HomeMy WebLinkAbout026-1116-10-000 (2)Wisconsin Departrnent of lndustry,k r7l ar-l Human Relations
ttivision of Safety & Buildings
t Il-
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adm. Code
Page 3of1
Attach complete site plan on paper not less than 8 112 x 11 inches in size, Plan must include, but
not limited to vertical and horizontal reference point (BM), directiqn andyo of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PR!NT ALL INFORMATTON
St. Croix
PARCEL I.D. #
REVIEWED BY DATE
PROPERTY OWNER:
Derrick Constntction, fl{c.PROPERW LOCATION
cOW. LOT gg 1/4Nt{ 1i4,S1 T30 ,N,R 18 >E(or)W
PROPERry OWNER,:S MAILING ADDRESS
I 505 IIy. l!65
LOT #
20
BLOCK#nla SUBD. NAME OR CSM #
Wi11ow River }leadows
,?XI
tilftthronct , Inrr . 54oLz)P
coDE PHONE NUMBER
QL5) 246-2320
ncw EVILLAGE Efowtt
Di nhmnnrl
NEAREST ROAD
Co . RC. ltciG
Code derived daily flow 450 gpd Recommended desrgn loading rate . 7 beO, gpdfp:X_rench, gpd/lt2
Absorption arca rEuired 643 UeO, tP 563 renOr, t2 l aximum design toading rate . 7 bed, gpf8:9_rench, gpr,/{t2
Recommended infi ltration s urface elevation(s )q1 ?5
ffiNew Construction Use [ ]
[]Replacement II
Residential/ Number of bedrooms 3
Public or commercial describe
I 1 Addition to existing building
ft (as refened to site plan benchmark)
Additioflal design / sib consideratiors entj.re area to be cut to el. 95.35
Parent material orrtwash Flood plain elevation, if applicable nla ft
S = Suitable for svstem
U = Unsuitable foi system
CONVENTIONAL
trLs tru MOUNDtrs Eur
IN.GROUND PRESSURE
ETS trU
AT-GRADEEks tru SYSTEM IN FILLtrS EIU
HOLDING TANKtrS EKJ
SOIL DESCRIPTION REPORT
Boring #
Ground
elev.
93. 60 tt.
Depth to
limiting
factor
>B/_
Remarks:
Horizon Depth
in.
Dominant Color
Munsell
MotUes
Qu. Sz. Cont. Color
Texture Consistence Bo.Irda,y Roots G P D/ftz
Bed Trendr
1 0-16 L0yr4 I 3 none L 2lmlsbl<mfr cls zlf 5 6
2 L6-43 1Oyr4 I 4 none sil -s1 . L/f lshk mfr E/w L/f 2 3
3 43-82 Lqvlr414 none CO.S.0/sg ml n/a n/a 7 B
Boring #
Ground
elev.
96.7O tt.
Depth to
limiting
factor
>LZO"
Remarks:
2,lmlsbk mfr c/s ?/f I5 610-1 5 Ioyr4 / 3 none L
0. /sg m1 glw rlt oL)72L5_27 Lqfr4l4 none ls.
3 27-48 LOyr4 I 4 none CO.S.0/sg m1 c/ .s nla 7 B
4 48-T2(Loyr5 I 4 none co. s.0/. sg m1 9/<{B
\/,,}PN4
'.<?,^rt\
,7
\;D
..<
./)L'J=
nsu,L%-6200Name:-Please Print L. Steel-
t554 . Ave.,Richmond, Wf . 5l+017
,1 mber.Signature 22983-5-93 Date:
Structure
Gr. Sz. Sh.
/)v
PBOPEE OM{EB Derrick Const. /
PANCEL I.D. '
Boring #
SOIL DESCRIPTION REPORT Pere2 a 3
Gound
elE .
95.15ft.
Depft b
limiting
hctir
>q2
Remarks
Horizon Depilr
ln
oominant Color
Munsell
I\rodes
Cln. Sz. Cmt Color
Texture Stucture
Gr. Sz. Sh.
Consistsnce hrtEy RooB GP D/IIZ
Bed Trsdl
1 0-13 rw{/3 none L 7,/n/shk mfr c/s 2lf 5 6
)13-33 tw4l4 none Is.0/sg m1 8/w Llt 7 B
3 33-92 1.Oyr4/4 none co. s o/se p-l nla a 7 B
Boring #
Grcund
elev.
