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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS_&~
SUBDIVISION / CSM#jLh4p (~➢~7 3 LOT S
/J
SECTION T _N_R /g W, Town of
,~h,~,, rn
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3SS
~ /00
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: T,~ i~ Le-e- L~f
ALTERNATE BM•,v_Tfl/
SEPTIC TANK I/ PUMP CHAMBER / HOLDING TANK INFORMATION
-
Manufacturer: Liquid Capacity: 420
Setback from: Well House ,=,-22S-- Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 1c~ Length Z-y Number of trenches
Distance & Direction to nearest prop. line: ,166
Setback from: well:- House Other
ELEVATIONS
ST outlet: 97,21
Building Sewer ST Inlet: 97-Q
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system 2S ,q
Existing Gradek Final grade c
DATE OF INSTALLATION:
PLUMBER ON JOB: Gv -Z/
LICENSE NUMBER:
INSPECTOR'
3/93:jt
,Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ,
Labor and Human Relations
INSPECTION REPORT ST. CROIK
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284180
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
MAREK, DARIN RICHMOND
CST BM Elev.: Insp. BM Elev.: BM D I~Icription- Parcel Tax No.:
1,11d, ei~i 4C 0_
TANK INFORMATION ELEVATION DATA / ay
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S C~nc- I uj 04 Benchmark f~73' ec '
Dosing
`
Aeratio Bldg. Sewer 97-261
olding St/I-Ji Inlet 7 3// 97 Y-2
TANK SETBACK INFORMATION St/ V Outlet 7• S2/ 97x11
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic yS0 NA Dt Bottom
Dosing NA Header.- (P
Aeration NA Dist. Pipe '
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Ma urer Demand 0- 7- 93 ,
Model Number M
TDH Lift Lrlction SY TDH
ead
Force n Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length / No. Of TJenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 7 DIM
SYSTEM TO P / L BLDG WELL LAKE / STREAM G acturer:
SETBACK
INFORMATION Type O K d , CH R -
INFORMATION e
System: q0 --ORUNIT
DISTRIBUTION SYSTEM
Header / UaeKi5 - 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-G Systems Only
Depth Over L ~~(r Depth Over C ~N xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges T Top E] s Yes 11 No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND.16.30.18W, SW, SW, LOT 5, C UNTY OAD G
r )
Plan revision required? ❑ Yes 2-9-0"
- No q
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signatu Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
I
i
SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuilBuildinWater System!
ng 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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used b other government agency ou
y y by 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
Prope,qy Owner Nam Property Location
1/4 1/4,S T~ , N, R iE`(or~
Pro erty O er's ailing Add s Lot Number Block Numbe
City, tate Zip Cod Phone Number Subdivision Name or CSM Number
/I/ W.0c
. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road
❑ Vll age
Public 1 or 2 Family Dwelling - No. of bedrooms
2 /510
Town OF
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo n:~2el
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. Eg 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./ nch) Elevation
Feet Feet
VII. TANK Ca
in gal Ions Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
❑
Septic Tank or Holding Tank - 13 El . ❑ 1:1
Lift Pump Tank /Siphon Chamber El ❑ ❑ ❑ ❑ ❑
1
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for ins ;Ilationo e onsite sewage system shown on the attached plans.
Plum r' ame• Pr ) Plumber' Si at N to ps) MP/MPRSW No.: Business Phone Number:,
Plumber'sA dres Stream, y, St te, Code):
~~ll S
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Sta
XApproved ps)
❑ Owner Given Initial. n~ Surcharge fee)
Adverse Determination Id
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: UV C/
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
T
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-
11. 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.
Vl. Absorption system information. Provide all information requested for numbers 1 through 7-
V11. Tank information. Fill in the capacity of every new/or existing tank, list the tota! 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.
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LMM ano nwmn tw aUonS - ' - - • • • • r • • r • V rs . V rl L f V n 1 rap -i w 1
oiarilion of sawy a gwKngs in accord with ILHR 83.05. WIS. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 1 ! inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL. I.D. •
dimensioned, nth arrow, and location wW distance to nearest road. pending
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE.
