Loading...
HomeMy WebLinkAbout002-1042-20-000 Q o 3 °o r p er r. 0 N N C d O O E X co O Y Y c _N 4 O U Z O C U 7 m O U. C In O (O C ~ 73 O ~ E d ~ i co ~ CD w E U) of o v z o o a m ~ w c 0 O z d ca U w O N F- r 'v C N M N O (n • w.~ -o .c g z z U _ z N o 6 E N c 7 V) L O y - d N 06 O C. w U c (o (o t w y' d v F- U O O a) `O D D a N N O NU) 7 N 0 0 E ~ ~ H ~ ~ ~ N N 3 0 0 0 z o o • rv o a a a m I p to 0 0 N cn U W m N U) L N N U N O OOi o c) V V O N ` O ~ N N ~ r N d Q } N co Cl ,y U, O Iq Ill co °o o CL N E o c o m c 06 (n U) o o CO o c a~ c c Q o 0 0 \ N N O N Y Y c 'D N N N V 0 ~ ! `,r `n c c ccs a~ v v~ ~ v c m m X FN N N N N 'Vl C', m N (6 U L' O Co N O N g U) Y. C cis * E \J m ro w a xt ca a r r*Ali U 'c c r A L) n. 1,oinv i " III I STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSMW LOT SECTION _T N-R W, Town of (~GV9^ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~ 1 ebo ~ Cam b. 0 ~ 0 INDICATE NORTH ARROW tI g Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Deli, 6 o 1 12 ALTERNATE BM: PTIC TANKii/ PUMP CHAMBER HOLDING TANK INFORMATION ManufacturerA,(V~~ f~P(45 f Liquid Capacity:,-''%1,66 Setback from: Well House Other Pump: Manufacturer ( oa l d Model &16- SizeA_ Float seperation XV I/ Gallons/cycle: Alarm Location 6 U if Q :SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: ~fLS~ Setback from: well :,>v)6() House 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: LICENSE NUMBER: 3031 4 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIK Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Pet U5'1'T6ANa REN & PAULA ❑ City ❑ Village Town of: State Plan o.: CST BM Elev.: R Insp. BM Elev.: BM Description: Parcel Tax No.: o V. 1) 0,, 1; TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~,l,tgQe~,, . 4 r Benchmark 6 DO• 09 ~ Dosing ` J, 3i, Aeration Bldg. Sewer ~Holding St/ Ht Inlet n> ` TANK SETBACK INFORMATION St/ Ht Outlet yp~ .d 3 Vent TANK TO P/ L WELL BLDG. Airintato ke ROAD Dt Inlet Ar Septic > , -7S , aS , y_2 S NA Dt Bottom » y~ 93 Dosing NA Header/ Man. a,d /o ; Aeration NA Dist. Pipe a, a 16 a, 3 Holding Bot. System /0, PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number AG PM TDH Lift q~ Lrictior H~yste ead TDH Ft Forcemain Length Dia. ,21, Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , No. Of Tenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O Model Number: System: /So 2 o u' ,rJ CHAMBER OR UNIT DISTRIBUTION SYSTEM Header /Manifold I Distribution Pipe(s) I x Hole Size I 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/ SodMiT- xx Mulched Bed /Trench Center Bed /Trench Edges ja Topsoil [-Yes E] No Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: BALDWIN.18.29.16W, SW, SE, BALDWIN Plan revision required? ❑ Yes [E No Use other side for additional information. a/ f? u . 'lO SBD-6710 (R 05/91) Date v Inspector's Signature Cert . No. Y ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: S c'y~ j. SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code S4- _C Q STATE SANITARY PERMIT# -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% X 11 inches in size. Check if r vtsion o pr wus a hcation -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER c~. PROPERTY LOCATION Foil Ct ast I C 3 % S ~ TO N, R f E (o W PROPERTY O WNEJi'S MAILING ADDRESS LOT # BLOCK # C TATE (OJT/I7 y ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 9,Y41dolm 1,Jf . 6D D CITY NEAREST ROA II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE:' ` f- ❑Public N1 or 2 Fam. Dwelling-#~of bedrooms ~ PIN TOWN OF: ARCEL TAX NUMBER() r ` 111. BUILDING USE: (If building type is public, check all that apply) let d v V (J f G6 1 ❑ Apt/Condo v P (7 V" 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. 