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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ADDRESS n u
SUBDIVISION / CSM9 LOT
SECTION T N-R W Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
C:
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: / D O , i f~,✓
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION,
Manufacturer:
Liquid Capacity
Setback from: Well House Other
t Pump: Manufacturer Model#_ Size
Float sePeration -7121 ~
Gallons/cycle:
Alarm Location 2 r/
:SOIL ABSORPTION SYSTEM
Width: Length n7 ! Number of trenches
3
Distance & Direction to nearest prop, line:
Setback from: well: House Other
P. 4.
ELEVATIONS
Building Sewer ~4 37 ST Inlet: 117 ST outlet
PC inlet PC bottom ° Pump Off _
Header/Manifold
Bottom of system, y
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB:
/ ti /f~C~ (Inds Q
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) Sanitary Permit No.:
GENERAL INFORMATION 268554
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
DOORNICK, TODD RUSH RIVER
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA g
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Olcr-l Benchmark 3.5(0 16b, Cv
Dosing l ~~-/YT O. 3 d3. 13
AerafRom- Bldg. Sewer 9,19 5l 3 T 1
Holdin St4oW Inlet 9
TANK SETBACK INFORMATION Outlet S' 3, I/~
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic 3 7 NA Dt Bottom
Da~ ~9 Sl
~(o
Dosin NA HeaderHMan. 7, ?V/ 96-1
Aeration NA Dist. Pipe 9!5"
Holding Bot. System '1/v
PUMP/-Sd -INFORMATIONS Final Grade 3,0a' '
Manufacturer emand
Model Number -t~:.~3 0AGPM
TDH Lift( /r7/ Loss System TDH Ft
Forcemain Length l7 Dia. w2 Dist. To Wel l
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length No. Of Trenches PITS No. Of Pits Inside Dia. Liquid Depth
DIMENSION 7 DIMEN 1
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAF facturer:
SETBACK
INFORMATION Type O x&,j- 3 CH MwER Model Number:
System: Jpt,c~( 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 Systems
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed / Veit Center pt> Bed/ itch Edges - Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Rush Rive .24.28.17W, NW NE, 330th A)rgue -4 i f
iZr. ~r"Plan revision required? es ❑ No 3
Use other side for additional information.
~SBBD-/6710(R 0(111791~).* D/at_e- Inspector's Sign ure Cert. No.
k
ADDITIONAL COMMENTS AND SKETCH R
SANITARY PERMIT NUMBER:
W. .P
e
3
i
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
V~■■~■'■R 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- S 7- C/pr 5`'
• See reverse side for instructions for completing this application stateSanifai'y Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to previo s application
[Privacy Law, s. 15.04 (1) (m)]. AO 9 g044., i►w. jg6ud, State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner N me Property Location
p oo~-hoc lc tUGJ1A y~~IA, S .1 T N, RI E (orb
Property Owner's Mailing Address Lot Number , Block Number
w-. L
City, State Zip Code Phone Number Subdivision Name or CSM Number ~
/3 C 4~ ` S'4ioc 3 ( /411A
II. TYPE OF BUILDING: (check one) ❑ State Owned 't7.r4 Nearest Road
❑ Public or 2 Family Dwelling - No. of bedrooms Villa g of ~~T<
~-apply) Parcel Tax Number(s)
III. BUILDING USE: (If building type is public, check all that
®'2 lU's5'~ l U /oU
1 F1 Apartment/Condo All o - I 1 1n -`17 13,
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. ew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
' System System Tank OnlyExisting System _--_Exlsting 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
1 1;Ef 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./inch) Elevation
ZOv .2 1G S' 5Ff! Feet 9 Feet
VII. TANK Capacity site
in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION Gallons Tanks Concrete glass App.
New Existin structed
Tanks Tanks ~~yy
Septic Tank or Holding Tank kzz 11 eI/r c-r lei^f J~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 0101 I ❑ El
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 Signature: (No Stamps) /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
la 4 Y A(,'-`% e
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sptary Permit Fee (Includes Groundwater Date Issue Issuing A ent Si ture (N ps)
~
pprovecl ❑ Owner Given Initial Surcharge F ee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Di-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.
IL 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.
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SEPTIC TANK &'PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MIN. ABOVE GRADE WEATHER
PBOXF APPROVED
?251 FROM DOOR, WINDOW 0
FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER
W/ PADLOCK 6
FINISHED GRADE 4" CI RLSER WARNING LABEL
6" MIN. ADE ~.~_4" MIN.
