HomeMy WebLinkAbout042-1104-10-000 (2)60efl
S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ✓C�>%�c../�/n.ii
30� ,H�-..may ��/� /?6 'y2IO�(00 Fq H-
ADDRESS
SUBDIVISION CSM# LOT #
SECTION —T,-` N-RLg W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATE NORTH ARROW I
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK*
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manuf acturer : .� s ., . Liquid Capac i�ty : , Z
Setback f ram: Well t House _ _ lz��c Other
Pump: Manufacturer,
T Model # - Size ----
Float seperation Gallons/cycle:
Alarm Location
W idth : ' Length
.;SOIL ABSORPTION SYSTEM
2 -3 / Number of trenches 3
Distance & Direction to n arest prop. 1 ine : 3� � ,� Z";e
.
//Y A!10'
Setback from: well : House 7 7o' Other
ELEVATIONS
Building SeweST Inlet 640 ST outlet 97, z2
PC inlet PC bottom Pump Off
Ir '0 r . .
Header Manifold3 ��, P Bottom of system
/ y Ar
Existing Grade Final grade
�- 9� • ,�
.� Fir 7y
DATE OF INSTALLATION: � /r/
LICENSE NUMBER: 3 �-
INSPECTOR.��--f,-
3/93:jt
L29 - 108 -
WQZh%�'8rtWA1P9Wjst;, Vkr Vad Ets t Mr , ri�
-Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT)
Permit Holder's Name' El City [] Village [Town of.
-C 5 T _B_WE_Te v . ` Insp- BM Elev.-
cb
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Z. ZZ50
Dv
Aeration
Holding
TANK SETBACK INFORMATION
WARREN
BM Description:
as
ELEVATION DATA
STATION I
Benchmark
Bldg. Sewer
st/,Inlet
St / 4 Outlet
ounty"
Sanitary Permit No--
19 34 '10
State Plan ID No-:
Parcel Tax No.:
0 A —1-1 0L q`' 0 0
1421
1.0- 9f"%
A930000
BS HI FS ELEV.
A
7 dJ / _97,
7"ag / 1 97-171
TANK TO
P 1 L
WELL
BLDG.
vent to
Air Intake
ROAD
Dt Inlet
Dt Bottom
Header. z o
Dist- Pipe 7. q,5-
96. 75
96.r�„e
Septic
(A)
NA
Dosing.'e�'_�I,
NA
Aeration
Bat. System
Z�� 4�' -
Grade
9 ;r. _45S4
I Holding
LJE
PUMP/ SIPHON INFORMATION
99.0,0
MAntjf;irttjrer
Dpmand]
SOIL ABSORPTION SYSTEM
DISTRIBUTION SYSTEM
Header i IviaManifold ��
Distribution 1)IF nlc� fl x Hole Size X Hole Spacing vent To Air intake
I I
L e n g t h --w2v Dia Length Dia- Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over 'ef Depth Over xx Depth Of xx Seeded Sodded
Center 6*tk Trench Topsoil Yes ❑ No
Trench C Fdges6P9'(_ 3:2 i . I
COMMENTS: (include code discrepancies, persons present, etc.)
L U"'% C L-A-1 T 10 N 20 W A R R E N 2 0 9 8 5 7 .3 , N►N E 'ru 0 T _1 HIT WY _1 2 ''11)JI �101F
60
Plan revision required? El Yes
Use other side for additional Information.
SBD-6710(R 05/91) Date
xx Mulched
D Yes El No
RANITARY PFRIRAIT APPI -MATHIN
9L.1 owm I L HR In accord with ILHR 83.05, Wis. Adm. Code
COUNTY
—Attach complete plans (to the county copy only) for the system, on paper not less than
STATE SANITARY PERMIT #
8% x 11 inches in size.
❑ Ch 'cVif ision to previous application
—See reverse side for instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
PROPEWOWNER
PROPERTY LOCATION
Al 110V
_3"
SEW
AIAZ AA&9 Y41S ando T, , N, R E (oro
PROPERTY qfWNER�'S .
