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HomeMy WebLinkAbout040-1017-50-000 ♦ t V44. STC - 104 AS BUILT SANITARY SYSTEM REPORT RECEIVE0 ~o OWNER_ t Ili ! e I 4 l~►?f 1997 ST CROIX ADDRESS DO L r. v F COE1" ,v ZONINOOFRCE SUBDIVISION / CSMJ LOT SECTION_T t e~ -R e~ W, Town of ST. CROIX COUNTY, WISCONSIN D -alb PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i z, 0~ INDICATE NORTH ARROW s Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t a BENCHMARK: A ALTERNATE BM: SEPTI C TANK / PUMP CHAMBER / HOLDING TANK INFORMATION AAM!t Manufact rer: Liquid Capacity: Setback from: Well Z is House Other Pump: Manufacturer Model Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Lengthy b ^ S 'umber of trenches Distance Direction to nearest prop, line: Setback from: well:-/-= House Other ELEVATIONS Building Sewer - ST Inlet• ST outlet: PC inlet - PC bottom _ Pump Off DAoP to Bottom of system 51' L- gSgS ' Existing Grad0-111,0q-1A g'G.► Final grade -q3 M DATE OF INSTALLATION: PLUMBER ON JOB: , c C -,k" 1 LICENSE NUMBER:-- INSPECTOR: . 3/93:jt ,Wi.4consiii Department of industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) sanitary 299123 GENERAL INFORMATION Permit Holder's Name: ❑ Cit ❑ Village Town of: State Plan ID No.: NOWINSKY, SIDNEY TRY Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description: r ! 040-1017-50-000 TANK INFORMATION ELEVATION DATA A9700441 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptlc ~2 K' b~i Wt G/ f 0J~ Benchmark 2.2 1022 o0 Dosing Aeration Bldg. Sewer Holding OMT Inlet Xibfi TANK SETBACK INFORMATION a.E Outlet 6-5-2 S. Fs- TANKTO P/L WELL BLDG. Ventto Airlntake ROAD Dt Inlet eptic Q~C~S - NA Dt Bottom Z ri7 e) Dosing NA %3•% 910 S(q • I _ 0.1 ,C '7 - 171,51 Aeration NA Dist. Pipe 6'I fZ. ~ 3.g(,5- Holding Bot. System ~ ~ 5s17 , 89•~ e'.t rs . S~6 ~ 7S 8 . . ;1 112( i , 1/6•sS gift PUMP/ SIPHON INFORMATION Final Grade q,2 l147' 12.41 011.1r 21 Manufacturer Demand , yf<e 9 f 7S Model Number GPM TDH Lift Friction stem TDH Ft Forcemain Length D'a. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width S I Length ~S No. Of Trenches PIT No. Of Pits in 'de Dia. Liquid Depth DIMENSIONS 3 DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Man ac rer: SETBACK INFORMATION Type 0 T 3 ~ ~1 ► 13.E ~ Mode tuber: Systern'r CHAMBER T OR UNIT DISTRIBUTION SYSTEM TM '?2°► Header/Manifold Distribution Pipe~(~)l,~l ' x HoleSize x Hole Spacing V' To Air Intake Length Dia. _ Length Dia. Spacing 7 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 E] Yes El No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 04.28.19.61J,NE,SE 530 FRANCES AVENUE Plan rLVjA( ff required? ❑ Yes ❑ No , Use other side for additional information. ( ( p 7 SBD-6710 (R 05/91) Date Inspector's Si ature ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e E o 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 n than 81/2 x 11 inches in size: • See reverse side for instructions for completing this application State Sanitary Permit Number ag9rA3 The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location . G' Lt% t N 1/4 _SE: 1/4, S T N, R19 E (oIQ Property Owner's Maili g Address _ Lot Number Block Number 3 o ra NS /f Lc. 9 City, State Zip Code Phone Number Subdivision Name or CSM Number SON Sya/z'e, l71S )386-~~ II. TYPE F BUIL ING: (check one) ❑ State Owned ity Nearest Road V lage own OF r y~ yc~A/CES p-I E] Public 1 or 2 Family Dwelling - No. of bedrooms 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: (CWePlacement my one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. 