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HomeMy WebLinkAbout026-1068-80-100 z ^ ~ C) h O d M O ~ 3 I O ~ ~ N O N .0 O N e O) E I ~ O O N X A El Y 4 c O N C U N U O N N E E N ZS _O _O h v (n Y U (r a 3 a N C T y N ~ ~ O 0I i C Z 3 O O 7 C6 N ~ p~ O) i N' lL C m C 0 3 0 '0 C ~ N E d U) CO OO N U Co M N W Z O O i O d m CY) N F- (n O O Z d c (n d 2 7 5 CO F- O O z Q m N Cl) Q) co .Ni a O ~iJJ O N N (v of ti U) d ~ c O c O m 4 d Z F- z N LO LO r_ Cl) N > E C N ' (4 O) 'O ry - d a 0 Q l7 U C O 00 0 N i O L O O ° t o 0 a cu c ° v Z > F- F- F- d N U E a~ 0 0 0 z 0 •N z a a a a (D N N J U 3 rn rn } MTV O N N M O O C) E N~ co m d Q w C: O 7 O E N }`O'+ O 0 O O C C 0- O CO ~V Y N 00 00 C L C N N U V O N 00 ~ N M U CO O tp IO (6 U • O N O N O z (n o w w \ w £ L L: (D ° a w 1~~.1 E i c ro rr ~1 A 0 (L 0 v) ci STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER J a a ADDRESS F 111 SUBDIVISION / CSMJ LOT ~ SECTION Town of ST. CROIX COUNTY, WISCONSIN PLAN V SHOW EVERYTHI G WITHI FEET OF rSYSTEM fkcr-*-~ ' 0 o ~ 30 ti s Al( INDIC TE NORT ARROW l Provide setback and elevation information on reverse of this form. Provide dime ; , 4 ~ -r BENCHMARK' 6a _d~ SSG!/~2c~ ~dD r ALTERNATE BM: ~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: /&42 Setback from: Well__,gj~_ House Other Pump: Manufacturer Modell - - Size Float seperation Gallons/cycle:' Alarm Location :SOIL ABSORPTION SYSTEM Width .~J Length d Number of trenches Distance & Direction to nearest prop. line: 5o, Setback from: well: House , Other ELEVATIONS Building Sewer 992 ST Inlet: 4x ST outlet PC inlet - PC bottom Pump Off Header/Manifold 95-, '2--_ Bottom of system 9-Y Existing Grade_.?,?, 19 Final grade DATE OF INSTALLATION: '9- PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitar PermitNo.: GENERAL INFORMATION 168622 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: OFTENDAHL, KARL RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /OfJ ze.Gr~ TANK INFORMATION EL ATION DATA A9600314 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark AM, 83 Op, Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet /Z' 'J / TANK SETBACK INFORMATION St/ Ht Outlet ,,,(5' q?, 3 8 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic - 9 3 NA Dt Bottom Dosing NA Header/Man. Sgi 5-~ Aeration NA Dist. Pipe 0 73; q G . , Holding Bot. System qr G u. PUMP/ SIPHON INFORMATION Final Grade S3' gS 3' Manufacturer Demand Model Number GPM TDH Lift Friction Syestem TDH Ft Loss Forcemain Length Dia. FFii Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS O DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER Model Number: INFORMATION TypeO / , r OR UNIT System: lD 7l/ 4 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 Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges - O " Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND.23.30.18W, ySW, NW, HIGHWAY 65 Plan revision required? ❑ Yes ❑ No Use other side for additional information. Q 19411 ~ ! a SBD-6710 (R 05/91) Date I p o ' ignature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e r Safety and Buildings Division v~•~~nr. 