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HomeMy WebLinkAbout028-1024-40-000 g ~ ~ o ti ao > M a a o o I N ~ N 0 O O y c v ~ o I ~ v O N v e x Oi N u! Y N co ~ - O O d c c z N -5 I 7 (d co LL c m - O O) N O Q N m 3 ~ ~ m 1 Z N I- W E Z O i 00 w N u, N W a m f- U) c o i C C9 O U O Z ~ I' c V r I! 70 (0 N H 0 N Z 15 16 C E •o .O ch N S N 0) co cU ca. ) n N a O 0) co 0 CD l~~© Z co z 'O Z ~i (D N V H R 0) m - ~ a) V N c to 0 U O a a O ,It E F Cull Lo (n U) (n U) 0 • OOO z Y c a a a •i a 3 N O 0 0 N N J U 0) rn D) M Lo ^v c N N 0 0) 0 0 > 1- 0) r- N N Q O O -ry m co v v L m izz z :g I O 'p h «33 N 00 O M N a) d o ~2 ~ c 00 3 M ►~l + O Z- o c c E Q C14 a N y o °o °o _ E n _ v > E E 00 o _ C14 04 o o C ° ao ° ,n H H m o 0 1..1 00 N N c 00 c • N o cD E E co y,~ O N O - r.. V N L ° d a • d ,v £ L c c 0 a 2 O U) V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /e R AP G h ADDRESS 0 4.,41 Wit. SUBDIVISION / CSM# LOT # SECTION / 5 T 2~ N-R_0 _W , Town Of 4 S' 1 v a r? ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C\ i J s 3 INDICATE NORTH AR R311 Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. j BENCHMARK: Na i' h O &-i t ~p le- 1 G G ALTERNATE BM: L~O%G 4 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location ? SOIL ABSORPTION SYSTEM Width: 3 Length q Number of trenches fie, Distance & Direction to nearest prop. line: Setback from: well: ~S"Z House </1. Other Q~ G ELEVATIONS Building Sewer (2 ` 3 ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATIO PLUMBER ON JOB: LICENSE NUMBER: 41 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) Sanitary Permit No.: GENERAL INFORMATION 268542 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MONTPETIT, PERRY RUSH RIVER CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: AG) , G 11A c& A&Y TANK INFORMATION ELEVATION DATA9.2 % TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gy(cJ s `/-c~--,7 e e. /;n~) Benchmark 3, Dosin Aeration Bldg. Sewer /10, ;75 1 3 Hol g St/ f. Inlet 1113 ' 'TANK SETBACK INFORMATION St/ Outlet 7cl/ y¢' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet >rw Air Intake Septic NA Dt Bottom Dosing NA Header $ , f Aer n Dist. Pipe Lor Holding E~15 Bot. System9 ' PUM / SIPHON INFORMATION Final Grade Ma er errand a' Model Number GPM TDH Lift LFiction TDH Ft Forcem,ti,n Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Tjenches PIT No. Of Pits Insid i d Depth ,5, 1 DIMENSIONS / DIMEN I` SYSTEM TO P / L BLDG WELL LAKE / STREAM L Manufacturer: SETBACK FzCHA4i1ER INFORMATION Type Of na4--" Mode umber' System:6p 726 166 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 e Only Depth Over Depth Over xx Depth Of xx Seeded/Sodded Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No El Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Rush River.15.28.17W, SE, SW, 30th Avenue. /.~-C'O'CCJt.4~ CI.MD'~'-~, `S F. ' lc~x' C dry i]ulrl Plan revision required? ❑ Yes [~Vo / Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i Safety and Buildings Division ~~•~r■Ri SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 Num er C96 rrvcq The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Propyy Owner Name Property Location l e 2~e /?'