HomeMy WebLinkAbout038-1154-95-000
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Parcel 038-1154-95-000 09/13/2007 09:56 AM
PAGE 1 OF 1
Alt. Parcel 13.31.18.714 038 - TOWN OF STAR PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
O - NELSON, BRIAN J
BRIAN J NELSON C - LLOYD JEANNIE M
LLOYD JEANNIE M
2179 132ND ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 2179 132ND ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 1.182 Plat: 2348-PRAIRIE RICH ADD
SEC 13 T31N R18W 1.182AC PRAIRIE RICH Block/Condo Bldg: LOT 10
ADD LOT 10 A 1/1 5TH INT IN OL 1 HAS BEEN
ADDED TO THIS PARCEL 722/352 762/629 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
13-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/02/1999 607839 1446/68 WD
05/06/1999 602676 1424/481 QC
11/20/1997 568775 1278/58 WD
07/23/1997 762/629
more...
2007 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.182 31,400 135,400 166,800 NO
Totals for 2007:
General Property 1.182 31,400 135,400 166,800
Woodland 0.000 0 0
Totals for 2006:
General Property 1.182 31,400 135,400 166,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 211
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
ST CR-Ux cOUNTY
PLA NNNG ZO iNG
September 13, 2007
Brian Nelson & Jeannie Lloyd
2179 132nd Street
New Richmond, WI 54017
Code Administration
715-386-4680 RE: Reconstruction on foundation of existing house, Town of Star Prairie
Land Information Parcel # 038-1154-95-000 (13.31.18.714) Lot 10 Prairie Rich Addition
~
Planning
715-386-4674 Dear Mr. Nelson & Ms. Lloyd:
Real Property You have requested the Zoning Office review your reconstruction project for
715-386-4677 compliance with the state sanitary code (COMM 83). When remodeling or adding
onto a dwelling you are required to examine whether or not the planned modifications
Recycling
715-386-4675 involve an increase in design wastewater flows to the existing Private On-site
Wastewater Treatment System (POWTS).
According to your submitted plans, the project involves reconstruction of a two-
bedroom house on the existing foundation. The original septic system was designed
and installed based on wastewater flow for three (3) bedrooms at a design flow of 450
gallons/day and a maximum occupancy of six (6) persons. This project will not result
in an increase of the design wastewater flow.
The original system was installed in 1997 by Brady Utgard (see enclosed as-built) and
was inspected by zoning staff at the time of installation. The system was found to be
code compliant at that time. Inspection report, as-built, and sanitary permit
documents are on file in the zoning department archives.
To prolong the life of the POWTS, remember to have the septic tank pumped at least
once every three years or when the tank becomes 1/3 full of sludge and scum.
Other efforts to extend the lifespan of the system include water conservation
measures such as repair or replace leaking plumbing fixtures, reducing shower time,
running the dish washer only when it's full, avoid using a garbage disposal, using a
wash machine with a suds saver feature, etc. The projected lifespan of your POWTS
is dependent upon proper maintenance of the system.
If this POWTS should fail at any time in the future, the system will be need to be
inspected by a licensed plumber or POWTS maintainer to determine if it must be
replaced according to state code requirements in effect at that time.
ST CROIX COUNTY GOVERNMENT CENTER
1 101 CARMICHAEL ROAD. HUDSON. WI 54016 715-386-4686 FAX
The proposed remodeling project must comply with all applicable building codes. Please
contact the town's Building Inspector to obtain a building permit for this project.
Should you have any questions, feel free to contact me at the Planning & Zoning office.
Sincerely,
Pamela Quinn
Zoning Specialist
Cc: Brian Wert, Town of Star Prairie Building Inspector ed
Sanitary permit file
ST. CROIX COUNTY GOVERNMENT CENTER
1 10 1 CARM/CHAEL ROAD. HUDSON, W1 54016 715-386-4686 FAX
FROM :NEW HORIZON HOMES FAX NO. :17152463513 Sep. 11 2007 08:45RM P1
ads
'J Custom Built for Your Lifestyle
FAX COVER LETF
Tip; ~~A\
Date:
From., Pages: including this page.
comments;
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Tkank You!
715-246-9004 • 715-246-3513 fax 1477 Hwy 65 New Ri(;,Iunond,.WI 54017
FROM :NEW HORIZON HOMES FAX NO. :17152463513 Sep. 11 2007 08:45AM P2
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION-/ CSMf, l
LOT
t.