95.70 ft.
Deph b
limiting
hcbr
)110
Remarks:
1 0-13 LOyt4 /3 none L 2/n/sbk mfr c/s 2lf 5 6
2 t3-27 LWAl4 none sl.1/f/shk nfr 8/w ut 4
3 z7-53 tw4l4 none 1s.O/sg rn-l El.w n/a 7 B
4 53-11(LW4l4 none co. s 0/sg mI n/a nla 7 8
Boring #
Gound
elev.
94.3s ft
Depfi b
limiting
lachr
>80
Rsmarks:
1 0-10 rw4l3 none L 2/rnsbk mfr c/s 2/f 5 6
2 to-24 ro|'r514 none siL 1/f/sbk mfr P,lw rlt 2 J
24-36 rcyt|/4 none ls.0/sg m1 Elw n/a 7 I
4 35-80 l}yr5/4 none co. s 0/sg m1 nla nla 7 I
Boring #
ut+*-"*"^ir*
elar
Gound
ft
Depfr h
limiting
lacbl
El6aarl,..
sB0+330(R.0sr'02)
nsN?a3S8EltSE
$E $S
s4ES
-
STEEL'S SOIL SERVICE
Gary L. Steel
c.s.T. 2298
MPRSW-3254
Derrick Const. Inc.
sF,4t$,4-s1-T30N-R18I^]
PJctrnond, t$onship
tt4
t75
too
988 N. Shoro Orivo
Nsw Richmond, wl 54017
c/15) 24e62m
a
+
iN
/24t
Eill= fia-tt,tlsldb
Itt,nslo*^'-*"pt tL,loc:'4 5
L
a
5 0 ,+0
':;it,:^(-i ;ri
t;
ur)
{
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c +
U '/J/h.')
Nl
g\t',
6
aa\ rz-
AF
t:*
AS BUILT SA}IITARY SYSTEX.{ REPORT
SHIPowN
SECTION
ADDRESS
-nf€-w
o T
l'l (od Pl 4 t{,- ft .
N.l'L.cRolx couNTY, wIScoNSrN
PI,AN VIEI{
SHOW EVERYTHING WITHIN lOO FEET OF SYSTEM
BENCHI.{ARK: Elevation and description :
Alternate benchmar
SEPTIC TNIK: Manuf acturer :iquid Cap.,/oDt)
SUBDTVISI
No. of feet from: Well
oN t ', //e r, fr u&'' lot ,{0 Lor sIz E
inal grade elev:7f,
, Buildlng:sy'
q3,Rings usedI2Uanhole cover elev:
Tank inlet elev. :1J ank outlet elev. :??,SJq)
No . of f eet f rom nearest road: F'ront J-, Side , Rear Ft. //o /
From nearest prop. Iine: Front , Side -L, Rear-Ft.
8L,
(Include this information in the above plot plan)(2 reference dlmensions to septic tank)
SEE REVERSE SIDE
q,
0k
r)
\\y
INDICATE NORTH ARROWsa* tJyo
4
5
ri
t1
0f\
q
4L
Ilr/
/
./ ae
a
)
rE:::-= : a j
PUUP CIIAMBER
Manufacturer: Liquid Capacitv:
PumpModeI:-Pump,/SiphonManufaCt.:PumpSize-
Elevation of inlet: Bottom of tank elevation
PumponeIev.3-Pumpoffe1ev.3-GaIIons/cyc1e3-
Alarm: Man . ! Switch Type :
-Lo
cation
Distance f rom nearest prop . line : Front-, Side
-,
Rear_Ft . __
Distance from: WeI i ldin
SOIL ABSORPTION SYSTE,I
Bed:( Trench:s eepage Pit:
Width: /A Length Sq Numbe Bui ye </8 p
Exist . Grade EIev.35 1 .J
r of Lines: J Area
sed Final Grade E1ev.