G
ABOVE
18" IN. 6" MAX.
' Al
INLET
WATER TIGHT SEALS GAS-
-F TIGHT i
A SEAL APPROVED
4.. BAFFLE i_ ALM JOINTS W/ CI
CI PIPE B , ON PIPE 3' ONTO
S ONTO i SOLID SOIL
SOLID
SOIL PUMP OFF ELEV. ZWT• C c OFF RISER EXIT
D PERMITTED ONL)
IF TANK
MANUFACTURER
HAS APPROVAL
3" APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE
TANK MANUFACTURER: NUMBER DOSES PER DAY:
TANK SIZES SEPTIC 1 V GAL. DOSE VOLUME INCW DIN 1 0, GAL.
DOSE GAL.
ALARM MANUFACTURER: ST Cdr CAPACITIES: A = D_ INCHES = s_96 GAL.
MODEL NUMBER: - B = 2 INCHES = :sZ. Z GAL.
SWITCH TYPE: /Y,t.~c:-t.-•,
• C = 1i2- INCHES = /moo. GAL.
PUMP MANUFACTURER: CCc~-
MODEL NUMBER : r~ D = INCHES = 6 y GAL.
SWITCH TYPE:
REQUIRED DISCHARGE RATE 3,q GPM PUMP ALARM WIRING AS PER ILHR 16.23 WAC
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . /O FEET
.
+ MINIMUM NETWORK SUPPLY PRESSURE . . . -2-:- FEET
+ FEET FORCEMAIN X T/100 FT. FRICTION FACTOR . 43 FEET
TOTAL DYNAMIC HEAD FEET •
WIDTH DIAMETER .
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH
r 4 S,~ s
LIQUID DEPTH Af`tc SL, c
r .
i° 6~8oK DATE: ~-r;, 9L
SIGNED: LICENSE NUMBER:
3 15/16-6 5/32
W W HEAD CAPACITY CURVE • sib
"53157" -'655159" SERIES 1 112 -11 112 N1'T
25 TOTAL DYNAMIC HEAD/CAPACITY
PER MINUTE 3 15/16 )
EFFLUENT AND DEWATERING
e 50 SERIES 4 t/1s
Ft. Meters Gal. Ltrs.
! 1.52 a 103 I I
x
15 to 3.05 rr
s I! s.l7 ~5 72 1
1
YO
J l•e• V•M: WIT
G
O
2
5 I
10 1/16
I 3 3/32
30
0 GALLONS ip 20 40 50
U.S.
LITERS 90 160
0 FLOW PER MINUTE SKM
via
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Availablewith special cord lengthsof 16, 25', 35' and 50'.
• Variable Level Float Switches available. Alarm systems available.
• Variable level long cycle systems available. • . Duplex systems available.
SELECTION GUIDE
1. ltlt wd noel operated Mechanical WAIA no exb W aonuot required.
Standard cord length - automatic 9 ft. -2. Singh pWOMItlt variable level noel wAch or double piggyb O vadaW level moat
Standout _ non-automatic 15 R 3. Mswitch. Rder fa FM0447.
echanical allerrrebr'M4W 10.0072 or 10-0075.
0 4. See FM0712 for correct model of E%ddcd Altema la,'E-Palo.
8.0 t or t S 7 5. Variabb bust COrtirol 111NnCll 10.0225 used as a oonbol activator with E-Pak ( or
mom Y15 Ph Mode
M53155iiM57159 115 t A* (4)~o~taysteRL
-
6. Four (4) hob'J-PeK jtrrtdiott box, for watertight corNledpn or vnredNI slr►Wleu or
4.0 2 or 2 68 3 or41i 5 2 MM gwaft% PIN 10.0002.
E531558 E5 e 230 t rb^ 7. Two (2) hole -J-W, jtaft box for watertight cor111edion or splice, PM
53 Seriries s - VVL 221bs. 57 Serbs - WL 271bs. 10.0003.
55 Sstbs - VA 24 b$. 59 Swiss- WL 30 1*
CAUTON
All ~b1lWandeenlleb.P~^ bdea2nd4+Ube fAeiAd W dam M • 4•~ eten~ N•e6iei•n.
