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HomeMy WebLinkAbout032-1033-95-100 i y' STC - 10 4 AS BUILT SANITARY SYSTEM REPORT rrE 1' OWNER-_s N 1,AMF-RE c°~~ t c X~ i - SS GHQ . ADDRESS Kew R,atrrnbt'~' 0 w:l_- 5gol-t ~ . 4 SUBDIVISION CSM# 5~7~78 LOT # I SECTION 12. T j N-R W, Town of ~E-T- ST. CROIX COUNTY, WISCONSIN A Am N a° ( t fwcN PLAN VIEW SHOW EVERYTHING WITHIN 100 EET OF SYSTEM g 30 I I~ ~I~ I~ I, &RRfE 3 esD~20o n~ HD d5E r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. c , BENCHMARK: ~ - Z ALTERNATE BM:. Aar CI L,53 nsewehsv s F LOO SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: _ We.-&j Liquid Capacity: Jpw 6AL Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width- a Length Number of trenches Distance & Direction to nearest prop. line: 3~ Setback from: well: House 60 • Other ELEVATIONS Building Sewer ST Inlet- 7 ST outlet: 7 PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 11,61-7,7 PLUMBER ON JOB: ff,6FE 16X LICENSE NUMBER: S Q~~ S l t, j INSPECTOR : _ Q psi 3/93:jt f; Wiscons~ri Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) SanitaryPermitNo.: GENERAL INFORMATION 299143 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: LAMERE, JOHN SOMERSET CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: U O 3`4 / i op' /ode ~-cl~Z hon,c t 101 oece cf" TANK INFORMATION ELEVATION DATA A9700462 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gt ~S j D 0,0 Benchm9rk Z 'oo Dosing Aeration Bldg. Sewer tf gL'toea►/ Holding St/Ht Inlet 7.96 TANK SETBACK INFORMATION St/Ht Outlet 715' q/. M" TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic 7 Z >iZ A Clb NA Dt Bottom Dosing NA Header / Man. 11661- "d Inte-+ 614k Aeration NA Dist. Pipe 8 ~ 89J 9i ~v r Holding Bot. System 9•$v' °t'v PUMP/ SIPHON INFORMATION Final Grade Sv Qc/ Manufacturer Z Demand vt. rq Model Number GPM TDH Lift Friction stem TDH Ft Forcemain Length Did. Dist. To Well SOIL ABSORPTIONS STEM E TRENCH Width Length J-71 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu c rer: SETBACK CHAMBER INFORMATION Type O , Mo N m er: System OhV~dl fo(7 ✓)?J OR UNIT DISTRIBUTION SYSTEM A9rg4 272 Header/Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length - Dia. ` Length -SID Dia. q Spacing f° 7 Z S~ 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 code discrepancies, persons present, etc.) W✓ S 06t LOCATION : SOMERSET 12.31.19 , NW , NW 725 CTH "H" LOT 1 Sfsv+cd cL4 41ne h5 Per-661-7. 101• -f -6 0dict , DI &4eVeite code re V. 1 res Id elear'sPace_ Ce S I h le l rr uc~ 1 5'>< " !oe-Fwce Cc 'D,-F 1 t.+ avid -ItI ~ : I n int. ~Tarl K v✓ag s c+~ dude 4 e l~vc , 511' ►n1~ll V,/ 5 m-f" I V1'St?~ led. 1'IV~2~ II'(0.'g7 Plan revision required? ❑ Yes ❑ No R Use other side for additional information. JH 140 SBD-6710 (R 05/91) Date Inspector's gnature Cert. No. i ADDITIONAL COMMENTS AND SKETCH { SANITARY PERMIT NUMBER: I w Visconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size.'. 6✓o% • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used b other government agency 07 17/ V-5 Y Y Y programs Check if revision t previous application [Privacy Law, s. 15.04 (1) (m)]. 7Ol ~J 5 C?~It '°(-(it_ lQd ~ N. . State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner Name Pr rty Location- :n 61A0 Lhm-eka /►/W1/4 JAW 1/4, S IZ T X31 - N, R /7 E (or) er _7 Property Owner's Mailing Address Lot Number Block Number 5 I 60,5 T City, State Zip Code Phone Number, ub~ is op me CSM Number ~67,57 II. TYPE BUILDING: (check one) ❑ State Owned It~ Nearest Road ❑ VII age Public 1 or 2 Family Dwelling - No_ of bedrooms Town OF SOMERSC dry Ro H III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo l a. 3 N. l(pSA-/D (~j?a 103 - l S/vU 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 E Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 i❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) q) 1. New 2. E] Replacement 3_ E] Replacement of 4_ E) Reconnection of 5_ ❑ Repair of an _ System _______System _____________TankOnly ______________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 22E] In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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 y50 lu 6~/3 , 7 9b o Feet 9Y 8 Feet VII. TANK Ca in gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tank Septic