public or commer is _ cribe: Code derived daily flow 6 0 0 gpd Recommended design loading rate • 7 bed, gpd/ft 8 trench, gpd/ft Absorption area required 8 5 8 bed, ft 2 7 5 0 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft g . 8 trench, pd/ft Recommended infiltration surface elevation(s) 9 4 -4 qJ / , ho ft (as referred to site plan benchmark) Additional design /site considerations Parent material Glacial deposit Flood plain elevation, if applicable ft S = Suitable for system I Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [ S ❑ U � S ❑ U ®S El ® S El E] S ® U EIS ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots -_ - Bed Trench 1 0-1C 10yr3/2 none sil 2mabk mfr Cs 2f .5. .6 1 2 10-36 10yr3/4 none sl 1mabk mvfr cs if .4- .5 Ground 3 36-S6 10yr4/6 none ms osg ml Cs -- . 7 ; .8 elev. _ 100 ft. Depth to limiting factor — 9 6 in. Remarks: Boring # 1 0 -1 10 3/2 none sil 2mabk mfr cs 2f 2 16-43 10yr3/4 none sl 1mabk mvfr. cs if .4. .5 2 3 43-S6 10yr4/6 none ms osg ml Cs -- .7 .8 Ground elev. 98.4 ft, Depth to — limiting factor 9 &_ in. Remarks: CST Name (Please Print) Signature Telephone No. ,l/� ;*,- S'o h a �"'&__ I!5 -.3 d'4 - 3 l2 t Address fe CST Number Aa C' t/ /Y' � � 2 21 :7. '7 g Q d I ?ROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of _3 ?ARCEL I.D.# 3orng # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 1 0 -16 10yr3/2 none sil 2mabk mfr cs 2f .5 .6 2 16 -42 10yr3/4 none sl 1mabk mvfr cs if .4 around 3 42 -91 10yr4/6 none ms osg ml CS -- .7 ' . 8 Aev. 9 9 _2-0-ft- depth to miting actor 91 in. Remarks: 3oring # 1 0-14 10 r3 2 none i 1 2mabk mfr (1,q 9f 4 2 14 -40 10yr3/4 none sl 1mabk mvfr cs If .4 .5 3 40 -91 10yr4/6 none ms osg ml cs -- .7 .8 around alev. 98. ft. )epth to imiting actor 91 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 # 1 0 -6 10 r3/2 none sil 2mabk 5 2 6 -22 10yr3/4 none sl 1mabk mvfr cs if 3 22 -90 10yr4/6 none ns osg ml cs -- Ground elev. 9 8 . g_ ft. Depth to limiting factor 9 0 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) SOIL DESCRIPTION REPORT rRQPOTY OWNER , \ �1 Page" . of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 4 10 r 3/ Z A o ( b L w'-( r c_ S ', G %IS 16-NI 10 Y r 3 0 n P b' mJ-r` CS I I-C ' ZI ; - Ground 3 / -� a r Vy elev. Depth to limiting factor UHUIX �- Remarks: � COUNTY r Boring # 1 tj [3 3 y3 is l a W o a Ground elev. Depth to limiting factor tin. 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 # J a _ /" 10 r 3/ S y 1al /U r /(o ho ti .e- w15 C-5 , Ground elev. Depth to limiting factor in. Remarks: Boring # ¢ Ground elev. ft. , Depth to limiting factor in. Remarks: ��' _ _ -�- 1 fY9 cuwiQ SBD -8330 (R. 07/96) Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page Of ' • Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Data Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1 /4,S T ,N,R E (or) W Property Owner's Mailing Address Lot # I Block# I Subd. Name or CSM# City State Zip Code Phone Number ❑ City El village ❑T Nearest Road ❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/ft Uench, gpd* Absorption area required bed, ft 2 trench, ft Maximum design loading rate bed, gpdtft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT Grade System in Fill Holding Tank U = Unsuitable for system ❑ s El ❑ s ❑ u ❑ s El ❑ s El u ❑ s El ❑ s ❑ u E SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/1`12 