HomeMy WebLinkAbout042-1022-10-100
STC - 10 4r
AS BUILT SANITARY SYSTEM REPORT
OWNER zS9
,c V ST CROIX
ADDRESS ~k_ 4ZoNjNGOF- puNTY r,,v
' 0 FIC E 1Z \
SUBDIVISION / CSM# LOT
SECTION- S T _N_R_Zg Town of-
ST. CROIX COUNTY, WISCONSIN .
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~G'F r• yr:y l
L
~22 1
,pe. uajaffy
n
6J.C~~ r
3
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t ?ti
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well 7 House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:_ l ,✓a,~/
Setback from: well: /oR House_4L_ Other
ELEVATIONS
Building Sewer S' ST Inlet: g~ 73 ST outlet: 9s'.~7
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
F- cos 9 qG
Existing Grade Final grade i_s~ ~
DATE OF INSTALLATION:
PLUMBER ON JOB: 4:22
LICENSE NUMBER!
INSPECTOR: 4<y
3/93:jt
r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Countr
INSPECTION REPORT sT. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary2894 N4
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
Permit
y_n Village Town of: State Plan ID No.:
TOSOHoldeMAr'sRNaame: ❑_Cit
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel
Td4Y.:
-1o22-10-000
TANK INFORMATION ELEVATION DATA A9700275
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding F St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
Forcemain Length Fi Dist. To Well
7-
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 TypeO 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
lched
u
Depth Over Depth Over xx Depth Of xx Seeded /Sodded FXXOM
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No Yes No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: WARREN 08.29.18.1281SE,SE 1024 110TH STREET LOT 3
~r
l /
i
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 T '
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureau o off Building safety and uildildinWater Systems
g Water 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
than 8 112 x 11 inches in size. J '
• See reverse side for instructions for completing this application State Saannitary Permit NNuumber
The information you provide may be used by other government agency programs ❑ Check iii rionto previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prop Owner Name Property Location ~,~p
1/4 - 1/4,S T , N, R ~(orLyv
Property Owner's-Mailing A res Lot Number Block Num er
Cit t e Zip Code Phone Number Subdivision Name or CSM Number
Ill. TYPE OF BUILDING: (check one) E] State Owned El ty / Nearest Ro
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF -3 9 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
-000.
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. ® 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 [X Seepage Bed 210 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 ./j~rlch) Elevation
Feet
97
4~f Feet
VII. TANK Capaci
112111.4- ty gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 4+1 ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for stallation of the onsite sewage system shown on the attached plans.
Plu b 's Na e: nu Plum is t N t mps) MPlMPRSW No.: Business Phone Number:
Plumber' Address(Stre it, City, Sta Zip Code .
IX. COUNTY DEPARTMENT USE ONLY
(Includes Groundwater Date Issued Issuln A e t SI nature No S ms
❑ Disapproved Sanitary Permit Fee 9 9 g ( p ) pproved ❑ Owner Given Initial Surcharge fee)
Adverse Determination /020
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SHD-6398 (R. 015/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Div, ion, Owner, Plumber
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 wilt 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 thissanifary 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.
V111. Responsibility statement. Installing plumber into 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 contam°nation investigations
and establishment of standards.
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Wisconsin•Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less x i in size. Plan must county
include, but not limited to: vertical and h t n direction and S
percent slope, scale or dimensions, n , and II tion to nearest road. pare I.D. #
(O
APPLICANT INFORMATIO - lease print al rnfornitiQ . Reviewed by Data
Personal information you provide may for se ry,;u cy Law, . 15.04 (1) (m)).
Property Owner GfwO1X Property Location
Cr7UNYr / Govt Lot 114
_ T ,N,R(orjj
ZONING s - 1/4,S
Pr rty Owner's Mailing Address Lot # Blocc# Subd. Name or CSM#
City State Zip Code P
umber ❑ city village Town Nearest Road 1
"k2 )7 'eC
S -~J 1, l /
New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow - gpd Recommended design loading rate , ~ bed, 9Pd/ft2 , trench, 9pd*
Absorption area required 2 bed, ft2 7~trench, ft2 Maximum design loading rate _,.,~__bed, gpd1F 4~ trench, 9W P
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Z29Z Flood plain elevation, if applicable 44 ft
= l E] Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
S
U= Unsuitable for system s❑ U s❑ U R S ❑ U Os ❑ u ❑ s ®u ❑ s 0 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh.~ Boundary
Bed Trench
_ "
Ground
elev. id J
s
2a ft. I
Depth to
limiting
fa or
in. ,
Remarks:
Boring # /
J / 7
7
LV-
l -el )-.5 110
Ground -
elev. 7, ~8
Depth to
limiting
factor
~in. Remarks:
CST Name (PI s:P ' Si ature Telephone No. Address Date CST Number
'S - 5
9 7
v/, SOIL DESCRIPTION REPORT
PROPERTY OWNER ZY49& S~ Page s---v of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GMM2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
7 r i
Ground _ - y
lev.