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 than 8112 x 11 inches in size. T, C T_ 0 \ • See reverse side for instructions for completing this application State Sanitary Permit Number A& gbaa 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 Prope y Owner ame ropert L cation a Y" SW 1/4 1 1/4, S Q-3 T.30 , N, R f~ for) W Property Owner's Mailing Address Lot Number Block Number 5 3 Ct , tate Zip Code Phone Number Subdivision Name or CSM Number Y»aAd to a ! ( a------- II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Village Public 1 or 2 Family Dwelling - No. of bedrooms own OF I Ln mAli 111..5 II1. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C7°Z6- 1668 80 ~Oo 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.~R eplacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an ------System T'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 SSeepage 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 Feet ~r6 Feet VII. TANK Ca in gallons LTotal # of Prefab. Site Fiber- Exper. INFORMATION New Existin Tanks Manufacturer's Name concrete stCon- Steel glass Plastic App Tan Tanks Septic Tank or Holding Tank W R~.~-.41~ ❑ ❑ ❑ ❑ ❑ 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 Signat re: o Stamps) Dir/MPRSW No.: Business Phone Number: 0. h w~ r 13 ~3 7 /,S" -a Y6 -_9 Plum'ber's Address (Street, C- Code 1 e, l 4e 6,1 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa~tary Permit Fee (lndudesGroundwater ate ssue Issuing Agent Signature (No amps) Approved E] Owner Given initial j/~ / Adverse Determination fJ U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-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 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 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. ' I I i I I 1 I~/11 j r ; { cyl - ' , I I i ~ t I i I ~I I ' I , Q11, I ~ I I 1 I q I uX I ~ ~ + ~SGJI I-O-D { - - 3' _ - - 66 - , I ~r ~ I II I I I ! I ~ ~r ~ I ' I I 1 I 1 ; I i I i r i I + ~ i I f F ; i- I I . 1 I t i f } I ~ i I I ~ I ~ I ~ i ~ ~ i I I ' I of y i f r _ ' I i _ t _I - , , i i , I I I i I I ' , I I i ' I I I I I , ' j , I ; I i I I ' - I I { I , 1 1 I I ' . ' - r r. I r_ 1 ( I ( I I I I I j~J I I 1 ~ t 1 I ` ' ' _ I I I I ' I I 1 I r I i 1 ! I r ;I ~ I I I - I I - I ~ i I I j I I I Y 1 I I i ~ I , I I ~ I I - _ I ' I L I I ! _I I I i I ~ I , ~ ~ I I I L I l i~ I I I I I - I ~ I I i- - i ~I I I ~ I I i ~ I , I I I I I I ~ I I t ' I I I J i li r I _ t -L _ i I I I I I~ I I I _ I T I I I r I I ~ i- I I r - I l-- I I I , F- rt ~ t - i_ I I I I ~ i t r ~ I t I I t I l I I , I I I I - ~ i I 1 ~ 1 ~ I ' I 'I I a ~ ' - I I I I I I I I I I I I , I i I I I , f I i i I I ~ , I I I ~ I i I i I, I I 1_ I I y ' i I, I o- a-c 10i t.e n Ac0\ k • PAGE 1 OLZ R Iw T- 54,1% 1'%- O F CrvSS ~JIU1~ o~ A 1JC1~ S, set--) Frd►A Alr Inlal► And OD►arrollon PIP• Approaiid Vaal Cop MIAI-- 12' Above FlAal Grade 20. ♦2' Above Plpp 4" Cool Iron To final Grada V•nl PIP• Morin Noy Or SrmMrk Covrlny mrn 2' Ayyrayol• Orar Pipe - 01.IrI0rllod PIPd n 0 0 0 Tod = 0' Aggregate Banaal0 Pipe ° Parlorolad Pipe bolo,, o -Co-Mine Tu-Inollny AI Balloon 01 51616- q~ l Pr%D~oPIr1a-~ SOIL FILL DISTRIBUTIOM PIPE APPROVED Z` WT)4ETIC COVER r -/1ATf:Ftl~t- OR 9'r OF STRAW 2"OFAGG9E4A?E r OR MARSH NAy ELEV. OF--G-L"iFEET °YP ler0F21/Z AGGREGATE D15'rRI5'JTIUI) PIPE TU BE AT LEAST a y IMCHES BELOW ORIGIIJAL GRADE AQU AT LEAST tO IIJCHE- BUT 1.10 MOKC THAW 42 ILIC14ES BELOW FINAL GRADE MAXIMUM © rvi OF EXCAVATIOP FK01I OWWAL 6RAo~ WILL. BE IMCHES ru omm JPFF" of EACAVATIOM fA'0M O~141WAL C3RAVf- WILL BE IMCHCS SIGHED: LICEAISE LUMBER: Sr DATE : t Wisconsin Npartment of Industry, SOIL AND SITE EVALUATION REPORT Page _ of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ` ex