FiIl depth to top of pip e: el
l.lo . f eet f rom nearest prop. Iine : Front , Side X ,
No. feet from wel L' aE' No. feet from building
Rear-?t./oi
/ec
HOLDING TAT{K
Manufacturer:Capacity:
No . of rings used 3
-Elevation
of bottom tank :
No. feet from nearest prop. Iine:Front , Side , Rear_Ft.--._._:
No. feet from: WeI , building-, nearest roa
Alarm Manufacturer s
TNSPECTOR:
DATE:E /2-7 PLT'MBER ON JOB:
LTCENSE NuMBER ' / {z <
6/90:cj
Elevation of inlet:
. I0C&,T,tr S;.trft ItCtffi CIU
.Labor and Human Relationi
Salety and Eurldingr Division
GENERAL INFORMATION
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP/ SIPHON INFORMA
SOILABSORPTION SYSTEM
D 01 . 30 . l8PfffirfltsdhtHf3td1iver
INSPECTION REPORT
(ATTACH TO PERMIT)
ELEVAT]ON DATA A9300023 5 Bl%'.to 0O
^a
Pe.mit Holder'r Name:
i.'TTTrlw TQT\IE:P JOTNT VF:NT
O City E village q(Town ot:
R i chmond'CSTBMEI6v : '- -
/oo.o
lnsp. BM Elev
/ao. o
BM Oescriotion:
<1o L ol *;*. r{L,-,-,
ou v
an tm o.y
State Plan lD No.:
Parcel Tax No.:
o26-1115-10-OOO
TYPE MANUFACTURER CAPACITY
Septic Nie"r,/. ooo
Dosing
Aeration
Holding
TANK TO PIL WELL BLDG.Ventto
Ai.lntakc ROAD
septic / o/)8L,3./',ttq NA
Dosing NA
Aeration NA
Holding
IIIIII
III
STATION BS HI FS ELEV
Benchmark 4.oa /o4.01,/oo, o
Ctrt\fiv*5"lb ruE,IL
Bldg. Sewer
st / Ht lnlet //.t4 qa.9)
St/ Ht Outlet tt,9 )9ade
Dt lnlet
Dt Bottom
/ /,7c ga iHeader / Man
Dirt. Pipe tr 8,7 9s,ts
JA,?g /"3LBot. System
Final Grade 8,.t8 ?1,5-8
,rr.31 Q z.o','-t,Cot* ,,<,.-.ra
II
III
IIIManufacturer
Model Number
Demand
GPM
TDH Lift Fricti6n
Loss
Svstem
F(ead TDH Ft
Forcemain Length Dia.Orst. To Well
BED / TRENCH
DIMENSIONS
width/x Length
-r- 4 No. Ot Tren.het PIT
DIMENSIONS
No. O{ Pits lnride Dia Liquid Depth
SETBACK
INFORMAflO
sYsTEM TO PIL BLDG WELL LAKE / sTREAM LEACHING
CHAMEER
OR UNIT
Manuladure.:
rypeol Ma.,),
System: V-al-loot lb'Qs',t//a Model Number
DISTRIBUTION SYSTEM
Header/Manilold Distribution Pipe(s)
r-ength -!t:L{ r,
--+---teneth !!t-tl tDiaOiaSpacrng
x Hole Size x HOleSpa.ing Vent To Aar lntake
SOIL COVER x Pressure Syitems Only xx Mound OrAt-Grade Systems Only
Depth Over
ged /T.enah Center ),{
Depthover \Ll
8ed /Tren(h Edges 7
xx oeprh ol
Topsoil
xx Seeded / Sodded
fl Ye5 0 No
xx Mulched
fl Yes E No
j"COMMENTS: (lnclude code discrepancies, persons present, etc.)
LOCATTON: RTCHUOND Ot .3O.L8.672,SE,NW,Witlda
It,7
I r.1
1-/7 ?a
r}n 4 -oa q'- 1/-11
, ,.o\ A^j. /",.31
QcY)]"t-s"* o''t tt''/
CslYlerision.equireor E Yes dNo
Use other side for additional information.
SBD-6710 (R 05/91)
q
River l,Ieadorrs , LoX OLI iZ
lr.i7
E20- !n; - b 6,€,-q O.!r {a. o.* --
3 J I 6 d L
f\\
Date
t l,)(
lnspedor's Signature Cert No
tr
--
EII LHFI SANITARY PERMIT APPLICATION
!n accord with ILHR 83.05, Wis. Adm. Code
UI
-Attach comptete plans (to the county copy only) for the syslem, on paper not less than
81Ax 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT IilFORMATION - PLEASE PRINT ALL INFORMATION.
