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HomeMy WebLinkAbout040-1030-95-000 STC - 104 _ AS BUILT SANITARY SYSTEM REPORT R1 CROIX 1+ zO m'a Ice `v . OWNER /r/' ADDRESS SUBDIVISION / CSM# 116 l 9 LOT # SECTION _T2fN-R_Zy _W, Town of ST. CROIX COUNTY, WISCONSIN A g. M, /0313 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~Za xy'y,~3 I' sa o,~.loa INDICATE NORTH ARR W Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. y BENCHMARK: d ~ --c Gt- , / l ~ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: &,,V d Ps7`C~ Liquid Capacity: le fe) Setback from: Well pp House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /02 Length Z/ Number of trenches Distance & Direction to nearest prop. line: ldp Setback from: well: House 7 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: ~Of" LICENSE NUMBER: INSPECTOR:~~- 3/93:jt * - r Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT 5T . CROIX Safgty and Bdildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284315 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MADDEN, MICHAEL & SHARON KINKE DTROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: tt 040-1030-95-000 TANK INFORMATION ELEVATION DATA Aq7nonflA J .'r1' A" TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic= Benchmark 7 u Dosing 1?1 Aeration Bldg. Sewer Holding St/ Ht Inlet S • ;I, ~Fs TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic y ~~od NA Dt Bottom y A9Dosing _,7 Ida' e NA Header / Man. J` 333 S 943 '3y' . Aeration NA Dist. Pipe g354" Holding Bot. System 3 y/ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number _,t5 GPM TDH Lift ~~`~I Friction ~3 System TDH AEI Ft Lnv; 1, Head I Forcemain Length O( Dia. 1` Dist. To well,-r<v' SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 1W, I DIMEN I N LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Model Number: OR UNIT System: _/00 X0" .t/ 14 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 E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 7.28.19.103B,NE,SW CTY RD F LOT 11 r Plan revision required? ❑ Yes ❑-No Use other side for additional information. y 161/ SBD-6710 (R 05/91) Date tln eafor's Signature Cert. No. s - ~ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' 5 T Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 8305, 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 , cy"`ol than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number wq 31s 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 1/45'` 11/4,S 7 T 4r , N, R E (or)~ Property Owner's Mailing Address Lot Number Block Number It City, State Zip Code Phone Number Subdivision Name or CSM Number e~J e` (7i > Vsk e 41,,2- 11. TYPE F BUILDING: (check one) ❑ State Owned ❑ !t~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ VII age Town OF TYo- Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 ~3d ' 93 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 o ne box on line A. Check box on line B, if applicable) A) 1~New 2. eplacement 3. ❑ Replacement of 4. ❑ 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 J!j Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation f, `z _0 'q ,7,60 Feet , Feet VII. TANK i Capacity n gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks / Septic Tank or Holding Tank /edo exr-Ae m ~ El E D Lift Pump Tank /Siphon Chamber ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Stamps) PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): C ti , 5' IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San ry Permit Fee (Includes Groundwater ate Issued Issuing entSignature (N tam /j Surcharge Fee) pproved ❑ Owner Given initial ` 7 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-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 must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever _ necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 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. ~ I L vL . IJ p a ~ h ry e4l 4 ~ ~o f6 G d ~x.s'ti uy s ofi c To%Se et~a,r dc~.l~ B S2 ~+1~-+rry GQGp~`lc. ~aaJi~,Be /~?ai,~1-e.~'.us~ A61)l MO '3 Pt^c`c~ 4/GAO E E r PAGt GF PUMP CHAMBER CR055 SECT IOU AND SPECIFICA'nokis VEUT CAP 4"C.I. VFMT PIPE WEATHERPROOF APPROVED LOCKIAIG ?