OoMAILI RE SS
LOT #
BLOCK #
CITY, PST ATE
ZIP CODE
PHONE NUMBER
SUED I NNAMEOR7M
,024
Z_r
90 44C _
77,egg A" C-01
11. TYPE OF BUILDING: (Check one CITY NEARE T AD
El State Owned C3 VILLAGE : W.
A*14C
"N OF: oe I
E]Public 01 or 2 Fam. Dwelling—# of bedrooms PARCEL TAX NUMBER(S) e
111111. BUILDING USE: (if building type is public, check all that apply)
/0
1 El Apt/Condo
2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 El Outdoor Recreational Facility
3 El Campground 7 El Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 El Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. El Replacement 3. El Replacement of 4. El Reconnection of 5. 0 Repair of an
System System Tank Only Existing System Existing System
B) ❑El A Sanitary Permit was previously issued. Permit Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 El Seepage Bed 21 [:1 Mound 30 EJ Specify Type 41 El Holding Tank
12 0 Seepage Trench 22 0 In -Ground 42 El Pit Privy
13 El Seepage Pit Pressure 43 0 Vault Privy
14 1:1 System -in -Fill
ORPTION
ABS
V1. ABSORPTION SYSTEM INFORMATION:
's
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
GA
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
fro P5—Feet /457PO w* Feet
V V" T�
11. TANK
INFORMATION
CAPACITY
in g lions
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab.
Concrete
Site
Con-
structed
Steel
Fiber-
glass Plastic
Exper.
App.
New
xisting
Tanks
Tanks
r-
Septic Tank or Holding Tank
IlAw
F -1
E] I
I
Lift Purne TankJSiehon Chamber
I -
I
Lj
LJ
El LJ
F-1
V111. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
A
Plu er's Name (Print): Plumber's Signature: (No Stamps) -MP MPRSW No.: Business Phone Number:
I
Le I ( z Llop,
r'. 0 ,,.I 13 X 3
JD
t 4��dp
Plumber's Aad'rre--, City, State, {Sire 'tate, Zip
,�e): or I
IX. CObNTY/DEPIARIrMENT USE dNLY
y�
0 Disapproved
Sanitary Per 5t Fee (includes Groundwater
Surcharge Fee)
ate Issued
Issuing Agent Signature(No Stamps)
A
Approved
Owner Given Initial
/I--, On
-4-
Adverse Determination
1
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 0
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
a 4,, INSTRUCTIONS
r .
40
1. � A san irtary! permit is valid for two {2} years.
2. ' Ydur= shnitairy permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be ,
gbmitted. #o the cou , prior o installation.5. �°nsite se*age systeri)i must 'e properly Maie0d.- The septic tank(s) must be�purin�ed}by a licensed -
.pumper.. whenever necessary, usually, every 2 to 3 years. �
6. If you have questions concerning your onsite sewage system, -contact your local code a6knistralor ►er.the.
State of Wisconsin, Safety.& BuIldings Divisio' 608-26f-3815.
To be"cvmpleteTjana'Accurate thi a.njgj�y permit appl•tcation must include:
,. ,.,
I. Property owner's name and mailing address. Provide the legal description and ,parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type. is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VIl• Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks -and manufacturer's name. • Indicate prefab or, site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of '
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
Cj complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
, fequired _,=the i6� n E) sa1ljest data on a•A7b form; and F) alt-9*,M1q-,Jnformation.�_
'. GROUIID A' R SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges. (fees) for a number of
regulated practices which can effect groundwater.