!v it o I• S6- 1/4 S'el 1/4, S /,5 T 2j- , N, R ZTor) W Property Own 's Mailing Address Lot Number Block Number S_ 'I? d+ f''aec-n City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF -BUILDING: (check one) ❑ State Owned / ~t~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Ll g Town OF vt' /2 3U t 4 /¢v~( III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1E3 Apartment/ Condo I 1`— 0:2 IF--/V 2 Y- q O 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. $4 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 Og 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 v t G Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) 0^ f Elevation f~ 2 76 I TO y~ ` Feet 4 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION New Exisn Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App- ti pstructed T nks Tanks Septic Tank or Holding Tank ~,ZhU f?Z~ l~ ~~y~ ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibilit for installation of the onsite sewage system shown on the attached plans.- Plumber's Name: (Print) Plu er's Signat 2D yo Stamps) rMPRSW / 4/ No.: J Business Phone Number: J'G e. -Stcth ~ Gtr 6 lS 'G et 4~;(0 Plumber's Address SSStreet, State, Zip C de) ,oo ~ r' (lG w 0,2 VU iot /e 4-/,,s s"y&LY IX. COUNTY / DEPARTMENT USE ONLY / ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Age t Sign ure (No Sta s) A roved Surcharge Fee) pp ❑ Owner Given initial 160 C~/- Adverse Determination -X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly. 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 isto 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. .'Aleoe~ Mor)~,Pet/,l . _5N9q D,ok~~cEn+ St~'~~w~rcR ~3'~~2 G12-~/3a- 3A A 13'/Y1. N41'I '`h lca.e~ J'°4/tr lv v a t t" o N►, G~ 13c,d 9 G- 13 d 34' 11 eed . y. J i 30 ~ I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS .INDUSTRY, DIVISION LABOR P.O. BOX HUMAN RELATIONS PERCOLATION TESTS (115) MADISON W 53 07 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: SE sw~/ ~S /TzBN/RI~E(o NvsN Iv(F1 - - COUNTY: MAILING ADDRESS: S'Y'• C.R.I)I x CuLto E R~Ol~3SO►`l q ~~w! RwS S oQZ USE DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: PERCOLATION ROFILE DESCRIPTIONS: TESTS: Residence 3 )V P" . New ❑Replace I Z O_ g 0 4_ _ 9 p RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ZS ❑ U CHS ❑U Las ❑U as ❑U ❑ S oU zu k u 0' COIU U61J'nWUk L 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: D•y7 GPD/5Q. FT- Floodplain, indicate Floodplain elevation: - PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1 o °16. o t~olvE l 10 SLR pt1GE Z of 3 B- Z _8 6 )J• 3 $ $ v -2 r, B- Ll b h f 7 6 (a S L4 -7 y y B- b 8O „ 7 Fan ? ~O U ? 8 0 B- 8 QZ. 6 ? $ SGl~i f1 c~ 3 DF 3 9' $1 4Z• a ? 8-7 e~ B- I o of 2 01 l _ 7 41 IL 11 10 CIS - S » 7 LuS B 17-X18 ~i 3• S wvy.~E -Z X B PERCOLATION TESTS 41 EST. DEPTH , WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES F NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I P RIOD2 PERIOD PER INCH LE-. P_ 1 Z - l\3 1 ~s1)6 ~5116 j az,y P_ 2 35 - tQ) 1 31/ l31/6 ) Va 9 93.3 P- a 14 /6 - l0 ! 3//6 /16 q C)y-Z. 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- a o •y m 7 7' lr SEC, ~S 8 . E x ,o 1.4 L4 Lam- - K L 4 3 z~ 3 1 t L `c S I ? L` .T 3 'T- INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section 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 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 's1 - Loamy Sand - Less Than 'I - Loam Bn - Brown 'sit - 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 - Silty 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 BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point I SOIL DESCRIPTION FORM Attach Sold Pro Ic LocaLion Ma On a Su arata Sheet CLIENT, L° L~ L 1~ E `S CS PQ LINE LOADING RATE: 'SR PURPOSE: =~~t-U~ - Fop_ St~J S~-lST~7~1 slop °lo - ) u o DESCRTPT ION BY L. W EGLIZ. ASPECT. V PC~ I ~S N' S E_ r l` • DATI 14-10-90 CURRENT LAND USE: COUNTY/STA ST= CR4 X C-61JI-lt "14 l~1S r-W S i N VEGETATIVE COVER., GTL SS LOT DESCRIPTION:' 'T=0F SEJI -54'J 'I SC' 1SITZ$N~ /zt7 INAGE CLASS' wtfLL