Loading...
HomeMy WebLinkAbout020-1335-40-000 ST. CROIX COUNTY ZONING DEPARTMENT \ c.► AS BUILT SANITARY REPORT ECILI`WED F Owner 5~ n l /Y! /L L ~oZ _ , Address -739 w i L E a ~D~f 0 t h, City/State iq y DS o N W t Sy0/(o CITY ICrw ZONAICaf~FF Legal Description: Lot 3lBlock Subdivision/CSM # B~D~~NO s ~i~./ t V t/4 S4 1/a 14cj, Sec. Z 7 , T 29N-R /9 W, Town of ~YyGSa~ PIN # O2 a • - o SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer W E S ~L Size ST/PC/0~~ / Setback from: House Z 8 Well 9Dt P/L 8q I FAST Pump manufacturer Model - - 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: 7-l2 E M c q Width S Length < a Number of Trenches Setback from: House /3 3' Well / 9 ? ± P/L a Vent to fresh air intake a,,5- 3 fa ELEVATIONS: Description of benchmark / P t P.L c N z c'T Z / NE E / _ 7 Z_. Elevation 1 o©, c0 Description of alternate benchmark sue- o t4 I3 A c. K VCNV (Z C r 7. 5-!r- Elevation _1q? ~ I Building Sewer ST/HT Inlet =16' 'Ly ST Outlet 10, 9, 84 PC Inlet - PC Bottom - Header/Manifold 13 Top of ST/PC Manhole Cover r > s r F 04$7- S .07 Distribution Lines Q) 13 ~'=~3~ (z) ► 3 5 % ( ) Bottom of System (I) (2) ±-:r d - ~S ( ) ( (z) I d Final Grade 0 ( ) ) Date of installation /0/11 Permit number zR4 $ State plan number - Plumber's signatur License number 103S'00 Date -Z- / 3 / -/y Inspector Complete plot plan Or NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW I ~o I ~ N W 1 I ^Z P. E1= c.oO LTE2NA 1 E w~ 5 f LL 00 EI • - R4 ~ . a~3~ 3 3~ 2g zq r ✓SE , E 3g'~'~ 3w'x3~' ivol'E : 45 of L INDICATE NORTH ARROW W' 1ST /VSP~- Wisconsir'Departmentof Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT S4 - Gtro1~. 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)]. VIA/ / ! 0 Permit Holder's Name: ❑ City ❑ Village [K Town of: State Plan ID No.: Ile, r CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: le 0 0 r -P e7 /ot V^- ff 02-0 - 13 357-176 - 000 TANK INFORMATION ELEVATION DATA A °1''7Y8 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ep I W Ias C1e p d p Benchm r f6•2A /06.20 /00- Dosing Alt !3M -7•AC"-/5 Aeration Bldg. Sewer Q18~ cl&02- Holding Q>K Inlet g6.2-2-- TANK SETBACK INFORMATION ©1W Outlet 95.E TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic Sc f ~p~ Z$ NA Dt Bottom Dosing NA Header/ Man. ~Z•9S~ 93,2$ Aeration NA Dist. Pipe Holding Bot. System 9/.5$f PUMP/ SIPHON INFORMATION Final Grade Manufac Demand ounlte" 760Y 98,5/ Model Number GPM TDH Lift Fr' System TDH Ft mead ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED Width Length No. Of T enches PIT I N No. Of Pits Inside Dia. Liqu' Depth DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM L CHING Manufacturer: SETBACK CHA INFORMATION Type O _ o e Number: System O I00 A01. OR UNIT ,haAaL DISTRIBUTION SYSTEM Header/Manifold L •r Distribution Pipe(s) x Hole Size x Hole Spacing Ven~;ir In~aje Length 13.5 Dia. ,T Length.~~ Dia. ALI/ Spacing 'TjJ/1 (a 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include cod discrepancies, persons present, etc.) 7?~ql 1•~cd• (,l~Q, Pisa%f"%f%W' Qt4lf. -Top o•- jomee me4~,+ CA 00 V, C, r11 ~~19.15~ W,611 t16+ ► n Sfal I c-d 0 ine7paAm I 3 ~ /Q Ia~cmrov~ ~It-~ ► 5 ~~h~,l l , at~l i~-iv r~~ roo r i~5 vKar~ be v1Y-P~ ~'b P,It Si I A vci(m we.ec ot-W in *eKcbrs d ~d N~f ,w•b ~ •~i'► dlaf->7o nG` y Plan revision required? ❑ Yes No ~l Use other side for additional information. 2 1',q 1161 7. 