Loading...
HomeMy WebLinkAbout020-1117-40-000 o a) oo o- p ea a Q~ e h o ' 0 N i O O L X ~ N O O U c I N `v i Co 'q O ~ I N U 0 CL Z C 3 m I LL c m O O) 0 Q I 3 v 8 Z w °o -It z d d w a co rn z o c z o z U W 2 z fn F- o z I c 'o O M O CL 0 0 U C a~ o Q I O c z H Z Q 0 N Q C N *It o) 16 i R > ( N !.~~y o a m Y o G o a 0 z N H H H m w 0 0 0 0) z o IL 0- CL tv a I = I m 0 o c rn (o (D rn } !n U -cli, rn a~ Y o m 0 0 E N CO a- O V N O N N m w 00 tn CO 7 'O O O n C O Cd O c O U O O O O O rO 'Od' 30 N N CL Q n- O O N r 04 n E E N c0 ' N n - L L f- - N O :3 0) z N E E U O 6j 3 U) • L' O = Y N O N '5 O ~ II (U m l d a #t EL L a w CL y U d ) C rw J 3 r A 0 a 2 o v~ 00 STC - 104 AS BUILT SANITARY SYSTEM R131 N OWNER 00 r'!~N- -J~M-P-s Cr~0ir. ,w R,a ~ 'GE ADDRESS Zotyl \ SUBDIVISION / CSM# LOT I)~ # SECTION T N-R_rq__W, Town of ~dn ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM PA INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: too + -lo Dr 16 &-g-, t 1 - ALTERNATE BM: lz) 3 I~ 4ez~n o:) d~ip~1 j~r'S LAD l Q SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: MiAuje,S f LC,e+ Liquid Capacity: I~~U r Setback from: Welly House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: Length 6~ Number of trenches 3 Distance & Direction to nearest prop. line: X61 Setback from: well:_ House / Other ELEVATIONS Building Sewer jCq. &0 ST Inlet, 10 "T ST outlet O PC inlet PC bottom Pump Off 0 Header/Manifold Bottom of system -7 Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt '0'Wiswn-sin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations ST. CROIX -Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: i Permit Holder's Name: ❑ City ❑ Village Town of: State PI KRUEGER, JP.MES CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI ~F ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Hold in St/0(Inlet ~0• /v~Q~ TAK SETBACK INFORMATION St Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic )5() 7 NA Dt Bottom Dosing NA Headers Aeration A Dist. Pipe Holding Bot. System '7~ PUMP/ SIPHON INFORMATION Final Grade °r 4 t,~., <.f fry Man acturer Demand ie Model Number GPM X TDH Lift Fr' 'on System TDH Ft Head Forcemain ength Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length r No. Of Trenches PIT No. Of Pits Inside D Liquid Depth DIMENSIONS 5 DIMENStONS- SYSTEM TO P/ L BLDG WELL LAKE /STREAM LPAM -Manufacturer: SETBACK BER INFORMATION Type O A Moe Number: System: Ccn1 LV c OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) ~ i 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-Grad stems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)-)AS LOCATION : HUDSON-19.29.19W, NE, NE, LOT 16, TROUT BROOK ROAD Plai'revision required? ❑ Yes ❑ No Use other side for additional information. I/E SBD-6710 (R 05/91) Date Inspector's Signa ure Cert No. ADDITIONAL COMMENTS AND SKETCH - SANITARY PERMIT NUMBER: r 11:i and SANITARY PERMIT APPLICATION Safety of Buill ng Water S n 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 than 8 112 x 11 inches in size. . ('Y>i • See reverse side for instructions for completing this application State Sanitary Permit Number 19 The information you provide may be used b other government agency programs y y by ❑ Check if revision t previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Propert Owner Name Propert Location 1/4 1/4, S )I T , N, R E (or) W Property Owner's Ma Addr ss Lot Number Block Number C~ Iv 1 U City, State Zip Code Phone Number Subdiyision Name r CSM Number ( /S)7 irv I1a,o I~t~1 Oct) dl)II (U Ill, I I II.. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road ❑ Village LL n ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ~TI~ Q~ VL4 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo ~O ^ 1 117 ` ya 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 / Mote] 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. M 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 NJ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: j4j tv- j q'7 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 00 q7#0 Feet ci„ Feet VIL TANK Capacity gallons Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic . App- New Existin strutted Tanks Tanks Septic Tank or Holding Tank I9w j oo I W r ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber17 Q 1 I t t t IX 1 ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY S ATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu ber's Signature: (No St mps) P/ RSW No.: Business Phone Number: Plumber's Address (Street, Cit. , State, Zp Code): Le / S~ S~ IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved San ary permit Fee (Includes Groundwater ate Issued uit Sign (No tamps Approved ❑ Owner Given Initial Surcharge Fee ) 3/// Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Divi 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 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,, rc.(:onnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all informatior requested for numbers 1 througf- VII. Tank information. Fill in the capacity of every new/or existing tank, list the tota' gallons, IIUMI); r of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Conplete fo- ail ?::,tic, puiTrp/siphon and holding tanks for this system. Check experimental approval only if tanks received experirr,ent .iroduct approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with approj.ria' :refix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only X. County / Department Use Only. n).,,2tE II(atlOnSnOi_Sni0 R 1/.; X 11 1nchE"; nty. leplc~nSmUSt fc., A) Eliot p'an, draw'; -,;;e or with comp;:. L )enslo JC' ding tank(s), septic .Vel ; w ..ter r: r se~. iake pump or siphon ;I , h<.prpt..; ; eK?1-: ert erg he bi:i ding served, or, i:r~fc ( Cif' r Onti :~ls dtiSe VOUr?^c'; ee....,or.;,iifier,'l _:l `C~:ur t' -3f.: '(r, _ Crn555PCt?rJn of thc,oil abso ,i i ii requi J}s : ~r, soli fie}., , dZ,t 3 information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (lees) for a number of reguJa_ed pr :e which can effect groundwater. 77. he monies collected through these surcharges are used for monitoring groundwater, oritaminel.ic - investigations and establishrnent of standards. rou plo+ piprr) [LiIA Llamno-) n -7200 3 - - 9l~ FROM : ED I NA REALTY HUDSON 1996,03-11 0.3:45 #0'33 F. OS.''U5 ~a SCAL6 30' C wGLL - TOP oe cA •.xJ SeT' ra" +~i p n3 .'i0 , 33. ~'I~VhTco~ -/00.Q Yf o . for L- N ~ 3° 7G ys / . r / • 4. !Oil l! l ' ~y Y iK 3 , ~ to r I - - ~ O° Q1 Q Sa. Lor- 3 mil, y5 , i~ - fF4tfVATi'aA.%,S Iod. ~a ! ri?~cpH+~tND E~ - use 3 W. 6 `+f SO 0- "I`pot~-ud-i c - L!'AC& VE AIT CAP C.Z. VENT PIPE WEATHER PROOF APFROVED LOCKIAIG T JUkJCTIOM BOX MA►JHOLE COVLF. 