HomeMy WebLinkAbout040-1034-95-001
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AS BUILT SANITARY SYSTEM REPORT Src qo, 1
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OWNER ,-tee ~~~rc.C
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ADDRESS
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SUBDIVISION / CSM# 4,1 LOT # I
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COD
SECTION T 2g N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t
BENCHMARK: It :F-,/ wed
ALTERNATE BM: A4tl CGr r ~ ~
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: C', f'9- Liquid Capacity: /,2,0
Setback from: Well House / - Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 7 L, Number of trenches 2
Distance & Direction to nearest prop. line: /7
'
Setback from: well: z House 2 4 Other sU~s,} y~, 5
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: 7
PLUMBER ON JOB: ,a
LICENSE NUMBER: ~.fi~'if 3Z2
INSPECTOR:
3/93:jt
n.cycd wov
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
`isconsin In accord with ILHR 83.05Wis. 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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Na a Pr perty Ljocation
, N, R 14F (or)
I/4 1/4,S T 4-10
Property Owner s Mailin Address Lot Number Block Nutrsbrl,
City, State Zip Cod Phone Number Subdivisi n Name or CSM,Nu ber
D/ (7f / vd
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ~t~r arest Road
❑ vil age
Public 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 E] Apartment/ Condo D
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. g 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 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12,N Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13E] 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
-766 '7Jr Feet 1W. Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ 1,," .1 / Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb 's Name: (Priinntt))Plumb 's Signature: (N tamQs) MP/MPR W NP.: Business Phone Number:
Plumber' Ac dress (Street, City, State, Zip Code):
A17 , 2
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
❑ Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
1
s
INSTRUCTIONS
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:
I_ 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 Fine 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 isto 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.
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
.Labe- annHumanRelations INSPECTION REPORT ST. CROIX
Safes and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 284247
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
CERNOHOUS EDWARD TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
~4J UJ &U "G 040--1354-95-061
TANK INFORMATION ELEVATION DATA o
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark 60
Septic ZGve.,o
Dosing ~ ~ ~S%
Aeration Bldg. Sewer
HOB' Ing St/ Inlet
TANK SETBACK INFORMATION St //wt outlet 9
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 35/ NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe
Hold' Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM 3 z '
Loss riction System TDH Ft,
TDH Lift F
r- cJr
Head i
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches P No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S 7J DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA Manufacturer:
SETBACK C, MBER
INFORMATION TypeO n~~C«,j' , Mo ber:
System: tr(jCks 1760.1 02(, $Z OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold / Distribution Pipe(s) „ x Hole Size x Hole g Vent Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges - -S-6 Topsoil ❑ Yes ❑ No / ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) -Y
LWATION: TROY./8~.28.19W NW NE COUNTJY~ ROAD F fi
vd' ✓'/Y~ r'"C. 3!!./' a'7 C_ ~"~n'~" , jQ. ~ ` (~~"J c-'l,{.✓1 .°t-.' L'YA,+,"7 IJ~C_ ~l U✓ ~ L'LJ~(: .f.
Plan revision required? es ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
:
Safety and Buildings Division
v~i`Irrir"i SANITARY PERMIT APPLICATION Bureau of Building Water System!
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 (L-L t
than,8 112 x 11 inches in size. ..Y► - 0ed 1
• See reverse side for instructions for completing this application State Saann,itaarry P@rmiit. Nu~mbgr
The information you provide may be used by other government agency programs ❑ Chetk it revi()s-ifo%n Yo prey" iou~ application
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Pr perty~Lp cation
AlkJ14 N 1/4, S T , N, R
Property Owner's Mailing Address Lot Number Block Number
''2 f 1,1e
City, State Zip Code Phone Number Subdivision Name or CSM Number
u/ vi) / 49 1(-71T) 3e/-/2!5i6 GS' o I
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms 3_ Town of
I11. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo o 1/0 i3j`~- ~S- Dvl
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 if 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. S 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 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
7`(5a '54, Z f 5 Feet 3?8, 3 Feet
VII. TANK Capacity acits Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank ~C 44b S 1 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number:
717-7z 3z/,-,"
Plumbe Address (Street, City, State, Zip Code): I
IX. COUNTY / DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Agent Signature (No Stamps)
jvA roved surcharge Fee)
pp I ❑ Owner Given Initial
Adverse Determination a-!7^
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-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 !3 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.