1 SBD-6710 (R.3/97) Date Inspector's Sign ture ert. N ra Safety and Buildings Division 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 l than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 2.91/9 1 1 The information you provide may be used by other govern me e nnc programs ` ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 73 Will lR~~//~~ State Plan LD. Nu ber 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ~LLEI~ 5r- 114 1/4, S Z T Z`/ , N, R/f' E (06-W--) Property Owner's Mailing Address Lot Number Block Number *1 / ~i 43e X City, State Zip Code Phone Number Subdivision Name or CSM Number v w/ ® 1(324) Z7 07 14 L. f1 14//-,) _j rie,1?1 II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city earest Road 3 ❑Vllage //0D.Sta l~/LLFi2~L? 2/~ ❑ Public lij 1 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) '17. 99• /9./77f- 1 ❑ Apartment/ Condo m Z v_/ 3 3 5- ~Kd 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. g 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 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) C Elevation Z/-TQ .Slo Oo Feet 94of Feet VII. TANK Capacity site in gallons Total # of Prefab. Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass App. New Existing strutted Tanks Tanks ❑ 1:1 1:1 1:1 Septic Tank or Holding Tank 1,5 0+E1 I El I El 11 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) M/P/////M//~PRSW P No/.: Business PhoneQN'/uum/./b_er: MlkF, MS Plumber's Address (Street, City, State, Zip Code): o t/ NfiA t, a -c eo "4 fD 14 t--, D o H vA! S' Sid ~G IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial k or 0 Surcharge Fee) / 7./1/17 / ~/tr Adverse Determination FI/ irl X. CONDITIONS OF APPROVAL / REASONS F DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Divi ion, 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- 11. 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 1/2x 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; Q 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. S R yz~ l[ c. E 2 /,yr , i4'~.~~" ~fRS-o 3So0 / z.i,oz' B'3 r e ~(o7E' C 7 7c MADE To /rIN/ryfj~~t' r ~i 0 2q 6• . ~ Lc r ~/NE 6 3-S 3 `I 1LSX S LOT DoT 1,5' Z 4 aj o ~ c C' I Z'~l F ~ r ~Y j l j r i 5~ Z VI u1 a ; o o _ LL. F~ 0 o ~ ~Y i N Q ~ QZZ ti O ~r S< ? v ^ iT r w I Z I M ~r l \N I s a- I tt! N I a M 1 a l.y LL ~ I 0. v ' i n. ' j co ~ I ~ y R I QN, I w Q.. V) Wisconsin Department of Industry, SOIL AND SITE EVALUATION • ' Labor and Human Relations Page of _ Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less t"h 8112 x 11 inches 'in•size. _ Plan must County include, but not limited to: vertical and hori4Sptaf r6fere a pf~t (BM), direction and percent slope, scale or dimensions, north Jlrawt and lof) 1stanc@..to A; arest road. Parcel I.D. # OD APPLICANT INFORMATION - ea. a P14ki Date Personal information you provide may be used f fs ndary pui I L5-~~ Property Owner ZOO t ` ( .1 QYs[ 57Oa T .Z'7 T d ¢ N,R Ir E (o rf Property Owner's Mailing Address ;M# l 111 City State Zip Code Phone 2 Nearest Road i1 G h~u dso-~ tJ.' Y0/6 ~~S b vti i CIGG~ d ms 0 New Construction Use: ® Residential / NumUG ❑ Replacement ❑ Public or commen Code derived daily flow gpd d, gpd/q-.Y-trench, gpd/ft2 Absorption area required eY3 bed, ft2 S4f d, gpd/ft2_ _F trench, gpd/ft2 Recommended infiltration surface elevation(s) an benchmark) Additional design/site considerations Parent material ~A~' c r CC S ~r T 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 ❑ U [A S El U 0S ❑ u (z s❑ 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 1 /0 7, 5'1,,? 