SUB toN OR CSM NUMBER
COUNTY S€ -Ltu r /
STATE SANITARY PERMIT #
"lfl A;""+" fu o," appr i cation
STATE PLAN I.D. NUMBER
'i,i'iil;*/],"r., S, nt tl-,t ,,in,k. 5*"*'Se Yr/VhYl,s I tg , N, R lg AXorlw
PROPERW LOCATION
PROPERW OWNER'S MAILING ADDRESS
/Sos t'tatv L5
/LOT #90 BLOCK #ru/ A-
"il;'Pih";.h)t ZIP CODE
5Iot 7
PHONE NUMBER()rs vl/tal-ztt
oeb- //l b- /0
1
2
3
4
5
6
7
I
9
trtrtrtr rg E other: Specity
E
ft,ddVILLAGE :
lll. BUILDING USE: (lf building type is public, check allthat apply)
State Owned NEAREST ROAD
G!I. TYPE OF BU (Check one)
10
11
12
Outdoor Recreational Facil ity
RestauranUBar/Dining
Service Station/Car Wash
Medical Faci lity/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Otfice/Factory
ApUCondo
Assembly Hall
Campground
Church/School
Hotel/Motel
f] proti" p r or, 2 Fam. Dwettingrfl of bedrooro3-
lV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
B) E O Sanitary Permit was previously issued. Permit #
2.4.5.A) 1.8
Date lssued
Repair of an
Existing System
Replacement 3.
System
Replacement of
Tank Only
New
System
Reconnection of
Existing System
rI
Other
Ktrtr
V. TYPE OF SYSTEM: (Check only one)
Experimental
30 E Specity Type Holding Tank
Pit Privy
Vault Privy
+rE
424€E
Non-Pressurized Distribution Pressurized Distribution
11
12
13
14
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fill
21
22
Mound
ln-Ground
Pressure
3. ABSORP. AREA
PROPOSED (sq. ft.)('/g
5. PERC. RATE
(Min./inch)
N/k-
6. SYSTEM ELEV.
?5.3s r".,?/'ss Feet
RED (so. ft.)
11 yso.n.t
VI. ABSORPTION SYSTEM INFORMATION:
4. LOADING RATE2. ABSORP. AREA 7. FINAL GRADE
ELEVATION(Gals/d
a
REOU!
G
CAPACITY
in oallons Prefab.VII. TANK
TNFORUATTOI{New
Tanks
Total
Gallons
#ot
Tanks Manufacturer's Name
Site
Con-
structed
Steel Fiber-
glass Plastic Exper.
App.
Septic Tank or Holdino Tank X ,/6to I l*O.lqei-
Lift Pump TanUSiphon Chamber
VIII. RESPONSIBILITY STATEMENT
l, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
Cq/urn fr,^orv Tr-
Plumber's Si llFlMPRSW No.
/5Ls
(No Business Phone Number:
1 7/S 8/e-983
/?b, /gs "e State, Zip Code):
,fr ur- ll*J ,r?rzr)Plumber's Address (Street,
ltr jya / 7
IX. COUNW/DEPARTMENT USE ONLY
ApprovedP
Disapproved
Owner Given lnitial
Adverse Determination
Et](lncludes Groundwater
Surcharge Fee)q1g Agent Signature (No Stamps).
V-AwX. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD€398 (formerly Plb67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
tt lt
STEEL'S SOIL SERVICE
TIr
Gary 1.. Stcel
c.s.T. 2298
MPHSW.3254
ttrerricll Const.. Inc.
snlN'r2-s1-r3oN-R1 BI,l
Richmond, twonshiP
til
0rt
988 N. Shore Drive
Nerv Bichmond, Wl 54017
(7151 246-6200
I /' 'lfo'
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frrrh Alr lhJrtr And ODrrrrollon plpr
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lllalmurr l2'Aoorr
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DtsrRf DUTrou prFE To bE Ar LE Asr et - rucHEs BELow oRr6ruAL cRAoE
AUt, AT LE.AST EO IUCHEg BUT tIO A,IORE, TI-IAN 'IZ IUCIIES OELOW FI\JAL CRAOE
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lllrtnurl DEPrH oF EXcAyATtol., FRon otttc,wAL 6I{ADE wrLL BE 5,#- rucHEs
itrMtnut'l O€fnt oF ExcAvATtoN f.Aorr. o4,6rlJAL GRngf wruu Bc a,35' tNclrE s
SIGUEO:
LIC EUSC IJU^^BE, II:
-gt1 '?