SECTION no-OR
T.~N-R , Town 'o f T
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET__OF .SYSTEM
N0--
303`(
0
~r
715-
- - - g4
S-
76-1
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ell --O~
,/L,~r-•~ • ~OALTERNATE IBM:
SEPTIC TANK PUMP 'CHAMBER f, iO ..~ip {C,A21K: ~IE~OPtMATiON=':---
Manufacturer: Liquid Capac~ 3 i
Setback- fr6m. ell" iouSe
O eX~ z
Pump:-°ManufactureY- Modell - cite
Float seperation _ Gallo
,cycle:
W3, TV A-100,11
Alarm Location rt - -r Go f t4 f iT N
A
SOIL ABSORPTION SYSTEM
Width: Length_ Number.of trenches
Distance & Direction to nearest prop. line: /
Setback from: well: House Other -
ELEVATIONS
Building Sewer ST Inlet: /
~2 7 / ST outlet:
S
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system 3. 9CJ
Existing Grade Final grade
DATE OF INSTALLATION: 2,_
PLUMBER ON JOB:
LICENSE NUMBER: /Lot
M
INSPECTOR:
3/93:jt
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~Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division CountY ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary~gjgl1ft
Personal information you provice may be used for secondary purposes (Privacy La s.15.04 (1)(m)]. y
VELDH8dU~NE!meIIEATHER ❑tQ yAW V ?gn of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: l C; Parcel TI~_1154-95-000
TANK INFORMATION ELEVATION DATA A9700503 061i7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark EGG, C~J~
Dosing
Aeration Bldg. Sewer
Holding StInlet s
TANK SETBACK INFORMATION St/,*ft Outlet s/Ga
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Headet*A*arr q s Z
Aeration NA Dist. Pipe cJ?~3 y! Z~~
Holding Bot. System 12,7,23
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand e>-'.-5, r,
Model Number GPM
TDH Lift Friction System TDH Ft
oss Fi
Forcemain Length Dia. Dist. Towel
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 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
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.) 7
LOCATION: STAR PRARIE 13.31.18.714,NW,NW 2179 132ND STREET
c q '~.t.r -.,arc t h e°(_ / S 71
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
1
SANITARY PERMIT NUMBER:
I
I
Safety and Buildings Division
Visconsin 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. 57"T CA-"'c-,L
• See reverse side for instructions for completing this application State Sanitary Permit N& umber
The information you provide may be used by other government agency programs !
❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prope y Own r ame Property Location
/VII /4 Iv w/4r S /3 T__3 r/ r N, R/ or
Property Own is Mailing Add r3 Lot Number Block Number
94y, State Zip Code Phone Number Sub bision Name or CS Numb
( )
II. TYPE BUILDING: (check one) ❑ State Owned o vitae Nearest Road '-S,77
Public Off 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)
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. 1k 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 t 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/da /sq. ft.) (Min./inch) Elevation,
l d (of e
5 '19
et Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete Con- Steel glass App.
structed
Tanks Tanks
Septic Tank or Holding Tank 660000
Lift Pump Tank /Siphon Chamber El ❑ ~ El 0
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum r' N m : (Print) Plumber' ~o Sta /MPRSW No Business Phone Number:
Plumber' ~ress (Sty5pt, City, State, 4 ode): ~ r
o ~ l L- a~1
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit F e (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps)
JKApproved I ❑OwnerGivenInitial /~jt doh surcharge Fee) `7.-3 if ,K Approved
Determination /
X. CONDITIONS OF APPROVAL / REASONS OR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety a 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 owner%hip 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. 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 x 11 inches must be submitted to the county. The plans must
include the foilowing: 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.
t
WHOLESALE DISTRIBUTORS OF: MINNEAPOLIS Phone: (612) 871-8321 Fax: (612) 871-0928
Space - Gard® LAKE ELMO BRANCH Phone: (612) 738-0173 Fax: (612) 731-1372
FARGO BRANCH Phone: (701) 235-0230 Fax: (701) 235-2451
HIGH EFFICIENCY AIR CLEANER
ST. PAUL BRANCH Phone: (612) 646-6537 Fax: (612) 646-1458
ALBERT LEA BRANCH Phone: (507) 373-6412 Fax: (507) 373-9115
MINOT BRANCH Phone: (701) 852-9400 Fax: (701) 852-0942
01414. MANKATO BRANCH Phone: (507) 345-3012 Fax: (507) 345-6568
PLC.
MAPLE GROVE BRANCH Phone: (612) 391-7780 Fax: (612) 391-7851
i~
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X
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y
No - ~u
160
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and, Human Relations
Division of 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 St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to neares 038-1154-95
APPLICANT INFORMATION-PLEASE PRINT REVIEWED BY DATE
PROPERTY OWNER: t y r n ERTY LOCATION
Herman Hulsey RECEIVED ~ OT NW 1/4 NW 1/4,S 13 T 31 N,R 18 ft(or) W
PROPERTY OWNERS MAILING ADDRESS ~ LOT*- BLOCK # SUBD. NAME OR CSM #
2181 132nd. St. 6, - t'v [ IN W1 I na Prarie Rich
CITY, STATE ZIP CODE 1 PHONE NUMB,0 CROIX M7YJ ❑VILLAGE [MOWN NEAREST ROAD
New Richmone, WI. 54017 7i 248tZ53!48Y Prarie 132nd. St.