~ft. / Az /s 3 9
Depth to b
limiting h, -
factor /
Remarks:
Boring # 9
S s S
5
-ys
Ground 1~
eley,
Depth to
limiting
facto
?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
G
Boring # SC
zj -421
A/ tj
-5
Ground - 8 9-7 A, /0
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
tt. ,
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R. 07/96)
'4~/,C
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/~Dogi./J
~ut~
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations fol Division of Safety 8 Buildings in accord with ILHR COUNTY
-Attach complete site plan on paper not less than 8 1/2 x 11 inches in srn%de,but
not limited to vertical and horizontal reference point (BM), direction anCEL LD. dimensioned, north arrow, and location and distance to nearest road. -PAR APPLICANT INFORMATION-PLEASE
PRINT ALL INFORMA ! f` ' REf/IEWEDBY DATE
1 -
PROPERTY OWNER: J ROPEA ry, gCATION ; J
7 / L~O~ L'/d ~f~Th,' s' "1/4,S 8 T o79 N,R / g) W
1; 1 W'
PROPERTY OW ER':S MAILING ADARESS OGK#'. ;SUB$: NAME OR CSM #
~02~ lJD f~ ~~dE' mw CITY, ST E ZIP CODE PHONE NUMBER CLAGE [MOWN NEAREST R94D
lcf-a b4 New Construction Use K] Residential / Number of bedrooms e% L. 3 [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
gpd/ft2
Code derived daily flow -q2§_0 gpd Recommended design loading rate IUD bed, gpd/ft2 , 2-...trench'
Absorption area required P bed, ft2.2A:50 tr ench, ft2 Ma)amum design loading rate AtP bed, gpd/ft2 • a trench, gpd/ft2
Recommended infiltration surface elevations 9 7. 3 ft as referred to site an n mark
Additional design / site considerations ow vc 40aZje or- =,I .1
Parent material to-It 6- Ch e- Flood plain elevation, if applicable -ry/ ft . .
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ❑ S ®U ®S ❑ U ❑ S ®-U ❑ S Z U ❑ S gU ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistience Bourxl3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
fie
Ground 3 ~~.3 y D y~~/ C rn s}~k Y~ F i S l -F . 3
elev..
ft. ~j 3y 52 s 5L 1 rn 5bk In F 05 -F A :.5
Depth to -5, $2 - S d n1 s Y1'l )45 - c _ 3
limiting/ l a
factor 42 z' S 7. s S) l
Remarks: I Si AA- enct-Ar- n an
Boring #
O:...:
16 q,,e `3
jup
a m.sbk Oft, 14 s
Ground
elev S 0-2Z .5-ale s SiL m - `r 6 5
ft.
Depth to .
limiting
fa j ~O O CJI~
c~~~tgq r
Remarks:
CST Name:-Please Prime ~1 EI s~ Phone•
ddress:
Signature: Oate: CST Nuvb
PROPERTY OWNER:2Z ciZZLc r /rar C~ SOIL DESCRIPTION REPORT Page of. r'
` PARCEL I.D. # t144-9- " /O - - ►
Depth Dominant Color Mottles Structure GPD/ft .
Boring # Horizon Texture Consistence Bound3y Roots
in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. Bed n~ch
ti3 -51
.
Ground JS-3~ /D IVA/ ~ C Z m Sbk (YI R C S
e1Zft. 5' ,e '/A s/ a l sak r~ Fs I . s
Depth to Sy' 2 '~lo .S Q Y>'M ~.C , 8
limiting
factor
G ID /4- 4 a
Remarks:
Boring #
Ground
elev:
ft
Depth to
limiting
.factor
Remarks:
Boring #
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
Boring #
fin
Ground
elev.
ft .
Depth to
limiting _ . , . ,
factor
Remarks:
SSD-8330(R.05!92)
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7 ~S 11/1- 330T 't
FILED
~
"l/ 2 7 1996
KATHLEEN H WALSH
ReOlsler of Deeds
55265 St• C/oix Co., wl
0
ti
CERTIFIED SURVEY MAP
DONALD AND DORIS ERLER
Part of the Southeast 1/4 of the Southeast 1/4 and the Northeast 1/4 of the Southeast 1/4 of Section 8,
Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin.