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT NW 1/4 NW 1/4,S 27 T 30 ,N.R 18 A (0) W
PROPERTY OWNERS MAII iNG ADDRESS LOT # BLOCK # SUED. NAME OR CSM t
1369 120 th. St. 3 na cm pending
CITY, STATE ZIP CODE PHONE NUMBER f Y iLLA66 OWN NEAREST ROAD
New Richmond, WI. 54017 (71$ 246-5429 Richmond 120th. St.
New CmtMicoon use (xj RaMeM ► Number d bedrooms 3 (1 AdCUort ID existing btilLlLtig
i t R~haner►t i J Public orcommercbi describe
Code dqfived daffy flow 450 gpd Recommended design be ft rate • 7 bed, gpd11t2 ' 8 ten* gpdRt2
Absorption area tegi*o 643 bed. ft 2 563 tench, 112 M wftum design ba ft rata • 7 bed, go* . 8 MO. WW
Re=Mw4ed Wiftatlon surface elevation(s) 98.10 R (U refetW b site plan benchmark)
Additional design / sloe adons trenches 0 99-201--97.60,--97.10,--95.8G, if used
Parent malarial stream terrace Flood pkva elevation, I ap na Q
SYSM IN O FILL 13
C~1 ❑ U PRESSURE U SrS u D
u- Upsuitim t m CONVENTIOW
3 IM uK
at uu 3a S 13 u
7 s -
SOIL DESCRIPTION REPORT
Boring 8 Horizon Depth Dominant Color MottlL3is Texture Structure C;onsislorwe Sou daly Roots QPO
in. Munsell CIu. Sz. Cent Color Gr. Sz. Sh. g~ Lertdt
1 0-9 1 r4 3 n
1
2 910yr4/4 none sicl lfsbk mfr 9w if .2 .3
3 23-40 7.5yr4/4 none sl Imsbk mfr gw na .4 .5
1024 iL 4 0-90 7.5yr4/6 none Co s Osg ml na na .7 .8
uniting #
Tam i
*901,
Remarks:
Boring 8
1 -9 10yr3/3 none 1 2msbk mfr' if .5 +.6
2 2 9-I8 10yr4/4. none sicl 2msbk mfr gw if .5 1.6
3 18-36 7.5yr4/4 none sl 2mgr mvfr 9w na .5 j.6
{aal~eeo~~,,txld
102v 4 36-55 7.5yr4/6 none is Osg mvfr 9w na .7 .8
5 55-86 7.5yr4/6 none co s Osg ml na na .7 .8
Do ID
~alaDr
+8611 Lr
Remarks:
FNamr-Ano Print Gary L. Steel PI0^M 715-246-6200
1 200 e, Ric 12-15-95
PRO WYMNER Richard W. Hopkins. SOIL DESCRIPTION REPORT 3
PAWEL L0 ! vending
Boring # Horizon Depth Dominant Cofor Mothes Texture Structure
QPD/ft
in. Munself QL Sz CM t. Color Or. Sz. S'h. ca mhos y Roots g~ I ftt2
3, 1 0-9 10yr3/3 none 1 2msbk mfr gw
2 9-22_ 1 10yr4/4 none sicl ifsbk mfr gw if 1.2 .3
hound 22-36 7.5yr4/4 none si lmsbk mfr clw na ,4 ,5
100.6 k 4 36-86 7.5yr4/6 none cos O r-9 ml na na .7 .8
tadar
+86"
Remarks:
Boring #
1 0-8 10yr4/3 none
1 2msbk mfr 9v if .5 .6
4. 2 8-15 10yr4/4 none sicl lfsbk mfr gw if .2 :3
3 15-24 7.5yr4/4 none al 2mgr mvfr
ttoutd gw na .5 .6
1 .1
elev. 4 24-84 7.5yr4/6 none co s Osg ml na na .7 s :8
99.7 ft
b
filing
+84"
Remarks:
Boring #
2msbk mfr gw 2f 1.5 1.6
F3,16-226: 10yr3/3 none 1 }
5 10yr4/4 none sicl lfsbk mfr gw if ,2 =,3
7,5yr4/4 none sl 2msbk mfr 9w na .5 ;.6
Gound
dw. 4 26-80 7.5ry4/6 none Co S Osg mi na na .7
98.8 ft .8
Depth b
&dM
Uft
+Rn„
i
Remarks:
Boring #
G mund
elev.