lz:5P~-Ak1)jET_13 LOCATlON• (/lJl`l O F U S (V ER GALLONS PER S . FT. PER DAYS d I PARENT MATERIAL(S)/DEPTH: SOIL SERIES: SPVU'~n h~ " G~ C4f~ ~L EX _ c ~~aps To T7~r &o wRIZON DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PII BOUNDARY REMARKS in. moist Gr. Sz. Shp. COATINGS ~ bR 1 O-~ l0`Cf` 3t~ - SL I ~.h'1 ~ ~v~~ cs 3JL/ C3- 4)-1I )b`tl- Y/(6 - mad s S M no 0~ - b 1ulr>z 313 - s i ) lti v c Z 1b-i R 3) - I 1 ble m U'F~~ - 9 w 3 ►8 - l 1J` tR l 1►1 d(~ S c~ S Wt I 6 3 1 0-~ ~o-t~ 3! - s' j 3 cSbk ~~r `'L Z 6-~ y I tJ 3! - s' 2, m s bk. wl c s S °l0 l~t.zt to-T 3t - 51 l 9bk m c S l11QS S D 5 PA 0 s o-$ lW-fIL3 - si 2msb 1Ylv~~` `3w S "I Zmsbk m ~ cs Z _SI lo`C(z.31 /u 6 S 1 - $ l D->TZ- 313 S Z Y►19 b1z Yr) V`~C~- w Z $ -4 ley Ct 3! - S)~ n S r- ~u a w~ 313 - S) I zmsi~ m v - S) Z S 6~ m S Z -7 -3U I V14 cz 731y 3 6.3 1 W-i (Z 3/ - S 1 S _Al&' L0~ Y/ - ht¢r9 S o S IKXTIION DEPIII MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PH -BOUNDARY REMARKS Gr. Ss. Sh. COATINGS in. moist oz1 6 a 9w z 9-8.7 lb,-fP ~~5 - ~np~ S o s9 m l pill 6 l p o- l~ 313 s l~ Z SSS\T my ''v Z. ~ Z~ 1 D`-t [z: 31 - 5 ~ I Z 1n b ~ c S 11 1 0- ~~~R31 - s l 1`~sb►z mv'F►- s J ~sbv cs lu R 3! )a ~_Nbs. 4,9 L2 S_ m t S ~lz A t U C S 2 9 -2Lf lb-f 2 31 - F"s 3 -gs IbLm V/6 - O S m STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER G R 2 A*?o t -e_t " t MAILING ADDRESS G- ,PE c et CZ- PROPERTY ADDRESS 3 D " (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION SL-^ 1/4, s 1/4, Section S ^ T 2 N-R [ W TOWN OF Rtt j- ~t /2 c w ~ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 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 complete and returned to the St. Croix County Zoning Officer within 30 days of the three year SIGNED: DATE: 2 7 T tj St. Croix County Zoning Office Government 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 0e,C vJ I'j?~ tithe- t Location of property S~ 1/4 S k/ 1/4, Section ! S' , T 2~ N-R ? W Township lekr4 Mailingaddress s-y47 ,SC wA~CI~ h4(, 4 5 btr Z- Address of site I K y`r 3 Subdivision name Lot no. Other homes on property? Yes 4--- No Previous owner of property J ~ c e4-rv P-%- Total size of property L(U Total size of parcel 14 U Date parcel was created 9- 2-1-f6 Are all corners and lot lines identifiable? Les No Is this property being developed for (spec house)? Yes 6--go Volume 1112- and Page Number G / S - 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. 5 1( 7 3 y ~ , 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. s'y~ y Sig -e of plicant Co-Applicant / /_7- Date'of Signature Date of Signature ' M ldv~~ 547347 STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED DOCUMENT NO. iP FACE Clyde S. Jacobson and JoAnne E. Jacobson, REGISTERS OFFiCE husband and wife ST.CROIXCTY., WI PAWOOrReod JUL` 2 6. 1996 conveys and warrants to Perry D. Montpetit and Joan M. _ Montpet i t , husband and wife at 4: 30 P. M *Ir~~ -K 044k. a Fd®gi~lr ~f ~seds THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, ` State of Wisconsin: MIELE 22 Tuigren Square - 502 Gooond Street Hudson Wisoonsln 04016-1043 ~I 028-1024-40 PARCEL IDENTIFICATION NUMBER I The Southeast Quarter of the Southwest Quarter (SE4 of SW4) of Section Fifteen (15), Township Twenty-eight (28) North, Range Seventeen (17) West, St. Croix County, Wisconsin. T A !%oER r ! This is not homestead property. Xt4X (is not) I Exception to warranties: Easements and restrictions of record. I Dated this 26th day of July A.D., 19 96 ! ~I (SEAL) (SEAL) 4yde S. acobson (SEAL) (SEAL) * JoAnne E. Jacobson AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. L_r___ 26 rinv of