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number 5�(j - Boa tort& _S Ern ( Z' 1JvC.. o'nP �- ra elm /Oy ,� �.e.e.. cLc- Ski o�,•ea c -- . / R�r CC'l Z - ST CROIX COUNTY P po5 e ZONING OFFICE 14 OV � t33 e I \ \ l 3� I I W e( k �G �� �I- C2 P � 3�� I 0 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner s Bu er � hbr k4_0 I�•... Y � e'�°t t Mailing Address 06X s / 5 1 Property Address 4e_ bM A PLF L A N D (Verification required from Planning Department for new construction) City /State 4 N tom( Parcel Identification Number O 20 ' t 33 4 LEGAL DESCRIPTION Property Locations W %4, / 1 /4, Sec. 2- , T 3-1 N -R i?A'_',�Town of St* ,Subdivision R A 0 L A N D - PA?- 61 k 19 , Lot # Z 7— Certified Survey Map # lP 8 — ,Volume , Page # Warranty Deed # 5_7 3 3 8" 2 - . Volume Z 9 , Page # d Z (o Spec house �k yes ❑ no Lot lines identifiable $ yes ❑ 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 wastewaterdisposal 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 St. Croix County Zoning Office within 30 days of the three year expiration date. Z tetcA APPLICANT DATE D OWNER CERTIFICATION 1 {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 propt;hy iescribed above, by virtue of a warranty deed recorded in Register of Deeds Office. F J SIG T F ` pLCANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** i '* 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 573382. VOL 1298 PAe_FO . ?6 ' k STATE BAR OF WISCONSIN FORM 2 — 1996 DOCUMENT NO. WARRANTY DEED RICHARD O STOUT REGIST OFFICE SAM E. MILLER, a single p er- ST. p R OIX Co., WI conveys and warrants to g P R R d for P. son, FEB 19 1998 11:10 A Re Later of Deedsw the following described real estate in St. Croix County, State of Wisconsin: RETO TO Lot 22, Plat of Badlands Prairie, Town H b -- yV w of Hudson, St. Croix County, Wisconsin. O /,6 oa u- i33� -�0 Parcel Identification Number (PIN): TRANSFER $ 03 E This is not homestead property. (is) (is not) Exception to Warranties: easements restrictions, rights -of -way and covenants of record, if any. Dated this n /� (� 1 , day of February '19 RA � ' r `�' " ` (SEAL) (SEAL) Richard O. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County authenticated this day of ,19 Personally came before me this 19 th day of February 19 98 the above named Richard OC,Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person who executed the authorized by § 706.06, Wis. Stats.) R9 e t ffE "oin ' str nd acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY KiJi7 t,t Janet P. Stout NO'fARY IlUBL.IC wa u ee r . Hudson, Wi. 54016 Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both are not My Co mission is per anent. (If not, state expiration necessary.) ) date: * Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021A WARRANTY DEED STATE BAR OF WISCONSIN Nelco, Inc., P.O. Box 10208, Green Bay, WI 54307 -0208 Form No. 2 -- 1996 r >- lam'' •C I cl �W U a - J c I ] rn Y ry 1 PH wan 1 n1H I I; J Lij z o _ ��l_L� m� - ��� ��� rya 1 �_ I r F- t u) r Q W I at U _ C] I I I I i NQ NV A?1 Li. Z AMH sn LaJ J " Ld I U1 1 I <. J �+ n A' � M r ,Oe,00.00 N 1/1 IN 314; 10 b; LMS ML .A1 Z!lM Ski .10 3NIl 1SN3 ,L5�94Z d _ 'bZl M „OZ,OO.CO N 4 r` _ • �cc+ . i' �I Ln N u ci u vi ` (.> •I• :•] `u l, T1 ' -•( •'1 r`,r• 1 ` 6` 1 !T i t 4 I IN YC � r/ ^1 i 1 > ] W rr • �� ' c1 r� 1 •^"° c � \ l ri ,r i T i' i I (1 1 h . / a U r w , , �\ , �,i• -� J I , c�S ry. l