Tank or Holding Tank O(9Q 1 s 1 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. lumber's Name: (Print) PI m s Signature: (N a S) MP/fiItPRSW NO rf-i usiness Phone Number: f* s L2- - Plumb 's Address (S eet, City, State, Zip Code Z i p o 7 IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved ItaryPermit Fee (Includes Groundwater ate Issued Issuing gentSignature(NoStamps) (Approved ❑OwnerGiveninitial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SM-098 (R.11/86) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. FIrovide 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 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; 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. ~7 ortx/ l rlM~r AIW A~ AIW v sce iz. lwsP 31 Al, 9, /9 v✓ '7l l05 ST. $O.vI E a_ s~-r TD ul~dSH~ P VIr S yc),/6 r A/AII. ix) )h w'E2 ,V, LE7 ELG f /DO D SOIL ~PIN~S -vy r~~opoo.,~ a O ~'oaJs~ i lDOo 6sai SE r~i a T~.~JK_ Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services 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 •M (BM), direction and percent slope, scale or dimensions, north arrow, an a rtce to nearest road. Parcel I.D. # APPLICANT INFORMATION - PI intpur iReviewed by Date Personal informatbn you provide may be used fo ry 8 law, s (1) (m)). t t - - Prope Owner rty Location 1997 vt. Lot 1/4 1/4,S/ T 31 ,,R ~(or) W 7 J. 4 ZY/IU - Property Owner's Mailing Address t # Block Subd. Name or CSM# comy }s! ZC)NINGOFFICE City State Zip Code ~Numbe Z 1::] City E] Village (a Town N Road New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 gpd Recommended design loading rate _,.~bed, gpol _,X__trench. gpd* Absorption area required eL Lbed, ft2 S trench, ft2 Maximum design loading rate ~ 7 bed, gpolft2lff_trench, gWI? Recommended infiltration surface elevation(s) A, e-) ft (as referred to site plan benchmark) Additional designtsite considerations Parent material 7 2 ' ` - Flood plain elevation, if applicable S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in FlII Holding Tank U = Unsuitable for system ) S ❑ U Os ❑ U L o s ❑ U (S S❑ u ❑ S ® u ❑ S O 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 ~ L Ground ele 9 S' ft. Depth to limiting factor ? in. Remarks: Boring # / .41 - L 21 Al 3 - 10 Ground ele ` ft. Depth to limiting factor '>~in. Rem ks: CST Name (Pleas Pri Signatu Telephone No. Address q Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Pag of -3, 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 s -,2 ZJ Ground _ S elev. 44 ~Y 7n Depth to limiting factor 2~Llin. Remarks: Boring # L r O Al 0 1 1j Ground elev. g~ztt. Depth to limiting factor 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 # ; s/ Ground elev Depth to limiting factor ;11C~yjn. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) X37/ ~S'``s~ J S®~=„r;~s~ J~ ~ S, ~~a/ a,~, s~' ;~G~~~ ~ ~ I / ~ 4 ~ 5-h ~ /G' f. ~--~8 ~ A D.rs✓ cz~ . .o FILED oC r 2 9 1997 ,o 567578 3 KATHLE- H w Re0Istorof Y CERT EIED SURVE~l Located in the Northwest quarter of the Northwest quarter of Section 12, Township 31 North, Range 19 Town of Somerset, St. Croix County, Wisconsin. Owner: Marvin J. Viebrock Box 186 Osceola, Wi. 54020 Northwest corner, Section 12-31-19. PK nail shaft found from ties. North quarter corner, Section 12-31-19. - - - - - - - -Reproduced from ties found. C. T. H. "H " S88°5458"E 2646.91 Description. !323.455' ti. 'o O. U) S 8 8 ' 5 4 ' 5 8 " E ui; A parcel of land located in the Northwest quar- t 0 9 . 0 0 ' ter of the Northwest quarter of Section 12, Town- ship 31 North, Range 19 West, Town of Somer- 100 Foot Building set, St. Croix County, Wisconsin, described as follows: Setback he. Commencing at the Northwest corner of Sec- tion 12, thence South 88 degrees 54 minutes 58 LL_ O T I seconds East 1323.455 feet along the North line of the Northwest quarter of Section 12; thence 130,808 Square Feet South 00 degrees 03 minutes 42 seconds East 3.003 acres. 