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 ❑ S page Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 'S~epage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill ~ 9:~ ~ VI. ABSORPTION SYSTEM INFORMATION: %2 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc_ Rate 6. stem Eley. 7. Final Grade y~,L~-~ Required (sq. ft. Proposed (sq. ft. (Gals/day/sq. ft.) (Min./inch) $ 7.5-0 Ele,v tion 00 d ~O e{v , Dfeet 7 tet VII. TANK cap ty in allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks / Septic Tank or Holding Tank 61 -Ab'_ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1:1 ❑ El 11 El ❑ 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) .7 rP/MPRSW No.: 71 Business Phone Number: ~/V~^ 7i S =7y9 3 2 Plumber's Ad ress (Street, City, State, Ziip' Code): L IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing A? ;tSi_gnature( ps) A rovedurcharge fee) pp F1 Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems muse '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. fl. 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; CI 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. ' )'/Q84- ----P-9-z" u ) - -- ' • . .__ a IP-'t (0t1' 41 `% fte) )A//6rD° (5'°X 1 , 4 i t - --:)/ ° ' 641"6 Jli Za I if? ►v ict 6, ( . !_ - (3 �EVAH .5" ') 2,6 hov S-e \1 , \ . Oi-0 r ___ �Sr — I 7 �o \ 6 .*,, ••neo•a ' ,4 _, e, xi- -5'r:?--- ci. 1 (2 ,.. 5.. ,g I . -----. o---- 3 -____. y pb .2" it Gf PA.,/ of 5yrs Ai y , 6/.eo, _ f 95 I eleUllT1ou S — / /3 f 5 3• 15'1 ._ . ._ N, 73 Z - 2. . I�1` 3 D Sc Act / '33 - ya • y( - ''\'----------,---1- -o . i ', L'i,,,,,,C*_ =- 8,16e4o-C,. eir_s o .1QA''` All : P 9 t ,i,,, ill 00-,, --:.7:7:,,,,o (._f 06; 5 6 i: "A.,' 6"- I t _ ...te:: Te _,!,,.Y_ _, ___If)_._.. ___ ict..),s,_ . ' .......__________J \_ /‘!44-"Di.*?2 ,7 ze'aff_______. S<__2..._ ....______ 14N6/S rf 71-e . 3 61fEv,¢Tmv 5 g7, D ( 9, 1:e) 5:Q.1Y' /071e. $ /9 3 Wti-dai 5 ', l,0 Wisconsin.Department of Industry, SOIL AND SITE EVALUATION / 3 .Labor and Human Relations Page of ' tivision of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County Cam^ G."4,O include,but not limited to: vertical and horizontal reference point(BM),direction and ` . ' 0/ percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# o yo -/O/7• 6 7 APPLICANT INFORMATION- Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner . • Property Location 5/s9 k'Ott/Ai 5i 7' Govt.Lot fr 1/4 5g 1/4,S T 1453 ,N,R /9 E(or)W Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 53 0 FPS,occ5 /4 t2 - . City State Zip Code Phone Number p Nearest Road /fUFO,✓ I Cl1/. I .S4O ttoy ( 7is )3Z•86 75 ❑ City p illage Town I p,(%!G/s 4l/•e • ❑ Ne Construction Use: Residential/Number of bedrooms `� Addition to existing building rWAreplacement ❑Public or commercial-Describe: /t//� _ ,t/O T ,PEaze-bve-4.9,f�r-t, . Code derived daily flow %5:0 gpd Recommended design loading rate &//e bed,gpd/ft2 ' Scench,gpd/ft2 Absorption area required N/� bed,ft2 trench,ft2 Maximum design loading rate M" bed,gpd/ft2 ' 5- trench,gpd/ft2 Recommended infiltration surface elevation(s) sue- r •3 ft(as referredp to site plan benchmark) Additional design/site considerations Z'S - /v'46- E,' J e.S et,/ PAV , a X .3c STK"(Qo110 • Parent material /04,4ty .O/,elL-ti/ 5 out,. 7L _ _ Flood plain elevation,if applicable /l_M--' ft S = Suitable for system �Conv ntional �MMou In-Grrow�n 'Pressure AT,-Gr a System in Fill Holding Tan U = Unsuitable for system (� S III S ID U [I S CI [ s ❑ U El ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench / t a/f /OW i/f L ,9's ,e ds4 es 3-f . q ' . s 2- l/•25 /OW Y/Y sL n c fe ds CS /f -4f . s Ground -3 25-//o /0fe Yl‘. mtu: SL. /i 54e 44wvfie a" •q • 5 3• LSft. G,,lf,.. ,po cle --5 0F cQ Depth to f�4 5/e 2 5 D, J`j �h% Q,r- . 7 • f limiting factor 70 in. Remarks: Boring# - - - o•G, /0 ye 3/y - - L. /isle ,sk CS 3-f . `f :. 