JOB ~~/-LOKOU~A
TIMM EXCAVATING SHEET NO. f OF 7
Route 1 Box 192 2- ~y.7
WILSON, WISCONSIN 54027 CALCULATED BY r DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 ~Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800"2256380
JOB tl L~Lf2/) /Ldfir1
TIMM EXCAVATING
Route 1 BOX 192 SHEET NO. Z OF Z
WILSON, WISCONSIN 54027 CALCULATED BY DATE 2-
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc.,Groton, Mess.01471. To Order PHONE TOLL FREE 1.800-225-8380
D
D ~5 1 CERNOHOUS WEST
CERTIFIED SURVEY MAP
VIRGIL CERNOHOUS
Part of the Northwest 1/4 of the Northeast 1/4 of Section 8, Township 28 North, Range 19
West, 'own of Troy, St..Croix County, Wisconsin.
A
hp UNPLATT90 LANDs
. $4 p~~yy 300.10' 3Y"W 4 76.00'
.d .Iy s, 4 i 1.00' 43.00' 30.00'
W q ' W
(~mxb , r4 i
00 4-I a
~-QQQ1 Q ~fy' O 0 N
O ) i' r-1 W W w ~ I K « IN W W ; Y
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Id u •(D •m 0 "j « °w z o 0 0 • •
00
b 49 O A f, 4) o d s
9d 0 (1k) +3 • a yN w I J
14 j~
Cm 0
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4.11 a1 E+,
to Id. g C;
49 > "Id H 11 b,
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W ' r
wP
Z =DO V apo
W AIL«"'«_ / 1 I
a« z Olim~ 1 / 1 ~
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4100.00 00' 00"[ $ 3 00. 00' 00. W 103.D3' DIP#
Mi
71.34 • $ 20~ 0 I t
•o Noo•oo•oo•'E 140.901 •.o~w
sa` JI
z3z.iz• - N 14.20 .
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MOO.00'00`[ !=♦1.1~' Zsas7%~ 283.a,.
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of 800.00'00°F F' » « ,«j / i N ~ ~ M
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APPROVES /
DEC 81983 144.31' '
Q o s oo•oo'st"w'R 4214.47,
That certain parcel of land located in the Northwest 1/4 of the Northeast 1/4 of Section 8r
Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wiscaasin, more fully
described as follows;
CONMENCING at the North 1/4 corner of said Section 8, .
thence 3 00° 09' 52" W (assumed bearing on the North/South 1/4 line of said 33etion•8)
a distance of 1322-51'; thence N 90' 00' 00" E on the South line of the Northw t 1/4'"r- t.
of the Northeast 1/4 of said Section 8 a distance of 949,1)1 to the POINT BE
of the parcel to be herein described; thence on the centerline of C.T.H. .F"'" is described
in Vol. 424, Page 43, Doc.#284678, St. Croix County Records, on a curve concave to the
North, having a radius of 1273.33', whose chord bears N 72' 28' 30" W 766986'1
thence N 54' 57' 00" W 161.17'; thence leaving said centerline go N 00' 09' 5r., E
(recorded as North) a distance of 223.861; thence N 90' 00' 00" E 583.551;
thence S 00' 00' 00" E 71.341; thence N 900 00' 00" E 457.9911 thence S 00' 10' 39" W
476.60' to the centerline of C.T.H. "FF";-
thence N 90' 00' 00" W 177.601 to the POINT OF BEGINNING, containing 10.26 acres, more '
or less, being subject to easements of record and also being subject to a roadway easement
for the benefit of the Grantor, his Heirs and assigns, more fully described as follows;
EASEMM DESCRIPTIONS
CO*MNCING at the North 1/4 corner of said Section 89
thence 3 00' 09' 52" W (assumed bearing on the North/South 1/4 line of said Section 8)
a distance of 1322.51'; thence N 900 00' 00" E on the South line of the Northwest 1/4
of the Northeast 1/4 of said Section 8, a distance of 949.13'; thence on the,Centerline
of C.T.H. "FF", as described in Vol.424, Page 43, Doc.#284678, St. Croix County Records,
on a curve concave to the North, having a radius of 1273.33'9 whose chord bears
N 72' 28, 30" W 766.86'; thence N 54' 57' 00" W 161.17'1 thence leaving said centerline
go N 00' 09' 52" E (recorded as Noi~%4) p distance of 223.86'; thence N 90' 00' 00" E
583.55' to the POINT OF BEGINNING of said easewauL; t,hxnae 3 00' 00' 00" E 71.34';.