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DISTRIBLJTIOI.I PIPE,
sotL r tLL
t' oF !,i - z'ri AG 6R E,GAT L
DATE:7
6
110
/
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t 07tsr
435.1 Outtot 1 Willow
iver
eadows
R
M
a
oo
Public
o)
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a
(,
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q-
Higlway GG
DERRICK 6
(715) 246-2320
Route t
New Ricnmond
Wisconstn
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Rivr
CONSTRUCTION -Oa-oq
19
2-Ol Acrr
w,"Jon.,,,Bprr tnrcpt of I ndustry,
Labor and iluman Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adrn. Code
Page 1 of 3
Attach complete site plan on paper not less than B 112 x 11 inches in size. Plan must include, but' not limited to vertical and horizontal reference point (BM), direction andyoof slope, scale ordimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
COUNIY
St. Croix
PANCEL I.D. #
PROPERTY OWNER:Derrick Constructj-on, fl.trc.
PROPERTY OWNER'I505 IIy. l!65
:S MAILING ADDRESS
CITY, STATEllew Ri ctrmond, 1.11 . 54Ol ?P
CODE PHONE NUMBER
(71 246-2320
REVIEWED BY DATE
PROPERTY LOCATION
GOW. LOT gg U4I,il.J 1/4,S1 T3O ,N,R 18 >6(or)W
LOT #
20
BLOCK #
n/a
SUBD. NAME OR CSM #
Wi 1low Ri-ver lleaclows
ncrTY ILLAGE N NEAREST ROAD
Co. Rcl. llGG
Code derived daily flow 450 gpd
Absorption area required _!!]_bed, ft2
Recommended infiltration surface elevation(r
Recommended design loading raB .7 bed, gpd/ft2_. X_french, gpd/ft2
563 trench, ft2 lv'taximum design loading rale .7 bed, gpd/ft2- & __trench, gpd/ft2s) a1 - 15 ft (as refened to site plan benchmark)
I I Addition to existing building3Use
eIt
Flood plain elevalion, if appl icable nla ft
ti.re area Lo be cut to e1. 95 .35
I Besidentiali Number of bedrooms
I Public or commercial describe
[.f, New Construction
[ ] Replacement
Addilionaldesign / site co
Parent material
nsiderations
out-wa sh
S
U nt
IJ foritableS tem
IIU SU itable
CONVENTIONALEts uu MOUND
S Eru
IN.GROUND PRESSURERS UU
AT.GRADE
EKS DU
SYSTEM IN FILL
tJ S E}U
HOLDING TANKt] S EIU
SOIL DESCRIPTION REPONT
Boring #
Ground
elev.
93.6() tt
Depth to
lintiting
faclor
>B?" -
Remarks:
l'lorizon Depth
irt.
Dominant Color
Munsell
MotUes
Qu. Sz. Cont. Color Texture Structure
Gr. Sz. Sh
Consistence Bcurda,y Roots GPD/ftz
BerJ Trsdr1_
2
1l
I
0-16 IOyr4 / 3 rlone L 2/n/shl<mfr cls 2/f 5 6
3t6-43 1Oyr4 / 4 none sil.-sl-L/f/shk nr f'r 8/tt r/f 2
43-82 1.oyr4l4 none co. s 0l sg ml n/a n/a 7 B
Boring #
Ground
elev.
96.70 ft.
Deplh to
linriting
factor
> L20"
Remarks:
1
2
0-1 5 IOyrA / 3 none L 2./n/sbk mfr c/s ?lf 5 6
t5-27 tOyr4 / 4 none l-s.0. /sg m1 g/w L/f 7 o()l,
l-.-
27 -t+B Loyr4 / 4 none CO. S Olsg nr1 c/ ,s n/a 7 ot)
4B-t2(Loyr5 / 4 none co. s 0l.sg nr1 nla n/a 7 B
Name:-Please Print
7r5P.y.If6-6200GaL. Steel-
Addrcss
Signature
1 554 Ave. , New Ri chmonrl, Wf . 54017
3- 5-() 1
Dat"
?'l()t\
CST Nrnrber
PROPEFiY OWiIEB Derrick nst. /SOIL OESCBIPTION REPORT PryZ ot 3
PiRcEr r.D.,
Boring #
Grcund
elet/.
e:._15n
Deph b
lilriting
lac{a
>q?