45.01 feet to the Point of Beginning; thence con- 6: tinuing South 00 degrees 03 minutes 42 seconds O i Z i East 626.00 feet; thence North 88 degrees 54 min- Z ; Q I utes 58 seconds West 209.00 feet; thence North Q J 00 degrees 03 minutes 42 seconds West 626.00 3 feet to the southerly right-of-way line of County _ W Trunk Highway "H"; thence South 88 degrees 54 N - Each parcel shown on this (U minutes 58 seconds East 209.00 feet along said onap is subject to state, p right-of-way line to the Point of Beginning, con- ch opounty and township laws, o taining 130,808 square feet (3.003 acres) more or o LL-rules and regulations (i.e., LO o less, and being subject to all easements, restric- o wetlands, minimum lot N O tions and covenants of record. o size, access to parcel, etc.). co o I, Harvey G. Johnson, registered Wisconsin C)i z Before purchasing or Cf) Land Surveyor, hereby certify that under direction W i developing any parcel i of John LaMere, purchaser of said property, I F" contact the St. Croix Q' have surveyed and mapped the above described Q , County Zoning Office and L property; that such plat is a true and correct rep- _J i the appropriate town resentation of the exterior boundaries of the land CL i board for advice. Q surveyed; and that I have fully complied with the Z _J1 provisions of Section 236.34 of the Wisconsin i Z Statutes and the Town of Somerset subdivision ordinance to the best of my professional knowl- i edge, understanding and belief. Harvey G. Johnson S-1899, Johnson Surveying, Inc., 216 Meadow Drive North, Hudson, Wisc. 1!11111"1011 X5 209 . oo \SGONS~ WWI N 88'54'58"W HgRv~~ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER J_6y W ILA N~ERE MAEMG ADDRESS 07 1'0 7 H AVI=- PROPERTY ADDRESS -2919* (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1411/4, IVW 1/4, section Z , T 31 N-R_ l 9 W TOWN OF -`_i`~1Er~r ST. CROXK COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED S UR VF,Y MAP 56757 Z, VOLUME., PAGE 3~7L, LOT NUMBER; 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 I, 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 (I) 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 113 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 staring 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: 9 St. Croix County Zoning Office Government Center I101 Carmichael Road Hudson, WI 54016 11/93 03/28/96 10:19 -Ta COUNTY CLERK 10002%003 S T C - 100 This application form is to be completed in full and signed by the f::)wner(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 Y and submitted to this office with the appropriate deed recording. owner of property ~_Am ERE Location of property NYi/ 1/4 ___y6/1/4, Section Y Z , T 3/ N-R - Township _SoMg_- Ma xl ing address __37 5 T'+ ~T 111 Nij MI sge17 (Cue,?,,rr Address of site` Subdivision name Lot no. r Other homes on property? Yes- X -Na Previous owner of property Aylld (j effzoc Total size of property _ ,ZD03 acre Total size of parcel Date parcel was created ©of, c7 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _.)(~No Volume and.Page Number .,~ROS_ as recorded with the Register of Deeds. p - 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. 5"(e 11 O , and that I (we) presently own the proposed site for the s wage 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. Signature of Applicant Co-Applicant _ so~o~9i ate of Signature . Date of Signature V790 is-7 30~ / WARRANTY DEED Document No. RETURN TO: _.-3 , 9 r7 Laux & Associates, S.C. P.O. Box 456 3 UCH P M Osceola, WI 54020 TAX PARCEL NO. Part of 032-1033-95 This Deed, made between Marvin J. Viebrock, individually THIS SPACE IS RESERVED FOR and as Trustee under Agreement dated October 11, 1978 RECORDING DATA made by Marvin J. Viebrock, Grantor, and John A. LaMere and Jane M. LaMere, husband and wife as survivorship marital property, Grantee, Witnesseth, That the said Grantor, for a valuable consideration conveys to Grantee the following described real estate in Polk County, Wisconsin: Lot 1 of Certified Survey Map recorded in Volume 12 Certified Survey Maps on page 3371 as Document No. 567578, located in the Northwest Quarter of the Northwest Quarter of Section Twelve (12), Township Thirty-one (31) North of Range Nineteen (19) West; Somerset Township in St. Croix County, Wisconsin. this is not homestead property. Together with all and singular the hereditaments and appurtenances there unto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Easements, Restrictions and Ordinances of record and will warrant and defend the same. Dated this c3rel day of , 19 4 -7 (SEAL) (SEAL) * *Marvin J. ebrock (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. authenticated