thence N 90' 00' 00" E 33.00'; thence S 00° 00' 00" W 165.131; thence S 14. 20' 00" W
239.941; thence Westerly on a curve concave to the North, having a radius of1233.331r
whose chord bears N 74' 07' 59" W a distance of'66.001; thence N 14' 20' 00" E 229.8811
thence N 00' 001.0011 E .228.181; thence N 90' 00' 00" E 33.00' to the POINT OF WGINNING;
AND ALSO said parcel being subject to easement for C.T.H. "FP" R.O.W. purposes niare fully
described as follows;
EASOGNT DESCRI PTION:
COMMENCING at the North 1/4 corner of said Section 8,
thence 3 00° 09' 52" W (assumed bearing on the North/South 1/4 line of said Section 8)
a distance of 1322.51'; thence N 90' 00' 00" E on the South line of the Northwest 1/4
of the Northeast 1/4 of said Section 8, a distance of 949.13' to the POINT OF'•BEGINNING
of said easement; thence Westerly on a curve concave to the North, having a radius of
1273.33', whose chord bears N 72° 28' 30" W 766.861; thence N 54' 57' 00" W 161.171;
thence N 00' 09' 52" E (recorded as North) a distance of 54.861; thence S 54' 57' 00" E ,
192.541; thence N 35' 03' 00" E 10.001; thence Easterly on a curve concave to the
North, having a radius of 1218.331, whose chord bears 3 62. 51' 09" E a,p stance of 3350011;
thence s 19° 14' 42" W 15.00'; thence Easterly on a curve concave to the North, having
a radius of 1233.331, whose chord bears 3 80° 22' 39" E a distance of 412.321;
thence N 00' 00' 00" 8 5.001; thence N 90° 00' 00" E 177.740; thence s 00' 01' 46" W
a distance of 45.00'; ~ thence N 90' 00' 00" W 177.60' to
the POINT OF BEGINNING.
CERTIFIED SURVEY MAP
VIRGIL CERNOHOUS
Part of the Northwest 1/4 of the Northeast 1/4 of Section 89 Township 28 North,
Range 19 West, Town of Troy, St. Croix County, Wisconsin.
CURVE DATA
CURVE CHORD BEARING CHORD RADIU8 CENTRAL ANGLE IST TAN.86ARIN$ 2ND TAN. DIAMINt AMC
1 - • " 23. IV 1273.31' 1.07.46" "90.00'00" 38•1 '_19"w
2• 3 N 31. 31'32"W 323.34 1273.33' 14. 41'20 N 08132'12"W N74.10'32"W 326.43'
3-4 N64'33.340W 123.36' 1271.33' 19'L3'32" N740 10'St"W N84.37'00"W 427.38•
3.3 ' 8" 333.01 1218.33' 13.48'1!•' !34'37'00"E !70'4 13" 334,019,
7.8 - 71'40'311" 39.70' 1233.3311'30.40" 870.43'18"9 $730 W 5909 39.70•
8 873.21139"t 33.00' 1233.33' 1.32.02" 972.33'114"t !74008'00"6 33.01'
6-10 9 + 33.00' 1233.33' 1.32. 00"` 874.08'00"6 873.40'00"6 33.01'
9 74• . . 3-04-02- 271*33138"It • . 88.02'
7-12--- 990.22' 39'•9 112.32' 1233.33' 19'14'42" 970.43'19"9 N90•00100„E 414.28'
10-11 §42-13-00.g 1233.331 Y 9 73. 40'00" E s88•s E 233.421
11112 889.23100'9 23.11' 1234.33. 1.10.00" 888.30100"6 "80.00`0009 23.11'
7.12 ! 2 8 t 412.32' 1233.33' 19'14.42" 870.43' 18 "t 1490.0010016 414.261-
1-4 N 7 •28' 90"W 766.88' 1273.33' 33.03' 00" H 90o 00,0019 "34.37' 00 "w 778.9!'