Remarks:
Horizon oepth
in.
Dominant Color
Munsell
irottes
Ar. Sz. Cont Coior
Texture Structure
Gr. Sz. Sh
Consistgnce Bqrday Roots GPO/ftz
Bed TrErdl
1 o-13 toyr(l3
loyr4l4
none L 2lnlsbk mfr c/s 2lt 5 6
13-33 none ls.o/sg ml P,/g Llf 7 B
3 ,1.Ovr4l4 none co. s.o/se ml n/a 1la 7 B
I
Boring #
Ground
elev.e5. 7() 1
Depth lo
limiling
laclor
>t to
Remarks:
1.0-13 lOyt4/3 none L 2/nlsbk mfr c/s 2lf 5 !.4
2 L3-27 L{.tyr4/4 none sl .1/f/shlc mfr ?,/w 1lf 4 5
3 27-53 Loyrh/4 none ls.olsz m1 Elw nla 7 B
7 Btt53-11(t loyr4l4 none co. s O/sg rnl n/a nla
Boring #
Ground
elw.(l4 -:15 lt.
Deph to
fimitrE
tacbt
>BO
Remarks
2lf 65rnfrc/snoneL2/msbk10-10 l0vx4l3
mfr ?,/v Llt ,none si1 .rlf.lsbk2to-24 rorr5l4
Eltt nla B7ls.0/se mL24-36 loyr4l4 none3
nla nla 7 Ico. s 0/sg ml35-80 LOyrSl4 none4
II
Boring #
elar.
Grourd
It.
Depth to
limiting
lactor
Remarks
snD 811r'(R 05/92,
'FH€.:Dn" an(.t{t. (r_ t-tttJ;t_ !rul ..rL.t, \-;. lS
d,.:::-&ij-i-.J
Si0f! J.j', 'Drloururtr;
ca: ; I n .-.uTuel j.Suncj
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xo! 'o'd
a r {vr -l .J 5
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i:Tr. s5u?P:c33E Ui EBABJ|,S TEEosET? 3!E!.DE C=:a.;ed Dq: E?srETru Ei
-E:5E pu? sfDeuB:TnbB! B^oqE aq: ps.: a&?tl . p.a!:s:l-pEn Gii-. .Ali,,:
o! rD-rrd s{rp o! rTE!En:::,orodE 2u-a .o .ril!.t1I-.;T""r;::';r;::::
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-iDD ;;) EEroErd prrr .uo.T:iDdBu: ,Ei.JE (:) pu! Do;!;plror EE;3r:.rioiiDrior.d uT Ej rlc!B{s lrsods;p JE:r,leaEDr, B::E-uo Dsit (:) :rq: gr:-,i;
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li:rrio:d s,eeBl,G :iDri! 6a.:i 03 DG:E. ffi;G
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'aEfr.d's Er;TTal r Jo !rr.E.r?To.: :n f Es:r Drif :o ZO9 lo EiffiE t:o; luE:S t -ar3a.i D: GTq:t.iT= cq i6 Efuep:EEJ :.rune! =To:! .:S
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-rrGD sDltsllsf UTAD :DOO:d 'ECtEGr. FTPutrl Of E:rr::El ajr-f rrBEld Er;
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--t l!F- Fl.i.ll t.J J. )
-
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:DglgnD f 01 LroTs?a?Pqr's
='ro:D 'f s OnoHtny ID uraoj
'rjz 'n{r 'fuo;:a"s ';,7F 'r,B'No:.trl?o: riu3eo;.d
-uw c.tJ t/\ 'QNowlfiU
sosl
S
?D,nl H2/4 Jn ta; zgaty /aro11
r.funoS ='lo:, ':, li
.IIiSii=3:::)\' =3
FVI:iJ.t;f V,.- )l li\'- 3: .].e3 S
ryy =I1':.S /).2J,)
?:38,iAN :;OE/3J.nOESoS/ sDgrrtrN G:'ij
E3.i-nE /X3NAo
J
a
a
-
APPLICA'I'tON .tloIT SANI '']ARY I'F]IIM I'I
S'TC t00 ?-
Ttrls appllcatlorr li-orm Is to be conpleted l.n full ancl signecl by the owner:(s) of tlrcr
property belng developed. Any lnadequacle,s will only resul t itt delays of tlre permit
issuance. ShouId thls dcvelopment be l',nten(led for resa.le by owner/contractor' (rrsPec
lrouse"), then a second form should he rctaJrred and comple.ted Lrhen the proPerty is
sold and submltted to thls offlce wlth the appropriate deed recordlng.