this day of Polk County ) 19 r,~ For completion see separate "Instructions for Real Estate Transfer Return" PE-500A. WISCONSIN REAL ESTATE TRANSFER RETURN -CONFIDENTIAL Submit all parts to Register of Deeds with document(s) to be recorded. I: -GRArPfOR: V. PHYSICAL DESCRIPTION AND PRIMARY USE BY GRANTEE 1. Name Marvin J. Viebrock, Trustee 15. Kind of properly 16. Primary use 2. Address - New address if property transferred was primary residence ® Land only a. ® Residential: 1020 Prontage Road ❑ Land and buildings ® Primary Residence for LOTTERY CREDIT Osceola, WI 54020 ❑ Other (explain) ❑ Single Family/condominium 17. Estimated land area and type F-1 Mufti-family - / units 3. Grantor is ❑ Individual Partnership ❑ Corporation ® Other a Lot size x ❑ Time share unit or b.❑ Commercial II. GRANTEE: b. TOTAL ACRES c.❑ Manufacturing 4. Name John A and Jane M LaMere c. MFL / FC / WTL acres d.❑ Agricultural 5. Address d. R. of water frontage adjoining land within 3 miles? E] Yes ❑ No 2371 65th Street e.❑Miscellaneous (explain New Richmond, WI 54017 VI.TRANSFER 18. Type of transfer. ❑ Sale ❑ Gift ❑ Exchange ❑ Other (explain) 6. Grantor /grantee related: ® NOME] Corp/Shamholder/Subsidiiary ❑ Partnership ❑ Rremdai ❑Family ❑ Other, explain 19. Ownership interest transferred: ❑ Full ❑ Partial (explain) 7. Send tax bill to: Name and address 20. Does the grantor retain any of the following rights?❑ Life estate E] Easement Grantee 21. ❑ Deed in satisfaction of original land contract? Dated? 22. Points (prepaid interest) paid by seller $ 111. ENERGY 8. Is this property subject to the Rental Weatherization Standards, ILHR67? 23. Value of personal property transferred but excluded from (25) $ ❑ Yes ® No Exclusion coded If W-11, explain 24. Value of property exempt from local property tax included on (25) $ VII. COMPUTATION OF FEE OR STATEMENT OF EXEMPTION IV. PROPERTY TRANSFERRED 25. Total value of REAL ESTATE transferred $ 13,8W.00 9. ❑ City ❑ Village Town Somerset 26. Transfer fee due (line 25 times .003) $ 41.40 County Polk 27. TRANSFER EXEMPTION NUMBER, sec 77.25 10. Street address 11. Tax parcel number part of 02-1033-95 28. Grantee's financing obtained from a Seller 12. Lot no.(s) Bk no. g) N box a or b is checked. ',b. Assumed existing friancing . Plat name complete Part VIP- .:t~ ❑ Financial institution / Other 3rd party 13. Section Township Range' Financing Tom, d. fl No financing involved 14. Legal Description metes and bounds: (attach 2 copies N necessary) Lot 1 of Certified -Survey Map recorded in Volume 12 of Certified Survey Maps on page 3371 as' Document No•`.567578, located in the Nortbwest Quarter_of'the Northwest Quarter of Section Twelve (12),'Township Thirty-one (31) North of Range.Nineteen (19) West; Somerset Township, in St. Croix County, Wisconsin. VIII. FINANCING TERMS (FOR SELLER/ASSUMED FINANCED TRANSACTIONS ONLY) 29. Total dorm payment $ (Line 29 = Line 25 minus Lines 30a and b excluding payments for personal property) 30. Amount of mortgageAand 31. Interest 32. Principal and interest 33. Frequency 34. Length of 35. Date of any lump sum 36. Amount of lump contract at purchase rate (stated) paid per payment of pymts contract (balloon) payments sum a $ % $ - - $ b. $ % $ - - $ 37. If the dollar amount paid per payment (32) is scheduled to change (not as a result of a change in the interest rate), fill in the line letter from above Enter thTdate of change - - - - and the amount it will change to $ IX. CERTIFICATION We declare under penalty of law, that this return has been examined by us and to the hest of our knowledge and belief it is true, correct and complete. Gra for or agent Grantors social security number or FEIN Date Grantor's telephone number SIGN 386-16-1233 11/3/97 (715)294-2752 HERE Grante or agen Grantee's social security number or FEIN Date Grantee's telephone number ~L_,Gr.~ 398-52-5840 11/3/97 (715)294-3358 Print name an address of grantors agent Agent's telephone number Document number VoL/Jac. Page/Im. Date recorded Date and kind of conveyance Conv. code 1 2 3 4 FOR ASSESSOR'S USE ONLY Assmt. year 19 ❑ Field Sales number Parcel classification/Acres L Co. ❑ Use 1 2 3 4 5 6 7 1 Dist ❑ ❑ 0 0 ❑ 0 ❑ T ❑ Reject Wisconsin Department of Revenue PE•500(R.1-97) DISTRICT SUPERVISOR'S COPY