-5' FROM DOOR, JUNCTION BOX MANHOLE COVER ~ WINDOW OR FRESH 12"MIU. AIR INTAKE GRADE I ( `1" MIIJ. ~ ~ Is"Mlu. COIJDUIT-- - 18"MI1~1. ~ 11~ IAILET PROVIDE I AIRTIGHT SEAL Ir ~ I / * A I III I I I ( ALARM a I ~I. I *APPROVED i I ow JOINTS WITH ELEV. FT. APPROVED PIPE I 3' ONTO PUMP OFF D SOLID SOIL COAICRETE BLOCK RISER EXIT PERMITTED OIJLH IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIOUS DOSE TAAIKS MAAIUFACTURER: IJUMBER OF DOSES: PER DAy TANK SIZE; IdQD~C Ga ~G GALLOWS DOSE VOLUME ALARM MAMUFACTURER: C 4"</' 60" A"' INCLUDING BACKFLOW: 122117 GALLONS 3.1'33 MODEL NUMBER: J f IWCHES OR Altt' GALLOWS CAPACITIES: A 24 SWITCH TYPE; B = o~ INCHES OR `n•~ V~ GALLOAIS PUMP MANUFACTURER: C=7,1~ IAICHES OR GALLOWS I MODEL MUM5ER: 3771 D= INCHES OR ~OGALLONS j SWITCH TYPE: m -ec'G NOTE: PUMP AMD ALARM ARE TO DE MIIJIMUM DISCHARGE RATE-GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEELI PUMP OFF ARID DISTRIBUTION PIPE.. 8- FEET + MINIMUM NETWORK SUPPLY P~R.E~SSSURL,E~.. , , , , , FEET + FEET OF FORCE MAIN X -~S Z- 101 F,FRICTIOU FACTOR. 1'G3 FEET TOTAL DyWAMIC. HEAD = FEET IAITERLIAL DIMEMSIOMS OF TANK: LENGTH ;WIDTH -;LIQUID DEPTH 31GNJED:1 T 12d~-~ ~7" D nK-r r LICEI~ISE NUMBER: A 3 f L 3871 EP04 / EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. Available for automatic and tic cover with integral handle • Farms Motor: and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP, manual operation. Automatic points. 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water transfer Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- Solids handling capability: automatic reset, plastic Semi-open design AGENCY LISTING 3/4",maximum. • Power cord: 10 foot with pump out vanes for -.Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding ®EP05 Impeller: Thermo- • Discharge size: 1'h" NPT. plug. Optional 20 foot (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for improved performance. end in "F" or "AC".) rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104°F (40°C)' continuous superior strength and 140°F (60°C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 - -~T • Capable of running - r- 6 dry without damage to s 30 7777t7_-!_._ components. Pump: EP05 8 x~Fr • Solids handling capability: c 25 3/4" maximum. W 7 • Capacities: up to 60 GPM. _ Q s 20 - - - - - - • Total heads: up to 31 feet. • Discharge size: 11/2" NPT. Z 5 I - - • Mechanical seal: carbon- 0 15 ! rotary/ceramic-stationary, 4 BUNA-N elastomers. o Epos - - • Temperature: 3 10 - - - 104°F (40°C) continuous 140°F (60°C) intermittent. 2 j ePOa I ' 1 i 0 00 -fib 2 0 30 40 50 GPM L 0 2 4 6 8 10 12 ml/h CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 83871 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page of Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County C y^e.- ~ include, but not limited to: vertical and horizontal reference point (BM), direction and S 7 ~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 0/yo Id 3'0 - 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 r c./ &Xl Govt. Lot W,5 1/4 T6,) 1/4,S T;2 e N,R lQ E (or& Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# e o g d I)oA d 3?`! ! 8'~ City State Zip Code Phone Number El City ❑ Village Town Nearest Road / 'Id 5- 16 1 (38~ ) b-'? 9 r '~v a Co l~cL~ ❑ New Construction Use: ®Residential / Number of bedrooms 3 Addition to existing building Us Replacement ❑ Public or commercial - Describe: G Code derived daily flow gpd Recommended design loading rate , 7 bed, gpd/ft2 ~Q- trench, gpd/ft2 Absorption area required 4~'4/ bed, ft2 s trench, ft2 Maximum design loading rate , 7 bed, gpd/ft2.,trench, gpd/ft2 Recommended infiltration surface elevation(s) 7 a 5 Q ft (as referred to site plan benchmark) Additional design/site considerations Parent material & T 57,'4. Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ®S El U ®S El U WS ❑ U ®S El U El s [9 U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o, a db4 ina f c < a2m lY3D ef A y 3 5 zIna16 /c/f e 1 F '1c .15 Ground 3 3e /jJ ,Q /~L rn S ? a elev. 48: 70ft. Depth to limiting factor , Remarks: Boring # 02 3! e 3 - ::5,4 ;Z inabe el 3 NI-12 /d V'P 5 c 5 Ground elev. Depth to CC) Tr limiting ? factor 000•CiF"- 7T2 in. Remarks: „r CST Name (Please Print) Signature T p ago Address Date CST Number e a ~ ~ ~ as ~4 a PROPERTY OWNER ke"Ld de.