ForW0001b0onaddlbml2od2r p•a~• br.FMC514;PINVIII&VoIbbb AIId~MMdoollelvotto= MMloee1101eY M~•n~oNnewAN211emIE14el~lefed•IME01~
FW477' E KMW AMNIMor. FMMa6• Medw~ial Awnilot, FLOW. Abon Psdae2. ewoo~+lM endNMIU AdIt W
l
FMp51d51% ; IX1 WA &nipr6enwr@MeP Saba, FMa4a7. end Off0a CwW SM FMp732.
RESERVE POWERED DESIGN of every ZoeNer pump
For unusual Wilions a reserve safety f8M is engineered NO the design
OL To P.O. Box f#W
LmW%KY 4GnA•G347
XVM 3M OfOAwslsLsrls
LGUW^ KY 4018 ¢rrr.TrPuww► S /939"
~O T(80 as~
PUMP !O. FAKE M"4,XX
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Wisconsin Department of Industry, SOIL AND SITE EVA N Page of
Labor and Human Relations A,
Division of Safety & Buildings in accord with ILHR y WiCode
VV UNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in ize Plan st itpclde
not limited to vertical and horizontal reference point (BM), direction a ° of S16 P6, scale`or RCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMA EVIEWED BY DATE
PROPERTY OWNER: G^ O~ERT_~LOCATlON4
err 1/4,S T N,R Eor l
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOC # S BD. NAME OR CSM #
I EmnWin IV
QEY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE OWN NEAREST 59AD
( ) _
New Construction Use Residential / Number of bedrooms S~ [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate , bed, gpd/ft2_trench, gpd/ft2
Absorption area required ~ %D bed, ft2'Z, n trench, ft2 Maximum design loading rate bed, gpd/ft2 -(trench, gpd/ft2
Recommended infiltration surface elevation(s)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 I FILL HOLDING T NK
U= Unsuitable fors stem ®S ❑ U ®S ❑ U ® S El U 21S ❑ U El S U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
elev.
-
ft. lor'e Z/
Depth to - jz '7
limiting
factor r c ' 1 7 / - I(IJ
7 WV- Z. Z~egl_?
Remarks:
Boring #
ez6
Ground
elev.
ft.
Depth to
limiting
factor
7 ~l
Remarks:
CST Name:-Please Print / Phone: `
Address:
Signature: Date: CST Number:
.--3, - -
s
PROPERTY OWNER SOIL DESCRIPTION REPORT Pagel-~Lor~
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. 24t. Color Gr. Sz. Sh. Bed Trends
Ground - 'be -7
elev.
ft.
Depth to i - -
limiting
factor
> IS
Remarks:
Boring #
;.4{ 3
a-5 I
Ground
elev. 5-gr 7-
j~ft. -
Depth to
limiting
factor
Remarks:
Boring #
Q- -7
Ground
elev _
sy~ya
Depth to r '
limiting
factor
Remarks:
Boring #
44
Ground:::;
elev. s s
ft. Syf'7 _
10
Depth to '
limiting
factor T-1
Remarks:
SBD-8330(R.05/92)
odck Lvsck ^Dor'mnt5
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FILE
8 JUN 2
1996 ►~2
KATHLEEN H. WALSH
Register of Deeds ~
SL Croix Co., Ws
546098
CERTIFIED SURVEY MAP
JON-DE-FARM, INC.
Part of the Northeast 1/4 of the Northeast 1/4 and the Northwest 1/4 of the Northeast
1/4 of Section 24, Township 28 North, Range 17 West, Town of Rush River, St. Croix
County, Wisconsin.
6
NE COR. SEC. 24, T 26 At, R 17 W,
N 114 COR. SEC. 24, r 28 N, R I7W , / Z"/ RON PIPE FOUND)
/COUNTY SURVEYOR'S MON.)
✓v / E N 89-40'49"W2610.09' R12610.14'1
66. /5'
'
1370.32 ' -0 1173.62
I O ~`NI \ N L IN F NE 114
p I
; h I Nee•4, W a
I .2233
O Indicates 3/4" x' 24" iron bar 66
weighing 1.13 lbs./lin. ft. set. a
3 I o h
M ~
° O N O
b b l O 2 2
O I ^ tY W
TTED LANDS z i 1 = 3
U N P,q
_
66.03' ~ R o 0
ly W O
327. 71
142 E 393.74' 2 r
N 84 • 3I J
Q 2 0
3 ~m
I 2
4 °
w~ ztQ
Q, Q e = W
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Win °o
JIM LOT / M o Q W
tu~ (a ~4:
W 2.724 ACRES W 2
118,642 SO. FT, m Q
3 Q I 41 am Q
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S 84. 51 '42"W
UN TED L A 5 y~.%`~\SG
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LAUR G
SCALE / _ /00' m t W M PFiY o y
0 25' S0' /00' 150• 200' 300
13
N V ALLS,•: y44J
Wisc.