Owner of Property Lt-o c.<)I vv-r?)L,l,/eu AE y'4 t ct+Ae.c P, S7.e,re<s
Locatton of Pr:oper:ty * k Nul \, Section 30 /g r^l'r N R
Townshlp (,*ro No
Mall lng Adclr:ess os
N*,(,*^oND, h-X -fy'ar ?
Subdivlslon Name h),un* K,r.rz- /LfcAaoours
Lcrt Number JO
Pr€,vious Or^mer of Property o€ Sr*r Llt€rL
1'otal Slze of Parcel 2,o3 A<rks
/o- /q - ?oI)erte Parcel uras Created
Are all corners and lot llrtes fult'rtti I i;rblc?x Yes No
ls tlrls property belrrg developed for r(,sa l(, (spec house) ? - X V"t - No
V<r l rrmc Sto t ancl Page Number 4Sb ;rs recorclecl with ttre Register of Deecls
INCLUDIi WIiI]H THIS APPLI-CNTION ONE OF ]'HE FOLLOWING:
2 . I-ancl Contrac t
3. Other recordlngs filed wlth the Reg-tster of Deeds offlce
ln ad(lltlon, a certlfled survey, 1f avallabl-e, would be lrelpful so as to avo.id delays
()f the revlewlng process. If ttre deecl descrlptlorr re.lt'rencc's to a Certlfiecl Survcv
Map, the tlre Certlfled Survey Map shall also be requirecl.
PR)PERI i' 01C,VER CERTI FICATI0N
I (WQl ee,n-t.i(1t1 tlrut all. atatene.n.ts 0h .tlLLL (ottm a/'LQ. tfiue. to tlrc Lte.tt o( mq (ounl
bnowll.e.dge; l-ha.t I (we.) ant lane.l t.he lunah(L) o( th.e pnopQ.n-tq de,scnibed in .tlub
LnrtonrnoJi.on (on.m, bU vitt.ttx 06 a wahrtantu dged tLa.co)Lded in.the.O$$ic.e. o{ tlrc-
Ct,i-n tq l?e qi.1 izn it i l)e.e.'lt n[ l)rttcttmovr f A/r, .
- !:S:gc- ; and that I lwo I
p.|tQAe.i.t-l.ti.clwn.the.pnopC|^e.d,si,t.e-dontho,s@l/,5.t.e.mlonI(wp-|have'ols.fa.Lnt,d an Q.daunQnt, .1'.0 hr.tyr w.Lt-h the. alsuve de,scnLbed pnupe)Lttl , (on tlrc.
c(:ytl.th.tlc.t),on oi Aa,Ld Lqa.t.em, and the. AunQ lmA lse.on. dtilt1 n-e,e.ohdQd.Lnthe 0(6Lce
o( t,lrc Counttl Regirste.n o{ De.e.d,s, aa Doeumevd No. 4SS"Zob ).
SICNATURIT OF OhINER s tcNATuRIi oF co-owNlilt ( I F
^PPLI
CABLII )
j -8 - q3
Wa rran t
DAI'N S IGNIiD I)A'I'I] S T(;NIiI)
s'r,\'r'l: rtAlt tlF WIS(:Ol'l!lll'l r(rllt\l 2-loia
45r,?-0G 'f tiGlPrct456
tltehael R. stevensl l^,tlllam.ll. Derrlek,
t{t111am M. Derriek, Thomas E. Derrlek and
Ronald t. Derrlck as tenants-ln:common ...,
r'nltt't'l s :t lt,l t. -11 1 ;1 111-.': [rt
. . ..Venture
t{tllow Rlver ,rolnt
REGISTER'S OFFICE
s[. cRolx co., wl
Ree'd for Reeord
.l,lN l9.lJut,^ol I : 3o' A. fvl
U* 0 h^".".e(
0 r' nonr of Dcodr
i
.t
rl
il
;
lhl follorvitrrf rlercl ll'r,l renl estnte ltr
St;rte of lVireonsin:
S.t . Cr.olx ...cotrntY,
Ttr Pateel No:
southeast, Quarter of Nortlrwest Quarter and Nottheast ouarter
of Southwest euarter oi Seetlon 1r Townshtp 30 Northr Range
lS t{eet.
n;runil ro
e
W
llirepilorr t. rrnrrrtnt.lel i lnUnlelpal and tonlng ordlnaneeE I €88€mentg and
rdBtrletlond df record r
ii
ll /d 90.