4,;V1 1 a / -16"q 122 15e s S: G .2 F v Cs F Ground 3 % d G C ~ ~ 7 elev 161 d/ le_ /I st? Z . , Depth to limiting factor Remarks: Boring # 13 "S 1/47, 5 r V0 YJ 1,4 1/ Ground 0 V. Depth to limiting factor min. Remarks: CST Name (Please Print) Signature Telephone No. r" sc ~Arev ?~5~.3 G °-3/21 Address Date CST Number l o 5 yd G a B I PROPERTY OWNER SOIL DESCRIPTION REPORT Page ~Z_ of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Y,(-,y6 y F5 c 5 'Y ; Ground 3 ~/e•• On/ S G s . 7; elev. i. act. ; Depth to limiting ; factor in. Remarks: Boring # F.5' !tea h a,- 1 S I5 7 ' Ground elev. Depth to limiting faoor 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 # wi-i ..rJ e- IFS Clhcr -Y S S 7 3 ~x 9 zza A2 Z C, Ground elev. ~y /d ft. Depth to limiting r Vi n Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) 1- 41 l + ~ 1 G i 'r ri ~ 1 J , + s~,~'t + a yt ~5 , + ' 1 All 1 i~r 1-Y I IV ~o Received Oct-30-97 12:44 from CCITT G3 7155496731 page 3 J ez' ~ 9y ' A 4L MU c~a y LA tz 4t~Ltza ~ ~ y p ~ N `J >B ru .0 ' S0032'30"W 331.83' 27.18' 198.Ot' 331.82' w V Q . rn P V N00'0 IVE 336.80' co tdJ9' 4.001 ~d AIM w y h1 (A a s ~ 1 N N0M'00'E 85.04 WWW[ tti.2T iV * O p o 201,1 T 900'00'00'W 232.3' m W 0) v Wisconsin Department of Industry, SOIL AND SITE EVALUATION 1 3 LabcGand Human Relations Page of Civision of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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 St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # Gao -/67 5-G0 APPLICANT INFORMATION - Please pri ,r f17' Reviewed by Date Personal information you provide may be used for seco ur~Cises (P04 (1) (m)). ¢ Property Owner ® operty Location Richard Stout vt. Lot SE 1/4NW 1/4,s 27 T 29 N,R1 9 XLK(or) W Property Owner's Mailing Address Loi1# Block# Subd. Name or CSM# 1353 Awatukee Trai - 4 Badlands Prairie City State Zip Cod o y Phone Wu a(y" City El Village Town Nearest Road C'„ FGyCE Hudson WI 5401 t 71 t►o4 X731 / Hudson Badlands [2 New Construction Use: © Residential /@(.g[becir~oms 3 - 4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 0 Q gpd Recommended design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Absorption area required 8 5 8 bed, ft2 75C) _trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 90 6 0 ft (as referred to site plan benchmark) Additional design/site considerations Parent material --`mil depe s ; } 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 E] U S ❑ U ®S ❑ U S ❑ U ❑ S U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Bed , Trench in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. 1 1 0-110 7.5 r2.5 1 none L 2mabk mfr cs 2f .5 '.6 2 10-28 10 r4/ none lfs 1mabk mvfr cs 1f .4 _5 Ground 3 28-90 10yr4/ none ms osg ml cs .7 .8 elev. 97.0 ft. Depth to limiting factor min. Remarks: Boring # 1 0-1 7.5yr2.5 I none L 2mabk mfr cs 2f -5 -6 2 2 10-28 10 r4 none lfs lmabk mvfr cs if -4 _5 3 28-SO 10yr4/ none ms osg ml cs .7 .8 Ground elev. 95-40 ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. / A ea- S / 2 Address Date CST Number o I-rlpd 7 IF 1-5L _-7a cs 7ggd . • ?ROPE'RTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 a~ PARCEL I.D.# 3oring # Horizon Depth Dominant Color Mottles Structure 2 p/ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 ? 0-1 7.5 r2.5 1 none L 2mabk mfr Cs 2f .5 2 10 r4/4 none 1US 1mabk mvfr cs if .4 .5 around 3 3ro 36- 4 none s sg 1 cs .7 ..8 95.10 ft. depth to imiting actor 9-0 -in. Remarks: 3oring # 1 -10 7.5 r2.5 none L 2mabk fr s f .5 ,.6 4 2 0-4 10yr4/4 none lfs 1mabk mvfr s if .4 ,.5 3 0-9 10yr4/6 none ms osg 1 s - .7 -.8 around elev. 91 .9 Ott. ')epth to imiting actor 9.2 in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Boring # 5 2 13-4 10 r4 4 lfs 1mabk vfr CS if .4 .5 0-9 10 r os 1 -CS .7 .8 Ground elev. 9 3 _.