25' FROM DOOR, !IUDOW OR FRESH ~Z I Q. IQ L- IR INTAKE I GRADE I 4„ 4 lea.. ( COWDUIT ` - - PROVIDE AIRTIGHT SEAL I I I q 9' ! c,-r-\,4 . v- es t: 2V yT I I I I I I APPROVED JOINT_ III W/C.I. PIPE I I ALARM EXTENO►uG 3' i ONTO SOLID SOIL 5 ~l oZ~ I I I I I ou _ I PUMP OFF BLOCK ~fyi I ~est Prnc 77soskLj y S'y f e ifYo I lo l H(--j & (►'r'rn c~ as-z5 ~1 15c, ,~is , d 6A (--oAAA- ;.a q,. 3+ 1 10AS CV4 v) fta- N~ t t--I ~ S ~ ry\4rC~r~ s.~ite~4S I le`1 • c~tilu~s +e-(A I Oche M I✓t I rn,.tlN t^# IS C~'► ~ ~ `a, ~o~~ r?"j 40 r I~ JD~s~r~x-?- he tom, P""lp i o Ff PC GPI prtM-4~ IOU Ft I fYl `ham tz'y -7 7d0 VENT CAP WEATHER PROOF APFROVED LCGCv~IA 4"C.\RR JUNCTIOAJ BOX MA~JHOLE COME r---T 2~Z~ w~ wAR WIIJI `A AIR GRADE I 41 COWDUIT Z I \ 11l PROVIDE - I AIRTIGHT SEAL I III i I II CrP►.JL. 5c- (L%o vT I III APPROVED JOINT-- III W/C.I. PIPE i ALARM C).TCNDI►J6 3' I I ONTO SOLID SOIL 1~~ I b, b I I OI,J I PUMPOFF g.jj~ BLOCK ci 4.4 r .i 4-3" Lg r F fir. ~ J~~ ~r M to ~~~~M ►~-b ~ ~ g r~d~ Sys ~...~tf .s'n P t~ RSgres~-~, ~ I~ d•.~ , _r, mss, +~awa;zur~e~kc~sawNai~eer4 r Wisconsin Deparo.,ant of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY sr c,Po/ x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (B", drection and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 11'M E U. /VI 4 NJQ GOVT. LOT /pE 1/4 NE 1/4,S 19 T 2 N,R E (or) W PROPERTY OWN R':S MAILINC~ AQQDRESS LOT # BLOCK # SUBD. NAME OR CSM # fi'Y5 7 ov 7 /0&- ~O - La"//ow ~iDGE ~~D~rio.~ CtTy, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD 1fUpSo"--1 60/S. ,S{016- (7/5')300/ /;706 f+upso~ 17;eOU7- ,61f`00E-IV I q"New Construction Use (residential / Number of bedrooms y [ ] Addition to existing building l 1 Replacement Public or oommercial describe Code derived daily flow CO~o . 5 G 9Pd Recommended design bad'ng rate _bed, 9Pdq2 o trench, 9PW Absorption area required bed, ft2 trench, it2 Maximum design loading rate bed, gpd/tt2 ' o trench, gpdrd2 Recommerded infiltration surface elevation(s) 54-Q- 3 It (as referred to site plan benchmark) Adifitional design / site oonsiderations W SiF T aQ E N S - A t s o S.~ 'pe-s f} I~oT£S la Parent material ~'S 37 E ~tH~Rr 15 - ?f 7l-t-v ouTwt6tf- Flood pain elevation, ifappli able Nom- R S = Suitable br system CONVENTIONAL MOWo "Paw PRESSURE AT-GRADE SYsTEM IN FILL HOLDING TANK U - Unsuitable br stem BS U LrTS o u Cl O u B~T U o u ❑ S Bti- SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxby Roots GPD in. Munsell Ou. Sz. Cone Color Gr. Sz. Sh. Bed ranch p 0--& /o yR 31.i-- oe 6,^,3 c I s l . rm ,sbK em R- C S • /}G Co-13 7, s yR y16P I S 0,n-A , 4 nM-a- C S 2f 7 '00 Ground 13'3 -S Yk M S d, S d~Z e s - r? 8 elev. /.00 o fL C ~ 4j o /0 yP- 5/Co S O.C , s e2 ~ . 7 ,00 Depth to limiting laClOr Remarks: Boring # D o ,6 /0 YA 3/i 046- -1A3 (C 1-5 Am , S6& S 3~. AC -7,syr? y14 s d, /VNk CS z*f .8 r 7-18 -7. S VP y114 s a, f, s d C S '991 Ground elev. /o/- 75 It Depth b limiting factor Remarks: TName:-Please Print O (3 IZ7- Z / L _M G h T+ / s 3 006 ress: C~ S 5 0 1 A-) t: t' L l2 D . HUDSON i` S~/ Y~v.,_ ` :/ZS } CsT~-! 2 y8~.. r ~ i r PROPEMOW HER SOIL DESCRIPTION REPORT Page?