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020-1325-90-000
v U STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Jf fM Al (C C. ADDRESS_ 4 Z 001V r~ /Y~1 SUBDIVISION / CSM tAA1 A1,f 1~ C> 4,E LOT SECTION 2- TAN-R Town of Ho iyS6 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM b f r/" jvl~ f l - Ion•oo Q y3/~ CAC Ad- i Tf: As or V f wEtl Al~7T ~c'f f,~u;1Mt[f,~~ ~1 r Sra a LoT liNf /;jC6 /V INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. a M co BENCHMARR• Tof' p F I. , - I C), OC"a S ALTERNATE BM: *1OC 14. FDaNU,4T lOn/ jF/, I G d~, 3 Y -SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION t Manu urer: LLJ Liquid Capacity: 10C00 Setback from: Well (40 House 0 Other y ~ 7a NC 1a2njtF1Z. 6F HaUSC Pump: Manufacturer Model# Size Float seperation- Gallons/cycle: Alarm Location- SOIL ABSORPTION SYSTEM Width: S' Length ~O Number of trenches Distance & Direction to nearest prop. line: 5 Tc~ f~ ="T Lo7` L /NX Setback from: well: I of House !a7 Other - y / Ta S'.T, /1AN hOlE 41,o>= I01•g3 ELEVATIONS q Building Sewer ST Inlet: l2. 21 Zl" /ST outlet: 17, S9-= PC inlet PC bottom --W- Pump Off - Header/Manifold Bottom of system -L! .2 S% of (,0 , "Z s Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: rYC,~,IL.I = LICENSE NUMBER : C ~S G7 INSPECTOR: 3/93:jt Z Wiscon& Department of Commerce PRIVATE SEWAGE SYSTEM ' Safety and Buildings Division CountyST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanital"Wft: Personal information you provice may be used for secondary purposes [Privacy L *v, s.15.04 (1)(m)]. Permit MILLER Holder's SAM lkebsluillage E] Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel b?26'113 25-90-000 i TANK INFORMATION ELEVATION DATA A9700274 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/*t inlet f 9 > TANK SETBACK INFORMATION St/W Outlet 13115' 17Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Septic > a3 ' NA Dt Bottom ,50 Dosing NA Header/ Man. ' y 9 ? . Aeration NA Dist. Pipe / 3 -761 Holding Bot. System I-V'-75 -7D G, PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM Fri on System TDH Ft TDH Lift I ss Forcemain ngth Dia. Head f Dist. To Well 3 SOIL ABSORPTION SYSTEM BED / TRENCH Width - Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ' ' DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 4u,~_d CHAMBER Model 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 - I j SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 36 " Bed /Trench Edges 3a_ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.19,SE,NW 842 MOON BEAM ROAD LOT 62 Plan revision required? ❑ Yes Q"No Use other side for additional information. ?Jffj~71 2-1 t., SBD-6710 (R.3/97) Date Inspe or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ; SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building WaterSystem~ 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 Pm Numbed The information you provide may be used by o er government agency programs / ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. 02 Mobil (1 em ~/V V__ii ~dC~IJ~A ~ l Y ~ State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 4,1 / LC / 5LC 1/4 #0,,f/4, S / L T N, R E (o W Property Owner's Mailing Address Lot Number Block Number A* 2 Bo (.V City, State Zip Code Phone Number Subdivision Name or CSM Number r1 .r 6) J ~ r 1 40 (3Sk 7- 7So -r,4 41D4.LC__ 2 II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 & vo n OF 14uDSfl 14 Ayeb V 9Flo44 R D 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1q • Ill. /16091 Ie) - 1 3ZS-qc~ 1 ❑ Apartment/ 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. 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 OnlyExisting 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 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required~(sq. ft.) Proposed (esq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation j Feet /00.7 Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank -515 00- 19 1:1 E 1:1 E E] Lift Pump Tank /Siphon Chamber ~ ~ ~ ~ 1:1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: r.. amps MP/MPRSW NO.: Business Phone Number: / 44 4,0 d 4. L. ,mac Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved F1 Owner Given Initial Surcharge Fee) ' Adverse Determination IM I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS - & 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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 submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped 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 administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. 