Attac h 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 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIONPROPERTY OWNER: PROPERTY LOCATION pjl'E~WE ~e4 u e-d ele / GOVT. LOT ~ 1/4~ ` /4 ,N ,R l E. 40~5 PROPERTY OWNER':S MA LING ADDRESS LOT # BLOCK # SUBD. NA GA D M # f 4LS,3 6.5 CI STAT; ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE„MOWN NEA ~w r c a 017 S~/ 3 v G /!to [ New Construction Use Residential / Number of bedrooms i3 [ ] Addition to existing building Replacement [ ] Public or commercial describe 1 bed, gpd/ft2_,..~trench, gpd/ft2 Code derived daily flow gpd Recommended design loading rate Absorption area required Wed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2_ trench, gpd/ft2 Recommended infiltration surface elevation(s) G~ ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 15M ❑ U LAS ❑ U ~ Ps ❑ U S ❑ U ❑ S 50 ❑ S W SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxclary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 4 :••.v:.vvv INK, C, Ground elev. ft. Depth to limiting factor •y Remarks: Boring # ® ~ r G - ts- ? Ground Depth to limiting factor i 5 Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: PROPERTY OWNER Cn~c., ,Cr SOIL DESCRIPTION REPORT Pagp_ofT~ PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench A Ground - G,.L~ r ► lev. lo~ ft. Depth to limiting ror ` 2- Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # w n .i Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) Soil Test Plot Plan Project Name Leonard Berg Byr Bird Jr. Address 1453 Highway 65 S New Richmond Wi 54017 STM #3479 Lot Subdivision Date 11/17/95 SW 1 /4 NW 1/4S23 T 30 N/R18 W Township Richmond Boring O Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft.Base of Siding System Elevation 94.1 * H R P Same as Benchmark x ~ Existing 3 30' Well Bedroom • House 16 100' .M. 90' 10' B-3 40' 20'~ B-2 1% slope 35' r B-1 WiisconsinLapartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page of 1 Labor and Human Relations `'DivisioraofSafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUI ` i Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but • ~ a, : , ~ . . not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PAQCEL Lu•"' ` dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION -REVIEWED BY D PROPERTY OWNER: PROPERTY LOCATION ~j~ rCl f~L'r GOVT. LOT ,&j 1/4/o/ ,N R l E'o PROPERTY OWNER'-.S MA LING ADDRESS LOT # BLOCK # SUBD. NA 0IkJD M1# CI STATE, ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE )YOWN NEARS (-J New Construction Use Residential / Number of bedrooms [ J Addition to existing building Pf,Replacement [ ] Public or commercial describe Code derived daily flow lik3V gpd Recommended design loading rate bed, gpd/ft2_,._~trench, gpd/ft2 Absorption area required _ f / - bed, ft2 B® trench, ft2 Maximum design loading rate bed, gpd/112_,._~trench, gpd/ft2 Recommended infiltration surface elevation(s) G1 ft (as referred to site plan benchmark) Additional design / site considerations Parent material ~-a 5 Flood plain elevation, if applicable r ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 'Rt ❑ U L'S ❑ U ❑ U S ❑ U ❑ S CEO ❑ S W SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tmr>ch A AV Ground Aw,- , elev. /7 ft. Depth to limiting factor 3.