The ro�ies.allec#ed through theseFscharges are use for mQni oring grooun�vr�ater, ground-
., � r .:-
w1ater cohtai�r' ation investigations and establishment 'of'�stan&rrds:-- ... ,
SBD-6398 (R.11 /88)
DAVE F06ERTY PLtMAK"NG
Ucqnsed #3233 Park Test*r & Plumber
FoaftY HoWts Road23
ROBEWSO-WISCON-sm
mone 749-3656
�2� Swayy -�
0
O i �
30 Z3
A Y.
lip 1�
2,5-
S/r/9 .17
r
1/, y� 2 70
V- ft
i)AVS FOQER� 01 UIONG
Ucster & plu r
Onsed pa* Te #32189
11323:3 V tWty 14*-. �.,;its ROW
ROBiTSCONSIN 5423
;, Wl * '
Phone 749-3656
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT
Labor' and Human Relations
--olivision-af Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
COUNTY I
not limited to vertical ,and horizontal reference point (113M), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
V I V�
REVIEWED BY
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION F
Page I of 3
St. Croix
DATE
PROPERTY OWNER: PROPERTY LOCATION
Ray Swapper GOVT. LOT �T 1/4 J\TF 1/40S 20 T 29 N, R 18 � r) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # ]
504 I-Ta.mter Kill Rd. #2 n/a n/a n/a
CITY STATE ZIP CODE PHONE NUMBER OCITY E]VILLAGE UFOWN NEAREST ROAD
i4uO,.son, 11111. 54016 V1 5 ) 386-6469 1�arren 89th. Ave
hNNew Construction Use Residential / Number of bedrooms 4 Addition to existing building
I I Replacement Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate . 5 —bed, gpd/ft2 . 6 _trench, gpd/ft2
Absorption area required 1200 bed, ft2 1000 _ trench, ft2 Maximum design loading rate . 5 —bed, gpd/ft2 - 6 trench, gpd/ft2
Recommended infiltration surface elevation(s) Q5.85 ft (as referred to site plan benchmark)
Additional design / site considerations rp(-ommend tre-n(--hp-s
Parent material. till Plain Flood plain elevation, if applicable n/a ft
S = Suitable for system CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system � S El U ).0 S El U -'4E S 0 U Mk 0 U El S -a U El S -E U
mom="
Boring #
Ground
elev.
100. 35t
Depth to
limiting
factor
8 0
Ground
elev.
99 ft.
Depth to
limiting
factor
\00
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundeiry
Roots
G P D/ft2
Bed Trench
1
0-10
1 Oyr4 / 2
none
L.
2 mi /abir'.
mfr
c/s
2/f
.5
10-22
10yr4/4
none
sil
I f / sbl�
nif r
g/w
1/f
.2 1.3
3
42 2 - 8 0
7. 5yr4/4
none
S-1.
2 /m/ sbl%-.
mvf r
n/a
I f
5
106
Remarks:
1
0-12
10yr4/2
none
L.
2 /m/ sbl.\-
mfr
cls
2 / f
5 1.6
2
121- 2 7
1 0yr4 4
none
sil .
2 /m/ sbk
raf r
g/w
1/f
.5 :.6
3
27-82
7.5yr4/6
none
S1.
2 /m/ sbk
mvfr
n/a
n/a
.5 .6
Remarks: X 07
CST Name -.—Please Print
Gary L. Steel 715-246-
Address:
1554 20Wi. Ave. TJe�.7 T,',.ichm, ond, WJ-. 54017
Signature- r Date CST Number.
2-8-03 2298
PROPERTY OWNER
Ray Swagger
SOIL DESCRIPTION REPORT
Page �
of 3
PARCEL I.D. #
r
Boring #
Horizon depth
Dominant Color
les
Mott99L,�
Texture
Structure
Consistence Boundary
S ;5�
�1S
'.:•.� f 3
s,tis. SSS�S'.11'.
Ground
elev.
ft.
Depth to
limiting
factor
> 82
Remarks:
Boring #
i i r i}'r'{•: ss ti
�yL�yr: 4 zr
', ..S'
X,
h::• L :•
..... .......... ............ . . . . . .
Ground
elev.
Depth to
limiting
factor
>78
Remarks:
Boring #
:.
{r. .......
r==
i:N
S
Ground
elev.
9 9.5 5 ft.
Depth to
limiting
factor
-�84
Remarks:
Boring #
s
1, OXXiv z
s:
y:
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBo-8330tR.05/92y
in .
M u nsell
Gnu. Sz. Cont. Color
G r. Sz. Sh .