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 on 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 for numbers 1 through 7. VII. Tank information- Fill in the capacity of every new/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. VIII. 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 1/2:( 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; C) 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 required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. l IVA r r r' 1 - = - a ~ I j /1 E T C rQ 'l; i l G u'r Ta AI K T E NOT R P Z OX z s S; t D~~tti TZa-0.1, 41" s Irq is~I~o,~~ , ~r I , toS " At 32- t,oT ~ Z. 1 g_~ `27~ -''Z rOa A ro o T4 K-'~ c>Zo-i?~z S yo q ~ zr GA2acE t4 L ;SF } 47 t u.~ E c L ' I. v a 3 3 Q rs.M ► ~P r WisconsinDepartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page of 3 x,abor "%.H fman Relations Dirtision of safety buildings in accord with ILHR 83.05, Wis. Ad-",, de t ¢4I~"a` COUNTY ' ='a, St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Pfau Must includG- not limited to vertical and horizontal reference point (BM), direction and %of slope, scA..or ARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION JIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION ~ ) Sam Miller GOVT. LOTSt 1/4NW 1/4,S 12 T Z 9 N,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS T# BLOCK # SUBD. NAME OR CSM # Trout Brook Rd. Z Znd Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®iOWN NEAREST ROAD Hudson W i . 54016 ( ) Hudson Tanne L ane [ J New Construction Use [ J Residential / Number of bedrooms [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate gibed, gpd/ft2Q trench, gpd/ft2 Recommended infiltration surface elevation(s) - - - - - ft (as referred to site plan benchmark) Additional design/ site considerations Soil evaluation done for plat approval. Parent material Flood plain elevation, if applicable ft S = Suitable for system C NVENTIONAL M UND IN-GROUND PRESSURE g GRADE SYSTEM IN FILL HOLDING K U =Unsuitable fors stem S El U S E] U l~ S El U ] S El U Jul S ❑ U ❑ S KU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch 6-1b IDNIRWI 4 M1 '54 l nr SLk rn ~r w - .Z 63 Ground 6-/0W4/3 S /tit r lh O,? O elev. Depth to limiting factor DrJ3 Remarks: Boring # -a 0y4 A, -Se A - a.z3 Lra. Ground 2 V-129 p yR 4 3 S r r /h - O. 09 1 elev. /Daft Depth to limiting factor Remarks: CST Name: Plea Harve G. Johnson Phone: 386 -4080 Address: ..P.O. B 91 Signature: Date: Oct. 96 CST Number: 3484 3 ' x PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # 6Z - Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 0- IN - -11 L r" Sy- r~ r CS l 0 4 6 /dyiZ.4 ~ S,L ►nsbL' r Fr Cw 0? O.3 Ground >g I-5S '7.~`/~d 4 s 0 /Mr- /'h J~ C.Lj e1% ft. $3 S oyk4 3 _ m r A Depth to limiting factor 7 Remarks: Boring # jh5b s'h~r C5 A o-/o /a\/ e3 1 - s,c 1~b r r- Li :z X03 7.SY4 S m r rh Ground elev. Jpy24 3 5 r m 0. D l~• ~ ft• Depth to limiting y Id 67 Remarks: Boring# A O-IZ lb 23 L I rns~K m r Cs 6A OS y.. S 1~~ 233 r pal R, ~4 q m 5Lk- ,m7r C w 'g1 333 -7. s `Y- 4 4 4 S © rh r CL-) 4 5 d Ground ` _ s Y►~t f' elevy 0•? 0 g3 ~-2 ID l►~4 3 S_ft. Depth to limiting factor Remarks: Boring # LMov, ~ Ground elev. ft. Depth to limiting factor Remarks: con_01)"to nSro?" Zl 1 .L Z~ ' Ip6 ~ 113' 1. ~ I~ -4- TZ NoeT\A I A r A/ b Z~ / I~t~N g~i+~ YJ ~`r I ~ Sw~ < Z4Jo I $-3 IDS ~ 113 i ~ I 3z, ~Z .g/ i NoeT1a ~.i4LC I ~ 4D I I I i 1 . 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), 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 5 lit J1,( I L C E Location of property5 1/4 At %V 1/4, Section N-R 1 1 Township h y p s Q t1, Mailing address Cs)( 2 y ^Z.,,,, H L.) 