This instrument drafted by Laurence W`.; Murphy + g' J 11 LAN 0 S_,.%
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~V1t.Aj1^j1e_
MAILING ADDRESS 71 S
PROPERTY ADDRESS cY2 0 6 3Q ¢
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION E 1/4, 1/4, Section T ° N-R 17 W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUM 3ER
CERTIFIED SURVEY MAP VOLUME AG E , 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.
1/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:
DATE: ~,2 -
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 fo(y(i W
Location of property NE 1/4 NE 1/4 , Section , T o;~'5 N-R W
Township la,5x- Mailing address 4 L~'..
L~L'i L~.,J c w ~ ~'~y vo.1
Address of site
Subdivision name - Lot no.
other homes on property? Yes X`No
Previous owner of property
Total size of property 702 ~L'reS
Total size of parcel-
Date parcel was created AIVILe-
-C7-
Are all corners and lot lines identifiable? _ _Yes _ No
Is this property being developed for (spec house) ? _Yes X No
Volume 1)02- and Page Number La- 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. 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--g IS-9 7
Signature of Applicant Co-Applicant
_ ~ ~V - 9
Date of Signature Date of Signature
DOCUMENT NO. WARRANTY DEED RECORDIN X O _ ON
54 75976 VOL q~ PA REGB M 0F1CE
ST.C OIXC awl
THIS DEED, made between JON-DE FARM, INC. a Wisconsin corporation, U 113.•~; t g96
Grantor, and TODD A. DOORNINK a married person, Grantee, _
WITNESSETH, That the said Grantor; for a valuable consideration of one dollar and
other valuable consideration conveys to Grantee the following described real estate in St. 535P. M 'WOrw Croix County, State of Wisconsin: ~
R0 WK of Deeds
RETURN TO:
Lot 1 of Certified Survey Map filed in St,. Croix Bakke Norman, .C.
Baldwin, WI 540 2
Register of Deeds office on June 28, 1996, in Volume 11 on Page 3122 as Document No. 546098 c":`
Also known ass Tax Parcel No:
A certain parcel of land located in the NEI/4 of the NE'/4 and the NW'/4 of the NE'/4 of Section 24, T28N- 17W, Town of Rush
River, St. Croix County, Wisconsin, more fully described as follows: Commencing at the Northeast corner of said Section 24,
thence N 89°40'49"W (recorded bearing on the North Line of the NEI/4 of said Section 24) a distance of 1173.62'; thence S
03°28'30"E 644.15', to the POINT OF BEGINNING, of the parcel to be herein described; thence S 05°08'18"E 301.32'; thence
S84°51'42" W 393.74'; thence N 05°08'18"W 301.321; thence N 84°51'42"E 393.74' to the POINT OF BEGINNING, containing
2.724 acres, being subject to easements of record.
This is not homestead property. Vps ER
Together with all and singular the hereditaments and appurtenances thereunto belonging; an r warrants hat the title is good, indefeasible
in fee simple and free and clear of encumbrances except:
Easements, highways, utility rights and reservations of record, and will warrant and defend the same.
Dated this G day of June, 1996.
JON-DE FARM, INC.
(SEAL) (SEAL)
* *Ja es Doornink President
(SEAL) ` (SEAL)
* *Barr Serier Vice President
AUTHENTICATION ACKNOWLED EMENT
Signature(s of -7A-W t S •t yiiv rC STATE OF WISCONSIN
3Arz/l1/ en.i ex- ss.
ST. CROIX COUNTY
, 19 9 L
authenticated this ,L day of .T'A nI E "Oe
Personally came before me is day of
June , 1996 , the above named James Doornink and
*Thomas R. Schumacher #1014986 Bar Serier
TITLE MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) to me known to be the persons who executed the foregoing instrument
and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY:
BAKKE NORMAN, S.C.
BALDWIN, WISCONSIN Notary Public, St. Croix County, Wisconsin
*Names of persons signing in any capacity should be typed or printed
below their signatures. My Commission is permanent. (If not, state expiration date:
,19~