- 013 PARCEL I.D. A-tz Depth Dominant Color Moldes Texture Sirucbure Co enoe Boundary Roots GPD Boring f Horizon In. Munsell CkL SL Cont. Cola Gr. Sz. Sh. Bed 3 0 &)-y /OYKe -1/t 0 P-6-A,i• c , rm, s b k / M,P- s ImA 4c ~S ye y/6 . 7 •(51, Gnrv, +d Depth to bngng to ~ Remarks: Boring # V/ C AS 1.Mt, 5hc /m S g t i F~0- ~ -/0 7,5 y,e Y/4 /S o, CS 3f ~ Bonn (f 1.020 7,5 y~e Ground .S O, C, S d-e • 7 r;1 -9y /o yR 511(v elev. Po ioo . 7 I Depth to imRng Remarks: Boring # p /0 ye 2/ I o,.°s,9 ~c /S S vfe S 3 /4C -30 16y/~ El C 30-qy /0 ye 3/3 1. -F s 0,52 at S C, Ground elev. h, 9 belorg Remarks: Boring # Ground elev. K Depth to G.."nn 3 0-f 3 ~ 5 c Apt : t 30 I- n T 13 we~L - TOe of cASIII 33 , ~lEUkr~o~ -/00-0 1~ 9r. No. LoT 0 3 ° 7G ys `Ayo0T / / / l l l d /Oil © 4 l / 0/ 0 / /p i~ll W llhl v ~ 3 g3 T,• I (o so. GpT L fL=VATI'oj-SS J / `R Irt X4 .A 4-,- ~ - ?.SSE 3 ~ 1o2'Si'd. 4 III` w lllooi 30 0 tf•, • n,dac~ 139° 44 ~o" W •\T' fly©jr.: ltaG° 30 4b 3 141'30' V d i IZ 9 01~8.3p - to o 224.54-' 254•o6' EAST r Q 3 N eq oa' 14 "w Or N o- V 44 13 1 q„ ~,5 9 J1 - ploy/ 40 -g s o 2115. 7Z' ro o1P` Y/~r ;1~ rc o ST E AroT Gl~ , hp d o . ,bb~ y QQ u Wd 3'aoy X~ 1 • 0 - o 6 6 ~ a 321.45 Soo' Q FACT 10 ap • I ~P / ~ 41 I,~ O 1 8 280' 3p N Q~ ~ ~ 8 Se°2 9 ~ z2 0/ S3 I a ~ & 9 Co e - 338. 6 4-' ' ~ N EA6T N e o J 4~ S 81 °.2` 1,. N o 3-7 E r 'Z O ` J ~ S 80 ~ ~ 22 g ~0 292 3 , 'L' 105 tiI:*PTIC'IAN K. h'lAtlvT r,NAr4i;L,~c;ttt'.t:hat:~ t St. Ctoi% County ( ) WN 1~:I2/I3l.l Y I".It MAL1.lNl; At)Uit>+:SS AI)1)121 tiS` ~ • r ~~0~~ ~f~~~ f ~ _ PROPERTY (location (i( sc{rirr. syslc~ttt) f'lr.. se OW."11 hltnl tlrt' l'I,nn Ile, I)c1)t 1'12OI'L12•t•Y 1.0C'ATION ''O\\'N _ ~'I . <'[t(_lll COUNTY, \VI 1.O'I' NUMBER J (P t_: h.I2'1'II It:USI.lItV1:Y MAP VOLL1MIF , PA(Al C/ 1,O l' Nl)h'[1.3k'.It lntprcipc?t trsr and rnainterumce of you" septic. system could re-,,ult In its picrnalutt: fxilutC to IIauldlc was;((, Plolwr mai 1cf"I' nee. Cons u;lscof pumping out the septic. tank cviny rhra:. ycals or snoflcr, it lv.cdcd by lic.enseci sr..I~tli' tarn: pumper. What you put into the systeltt can ',10C..11 tfrc (unction of tllr• s,c-pile: wi 4. w. n (rcatment sta€c in the waste disposal system. Sr ('lotx ("aunty rvsidents may be. 61gible to rceclVC. a pratot l'Of- :I M3XIntu111 Of 60°/0 (If tile: Cast of rc;ltlat;c: mcnt of a failing, systcrrl, which wars in operation prior to lolly 1, 1971+. St. rolx (.'oust), ;w:c:cptcd Oil" program In August of 1990, with the requiremenl that owners of oll new systems ;gv'fc.c to keep their yt;tent properly maintained. { 11,: I11rliP'111 (.)wncu a).?,IM to !,Lb tit to `it. (_rui"l.M1111i', a r:rrtillr.Miur, lurnr, ',y;nai lty tllr.. c,wuc'I ,ncl b c ,,,lcr plumber, jokirrtcyrtt;ln plunlltl'l', nstrirlrci p{untl,r:t "I 11cv..w.cd plnrtlrct vc ril), ll', th;rt { I ) sysu,ni it, in prolwi operatilip c.clnditlt,n ;Ind after In~licctn,n :IfId rl,e un ,,r,. wxsc wau.:f dl,ttn,url I unlltinl, (,I nears;;,ry), the septic tank P, less thin 1l3 full of r,lucll c and sc.11m. ,,,'.wt+E'.r I/W , ilia under dgucd have rr.ad the ;+lbc)vc rt:clmicrnent" mid ;,I re ti, nimnUm III,' 1MV;'10 l,',lut,,,l •;',Ir„I n ;tcCr~icl;tnci. whit the >,tluid rick sct forth, Itcrokin -,ct I,y the \i" ojv111 1tC~I~ ('eftlfi, ,It~I,It ~,t;rtullt, float yuui sc•.ptic Ilan 1,c•r.n nlau~t.alned ntu5t he cn,tll~lrlrci ;Intl teturn~.:~.t ttr lhr `>t t lulu ( r,cml Lc„cult'. ( )llic:c:r within 4(I clay, ,.,f III(-. tlltcc: yeat r. piratlun cl,itr. 1 I t l l r .t'. 