~ Remarks: Boring # i\ I Ground Depth to limiting factor i 5 Remarks: CST Name: Please Print Phone: Brl r r- o ddress: 14 Signature: Date: CST Number: PROPERTY OWNER a-,? -.e,# SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Texture Consistence Bourxiary Roots Qu Sz Cont. Color Gr. Sz. Sh. Bed Trench Ground .elev. ft. Depth to limiting ror 2 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # 4;i? Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Soil Test Plot Plan Project Name Leonard Berg Byr Bird Jr. Address 1453 Highway 65 S New Richmond Wi 54017 STM #3479 Lot Subdivision Date 11/17/95 SW 1/4 NW 1/4S23 T 30 N/1318 W Township Richmond Boring O Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft.Base of Siding System Elevation 94.1 * H R P Same as Benchmark x Existing 3 30' Well Bedroom • House 16 100' .M. 90' 10' B-3 40' I { 20' B-2 1 0 slo e 35' / I B-1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 1 d d \K l OWNER/BUYER *01 MAILING ADDRESS C,-~ 14 &7F PROPERTY ADDRESS SCE e_ o S 4 ,)w- V--Q (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4kW R I C- T ! PROPERTY LOCATION 5W 1/4, 1/4Section T_N-R~-w . TOWN OF I t G ~J ST. CROIX COUNTY, WI LOT NUMBER SUBDIVISION CERTIFIED SURVEY MAP , VOLUME 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 expiration date. SIGNED: r DATE:'" St. Croix County Zoning Office Government Center 1101 Carmichael Road - Hudson, WI 54016 11193 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 housej, 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 I\ Gt ~ )N •I ' . Location of property_,5W 1/4 /yU) 1/4, Section 03 , T 3 4 N-R W ' Township kt c,~rn~ 4 Mailing address ` _S3 A:E4 Address of site qa,- _ as. cX)D b ate„ Subdivision name Lot no. Other homes on property? Yes* No Previous owner of property dai2r4 Total size of property Total size of parcel Date parcel was created o o - 9 0 Are all corners and lot lines identifiable? /'C Yes No Is this property being, developed for' ('spec house)? Yes IV_-No Volume 3 and Page Number Q ~ 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, o ice of the County Register of Deeds as, Document No. _ S a(~• , 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. Signa re of Appl' ant Co-Applicant U °-(Z-~ Date of Signature Date of Signature 5-14520 VCL' 1183gz C? WARRANTY DEED Document Number ap/~~y./Mw rMe'd IOf A~oOrd JUN 6 1996 Return Address _ at 10:00 A.M KAY- -t L,)J k ft*wotDeeds Psrcel I.D. Number: 026-106NO-100 77;409- - Ka rlyce or Ofted/ahl Leonard A. Berg and Carol A. Berl;, husband and wMe, conveys and warrant and Dora L. Ofitedahl, husband and wife, the following described real estate in St Croix County, State of Wisconsin: Part of SW] /4 of NWI/4 of Section 23, Township 30 North, Range 18 West, St Croix County, Wisconsin, described as follows: Lot I of Certified Survey Map Mod December 20, 1990, in Vol. "8", Page 2305, Doc. No. 465057. This is homestead property. Exception to warranties: Easements, restrictions and ri bts-of-way of record, if any. Dated this day of?mow , 1996. S w A~- (SEAL) (SEAL) Leonard A. Berg Carol A. Berg ACKNOVVLAMGMENT STATE OF WISCONSIN ) ) ss A46141 COUNTY ) Personally came before me this day of 1996, the above named Leonard A. Berg and Carol A. Berg, husband and wik a known to be the person (s) who executed the foregoing instrument owledge the same. ,&z~7,-- • rJOW0 , County, ~ OF V~PUttl gaiky Public Coun WI My commission expires THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristina Ogland Hudson, WI 54016