HomeMy WebLinkAbout030-2089-30-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER CJ c~ c a 3S
ADDRESS Gu
SUBDIVISION / CSM# LOT #
SECTION Y T 3d N-RW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF YST M
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
RECEIVED MAR 0 4 1997
BENCHMARK: ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: j.'dWes'7`~Y.c/ Liquid Capacity:
Nu~-p~,' ~ 'I
Setback from: Well House Other
Pump: Manufacturer Model# 33 Size 3
Float seperation ~..2 Gallons/cycle: /S~
Alarm Location s
SOIL ABSORPTION SYSTEM
Width: S Length ?O Number of trenches 3
Distance & Direction to nearest prop. line: 7~ S'c cZ`Lt
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
2~yI~ ~3 ~Z
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human.Relations INSPECTION REPORT ST. CROIX
Safety apd Buildings Division
(ATTACH TO PERMIT) sanitary Permit No.:
GENERAL INFORMATION 284242
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
LACASSE R.W. ST JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
030-2089-30-000
TANK INFORMATION ELEVATION DATA A9700017
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV-
Benchmark
Septic
lDosing
Aeration Bldg. Sewer
Holding St / Ht Inlet d Qd e/$ '
TANK SETBACK INFORMATION St/ Ht Outlet q ,
TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet p,US ' S•'7
Septic NA Dt Bottom aS .5
7G' 9r,99'
9 ; e s'
Dosing NA Header / Man. 7,7
7.116 ' 97.79 '
Aeration NA Dist. Pipe 'q_ , 47 ?p
F, 79' %4•. 96 '
Holding Bot. System 9' 4t;yb '
PUMP / SIPHON INFORMATION Final Grade Al, Qd' Fi3'
Manufacturer Demand
Model Number 1 3D GPM
TDH Lift Friction q(,, System 15y TDH',7~o Ft
Loss
Forcemain Length bh5d` Dia. Fi Dist. To Well.
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING
SETBACK Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER
INFORMATION Type O 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
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over I xx Depth Of F;xx~Seedecl / Sodded xx Mulched
Bed/ Trench Center Bed /Trench Edges Topsoil C] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST JOSEPH.NW.SE.34.30.19W OAKWOOD LANE
I°
Plan revision required? ❑ Yes [ZyNo
L ot (9q y 7 ~~y= ` -1
Use other side for additional information.
SBD-6710 (R 05/91) Date n br's Signature Cert. No.
SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuilBuildinWater System!
ng Water 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 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check if revision tD previous application
[Privacy Law, s. 15.04 (1) (m)]. ^ ~,t QC~ ~OOd LQ,r State Plan I.D. Number
1. APPLICATION INFORMATION D-- PLEASE (•IPRINT ALL INFORMATION
Property Owner Name Property Location
w ~CL(Z0, C W1/4_<e 1/4,S ey T~(~ ,N,R/Q E(or&
Property Owner's Mailing Address Lot Number Block Number
/a A 1' QG'c 4AI06 2 A/~
City, State Zip Code Phone Number Subdivision Name or CSM Number /
154 Q E, v .irk Q
II. TYPE F BUILDIN : (check one) ❑ State Owned El (age Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF gage AA J-61a h
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 3y- 30. 19 - 7- 5a 0 3 cr - 7O ^ 3
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. 1& New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -
------System System Tank Only-____--_-_--_- Existing System Ex -
B) O<A Sanitary Permit was previously issued. Permit Number Date Issued Ul/
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 RSeepage 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) Elevation
Oleo o? O 0 a d d c WA, '?7-99' Feet 00.79 Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks r
Septic Tank or Holding Tank ,?O!3 c U~S'TPY~t/ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber keg l f2j.'Gr!A~e r''ey..fl ❑ ❑ ❑ ❑ ❑
VI11. 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) MPRSW No.: Business Phone Number:
I ;a .4u S 'c .r- o38a 1,? /S-?6`G - -74Z /
Plumber's Address (Street, City, State, Zip Code):
Q U O Sc /Q~ u o r
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit F Includes Groundwater ate Issued Issuing Agent Signature ~Nq Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
91-1619
Adverse Determination
7
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 0"4) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, owner, Plumber
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PAC t GF
PUMP CHAMBER CROSS SECTIOIJ ANG SPECIFICA-r10u5
VEkJT CAP
`i"C.Z. VENT PIPE
- 25 WEATHERPROOF APPROVED LOCKIMG
JUIJCTIOU BOX MANHOLE COVER
' FROM DOOR,
WINIDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE i
~ y" MIIJ. ~
I
COIJDUIT-- IB"/'KIW.