3-14 837.36130" .r 126.396 1216.33' 6.03'00" 834'37'00"9 sil•00'00"E 128.88'
14 - s 863.32' 39"t 207.19' 1218.33' ' 43• 1 W, 981. 00.00" 6 _ 6 207.43'
3- 18 POT-63' Fe -W 279.02' 1273.33' 12*34'40 N74.10'32•'W NI1•38 04"1W' 279.38'
13-4 N38.16'52"W 147.73' 1273.33• 8.39.04" "81.36'04"W N34037'00"W 147.31•
APPROVED
OEC 81983
ST. CROIX COUNTY
COMPREM&0VE PAM ttAPOMO
AND ZONWO COIYIOM
State of Wisconsin)
County of Pierce)
It Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of
the Owner, Virgil Cernohous, I have surveyed and divided the lands shown hereon in
5.67/ -4 : pi,elci.z_ rt,ti/P176 ffous ,e 3 , //wy. 17 //012,Sa,0 S.
•s. >'-',c5tp
c,_PARTMEN'T OF [ REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, Wli07 DIVISION
LABOR AND BOX 7969
HUMAN RELATIONS COI PERCOLATION TESTS �11�) P.O.MADISON,WI 53707
/ (H63.09(1) & Chapter 145.045)
LOCATION: �I SECTION: TOWNSHIP 1t ir/ LI r': LOT NO.:BLK.NO.: SUBDIVISION NAME:
4/(x) 1/ 1/ 87 /T27 N/R t9 E ( r)W 7 & / cs,.H 3fe yS % • l/o/ 5 N • /vJ—
COUNTY: t3WINJER'S UYER'S NAME: MAILING ADDRESS:
S-/A,X mDi vz' ,�'�.17.iSE" 7 36 "h". f/rpe." r9U-e 57 p ...„
USE DATES OBSERVATIONS MADE
NO.BERMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:_
kesidence 3 ` ? ) XJ glNew ❑Replace /0_/9 P3 )y4, 2 // f�s
/ /` Scc C �0/Pk ,,4f- cc /
RATING:S=Site suitable for system U=Site unsuitable for system
C
°�1 S I U X S I U CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
X S 1 1 U I S ' U s < U /D:X Si.'v,,d f/,)i;44.4P
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: C Li9 S S Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS i1u D9ci,1,,,— 'f± •
BORING TOTAL I DEPTH TO GROUNDWATER _ CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- / F.L. /0 2 .3 -- > S2. p w A 4 so/L /ee-7)0,P74 fir/
B- f 6 i /° / ' F. /° _ Zo 43
G C 5 •/ # zyys
3 0' / 3 _ > F 3 / (Z. /fivA' ). 4-/( /,P flog Si 4i j 44
3
B-/ / A/• i'Lp-'-9.
f` / J E. ,„ ,'S O/t es- ri.�.-P Say
B-
sv ^t f a1ll'iaA) 'F 4e4,e SiICS is f.{ . PERCOLATION TESTS
TEST DEPTH I WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING ' NTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 _ PER INCH
P- j f!3 /o z.3 ` '2_-
6 '' v,7e ..49,"c•Am•-,() /A) sf
P_ 1
P- v .r.I to3./ ` 2— / ,,2- ..,,,,.G:, Ses. 'Ace'"1€7(11— 7
2- / U 1(-5 few- ``q
P- /0 2. - - GI
_P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 11 �wN j' 5"uAWEYA4PS
SYSTEM ELEVATION �° �o� �. _ . O T T • ,v 6. z or
co/P''E' .