5 i z 2- 6•/7 JOV, //K . — L. he lie is es /7c , of : . s 3 /7.30 /o yips "14 SL l f stie �, � cs ' .s Ground 1/ 3 log 7.s we y`� s - it' 44,j/7 ' _. . / , .5 elev. ft Depth to limiting , factor }/O ?Jn. Remarks: CST Name (Please Print) Signatu Telephone No. 2of3eLzT ?ALB Ric 1-fT- is. 3p6 • pips Address Date CST Number rtcht /� 9SOC{ates polv • fC'ST�!1 Y�Z— ate Sewageewa9eZ.onsuttants 655 O'Neil Rd. Hudson,Wis. 54016 ORIGINAL s, /Vplw,L,,s•k/,� SOIL DESCRIPTION REPORT 2- .✓3 • PROPERTY OWNER / Page •of • PARCEL I.D.# • Boring # Horizon Depth Dominant Color Mottles Structure G D/ft2 Texture Consistence Boundary Roots P in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench o•7 /o ye 3/ L /74'54k dj e's 3uf . it: .5 elevund 3 �C . 7 5 ?•S W y/ 5 L- 2-f she Mi ti-Fie e,S •S • (0 f 0.q / ft. J5/ /'y,es y/4 L5 /40 y,P • 1: • Depth to limiting factor - 7�O in. Remarks: Boring # • • Ground elev. — ft. Depth to limiting factor in. 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 # • • Ground elev. ft. Depth to - limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: • SBDW-8330(R.08/95) IMPORTANT NOTE TO OWNERS & INSTALLER: All the finer t'extured soils ( loams, silts, etc. ) can & will be easily smeared Or compacted even by a backhoe bucket during trench construction. When this occurs premature failure will result. As per ILHR 83 . 13 ( 4 ) , the installer MUST be very careful to properly hand rake the sid'ewalls £ ,botkkoms to re-expose all of the soils natural structjiz7.4,; Mifti , even recommends that scarifying devices be mounted on the sides of the bucket. Only in this way can treatment & absorption be most enhanced for normal longer system life. • 6�L /6r°° 54716 za ig 11- 83 g (3 / PAil5 z G, Ao SilJi�� /g 7 670 te,0•o 2-2 19 . 0 3 y /32 y' of sysT ‘A, _ -2 • 9.5 f/U4rro ) /3 f3 - • ScAt / = 3D v I 3 = 84(%to-P P' r15 of hi 14vG/S iv-e- 17,S . 2- / ors �'£El) 47/DA) > .2_. h//gZt, rieeteG g/, 0y•zre) 2/1 /p 7 4, i 4 g cd °,/e 5 X low how T , ��- o � ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the Xcuj JAl s~ residence located at: Section T;i N, P,/~W Town of Upon inspection, I certify that I have found the tan and baffles to be in good condition, and it appears to be functioning properly. Last time serviced:„ 7 Did flow back occur from absorption system? Yes ` No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer: (If known) : / ~-I- Age of Tank (If known) : (Signat e) (Name) Please print C 0 0 Cep ell ;:-Ix s°` S' (Title) (License Number) (Z-4 -7 Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name /dry i n-X )-&-r'Signature ~ + c~ r~% MP MPR ©3~ I N 138.79' N 66 20'u' 8S. ~ I 00 ° p 34, ~6 N .tib• X04 O p #g i W y N C 9 O J A I ° I o 3 S° 0. O 4 z z 190' 21' 12 ° 1670-34147.50 ° o I i w 1 3 6 1 33' 33' 1 I = r 1 1 1 c o ss, 1 1 m 175.53' s'. 1 1 •~A 69.49' ~A 182 4 5 I 200.00' I 58956100=E UNPLATTED N LANDS , o C) UNPLATTED LAND A. m to w I o 2 0 C) CURVE LOT RADIUS NO- NO, LENGTH - o 2- 1 550.17 o 4 1. 3 550.17 3- 4 270.13 zoo•oo' 5- 6 336.13 S 89156' 00"E c" 7- 8 1 4 9 0. 7 1 I a~ S 1 STREET " 7 1490.71 I I I I ro N N 1 N I ~ o I o`O 190, I ~o Gp 00. 66.00' 200.00' S 89156100"E I UNPLATTED LANDS, SURVEYOR'S CERTIFICATE a I• RONALD G• PEMBER/ SURVEYOR, HEREBY CERTIFY- THAT I HAVE SURVEYED/ DIVIDED AND MAPPED THE PLAT OF VALLEI IN THE NORTHEAST 1/4 OF THE SOUTHEAST 1/4 OF SECTION 4. TOWNSHIP 28 P TOWN OF TROY. SAINT CROIX COUNTY. WISCONSIN. MORE PARTICULARLY DESCR] COMMENCING AT THE EAST QUARTER CORNER OF SAID SECTION 4. THENCE S 01' ALONG THE EAST LINE OF SAID SECTION 4 TO THE SOUTH RIGHT OF WAY LINE ' -.r -')CA -7-7 CccT At nAir CA i n FOr,T I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S I A,~~_ l i II~V MAILING ADDRESS / a hl e:G 5 a J PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. c~ cP SCE CITY/STATE PROPERTY LOCATION _/VE-1/4, 0~71/4, Section , T N-R TOWN OF 1^0~/ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE , 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 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 a 'ratio at . SIGNE DATE: O c) St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. --------------------------------j-/---------------------------------- Owner of property Srid 1~ V N c3 LU / s- /6y Location of property_AL4 114 /y'F- 1/4, Section T 6 f 1 Township _Fr 6 Mailing address o 7zjv h Address of site S 3 a i a h S~ ~c Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property 3 e1AA Q Total size of parcel Date parcel was created. Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _ /No Volume 2R/ and Page Number as recorded with the Register , ,62 of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. / , and that I (we) presently own the proposed site for the 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. ignat re o Applican Co-Applicant ~D - o 9, Date of Signa re Date of Signature THIS c►wcc wcccwvw Fool V,=*WsH4 DATA pO--UMENT NO WA 111'i% TY DEED STATE BA..! OF WISCONSIN FORM 9-3MSIi KCGMMpFflCe ~ 1 I I 42G731 ~La7 ST ~-ROIX CO., WL% i1 - day o .Tune A.C. 19 7 I Gary..L..Romberg--and..Linda.14_Romberg,...aa.his.----•-----•-•- ~l d r 11:15 AB M xife.And...in.her.:aYn-.right.............. l James 0' Conne i i Sidney-- P,•- NoWinsky- and -Janet- L....--..•. ~4 Deput conveys and warrants to ivorshiR ~ioioakY ..b~usk!and..and.-?i£aF..aa__aucy i! - - - - - !i wcTuaw To Box 94 iwa, WI 54408 An ` I _ - . St Croix Counts. ! the following described real estate in i ! State of Wisconsin : Tax Parcel No - 1 1 i (See Attached) 0 This S. homestead property. (is) (alxaatk restrictions nts, rights of way and Exception to warranties. Existing highways, easeme June 19 87 Dated this ay o (SEAL) (SEAL) Gar ...L~._-Rom erg d~C/.... (SEAL) a. .......(SEAL) . Linda M. Romberg _ _ - AUTHNNTICATION ACHNOW LEDOMSNT STATE OF WISCONSIN sa. Signature(s) ---••-•-•--•-•-•----••--•-•-•--•---•-y.•---•-•----•--•-•••......-•••---•------- BT.._CBA_IX------------------- County. 41 _ _ ._...d3y of authenticated thib da of_--------•--•--•--•-------+ 19 Personally came before m9 this the above named an bergx__ _ Gary_-L,--Rombe rg - and_ Linda_ M.-•Rom ?tusband d wife TITLE: MEMBER STATE BAR OF WISCONSIN (If not. authorized by 1 706.06, Wis. Stats.) to rr.e known to be Lhe person g---------- who executed the foregoin instrument and no ledge the same. _ _ ....~.r nOAFTED BY ///~tC _-M rlene M, Peterson PIC) r ATTACHMENT TO WARRANTY DEED A parcel of land located in NIhSEh of Section 4-T28N-R19W, St. Croix County, Wisconsin, including Lot 2 of Valley View Heights Subdivision, being further descried as follows: Commencing at the Eh corner of Section 4; thence S1 04'48"1 along the East line of said Section 741.22 feet; thence N85 301W 688.34 feet to the Southeast corner of Lot 4, Valley View Heights, being also the point of beginning; thence South- westerly 75.87 feet along the arc of a 270.13 foot radius rdurve which is concave to the Northwest and whosA long chord bears S32 57'12"W 75.62 feet; thence Southwesterly 130.38 feet along the arc of a 166 foot radius curve which is concave to the Southeast and whose long chord bears S180 30'W 127.05 feet; thence S40 001E 263.87 feet; thence Westerly approximately 307 feet to a point on the West line of Lot 1, Valley View Heights Addition, which pointois 100 feet South of the Northwest corner of said Lot 1; thence NO 041E along the West line of said Lot 1 and of Lot 2 a distance of 395 feet; thence S89056'E along the North line of said Lot 2 a distance of 200.00 feet; thence NO 041E along the East line of Lot 3 of Valley View Heights a distance of 66.05 feet; thence S85030'E along the South line of Lot 4 of said Valley View Heights a distance of 175.53 feet to the point of beginning. The above described parcel includes Lot 2 and a part of Lot 1 of Valley View Heights. t