�Y
Roots
y
C P Dlft
Bed
Trench
1
0-12
1oyr�/�
nano
L.
�1m1s���
mfr
els
21f
.5
.�
2
?—Z1
1C�yr41�+
nano
sal .
11f_ 1s��
�.f_r
�1��
l lf_
. ��
. �
�
1--4�
7 . Syr 1�
nano
s . c�
� Im.l s���
mvfr
� 1 ��
1 / f
.1�
. 5
��
�—��
7.5yr� 1�
none
s_l .
�r Iml s��
mvfr
n/a.
n/a
. 5 . �
1
--11
l�?yr412
none
L.
�Ir.�ls�k
m�.fr
cls
Zlf
.5 .�
�
11- � 5
1
0-12
1C?yr�►/2,
none
L.
2/m/sbk
mFr
c/s
2/f
. 5 � .6
2
12-2.4
l0yr/�/!s
none
sil.
2/rn/sbk
Mfr
g/w
1/f
. 5 .6
3
7.4—R4
1(?yr4/4
noen
sl.
2/m/sbk
mvfr
n/a
n/a
. 5 1-6
f V
STEEL'S SOIL SERVICE
Gary L. Steel
■Ave.
•
C.S.T. 2298
MPRSW-3254
' Ray Swagger
� }rTE � S2C7�-T�9� R18�
Richmond, WI 54017
71 5 246-6200
Warren township
i
W LA
P
r,
h v�
r�
r
V J, , •
r
ram}
1 4-v
Q Q `
4-
-70 2 ,
b
/ r-v �- .
/2 OF THE NE IX4
N , R18W, ST. CROIX
OF SECTION 20
COUNTY, WISCONSIN
UNPLATTED LANDS NE CORNER OF �
r r r r rr r r r r w1
N 89¢23'10"E 2625.171 SECTION 20, T29N, I 66 �
SOUTHERLY RIGHT—QF�
c,� M
N 89020'35"E 960-59 WA
Y LINE
0. 190-02I CQ4! `5�3
215.00` C� 199.23�
i
190. Q
Qa � �� s 0 � � r, `�o s $ 9 5735 E 3a
Vt>,
---------- - --- ------ -- - _ w_ ___ _ _-- q N89020`35"E
_I - 33 33 4
BUILDING SETBACk f- - - - _ ._
8 61
w LINE �
� o
r� 5 _�- �.
� _ 4 -,
3
Qc\j 2
c. .1.01 ACRES a a�' o 1.44 ACRES I.48 ACRES E -
i
-coo z N 1.49 ACRESw
oM I
1.40ACRES
M o
i r'C)
C+J on/ -0
0
00
.offs (\j s , , � 0 , 00
v
�l
9 4. 7 600
? ,�
-00 led 177. 0 0 i
M N 8 9 5 9 25 W 8 51.76 j
M 8 44.66EASANT
�
r'2 44 N 890 59 25 W 651.56
_- - , l
, 1� 0 94.56 0 :I
19C}.��' � � Of
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9 10
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS_-ZZO
FIRE NUMBER
CITY/STATE zip
PROPERTY LOCATION: A 1/4, SECTION
.IL Txi N—R W
TOWN OF
Sto croix'county,
SUBDIVISION LOT NUMBER / a
Improper use and maintenance of your septic I system could
result 'n its premature failure to handle wastes. Proper
maintenance consists of pump'
ing out the septic tank every three
years or sooner, if needed by a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system,
St, Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system which was *
I in operation prior to july 1, 1978a St. Croix
County accepted this program in August of 1980, With the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix . Zoning a
certification farm, signed by the owner an6 by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1), the on -site wastewater disposal system is in
-1 0
proper operating condition and (2) after inspection and pumping (f
1
necessary), the septic tank is less than 1/3 full 11 of sludge and
SCUM.
I/lie, the undersigned have read the above requirements and
0
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by •the Wisconsin DNR *
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix co. zo ,
30 days of the three year expiration d tis-.D ning Officer "thin
SIGNED::,Z, �,
o� A�
DATE:.*
St. Croix co, Zoning Office
911 4th St.