18"MINI.
11~
IAILET PROVIDE
AIRTIGHT SEAL I
I
~ I I
I ALARM
a ~ II
I 1 .
*APPROVED i Om
JOINTS WITH
ELEV. FT. APPROVED PIPE
3' ONTO PUMP-~ OFF
D SOLID SOIL
CONCRETE BLOCK
RISER EXIT PERmiTrED OAJLH IF TANJK MAWUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFICATIOKIS
DOSE
TANKS MAUUFACTURER: ~•dW~S~Py~icJ ~WMBER OF DOSES: PER DAS
TAMK SIZE: Id-d0 CALLOUS DOSE VOLUME mot- p
ALARM MAIMUFACTURER:_ INICLUDING BACKFLOW:_l__.J GALLONS
MODEL AIUMBEK: Q-4 L CAPACITIES: A= as $ WCHES OP, 74 CALLOUS
SWITCH TYPE: 1'!2 e►^ L ?
B INCHES OR 75' GALLONIS
PUMP MAMUFACTURER: 0,-fl'J/B G = ~2 IIJCHES OR !ss GALLONS
I MODEL MUMBER: ?
D- ~ INCHES OR 9100 GALLONS
SWITCH TYPE: ek- c MOTE: PUMP AWD ALARM ARE TO DE
MINIMUM DISCHARGE RATE ,31J GPM INSTALLED 0M SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID DISTRIBUTION) PIPE.. ~ FEET
+ MIAIIMUM METWORK SUPPLY PRESSURE . A;&- FEET
+ -E0 FE ET OF FORCE MAIM X h sy F - FZFRICTIOM FACTOR. _ r At/ FEET
TOTAL DHMAMIC. HEAD = FEET
INTERIJAL DIMEMSIOMS OF TAAIK: LEAIGTH-;WIDTH ;LIQUID DEPTH -
00,
3 IGIJED:A1 LICEMSE MUMBER:a~Fe~z, nwrc-.2
S95-41221
pf~6E of 6
4% 6'% -
W ° HEAD CAPACITY CURVE 45,8
W 6
W W "57" - "59" SERIES *14'VI6
25
_ 1'h - 11'h NPT
I
20-
6-
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15
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4
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0 10
33/,
- +
2 Zt_b i, I
5
TOTAL DYNAMIC HEAD/
FLOW PER MINUTE
EFFLUENT AND DEWATERING
HEAD CAPACITY
0 UNITS/MIN
FEET METERS GAL LTRS
US 10 20 30 40 50 5 1.52 43 163
GALLONS
10 3.05 34 129
LITERS 0
80 160 15 4.57 19 72
FLOW PER MINUTE 19.25 ' 5.87 0 0
CONSULT FACTORY FOR SPECIAL APPLICATIONS
- Piggyback Mercury Float Switches *Available with special cord lengths of 15',
available. 25', 35' and'50'.
- Variable level long cycle systems -Alarm systems available.
available. - Duplex systems available.
Standard cord length - automatic 9 ft. SELECTION GUIDE
Standard cord length - non-automatic 15 ft.
1. Integral float operated mechanical switch, no external control required.
2. Single piggyback wide angle mercury float switch or double piggyback mercury
57/59 SERIES Control Selection float switch. Refer to FMO477.
Model Volts_ Ph Mode Amps SIm lex Duplex 3. Mechanical alternator 10-0072 or 10.0075.
M57/59 115 1 Auto 8.0 1 or 1 & 7 - 4. See FMO712 for correct model of Electrical Alternator, "E-Pak".
N57/59 115 1 Non 8.0 2 or 2 & 6 3 or 4 & 5 S. Sensor mercury float switch 10-0225 used as a control activator, with "E-Pak"
D57/59 230 1 Auto 4.0 1 or 1 & 7 - duplex (3) or (4) float system.