(,fli*eue-t
JanuarY. .... . .
Ittl;z(
l.trh I s nbt
llsl (ls notf
-r., I . i t
...., holilhitortrl lrlrlrelt!',, llilrliiir(.1 l, l
Derrlck
lek
rlnt' ofllntb,l tftls
Mlchael R.
ll Wf l l.tam l! '
!if
r{l
DE
Ro
n
AUTTTNNTTOA'ION
il)r//r,,r,----
s tev.qns" " .7 I""'
/( K/,,,,
oeir lek
;",/-
* . t{11t tary1.ltr..
. ;;r,,1,'!//', ki/,
SIIA I,'
(,iiEA l,)
STATE OF' WISCONSIN
-- llcreottnlly efitno-btlord- nre thh
. .(sEAl,l
.tI
( s llA l,l
MET{f
Bl.
r'.. r!'i:.,,,.'..fln1t Of
the nhove nnnterl
*1(6ne
1.,
il .99
, 10..-.-..-
Tn'r,E: iltrMDElt sTAl'|, ltAR orr wlsclrNslN
(lf not.
iiuthotlzerl b.v ! ?00.011, Wls. Stnls.)
?Hrs ItrsrnuMENt tfr^s Dnn F'ED BY
BEtrltrcrqN llll grrugEs
(Slqrrntur0s ntny lte nttlltptltlenletl r,f' :trl(ft,,r.lerl'rerl. llol,h
nro not necersnt.v.)
to nre kltort'tt to be tho person "" rvho areeuted tha
foresolnr lnstruntettt trnd nclrnowletlgc thc tome'
(BS lfihrflrqnaTrfl! :"':i i e tl Notrr,'t I'trhtlc ....:... .-:..- .Count.s, Wls'
ilii'""rt',r';li;;i,;' i; ;;;;i;;;ent. iti iioi, itnia ei;irintlon
a
dnle:
..,rrrt?t ol peironl rlqnlnn ln ntr1, rnl.nrtlg nfr,rrrl,l l,r, lrlr...l r,.. l,tlrrt,.rl l,r.lrrrr lhtlr llltrnlrlrr"l.
rlrnnn^Ntt n!-rn st^'rr'i lttrl-ot -wlscoNsl!\,
, t0----. - ')
tt't.rrorr:ln t,rlrl
.a ., .,.1 !'"'
Itlnrlr l','. fr'r'
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,!
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t.:
il
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, f.,.'l | '.1 '.' i' '
1 R; Steii; iiiiii* Derrle
gE
o
a T I
,lt9
i iii Uf s.hll. De
-Thom
am M.
k.. and
ai e
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t
{s{l -t! .}:ng ton
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a
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REPT131 RICHIiIOND ST. CROIX COUNTY ZO}{I}{G
Q5/18i193'L6.46 REQUESTS FoR INSPECTION WORK SHEETS FOR: 5/L9/93
EPAG
!{aIAREA
1
Activlty:
Address:' Parcel:
Description:
Applicant:
Owner:
contractor:
A9300023 5/L9/93 Type: CONV93 Status: PEI{DING Constr:
RICHUOT{D 01. 3o. 1.8. 672, SE, NIll, Willow River Ueadows, Lot 20
026-1116-10-000 occ: Use:
193363
IIILI,oW RIVER JOINT VENT Phone:
WILLOW RIVER iIOINT VENT Phone:
PowERS, CALVIN Phone:
Inspection Request Infornation.....
Requestor: CALVIN POVIERS : /Lew*-
Phone:
Req Tine:
Items requested to be
OOO12 FIIAL II{SPECTION
Inspected.., Action Conments Tine Exp
Inspection History.. ...Iten: OOO12 TINAL INSPECTION