rV o/Cdt Lo T L'c'F ®� " ��•
{ y , • 1 /
.2,7 y v' is --4' 3k -'' E/E-t)' ' ,
. = 6/(. -/•N,1-/ /C 85 Alm /o 143 Q •/ ' _-- e,, t\ oo p
/ --1 1+4,c_ filesi ,,,,.. ;fr., ;(-'15) i/32_ 1\ 9 5
\ '
Sc / / ,, _ ya '474 • _..------"--7*
� • •
3() tN
� �5 z R.,
7 p( r 9,
t�oOS s" ./ 91b 7�
7—
/8 4 r i , ,(- iir J fo (-N.\ c.
�'Co�y stern s��� r �. �
\; qop, �`/
t °°yy��yylI�� !_ __i
I, the undersigned, hereby certify that the oil tests on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON: �--
HCMESITE SEPTIC PLUMBING CO. 2-/..._ /f PS
RT. 3 O'NEIL RD., HUDSON, WIS.54016
ADDRESS: ROBERT ULBRICHT CERTIFICATION NUMBER: PHQ UMB R(optional):
WIS. MASTER PLUMBER UC. NO. 3307 M.P.R.S. Sf -O 1- VP.1.-- '33 ((DD ?/�,f
u D6b. T SIGNATURE
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
.Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page 1 of 3
bivision of Safety and Buildings ith s. ILHR 83.09, Wis. Adm. Code
L County
Attach complete site plan on paper not less than 8 1/2 x 11 inches In size. Plan must St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
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
Ed Cernhous Govt. Lot NW 1/4 NE 1/4,S 8 T 28 N,R 19 VX(&) W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
452 CTHW FF 1 CSM 390 459, vol 5, p 1385
City State Zip Code Phone Number ❑ City ❑ Village >E] Town Nearest Road
Hudson, WI 51016 ( 715 ) 381-1256 Troy CTHW FF
New Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 562.5 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 93.5 ft (as referred to site plan benchmark)
Additional design/site considerations install 2 - 5' x 60' trenches w/ 14-12" rock beneath laterals
Parent material sandy/loamy 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 for system [9 S❑ U 91 S❑ U ®S ❑ U 0 S ❑ U ❑ S ® u ❑ S 0 U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD/ft2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0-8 10YR 2/2 - sl 1 f abk mvfr cs f/m .4 -.5
2 8-25 10YR 3/4 - sl 1 m abk mvfr cs m .4 '.5
Ground 3 25-33 7.5YR 4/4 - is 1 m sbk mvfr cs .7 ,.8
elev.
98.4 ft. 4 33-48 10YR 4/4 - mcos 0 sg dl cs .7 :.8
5 48-57 7.5YR 5/4 - s 0 sg dl cs .7 '.8
Depth to
limiting 57-96 10YR /4 - mcos 0 sg dl - 7 ;.8
factor
96 in.
Remarks:
Boring #
1 0-12 10YR 2/2 - sl 1 f abk mvfr cs f/m .4 '.5
2 2 12-22 10YR 3/4 sl 1 m abk mvfr cs if .4 ,.5
3 22-26 7.5YR 4/4 - is 1 m sbk mvfr gs If .7 '.8
Ground 4 26-10 10YR 4/6 - s 0 sg dl - .7 ~.8
elev.
98.3 ft
Depth to
limiting
factor
> 10o in. Remarks:
CST Name (Please Print) Sign tur Telephone No.
Henry F. Grote 715-665-2681
Address PO Box 57, Knapp, WI 54749-0057 Date CST Number
12/9/96 3065
PROPERTY OWNER Ed Cernhous SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 0-6 10YR 2/1 - sl 2 m cr mvfr cs 1f/m .4 , .5
2 6-3 10YR 2/1 - sl 2 m sbk mfr cs 1f/m .5 .6
Ground 3 33-50 10YR 4/4 - sl 2 m sbk mvfr cs if .5 ' .6
elev.
96.8 ft 4 50-53 10YR 4/4 - is 1 m sbk mvfr cs - .7; .8
5 53-56 10YR 4/4 - s O sg ml - - .7 .8
Depth to
limiting
) Vor ,
in.