-b.0-ft. Depth to limiting factor 91 in. Remarks: Boring # Ground elev. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) /yrC ~ ~ ,r •et~, t e ° "Ova 4 ~ 41 4 cs Q ~p lb ~n d4 IV 0 pn ~a STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /R//, L- MAILING ADDRESS So .k T-/ PROPERTY ADDRESS 7`3 9 W/ L L. AR.64 kO* 0 r" (location of septic system) Please obtain from the Planning Dept. CITY/STATE (4 0 S ON W t veyo 14 PROPERTY LOCATION ZE 1/4, N4A/ 1/4, Section, T -q N-R TOWN OF #U 0 50,--t ST. CROIX COUNTY, WI SUBDIVISION )A b iA M 1) S PQ LOT NUMBER -3 CERTIFIED SURVEY MAP , VOLUME 4_>1 PAGE LOT NUMBER Improper use and maintenance of fff 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. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, Wl 54016 11/93 S T C - 100 -This application form is to be completed in full and signed by the owner(s) of the propejly being developed. Any inadequacies will only result in delays of the permit i:,suance. Should this development be intended for resale by owner/contractor, (spec house) , then a second form should )>e retained and completed when the property is sold and submit 2d to this office with the appropriate deed recording. Owner of property f:g m lYj /L~ C /Z Location of property ~C 114,&W 1/4, 3& it J on _7 T :0 N-R 14~ W Township_ -V4 g,pN -Mai]._ n address Addressof site 737 Subdivision name t3041-,t) 4 IWO5 R0-4//Z Lot no. 3 _ Other home,- on property? YesX _I'-'o Previous owner of property Ate-jY s4R-0 -o u7 - Total size of property . Z.;r J051-c-- Total size of parcel, 2 g G. Date parcel. was created - Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house) ? C Yes No Volume /,L'7(? and Page Number 3a Z is recorded with the Register of Deeds. INCLUDE WITH THIS APPLICA9.'CON 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 M p, the Certified Survey Map shall also be required. PROPERTY OWNER CER'T'IFICATION 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 inforurltion form, by virtue of a warranty deed recorded in the off•.e of the County Register of Deeds as Document No. S(A j / 40 and that I (we) presently own the proposed site for the sewa(je dispos<ll system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the Name has been duly recorded in the office of the County Register of Deed:; as Document No. ro0 T i na ure of Applicant Cu-Applicant Date of Signature Date of Signature V • / V 569100 • ~a STATE BAR OF WISCONSIN FORM 2 -1996 bOCUMENT NO. WARRANTY DEED RICHARD 0. STOUT REGISTER'S ©fF !CE ST. CROIX CO.$ WI liac'd fn: F2;:card conveys and warrants to SAM E. MILLER Nov 2 6 1997 M Ri isfar of Deeds the following described real estate in St. Croix County, State of Wisconsin: RETURN TO tpr Lot 34, Plat of Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin, except that. part of said lot described /0/ within Parcel B attached hereto. Parcel Identification Number (PIN): TRANSFER FEE This is not homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights-of-way and covenants of record, if any. or not Dated this 25th day of November 119 97 I; CkA 0J 0 yC.O ~i (SEAL) (SEAL) * Richard O. Stout (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. authenticated this day of 119 Personally came before me this 25th day of November 19 97 the above named Richard O. Stout