2 Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ~9 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 120 Seepage Trench 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 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./cinch) +-s ELEVATION -1/5 7 / Feet ~a56 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank k ' vU e C' F-I Lift Pump Tank/Si hon 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): Plu be Signature: (No S )amps) MP/ RSW Business Phone Number: 303 Plumber's Address (Street Ci , State, Zip Code)- 7u h ^ CPO 7 pi~J .f v' S S' IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved SaaMary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si na re (No Stamps) r Approved El Owner Given Initial Surcharge Fee) Adverse Determination 08 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS y 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 & 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) DEPARTMENT-OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W 53707 HR 83.09(1) & Chapter 145) LOCATION: SECTION: rjICIPALITY: LOT NO.:BLK. NO.: SUBDIVISI 3"~ 0V/ S0/ IUa N/R&E (or a ---101 COUNTY: % MAI~ G ADDRESS: ` F4 115 Sq.46l J l e USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRO S: TESTS: Residence ❑ New Replace g RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: REC MMENDE SYSTEM: (optional) 1 ❑S ~U ❑U ❑S ®U ❑S ©U ❑S ®U o~n b,f,t'~iefr Sah~) under^ e re o e If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: Ff PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHW,, ELEVATION OBSERVED ST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- DO,p oo- 'Vs i q-n Dark 9h S1 i l?'= .0 n B- sc1 3o- 8 G 0_- -h 130 B-a 1 -aS 1i j q7 Non~ 05 d (s ~ 6~ s~ 1 y~ 6~ C m xe~ B- 10 l~o~S aJ B- y, Iol1, I~Lo 5 It 6ls 11~ B- c/3o'= " C to us1 d 6q kv ~s I PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P PER INCH P_ / o S") S P__ P- P- P- 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. SYSTEM ELEVATION 3 ~ Iy! 0 1e d I I I I i i i 112 11 N a ~3 3 I E , 1 ( ~ x t I I INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use soction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols I st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well Is - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand < - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silly. Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures SM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations a2 May 31, 1994 2226 Rose Street La Crosse WI 10 WANG EXCAVATING THOMAS WANG W9672 770 AVE RIVER FALLS WI 54022 { A, r RE: PLAN S94-40382 FEE RECEIVED: 180.00 JUSTICH, KEN & PAULA SW,SE,18,29,16W TOWN OF BALDWIN COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, Gerard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 4028R/ 1 SBD-64231 R. 01/91) SWS>~~7~aq~1nIj f 8 2 w = well D ~a~l~O Ian~S ~ ~S ),voo r cL I i boo 0 Q i ~a 41 ~ 1'0 . A . h1, U0. F d e q0~ ~ S f. _ 5 F 82 Page . Of Perforated Pipe Detail 0 End View Perforated End Cap PVC Pipe • d,•~ Holes Located On Bottom. S Are Equally Spaced A f Q PVC Force Main Q Distribution Pipe Lost Hole Should Be Neat To End Cap Distribution Pipe Layout P Ft. R.0 S X Inches Y 3_ Inches Signed: h~% Hole Diameter Inch _j,&42k. Lateral Inch(es) License Number: ; C Manifold " Inches Date: Force Main " vZ Inches # of holes/pi pe_U Invert Elevation of Laterals/.0475 Ft. . _ . • d r~ Page Of - - Straw, Marsh Hay, Or Synthetic Covering Distribution Pipe Medium Sand G Topsoil F -.J E D 3 % Slope Bed Of Force Main Plowed Aggregate Layer D 1,5 Ft. Cross Section Of A Mound System Using E 1,6 Ft. A Bed For The Absorption Area F .15 Ft. G I Ft. A ~ Ft. H I,S Ft. Signed: V9~L B = Ft. License Number: K 10 Ft. Date: e~-J~'~'_'~. L &-7 Ft. L_ Ft. T Ft. of% U.4 W_ Ft. L Observation Pipe g K .2 00 'W 4 acp'~ A I I I•---- I Force Main W ° - Distribution Bed Of 2r- 2 %2 Pipe Aggregate I Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area C-Al ep ' G:E of PUMP CHAMBER CROSS SECTIOW AND SPECIFICATIONS a ` , sctiea4ovcuT CAP . APPROVED LOCKIN WEATHER PROOF MANHOLE COVER W 25' FROM DOOR, I.v4rryrfl n~tbtl/ WINDOW OR FRESH IZwMiV' I AIR INTAKE I GRADE i y"lgl~i I 19" MIIJ. COWDUIT-- 16"MIN. 1 ~11 INLET P OVIDE I - AIR IGHT SEAL I III ~ I III APPROVED