E57/59 230 1 Nbn 4.0 2or2&6 3or4&5 6_ Four (4)hole "J-Pak", junction box. forwatertightconnection orwired-in simplex or
2 pump operation. 10-0002.
7. Two (2) hole "J-Pak", for watertight connection or splice, 10-0003.
57 Series - Wt. 27 -.3 H.P. 59 Series - Wt. 29 -.3 H.P.
CAUTION
For information on additional Zoeller products refer to catalog on Combination Starter. All Installation of controls, protection devices andwlttngshould bedone byaqualNled
FM0514; Piggyback Mercury Float Switches, FMO477; Exectrical Alternator, FMO486; Mechani- licensed electrician. All electrical and safety codes should be followed Including
the
cal Alternator, FM0495; Alarm Package, FM0513; Sump/Sewage Basins, FMO487; and Simplex most recent National Electric Code (NEC) and the Occupational Safety and Health Art
Control Box, FM0732. (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. i
MAIL TO_ P.O. BOX 16347
L. Louisville, KY 40256-0347 Manufacturers of. . .
O O`/ /~O O. SHIP T0: 3280 Old Miters Lane
o Z `LL o
Lguisi78e, KY 40216 rr
(502) 778-2731.1(800) 928-PUMP ,oU,IL/rY PUMPS Fh'Cr 1P,7J
SANITARY PERMIT APPLICATION Safety and Buildings Division
Bureau of Building Water Systems
In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave.
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. I (!A
• See reverse side for instructions for completing this application State Sanitary Permit Nummbler/
The information you provide may be used by other government agency programs ap
(Privacy Law, s. 15.04 (1) (m)]. E] Check if revis o o previous application
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
f C.. i t~4 c- - 1/4, 5:3 T 3d • N• R/ E (o W
Property Owner's Mailing Address ' Lot Number / Block Number
.72 r^ ;
City, State Zip Code Phone Number Subdivision Name or CSM Number
c P- .f -
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
Public ' 1 or 2 Family Dwelling - No. of bedrooms_ ❑ village
Town OFD
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo Q?D - -3 0
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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 online A. Check box on line B, if applicable)
A) 1. L,New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System --------System Tank Only Existing
B) 5 stem Existing 5 stem
❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11E] Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 2 Seepage Trench 22E] 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) Elevation
-o
Gl N Gc-- 12, 2 '1 Feet 'e6, % % Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. FCo' Fiber- Ex per.
New Existin Gallons Tanks Concrete Steel glass Plastic App
Tanks d
Septic Tank or Holding Tank ❑ ❑ ❑ ❑
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) AVYIM No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code
!d 310 ~ v f , z 6
1X. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) ,
97
Approved ❑ Owner Given Initial Surcharge fee)
/
Adverse Determination ®
XQ;qr~
. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,
DIVISION
707
LABOR R PERCOLATION TESTS (115~ MADP.O.ISON, WI BOX 537969
HUIV~AN RELATIONS \
3707
OLHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/NARk1 Y: LOT NO.: BLK. NO.: SUBDIVISION NAME:
NW SE 14 34 /T30 N/11191(or)w St. Jose h 16 n/a
NTY: OWNER'S/SAME: MAILING ADDRESS:
St. Croix Steven & Norma Henning 665 Walsh Rd., Hon, 4Ji. 54 16
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence 3 n/a kalllilew ❑ Replace 10-26-91 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: JIN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
® S E]U ®S ❑U 2 S ❑U ❑ S Ra ❑ S ®U conventional.
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: class 2 Floodplain, indicate Floodplain elevation: na/
decimal' PROFILE DESCRIPTIONS page 42 OMB
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTFDM ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.17 101.20 none 1.17* less .75bl.1. 1.42bn.sil. .75bn. mot. sil.
than 1.00' 4.25bn.c.s.& r.
B-2 6.75 100.70 none >6.75 .83bl.l. 1.00bn.sil. 4.92bn.stratified l.s.,c.s., .l.
B-3 6.50 100.25 none >6.50 .58bl.l. 1.00bn.s.sil. 4.92bn.c.s.&gr.