A' y NBB•7~'17"WO
t 07~ C. S. /►/1, VQL.2, PQ VtF J / 4 I.Ij' a f //t COR.SEC. 8, rt9N,RlBW,
N b9- 44' tB "E 450. 60' 1000N rY SURVEYOR'S moN.I
_r.y. 17 J. PJ' I 'I 60,37' I
Owner's Address C/0 Tom Sullwol.~ (Son)
1228 100Th Ave, l e
Roberts, WI 54023 0VC~
I I 6 6 r .I C
LOT 33' 3J' h'~
O 2.-400 ACRES I °I • ° ltitlYhr~/'•'76`
i I 1
„ I O B, 9 0 0 S O. r:T. In O
N 2.164 ACRES fXC. ROAD R.O.W. H O p
94, $62 S0, Fr. I AFMIX CQMlY
/30' ;;,j,rMA0Slv4i Plant*
o I I Io and
°o I d~'~sQittro
J ^ S 89 41' 49"w 433.160' I„ °
Q 1 370.$7' I S6. J'' JI ~-40trveOCdw
W I :9x130 days oP
~ " I 70' 4
ROAD sErOACx LINE , ) if da(o
&t sh;0 bo
°
p 2.5bO ACRES O O
O /OB, 900 S0. r r. I h h R w m
O h 4I N -I 2 V
h Y. /BS ACRES EXC. ROAD R.O. W.
N 93, /73 S0. rT. I J ` h
Iw
S •891 44' 48 "IV 43.1, 6o' I I
04' Z54. 47' J. 9' z0' ,`,,~~1t1{Itff!!/h/~
307.16' CON
S
14•,.•••'""••••.•
Dated; Sept. 26) 1996 I I I MA
`
oIndicates 1" x 24" L07 4 LAU N •
iron pipe wei8hine • W M pPHY
1.13 lbs. /lin. (n o t. 500.4 CRES I o i 713
ft. set, Q v /08,901 S0.rr, I o V FALLS,-4
I 44-1
h
*Indicates Y.OR$ A CR ES EXC. ROA Q R.O.W. ° I b • Wisc. `
h
a . ~
l ~ 9.•~
iron pipe found ti 9/, o/7 so. rr. ti LAND
►.Indicates 0%
8 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 recprding.
W''----------------------------------------
Owner of property L~ o
Location of pr perty sue' 1/4 1/4, section N-R _W
Township Mailing address
Address of site.-z/
Subdivision name Lot no.
Other homes on property? Yes_ /-No
Previous owner of property /
41A
Total size of property
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 -
Volume 4LIZ. and Page Number? 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. S- , 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.
Sig ature f Applicant
4Co-APpli,,6aantt
?//9/9'7 _ '7 /q-9•~-
Date o Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
W
OWNERBUYER rSq ~50
MAILING ADDRESS S:~;-o /Z
PROPERTY ADDRESS ~N z")z
(location of septic system) Please obtain m the Planning Dept.
CITY/STATE
PROPERTY LOCATION .5'/ 1/4, IE 1/4, Section T N-R_,Zf_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP S s VOLUME _/I, PAGE2,/ff~-, 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 expiratio date.
SIGNED: ~GStS
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
553085 STATE BAR OF WLSCONSiN FORM 2 - IS=
DOCUMENT NO. REW E~'S CFFfCE R'3 C
W
~
ST. CROM CO., M
Thomas J. Sullwold and Nona S i1lwold- FAVA raw
husband and wi QED 9 1996
11:15 A. M
to l~la . F g~r
usban a wife, "aa` autviy~$ wari~tal n„pt~ o+.
- property',
TW ZPAU tit~HHp W FW FAMORDING DATA
K#,W #AD REit"AWAM
the ww'" SwR dnctibed iv~le
of 1vollcollft ~A
_
4 000
s
=end he 06 thes~~t. +
ox h, Range . Lte~ :
w , . ds #bad as- . r3ova r
5
, Ai;
`t-•s '.ter `~,y1 rr`~~'ZS '~4„ r
'Aiis s i*~tY. . bomesterE Pp0l~>< - . _
ettt* r"ttlctiouz and'"rights-of-:w4y of record,
Datedths 't,@CleRR~Er AD.,1St„96
s
CS~1U
•
si~rjl $tllsntd aE.=I. tSullwol
AUTHENTICATION ACYNOWtEDGN4ENT
_ .,rte....
V~pswtt{~ Ssats it W &CgRii►,
Comet
as this day of
Thnaas illlWnid anA a
~ S..l lwrc,l~'_ hLtahs~nA ~~ir;-yTj gQ.T
TITLE: NJIM STATE BAR OF WrAX*M
(R not.
amh-t-d by IM 06. Wk. stars.) to.e b9ifto be the person .rlso~ocuted cbe
TW P48TRUMENT WAS DtuFreD BY