'D SoN WI ~goi(a Address of site 950Z MOON 8 0 i4 n"N Subdivision name 1 A N Nf V P-1 C) $:6! Lot no. Other homes on property? Yes No Previous owner of property R A 6o 1 ( 4kw N is ~l Total size of property 2C~ /Q C Total size of parcel © C) Date parcel was created e7- Are all corners and lot lines identifiable? k Yes No Is this property being developed for (spec house) ? X Yes No Volume /a 31 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. S6 gg'„f"S" , 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 the office of the County Register of Deeds as Document No. ature of Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _S N r;1 MAILING ADDRESS aepX.-... PROPERTY ADDRESS 5? 414>0 N R ~I4 (location of septic system) Please obtain from the Planning Dept. CITY/STATE M V 4) S 0 1,A W 1 'r- 1"6 PROPERTY LOCATION 1/4, tU 1/4, Section t♦ T 6-7 N-R f TOWN OF DS Qt4 ST. CROIX COUNTY, WI SUBDIVISION T oktj N y V_ k~D toi~_' LOT NUMBER 4 Z CERTIFIED SURVEY MAP ~ ' oLuw 1z, , PAGE 3) , LOT NUMBER Z-- 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 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 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and 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 County Zoning Officer within 30 days of the three year expiration date. -I-) SIGNED: A DATE: Z~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 PPP' 1 1983 1"10 ! Al[ R[![RV[D ,OR RIC ORDi"O 741A DOCUMENT 140. STATE BA 4F FI[SCONSr00 ARRANTY 5048 35 VOL 1031/AGE 456 F7'.-'CJSTE-,q'S OFFICE This Deed, made between . 1 _ : ~~X CO.. • Randall W. Synan and Patricia E. Synan, 7ec•d brRec~o,d - husband nd Wife c . a. ---::-_,--cr.nto>r, SEP 1' 1993 I ..Sam.... Mi:1_ler.!...a...s...n~le person.......................... ~t 1,,'!oU:445,, O A. -M . { a- ~s~e. oeea~ Grantee, WitIlesseth, I hat the said Grantor, f r a valuable consideration...... Randall. W. SXnan and Patricia E. Synan - ` conveys to Grantee the following described real estate in ..S Cr0 RaruR" To County, State of Wisconsin: Tax Pareat `1o:.-------•-...-----••--------------- The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. Fri ~-Dd AND -fa A parcel of land located in part of the NE1/4 of SE1/4 of Section 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 30100"W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point rq of -eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence SOO 28103"E, 500.00 feet; thence N84 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. j This ...........ts..nQt.... homestead property. r (is) (is not) Together with all and singular the hereditamente and appurtenances tuereunto belonging; And..... R.4-ndi.ll..w.!.... Y.na-n._and_.Patr.i.c.ia...E -.Synan warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. st and will warrant and defend the same. Dated this day of Aug.US.t..... 19...9.1. ._(SEAL) tC'IQkU0s....E.A~ !rl!✓ ..........................(SEAL) i~ Randal . I .W. Synan Patricia Synan t, (SEAL) ...............................................(SEAL) . c. AUTHENTICATION ACKNOWLEDOMENT Signature(s) STATE OF WISCONSIN r, a. St. Croix ....................................County. n .,R authenticated this ........day of 19 P rally came before me ~ day of August 19_....... the above named ~t Randall W....Synan, .....f TITLE: MEMBER STATE BAR OF WISCONSIN Synan (If not, AW....... authorized b aw.^.._.. . by 1 706.08. Wis. Stata.) to me known to be the person .g N9WYx 1te I m j 4, 0 1 ~ ~ ^t I n fi i I O I I 0 1 ~ ~ ~I m i ~ 1 1 M 4 o I ~ n~ v I ' 1 Z i ~ L4 m o ° µ ~C) ° o ~a 6 z - ~ R ST. CROIX COUNTY WISCONSIN ZONING OFFICE N n 0 N p N-- ST. CROIX COUNTY GOVERNMENT CENTER ■ll■•6 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 April 6, 1998 First Federal of LaCrosse Hudson, WI 54016 RE: Septic Inspection for Sam Miller located at 842 Moon Beam Road, Lot 62 of Tanney Ridge, Town of Hudson, St. Croix County, Wisconsin To Whom It May Concern: A septic inspection of the above referenced property was conducted on August 18, 1997. This property is located in the SE%a of the NW'/a of Section 12, T29N-R19W, Lot 62 of Tanney Ridge, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, L Mary J. Jenkins Assistant Zoning Administrator /sm