Remarks:
Boring #
1 0-16 10YR 2/1 - sl 1 m sbk mvfr cs 1f/m 4 .5
2 16-4 10YR 4/4 - sl 2 m sbk mvfr cs 1m .5 .6
3 41-4 10YR 4/4 - is 1 m sbk mvfr cs - .7 .8
Ground 4 46-8 10YR 4/4 - s 0 sg ml - - .7 .8
elev.
9z-.5--ft-
Depth to
limiting
factor
? 86 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.
n. '
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting F-T
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
9
r 1
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ej
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t
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor apil'Human Relations Page 1 of 3
Viuieio. i of Safety and Buildings i o rD 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 point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal inforrnation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Ed Cernhous Govt. Lot NW 1/4 NE 1/4,S 8 T 28 N,R 19 tX (4) W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
452 CTHW FF . 1 CSM 390 459, vol 5, p 1385
City State Zip Code Phone Number ❑ City ❑ Village Z Town Nearest Road
Hudson, WI 5 016 ( 715 ) 381-1256 Troy CTHW FF
New Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 562.5 trench, ft2 Maximum design loading rate ' 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 93.5 It (as referred to site plan benchmark)
Additional design/site considerations install 2 - 5' x 60' trenches w/ 14-12" rock beneath laterals
Parent material sandy/loamy outwash Flood plain elevation, if applicable NA tt
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U
U = Unsuitable for system (US El U 0 S El U ® S El U Q S ❑ U ❑ S ®U El S 0
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0-8 10YR 2/2 - sl 1 f abk mvfr cs f/m .4 -.5
2 8-25 10YR 3/4 - sl 1 m abk mvfr cs m .4 .5
Ground 3 25-33 7.5YR 4/4 - is 1 m sbk mvfr cs .7 ,.8
elev.
98.4 ft. 4 33-48 10YR 4/4 - mcos 0 sg dl cs .7 -.8
5 48-57 7.5YR 5/4 - s 0 sg dl cs .7 .8
Depth to
limiting 57-96 10YR /4 - mcos 0 sg dl - .7 ,.8
factor
';t 96 in.
Remarks:
Boring #
1 0-12 10YR 2/2 - sl 1 f abk mvfr cs f/m .4 .5
2 12-22 10YR 3/4 - sl 1 m abk mvfr cs If .4 ..5
3 22-26 7.5YR 4/4 - is 1 m sbk mvfr gs f .7 .8
Ground 4 26-10 10YR 4/6 - s 0 sg dl - .7 '.8
elev.
98.3 ft
Depth to
limiting
factor
> 100 in. Remarks:
CST Name (Please Print) Sign tur Telephone No.
Henry F. Grote ~~_b /~V, 715-665-2681
Address PO Box 57, Knapp, WI 54749-0057 Date CST Number
12/9/96 3065
PROPERTY OWNER Ed Cernhous SOIL DESCRIPTION REPORT 2 3
Page of _
PARCEL I.D.1f
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GED/ft
2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 0-6 10YR 2/1 - sl 2 m cr mvfr Cs 1f/m .4 , .5
2 6-3 10YR 2/1 - sl 2 m sbk mfr Cs 1f/m .5 .6
Ground 3 33-50 10YR 4/4 - sl 2 m sbk mvfr Cs if .5 ' .6
elev.
96.8 ft 4 50- 10YR 4/4 - is 1 m sbk mvfr Cs - .7 ; .8
5 53-56 10YR 4/4 - s 0 sg ml - - .7 , .8
Depth to
limiting
Vor ;
in.
Remarks:
Boring #
1 0-16 10YR 2/1 - sl 1 m sbk mvfr Cs 1f/m .4 .5
4 2 16-4 10YR 4/4 - sl 2 m sbk mvfr Cs 1m .5 .6
3 41-4 10YR 4/4 - is 1 m sbk mvfr Cs - .7 .8
Ground 4 46-8 10YR 4/4 - s 0 sg ml - - .7 .8
elev.