11, 1. I,,t,.'1 I', i L„4 I t t) r ll,,,i•,.~~ ~ I 1f,lrZB ' d Sb : 8 Z 96~ ~Z Ntir 8 T C - 100 'rl-ji.s application 1`orm is to be completed in full and signed by the owner(s) of the property being developed. Any i.nadequacies will only result in delays of the permit issuance. Should this (spec development be intended for resale by owner/contractor, house) , then a _5cicond form -liould be retained and completed when the property is sold and :submitted to this of-tic:e with the °i'11•,r,• ; ~~P decd recordinq- Owner of property ~ci wutc - Location of property /4 IV 1/4, Section,14,A N-R C9-(1 W 111` ~ g Township _ t~v ~S n Mailing address S-7-3 Address of site ` Subdivision name l (cam, z~--~ _ _ Lot no. Other homes on property? __'Yes No Previous owner of property ~G~- - Total size of property 15-0' 1.300 1, 0 0~~ - - Total size of parcel 1S0 kl, - - - Date parcel was created aL No Are all corners and lot lines identifiable? -Yew Is this property being developed for (spec house)? __-KYes No Volume 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 or. THY, REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid if the dead do ncript i on delayer of the reviewing process. references to a certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION T (we) certify that all statements on this form ,irc true to this best of my (our) knowledge that I (we) am (are) the owner(s) (A the property describi=d in this inform;-ition form, by vii-tue of a warranty deed roc-orded in the office of the.'. Coui,t.y Roq i st (-r of Dodds a; Document No. X371 _I and that 1 (we) F)resently own the propose-!d cite:. Vor the sewaye~ di!;po:;,i l sy,;tem (it- l (w(t) obtalnE d an easement, to ruin the <thove (lescr ibed Fir~af~c'rty, fol the con :tract-ion of said :.yFstem, rated the ,;iiinc h1s. boon Diu1y 1-oc-01-ded in the off ice of t.hc+ County Rey i ster of decd:: 11 .7 No. S naturc c Appl i cunt Cis-Ap1.)1 ~ c..,i1)t. Date or S,,igriatui-e i),-ate of Sidn,.-tturc, EB'd 9b:8Z 96, 22 "ef State Bar of w a:-; in Form 2 - 1982 537780' WARR.ILNTV DEED - - - i DOCUMENT NO. - James D. Neumann A U EC 61 935 - - - - - - - - f.t 10:00 A. ra ' conveys and variants to _ P1~il R. Nel or _=C-Iem s i~:-_-- Knle er~dLbla Ne1so11Kruege r rtnersh _ - - - - j% PE iE 4vED FOR RECORDING DATA - - NAME AND NE TURN ACOPrS- IV ~ St. Croix the followi-ig described real estate In 'ounty, State c' Wisconsin: (Parcel Identific-uion Number) i! Lot 161 Willow Ridge Addition in Town of Hudson, St. Croix County, Wisconsin. l IRAN FER ii r ~I This is not homestead Propertf- (is not) Exception to warranties: Easements, restrictions and rig} is-of-way of record, if any. r II ' December 19 Dated this day of.--- w. FR' JA (SEAL) -+Z'- ~i ames D.~Neu iann ` ( NOTARY V; (SEAL) PI1&&t(6E _ i- rte' • O~c~,~ +s, % AUTHENTICATION ACKNOWLEDGMENT ` lN~tst+t Nc,TON STATE OF WISIF&45 , Signature(s) ss. County. ( -3 ~ day of authenticated this day of Personally came before me this Cecetti er 19_ ?5 the above named -James D. Neumann TITLE: MEMBER STATE BAR OF WISCONSIN (If not, - authorized by §706.06, Wis. Stats.) to me known to be the person - who executed the foregoing instrument and acknowledge the same. ~I THIS INSTRUMENT WAS DRAFTED BY