R.
DePfh b
taclor
Remarks:
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT age _ of
L bor and Human Relations ,O
Division oftGafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
GoU _ J
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ~
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or P R I.D. #
dimensioned, north arrow, and location and distance to nearest road. It]
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION WED AT
ST CPOX
PROPERTY OWNER: PROPERTY LOCATION'
Neon%
GOVT. LOT 1/4 Lc f1/4,
PROPERTY OWNER" . MAILING ADDRESS LOT # BLOCK # SUBD~. NAMES
1 3_'
I ST+T,~ ZIP CODE PHONE NUMBER []CITY VILLAGE 0 N REST ROAD
[New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ~aQ gpd Recommended design loading rate =gibed, gpd/ft2 • $ trench, gpd/ft2
Absorption area required bed, ft2 Ztrench, ft2 Maximum design loading rate _bed, gpd/ft2=trench, gpd/ft2
Recommended infiltration surface elevation(s) 49 It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable _ ft
S = Suitable for system CO VENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem S ❑ U S ❑ U f~'S ❑ U S El U ❑ S I&U [I S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundery Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
~.v O b C4ti~ r
Ground 6 0 3 AA2
ft.
Depth to
limiting
factor
~YG
Remarks:
Boring #
111 M'51_-10111111
Ground
e~leyv
/et Ff
Depth to
limiting
factor
~~tv
Remarks:
CST Name:-Please Print i^o Phone:
Address:
Signature: Date: ,r CST Number:
row. .S ~
PROPERTY OWNER ~ - SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # '
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bounclary Bed Trench
Ground
ielleev'..
7 ft.
Depth to
limiting
factor
3 Remarks:
Boring #
Ground
elev.
/A
Depth to
limiting
factor
Remarks:
Boring #
-11 X41-11
Ground
I v.
ft.
Depth to
limiting
factor
~T-
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
S13D-8330(R.05/92)
.
Soil Te t Plot Plan
Project Name Byro ird Jr.
A
Address t;f~,
C #3479
Lot Subdivision Date ~S-
1 /46/ 1 /4S,~tT N/RZ% W Township
Boring Well PL Property Line Count o
BM or VRP Assume Elevation 100 ft.2~~
System Elevation j / * H R P~
v e
y°
Scale 1/4" = 10 Ft. When Dimensions aren't stated /`~L '
02 ~
C\1
FILED
11 DEC 5 1995 ► 5
KATHLEEN H. WALSH
Register of Deeds
SL Croix Co., M tS
53'7130
co
CERTIFIED SURVEY MAP
Located in part of the sWi of :the,sWi.of section.16, T30N, R18W, Town of
Richmond, st. Croix county, Wisconsin, being lot 2 of certified survey
map volume moo" Page 2784.
i
I
L_E_G_E_N_D_
North line of the SWI4 of the SWI4
Aluminum County Section
Monument Found S89°59'00"W
• 1" x 24" Iron Pipe Set, Weighing 1.68 lbs 122.95'
Per linear foot
0 1" x 24" Iron Pipe Found, Weighing 1.68
lbs Per linear foot / ~h.
100' Roadway Setback Line
X SIB Corner position established from uwE
ties, see County Surveyor for ties.