97.5 ft.
Depth to
limiting
factor
86 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)
Q
S e MI
f
90
N y y ~6 Q
0 4
Gi a
T
r~
s
rr ~
1-
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C--
h
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pA I ro
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STC - 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 tug- 1/4, Section 61 ,T oZ8 N-R /19 W
Township Z,- Mailing address
Address of site
Subdivision name L~ Lot no.
Other homes on property? ---Yes ?G No
Previous owner of property /U/a<,1~~~
Total size of property 3 ~7
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 X No
Volume (//Z and Page Number 30 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 office of the County Register of Deeds as Document No.
ignatur' of Applicant Co-Applicant
,2 - %7 °f7
Date of Signature Date of Siqnature
i
' I
STC-105
I
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER e (~tseofia 0
MAILING ADDRESS Z e & a~ I L/t
PROPERTY ADDRESS Jwl"
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE fre~Am
PROPERTY LOCATION /Ifs 1/4, Ile- 1/4, Section T L6 N-R__Z?_W
TOWN OF % ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP y5 9, VOLUME 5 , 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 lexpiration date.. /
SIGNED: T~V ~r,(4 Lis' ho~-~
DATE: - f 9 -7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
DOCUMENT NO. I WARi1AMlf
j, THIS s►4CC *cup ~o FOR IMCORDINC. DATA
DEED
STATE BAR OF WISCONWN FORM 2 -1969 i
472G75______[ -_-~---~~~~~~`•~&as REGISTER'S OFFICE
ST. CROIX Co., W1
Virgil J: Cernoh~us-a d-.Jul-i.a--A.---Cern i' Reed for Record
husban~ and wife as oipr tenants
I
~,Ux131991
q:00 P. M
conveys and warrants to ...Ed-WAKA-.,J,....Ge.r.AAb~s2skSa---aLSi~
~I
...man .
- Of Deeds
'
-
It-" To Edward J. Cernohous,
455 C t y. R d. F F, Hudson, W I
- -
the following described real estate in _........S t . r o i a ---County,
State of Wisconsin:
Tax Parcel No:..............................
Part of NW} of NE} of Section 8-28-19 described as follows: Lot I of
Certified Suziey Map filed January 9, 1984 in Vol. Page 1385.-
,
Subject to Lots 1 and 2 of said C.S.M. being restricted to contig-ous
driveways for access to C.T.H. FF; said driveways being 15 feet wide
at right angles on either side of the common lot line as'it enters these
lands from C.T.H. FF to the North right-of-way line of C.T.H. FF.
Said restriction shallbe binding upon the Grantees, their assigns, heirs,
and successors.
The grantors transferred possession and all their rights, interests
and obligations concerning this land, except title thereto, to grantee
on June 3, 1989. The deed was not given to grantee on June 3, 1989 by
mistake and omission. This deed is now made to complete this conveyance
from grantors to grantee which conveyance was intended by grantors to
occur on June Z, 1989.
This 1_P n Q-t........ homestead property. •J
(is) (is not) O Spy
Exception to warranties: Y6
easements, protective covenants and restrictions of record, if any.
Dated this ...---..-8.th day of ugy ix....-- , 1S..91...
(SEAL) ."itiEAL)
' _ yir$ J. ernohous
...........................•--•--...........----•----•--••-••••-•••._(SEAL) / ~i
......(SEAL)
• Julia A. Cernohous
•
AQTHBNTICATION ACHNOWLBDGMBNT
Signature(s) STATE OF WISCONSIN
- ss
..............County.
authenticated this ..._..__day of 19------ ► Personal] came before me this -----8 t day of
August - - 19.9.1-- th above named
ViLgi_1•_J. Cernohous. h`tl i~
- Ju Z i a A. C it x an o h o 1. Z
TITLE: MEMBER STATE BAR OF WISCONSIN '
a -_.r}`_
authorized by ?06.06. Wis. Stata) -
to sae no to be the persoi I who ~z~tedsthe
THIS INSTRUMENT WAS DRAFTED ar - g instrument and ledge bli ll de.
~'--ft
SW "