-11 SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground 3 / elev. 3-Z-1 0 S 9 )2Z / C h8~~a ft. , Depth to limiting factor Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Boring # Ground elev. ft. Depth to limiting factor 'n. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) N1 l Cl~,~(/Sit o+~r ,1709 /<«N~ t /00, a S s-7`arw S .64 7a,ed aSCfes.. ro Gf'teytfe- 4 S lo69s'~`nbd e Tnyrr.'N,` ~Z~ 5`De`~ J?~L~a~-o Ua.L ~'rn/+'► a7 ~ ,t~3 Ya ~"y''""X- Gov~r ~b~ D~~ ~l ~i i i Y d I r i. O Pe ~ 4;.v i 0 3 ~ a. . FORM NO. 985•A N.CMNrCanVM'®M 374? CERTIFIED SURVEY MAP TRUE BEARING W1/4 corner Section 7, ~ 101,10, -IANNNM~ 2 T28N, R19W ►-'to 00 0 U4 1 to CNJi SCALE IN FEET RED 00 00 0 100 200 300 0CT291981 CA JAAWS 0, Of b""~L - rn 48 U 84 LEGEND 6' County Section Corner Monument, Found. o p 0 IC-- O 1" Iron Pipe, Set,Weighing 1.68#/Lineal Foot. r+ Iz Hi ~ t- 1 b jp~ Railroad Spike, Found. o P. lr ,A --i- Fence. H. P I N 1--3 Building. ~`~'14 (n Cn 1H •y5N~ ~c(uW oLn -P.- Its (D ct ~ N (Jt 1 APPROVED c FJ. :J 0 1 r n r+ u,o 4~- w 00 - 1> SAP 18 1981. W y 0 td 1 z N1011'E v P1 Id 227.411 s ` 20IX COUNTY . `7 0 ° F" CO.nl.:. EN51VE PARKS PLAWNWO fn CD O AND Z04HG COMNUTTEE H ' N F' • .''3' N LOT N N w N Barn H. P. IC ll 0 Iz Ib 7.77 Acres Ir Cn Q 1,320,788 Square Feet, 00 I'D more or less I> 0 I-3 w ly ~ I rn ~ w ~ Id Westerly Right-Of-Way Line ous I S89°2S' 58"E N89°25' S8"W Ir' 34 . 39' 2S. 01' I~ I 216.09' Existing driveway- 2 ' S' 1z S1°04'40"E 268.11' .M inQ Q71 I 1 5100414011E STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER eK_ MAILING ADDRESS PROPERTY ADDRESS -C_ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, SGr/ 1/4, Section 7 T 2 N-R_L_0'_W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE '/l , LOT NUMBER. Z4_ 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 returne the St. Croix County Zoning Officer within 30 days of the three ye on date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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. Owner of property Location of property 1/4 1/4, Section _:;7, T _geN-R ej Township Mailing address ~~✓y ~,Q~/ Address of site subdivision name ~~z z2a Lot no. Other homes on property? Yes__,k/- No Previous owner of property frt , ~ A--l Total size of property 7 !fA GM,e s Total size of parcel 7- ~7 6 Date parcel was created 4 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _ a,_No Volume 1o rl- and Page Number ass as recorded with the Register 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 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 o ice of the County Register of Deeds as Document No. gnature of plicant Co-Applicant r 7 Date Signatu e Date of Signature DOCUMENT Nth. I STATE BAR OF WISCONSIN FO$M 3-1.482!1 T"'• r- RE""O '0* REco R0" O•Tw QUIT CLAIM DEED I! f ' 51.9440 I. l REGISTER'S OFFICE loss a ST. CROIX CO., Wl .........Michael J. Madden, ...cantor Ij Rec'd for Record ...q..........• r.........---.•-----•-----•---•-.......... I JUL 2 5 1994 Mad~fen and R: 12:3 P quit-claims to Mic hae J. Sfiaron ...d••, us••-•h•--•-..._....ban.d an_..d . -----a----s---7---- ---oinE- . ten....... I~ at Kinkea . M with. r - t_ of-.surv worship..... antees Iie&WOfDleeft . . ~I CrOlX II the fol;owing described real estate in St ......t County, State of Wisconsin: R9Ty RH To Lot 11 of Certified Survey Mapy recorded ll in Volume 4,: page 1119; being a part of the NE 1/4 of the SW 1/4 of Sec. 7, T28N, R19W. Tax Parcel No: i This .......i homestead property. (is) (is not) Dated this .....................20th day of MaF , 19...94.. (SEAL) (SEAL) . a 1 d _ .n (SEAL)....... (SEAL) • . . AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN as. N .....................County. authenticated this ........day of 19 Pe.-aonaliy cama before me th ....r? ......day of Agly 18.4_ the #a!wems q~1 to 10i • TITLE: MEMBER STATE BAR OF WISCONSIN (If not . R-----------................................. authorized by 1 706.06, Wis. State.) to sae known to be the person exec the forgoing instrument and ckrowleda ~•sB"C THIS INSTRUMENT WAS ORAFT[O GY • " ohman..-&--Andr.ems Zlttnrncvc a1- T.=w t-- ..`r7..... ~..!ttu.•aatll~~, .