C ;
e °s~ r
"N
LOT 3
N v^O fit ,i
o vi io 5.47- Acres
43 Ln en
v coy o~. 238,281 SQ.FT.
d Co U.x~N
L N3N N / / ~ r'1
/
4- .0
L. 0
4- 4.) 001
S89°3312211W 541.06' Z
a / 270.53' 270.53' Ln J
N~ LOT 4 LOT 5 M
nn r N
c4 o QI
WI
4.20 Acres Co 4.22 Acres N F-1
N Inc. R/W Inc. R/W - - ¢1
L-OT I N -°o 183,106 SQ.FT. 183,749 SQ.FTm 8
ZI
r% 00 C> tA co Ln 4--
Ln r- %0%0 0
tD `0 4.04 Acres o 4.04 Acres m
Exc. R/W` Exc. R/W
`J~J`. 10 i'~•
- 175,820 SQ.FT. m 1757820 SQ.FT. y
184
I COD
o
.O. ........................M. z IJ „J 'I5
1
SW Corner co o Slq Corner
Section 16 N89°33'22"E 541.06' Section 16
270.53' 270.53
270.541 3TY
089°56' 40"E 541.091
- rMn ` ° ~r:*ttr
/ n u
South line of the SW>4 C , T H G;.s;:; en °56'40"E
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER a f-
MAILING ADDRESS ooj C) rro~to~ / S~ p / -r
PROPERTY ADDRESS ✓ 'c _
(location cf septic system) Please obtain from the Planning Dept.
CITY/STATE i J R; C \ ey-\ nA c ce j
PROPERTY LOCATION 4N LJpp1/4, S (.J 1/4, Section Jam, T N-R_W ;
"TOWN OF ~ C -\r\ ~ 0,1\ _rl ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP A-3-713o , VOLUW PAGE 3 , LOT NUMBER
Check +ti"S in fo a9a ns+ h;gk1 9~~S
Improper use and maintenance of your septic system could result in its premature failure to handle o survey
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed <M a P
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treaunent 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 I, 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 c' ration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1 101 Carmichael Road
Hudson, WI 54016 11/93
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 ~ ~ v\ /*'-Aase k
Location of property e _1/4 SLj 1/4, Section l6 Qr,T_,3_0N-R_JZ_W
Township PN 'C kYy\o yA Mailing address J\2 I Q,0+ % to V
Address of site Cw,,+y
Subdivision name _ Lot no.
Other homes on property? Yes 1/ No
Previous owner of property v~ \ a S.
Total size of property X70.5$' X bSU' LI,o`i C,,Crt S
Total size of parcel ~ 0 5S` Y S'o" L.c ~4 0, crr s
Date parcel was created q C
Are all corners and lot lines identifiable? L,-'Yes No
Is this property being developed for (spec house) ? _Yes 1,-' No
Volume and Page Number 0 2 3 as recorded with the Register
of Deeds, ~I
INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCI►MI NT NUMBL•'IZ, 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 dead 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) ain (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 syf;tein 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
tilt: office of the County Register of Deeds a:. (document No.
signature of Ap licant Co-Applicant.
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D:+te of Signature Date of Signature
' WARRANTY DEED
550616
w 19-RPAuV7
Document Number
ST. Co., W1.
F.': !.r p4=1
Return Address Century 21 Premier Group 'OCT 9 1996
P.O. Box 286 at 10:00 A.M
New Richmond, WI 54017 .r-;.. .E
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Parcel I.D. Number: 026-1048-30-104
Glenn A. Basel and Karen M. Basil, husband and wife, as teoaats in eernmoa, conveys and warrants to
Darin IL Marek, `.a single person, the following described teal estate in St. Croix County, State of
Wisconvin:
Part of SW 1 /4 of S W 1 /4 of Section 16.30-18 described as follows: Lot 5 of Certified Survey Map filed
December 5, 1995, in Vol. "11", Page 3023, as Doc. No. 537130.
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of--way of record, if any.
Dated this 8th day of October, 1996.
SEAL) - (SEAL)
Glenn A. Basel h'1' 13a~c1
ACKNOWLEDGM " TRA %FER
STATE OF WISCONSIN
) ss
St. Croix COUNTY )
Personally came before me this 8th day of October 1996, the above named Glenn A.
Basel and Karen M. Basel, husband and wife, as tenants In eommws6 1b me known to be the person(s)
who exec ted the foregoing instrument and acknowledge the same.
i cl
* Ga •'c illar eon
Notary Pu St. Croix County, WI
My commission expires 9-18-98 8W1IL 90-- Y
Iidt~Y
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristin Ogland
Hudson, WI 54016
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