[3] New Construction Use 14 Residential / Nurhber.df*, Brooms - ^ [ ] Addition to existing building
[ ] Replacement [ ] Public or rfb~
Code derived daily flow 450 god Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 106.45 It (as referred to site plan benchmark)
Additional design/ site considerations trenches spaced to code 3.5' below surface grade
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®sS ❑ U 936 ❑ U E S ❑ U E S ❑ U ES ❑ U ❑ S 62U
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 Trench
1 1 0-10 10 r 3/2 none 1 2msb mfr
2 10-24 10yr 3/3 none sl lcsbk mfr 9w if .4 55
Ground 3 24-84 7.5 r 4/6 none ms os ml na na .7 .8
elev.
109.95 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-12 10 r 3/2 none 1 2msbk mfr CIV 2f .5 .6
2 2 12-18 7.5yr 4/4 none sici lcsbk mfr if .2 .3
Ground 3 18-84 7.5 r 4
elev.
109.95.
Depth to
limiting
factor
+84"
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200th. Av New Richmond W 4L54017
Signature: V 1-f OZ Date: 10-18-97 CST Number: m02298
PROPERTYOWNER H. Hulsey SOIL DESCRIPTION REPORT Page 2'of 3
PARCEL I.D. # 038-1154-95
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0-20 10yr 3/2 none sl fill Crw 2f n n
2 20-80 7.5 r 4/6 none ms os ml na na .7 .8
Ground
elev.
107.5 ft.
Depth to
limiting
fact
Remarks:
Boring #
none 1 lcsbk mfr C1W .41 .5
1 0-16 10 r 3/2
<<
2 16-80 7.5 r 4/6 none ms 0sa M1 na .71 .8
Ground
105eV55h
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 0-8 10 r 3/3 none sl 2m r mfr Cfw if .5 .6
none ms os ml na na .7 .8
2 8-80 7.5 r 4/4
Ground
elev.
105.25t.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Herman Hulsey New Richmond, WI 54017
MPRSW 3254 NW'INW4 S13-T31N-R18W (715) 246-6200
town of Star PraRIE
lot #10-Prarie Rich
N
1"=40'
BM.= top of elec. transformer @ el. 100,
Alt. Bm.= top of Tel. ped by SW lot corner C el. 103.25,
-140
f
Gary L. Steel
10-18-97
STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
/ St. Croix County
OWNERIBUYER
MAILING ADDRESS b. zcQUs
= ub
PROPERTY ADDRESS J / 7 - A-)Le Ss
(location of septic system) Please obtain from the Planning Dept-
CITY/STATE
PROPERTY LOCATION Ll1_(.l 114, 1/4, SectionTZ R_R-/,a_w
TOWN OF
ST. cRorx COUNTY, WI
SUBDIVISION rLAA
,e~- LOT NUMBER _ZQ
CERTIFIEDSURVEY MAP VOLUME , PACE .1 NUMMER-
Improper use and maintenance of your septic system could result in its prentatbrelWA-we 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 1990, 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)
(tie 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/%Ve, the undersigned have read the above requirements and agree to maintain the private sc-age
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 Sr Croiz
County Zoning Officer within 30 days of the three year expiration date
SIGNED:
DATC
St Croix County Zoning Office
Goucrnrncnt Center
1101 ('.1r1t1idmc1 Road
1 tudsnn %%'t ),1016
t 1 /`l.
„ B 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 Qwner/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 (1nZp[14 S
Location of property PJ6 1/411/4, Sect ion1a--,T-3.LN-R,~_w
-3A- I Township L4-:d, Mailing address?. 0.3ax us ~il~~t clS. t~T 5~~
Address of site &P 5
Subdivision name Lot no. i
Other homes on property? Yes No
previous owner of property A/ QA,~,in r
Total size of property - 11 x
Total size of parcel J R ) A , _
Date parcel was created _ J/ - 2 O Jq 7"
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for (spec house)? Yes No
volume ` and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIs APPLICATION THE FOLIAWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
MMSER 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. y 723-
own the proposed site for the sewage ,disposaltsystem) orr Ie(we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
t
he office of the County Register of Deeds as Document No.
a('711A0
' qj ature o~AA p
plscant Co-Applicant
r
Ind /0, d1
1?7~ (fig
56877 5 WARRAMY DEW
Document Number
REQISTER'$ OFFICE
ST.CRdOfaXC~Q, ryl
Return Address NOV $ 0 1997
~'Sn-✓ix~5~
111:00 AM
Parcel I.D. Number.
Herman I Hnlaev and Sandra X Halsrv husband aid strife. conveys and warrants to GEM= S.
Veldhosm and Heather L Vddhoose. husband sad wits. it following described real estate in St. Croix
County, State of Wisconsin:
of t P a't pr in the Town of Star prairie, togaumc vd~ 1/1 5th interest in Dutlot one (11
e Rich,
St. Croix County, Wisconsin.
This is not homestead property.
Exception to warranties: Easements, restrictions and rthft-c€a of record, if any.
Dated this day of November, 1997.
(SEAL) "(SEAL)
erman B. Hulsey Sumba K- Hulsey
AUTHENTICATION s WFM
FEE
Signature(s) Herman B. Hulsey and Sandra K. Hulsey,
husband and wife, authenticated this tf4--- day of
November, 1 7.
Kristine Oglan
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristin Ogland
Hudson, WI 54016
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