Hudson, WI 54016
S T C - 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) -1 !'1 i i �+ ,1. f'j d % i �� iT� should
� 1 l 'ti i� e; f a M.
�_h�„ �. ;sec. :..,; .��.�!.�._;,, �; r?:..C.,It�.d grid completed when
the property' is sold and submitted to this office with the
appropriate deed recording.
------r---w w -------- w f--------rr ------------------
Owner of property
Location of - prop erty�l/i ��1/4 , Section C , T•N -R_W
Township
Mailing address _ /:Z - '
Address of site IZPO f-f 5!6-f
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property
L
Total size of. parcel_
Date parcel -was created_`
'Are all corners and lot lines identifiable? XYes No
I`
r
Is this property being developed for (spec house)? Yes No
Volume-C-_and. Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A I4A.RRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE.
NUMBER & 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
1 l we) ::ai tlfy that all statements on this form are true to the
best ^f my !our) kno Vyledge tea-'. I (we) a:tti ( are) the owner (s) of
the property d'esc;ribed in -this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. .�. 7 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction ,of said system, and the same has been duly
recorded in '.:he off ,ire of County Register of deeds as Document
No .'
Signature of appl nt Co-applio nt
I
-,9
Date of Signature Date of Signature
DOCUMENT NO. WARRANTY DEED
:61'ATE BAR OF WISCONSIN F 0 RM 2
49"107
V 10 L
Elsie D. McKenna, a single person
------------- -------------------- --------------------- ---------------------------
------------------------------------------- --------- I ------------------------- ---------------------------- -
--------------------------------------------------------------------- ------------------ I ----------------------
---- ------ - --- -- --------- --- --------------
Co - nvey S and warr a nts to E. Swagger and Kathy n R -----------------
-------------- - ------------------------- y
S` q_ggqr-husband - and - -wi-fe -------------------------- - I -----------------------
---- ------ *_1 ------------ -
-------------------------------------------------------------------------------------------
-----------------------------------------
------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
. I ---------------------------------------------------------------------------------------------- ----------- ___
--------- -------------------------------- ------------------------------------------------------------------------
-1 ------------------------
--------------------------------------------------------- _ ------------------------
tiie following described real estate in ------- St. --Croix ----------------------- County,
C3
State of Wisconsin:
THIS SPACE RESERVED FOR RECORDING 1)
R E G INC Z� G 17 1 C".1 f
ST. crROIA", Co., V1,111
FEB 1 6 19193
10: 2 5 A•
R f rz
ezister of Deeds
RETURN TO
Tax Parcel No: ----------------------------- I
Lot 1 and the East 20 feet of Lot 2, Pleasant Acres in the Town of Warren, St
Croix County, Wisconsin.
This ----- is --not ----------- homestead property.
I , (is) (is not)
Exception to warranties: easements, restrictions and rights-of-IvTay of record, if an�
February 19-- 9 3
Dated this -_--------------------------------------------------------------------
I -------------- Z_ --------------- day of
'7 T
E A Ij
Elsie D. McKenna
-- ------------------------------------------------------------------
-------------------------------------------------------------------- (SEAL)
I* - -------------------- ---------------------------------------------
AUTHENTICATION
Signature(s) ------------------------------------------------------------
----------------------------------------------------------------------- --------
authenticated this --------day of--------------------------- 19 ------
-------------- -----------------------
* - ----------------------------- ----------------- ------------------
--------------------------------------- (SEAL)
4 -- ---------------------------------- ------------------ -- ---------
ACKNOWLEDGMENT
STATE OF WISCONSIN
St. Croix --County.
------------------------------------
Personally came before me 6�s _______day of
February 1 19 -------- the above named
------------------------------------------
- - - -.Ri- - - 4, _(:� -.D --- ----------------- f ------ ��i --------------- ---
si
14 V,/y I 2
y2 AY �`,D r1 D , c . :�w V1GG E ,c
arc. � �r� Iq ve
p wtit
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