JOINT A I I I APPROVED JOINTS W/C.I. PIPE W/C.I. PIPE EXTENDiNti 3' ALARM ExTEWDING 3' O1JT0 SOLID SOIL I 11 ONTO SOLID SOIL I I I ow 6a~/~nc~I c I 'I LLEV. FT. PuMp--- OFF r D GO RTE BLOCK RISER EXIT PERMITTED LIS IF TAWK MANUFACTURER HAS SUCH APPROVAL F. pp Q SEPTIC E SPEC,IFICATIOWS DOSE W1 )t°S~f l~l~l NUMBER OF DOSES: J PER DAy TANKS MAUUFACTUR6R' 16 Ip Gal TAIJK 51ZE : 5U GALLONS DOSE VOLUME / ALARM MANUFACTURER: 14,m k .4 6 INCLUDING 5ACKFLOW: GALLONS MODEL NUMBER: ',4' CAPACITIES: A= I °XNCHE5OR GALLONS SWITCH TYPE: Awn Iy Z 5= INCHES OR 3 ~ GALLOAIS PUMP MANUFACTURER: O C= -CINCHES OR GALLONS MODEL NUMBER: D- INCHES OR~~ bi GALLONS SWITCH TYPE' / e MOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE GPM VERTICAL DIFFERENCE DETWEEN PUMP OFF ANO DISTRIBUTION PIPE.. ' a FEET + MINIMUM NETWORK SUPPLY PPKE65UKE 2 5 FEET ♦ J- n ,TEET OF FORCE MAIN X oCLZL'Yoo FT-.FRICTION FACTOR..FEET TOTAL DYNAMIC HEAD = FEET /I INTERNAL DIMENSIONS OF TAWK: LENGTH ;WIDTH ;LIQUID DEPTH J DAT E: ` SIGNED: LICENSE NUMBER: 3031 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St Croix County ow►NEIVBUYER a S It' C I Cn MAILING ADDRESS b d / OA PROPERTY ADDRESS 6 ~~10 ~ 1`n v (locat n of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 5- 6J 1/4, 1-4-7 1/4, Section l , T 6 ~ N-R W TOWN OF C/Q L~j ! ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE , LOT NUMBER r 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 dis system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacemen"f 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 ex iration date. SIGNED: 11 DATE: *19 C~ St. Croix County Zoning Office GoYernment 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. Owner of property 1 _,El/4, Section T d5N-R~W Location of pro rty 1/4f o~~b ~Q Township (rh j rl Mailingaddress Address of site ~r6 a P-0 Subdivision name - Lot no. Other homes on property? II,, >Yes No Previous owner of property KGB lc) l e o6 S S Total size of property v Total size of parcel Date parcel was created 9 Are all corners and lot lines identifiable? P(' Yes No Is this property being developed for (spec house) ? Yes X No Volume l0~ h 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 i /t e.o~fice 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 f 3 of the County Register of Deeds as Document No. Signatu a of Applicant Co-Applicant Dat of s nature natP nf ginnar"rP DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCOtisi`C FORA 2-1982 • s~_~ ~ VO 1076wa _ 44 -r-- Harold M. DeVos and Charlotte J- DeVos, Y`Cr=~J(~i~~,A - Redd brFawnd his wife.•--as---point tenants _ - _ - MAY 2 1994 - _ - - 4:15 - P. conveys and warrants to ..--Kenneth -F._-Justich ar_d Paula ~C C,---Ius and .wife . RETUR+ To.. _ - - - 7 Z . ' - - . . RI`s r~1Lj ,NISCaiSi, a-' St: Croix the following described real estate in County, State of Wisconsin: Tax Parcel No_ East 400 feet of West 1120 feet of South 947 feet of Southwest Quarter of Southeast Quarter (SWrj of SE4) of Section Eighteen (18), Township Twenty-nine (29) North, Range Sixteen (16) West. j f j J FEB ii This lS homestead property. (is) IdxxXX Ii Except.on to warranties: Easements and restrictions of record, and to the ilterms and conditions of that certain Well and Lease Agreement recorded Il in volume 513, page Q2, Document No. 322683 day of I9-94 it Dated this oZ C - I I II --------(SEAL) (SEAL) II Harold M. DeVos li (SEAL) - . . (SEAL) Charlotte DeVos i AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN II ple C-----County. da II authenticated this day of_____________________ 19 Personall y c e before me this _ Y of 19.99__ the above named _i~xQid Iii .DeYo ._an. Char °t---e-------- i ,---D?e -o-s----------•----•-•-•---------•-----•--------•-•-••-------- TITLE: MEMBER STATE BAR OF WISCONSIN i (If not, authorized by $ 706.06, Wis. Stats.) to me known to be the person -9 who executed the foregoing instrument and acknowledge/. PUBLIC ` THIS INSTRUMENT WAS DRAFTED BY ~Inda SIn9el Thomas A.. McCormack Wsco "jn - - -