B 4 7.17 102.00 none >7.17 .67bl.1. .50bn.s.sil. 6.00bn.l.s.&gr.
B-5 7.00 101.59 none >7.00 1.00bl.1. 1.00bn.sil. 5.00bn.stratified l.s.&s.l.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P-
P-
P- )
P- O
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings 10[i , he"~Aictile"nsior2s,Vf ~Jita a so ar s. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their to aticln of ,,t re plot,plan.':86Dw the ace elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 97.29
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Z S5~
MAILING ADDRESS
PROPERTY ADDRESS 1~ 3 mil
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION T-,L.C N-RW
' I/4, 1/4, Section ~3
'OWN OF
ST. CROIX COUNTY, WI
SUBDIVISION _1J_ LOT NUMBER
CERTIFIED SURVEY MAP VOLUM,7,PAGEZj~66, LOT NUMBER __I_
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 maximurn of 60%0 of the cost
of replacement of a failing system, which was in operation accepted this program in August of 1980, with the requirement r that towne s lof all new systems ag eento
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) aria 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 d1 c.
SIGNED:
DATE: ~ ~ r1 X 5 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11193
j S T C - 100
Tkis 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 1 r'i Lti,+~!) ( SSA
Location of propertyjLt% , section, `T'N-R lg W
Township Mailing address / ~L:).0
14 44 d--' T
Address of site Subdivision name a Lj Lot no. ) "L
Other homes on property? /Yes it No
Previous owner of property ~nd I d re / I
Total size of property
Total size of parcel
Date parcel was created /
Are all corners and lot lines identifiable? L- Yes No
Is this property being developed for (spec house) ? P-1"- Yes No
volume . and Page Number /~t-, as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICA'T'ION 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. 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.
1 scant - - - -
ignature
A
ZY
[ P Co-Applicant
12C) -7
h a k- n n r f; i n n t-1 1 - -
f ~innat~ira
At State Bar of Wisconsin Forn 2
J t [JS~7 WARRANTY DEED
E
~0Cj~~E ,7 ~a.1181PA~ 451 F RrC
_ - 61 it
Donald Yore111 aLlc/~ ~ J U
ell,r.a/kla-Beatrice A._ 2:c_el1.
3QaLric_Ann_,Xor
-a/k/a SPA rir_P Ior~ll, aS point-;e_,~~ 9:15 A. M
at
conveys and warrants to Rir!jard !r' T as g O psyswof Doeds
i
-THIS SPACE RESERVED FOR REC41. T NAME AN" nETL,RY ADDRESS ~
the following described real estate in _ St. Cr(?1X _ I v
County. State of Wisconsin: I
4-
-y
I)
F (Parcel Idenof:cation Number) I v?.
I
L
Lot 12, Plat of Deerfield in the Town of St. Joseph, St. Croix County,:
Wisronsin.
F.
This Warranty Deed is given in fulfill_nt of that certain lsrxi contract
i,et:Jeen C-iie Dirties .-W"eto dated buo-ust 4, 1994, recorded August 9, 1994, I ~x
in Vola, 1096, ?ate 536, as x'0020 in the office of the Register vT
o Deeds for St. rroix County, 'Nscor-lz;
4
A I
I
I
This is not homestead property.
.Iw(is not)
Exception:ooarrawies: F_a,7emnts, restrictiGa and rights-of-way of record, if any.
r
, ~ 19 rc ,c ~
day of `
Dated this -
- r
(SEAL)
(SEAL)
i Donald '4orell a/'-:/a Donald :oreli - _ °-ut ice_11nn ;~re117_ mot'"'-ce A.
t :orell, a/k/a 3eatrice ':o ell - (SEAL)
i (SEAL)
r
ACKNOWLEDGMENT
f
AUTHENTICATION I 3.
STATE OF WISCONSIN
Signature(s)
i. _St. Croix County.
personally came before me this r day of
19 19 (),'z_ the above named
authenticated This day of
Don~ld E. ':orell al a a Donald *lorell,
e _
- r atric Ann '1o ell, a/k/a ?eatrice A.
. ~'<Ja Beatrice )orell -
1 TITLE: MEMBER STATE BAR OF WISCONSIN - -
who executed the
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