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AS BUILT SANITARY SYSTEM REPORT' k~ty .
OWNER v.E r ,u
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ADDRESS4121
T ~Gt~S'2~ir~?~LC~ f's
SUBDIVISION / CSM9 LOT
SECTION 21/ T f1N-R W, Town of ST. CROIX COUNTY, WISCONSIN
PLAN VIEW ~eK
SHOW EVERYTHING WITHIN 100 FEE OF SYS EM
/Sb /
a
s'
INDICATE NORTH ARROW
k_
Provide setback and elevation inf rmation on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK •n~m/~„~
ALTERNATE BM:
e , e% Jam„ e~ ~L
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:- pe-5 Liquid Capacity:
r
Setback from: Well House Other
t Pump: Manufacturer Model # Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width: Length ,zF,-T_ Number of trenches
Distance & Direction to nearest prop. line:-
Setback from: well: /mA House Z/~ Other
ELEVATIONS
Building Sewer
ST Inlet: ,
ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: X773
PLUMBER ON JOB: b~
2W24 M (Z
99-17
f ,eild,fC
LICENSE NUMBER: -~9 s '0 6y
INSPECTOR:
3/93: j t ~3 / ee ~7~5"
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labora'hd Human Relations INSPECTION REPORT J'1. Ln::in
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 2,f-', In, `
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
d3 a r L
TL rT0`ir.ir d4-`ES , iYsiv O L
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A 0 21i0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
j J
Dosing NA Header / Man.
i 1
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
M el Number
TDH Lift Lriction stem TDH Ft
Forcemain l Length I Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Widths / Length r No. Of Trenches P No. Of Pits Insi Liquid Depth
DIMENSIONS ~-3 :3 DIMEN I
LE Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TypeO ~5 ^ AMBER Mo elNum e.
r / tf
System: OR UNIT
J~r"rkfs DISTRIBUTION SYSTEM
HeaderF Distribution Pipe(s) C/ x Hbl~ Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. T Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr Syste my
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded ched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
71 t14~r:y1Q:4,~L~ ,.)v. .J 0 .A '+yYJ a.1 W9Y , iJ LO T.i
P/-~ 0,1 X-4
Plan revision required? ❑ Yes Ept6--
Use other side for additional information. J
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
7-777/
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9G ~5~ 97,16) (97, 7J)
v
Safety and Buildings Division
~ti~Fi■ 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 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application ?Sanitary Permit Number
aGa3pT
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
Property Owner Name Property Location
114 1/4, S T , N, R (or N
Property Owner's Mailing Address Lot Number Block Num er
city,./ atea Zip Code Phone Number Subdivision Name or CSM Number
7 TYPE F UILDIN : (check one) ❑ State Owned :±E1 y Nearest Road_
lage
Public 1 or 2 Family Dwelling - No. of bedrooms wn of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) Qg
1 ❑ Apartment/ Condo
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. ro_ New 2. ❑ Replacement .3. ❑ Replacement of 4. ❑ Reconnection of 5.,/(] Repair of an
_____System ________System_____________TankOnly Existing system ____Existing5ystem
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 JR Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 E] Seepage Pit 43 ❑ Vault Privy
14 ❑ System-l ill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate L77- . System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min Anch) I 97 Elevation
a qr') Feet Feet
VII. TANK Capacity Total # of Prefab. Site Fiber- Exper.
INFORMATION in g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank I I 10i- -0 ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins allation oft onsite sewage system shown on the attached plans.
Plu be s Na t) Plumb s S atu S mp MP/MPRSW No.: Business Phone Number:
Plumber Address Street, City Sta e, Zip Co
IBC;``COUNTY /DEPARTMENT USE ONLY
❑ Disapproved S Itary Permit Fee (Includes Groundwater Date Issued I Issuing A nt Signature (No St )
~
Approved E] Owner Given Initial /Q'~ Surcharge Fee)
Adverse Determination lref;5~(5_ 60 Surcharge Fee)
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-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 8 112 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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Wisconsin Department of Ind stty 5OI L AND EVALUATION REPORT Page of -3
Labor and Human Relations
Division of Safety & Buildings in actor ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan onp*'r not less than 81($$ inches in size. Plan must include, but
not limited to vertical and horizontal-cii6ren",;,poiht direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location a~1'r! dt5iance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
11141d 7100'eV GOVT. LOT -5L 1/4 SW 1/4,S 3yT 3d N,R /j' E ( W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME 05 CSM #
C./D ~f 6 cif E L cS.y ,~uD~-~ G-
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE 0F8WN N REST ROAD
vDSo,v 'v/. SyosG (vs) :5yy-lo S i oSE ,S% .
[a4ew Construction Use [Residential /Number of bedrooms [ ] Addition to existing building
(j Replacement [ ] Public or commercial describe
Code derived daily flow (000 gpd Recommended design loading rate bed, gpd/ t2 trench, gpd1(t2
Absorption area required bed, ft2 trench, 112 Maximum design loading rate bed, gpd/ft2 • G trench, gpd/ft2
Recommended infiltration surface elevation(s) SEA 3 it (as referred to site plan benchmark)
Additional design / site considerations U / G'e,eygE~y o,~ aw,,v &u
Parent material SGi `1L Flood plain elevation, if appli6able ft
06,E~f S up
S = Suitable for system COW 1[5'S WI[] UL [~'S [~S 7m-ou MOUND U IN-G_ RO DD U ESSURE -GWE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 0S gi t?' ❑S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tench
l
Z 11-2-5 ioye 31z S11, A~.S~✓,C 1Wfe Cs y S
70~P C S /7~ S
Ground 3 S 3~ /6 //e 31- 511 L 4,1
elev. S
6-L- ft. Olrf 4*1/7~r
Depth to
limiting
factor
Remarks:
Boring #
yle 312 -{,e ~s /f y s
27-1 leVe /7"-'
Ground
elev. /D 31ZI S~ -1.14 411 7~e - - S ~
/61, 3 7 ft.
Depth to
limiting
factor ,y
7 ~F/ L
Qmm~rLn•
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of
PARCEL I.D. t
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 8ourd 3y Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
~
3 L - zz o 31?- . .ril(- ~,.-,e es Hof , S.
Ground 3 ~S 7. S 5,6,E ,~e e-5 Uf , S 4
/o3 •~ft. 7,5-y -e of , 7 •p
Depth to
Cmiting
factor ,i
Remarks:
Boring #
L f At- yj,e CS L-f-
72- J~ ;7,,5 151 2-4-M sie V,,~e 57 1
Ground
elev.
101•35
Depth to
limiting
factor
Remarks:
Boring # 10-/0 /D k" J i►~r 1/f,E' C S
Los ,s y
-3 75
Ground
elev.
!D ft
Depth to
limiting
factor
Remarks:
Boring #
1-3 1 A]
Ground
LoT c* Z
3.3 9 Ass w/
P,i~ N
UA T I'OAJ
30
/3 3
/Z lol,371 = ~,4c/~~oE ~,TS
/33 /03,05- ~o~~v, svPv~yo~'s
13 y /o% o5- />~~ES - 2rsEa
,¢s /3.y. 's .
n ~s /o/GD
N sysT~~ 975-0 iD T.~'r v 5F2,0
' ~dLvt71° Sys 7~ 96"0
WSE 3 7~'~.uGG~S ~'9 X
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qj / D S tv. /MEN r3 3 13y-/35- Cu.l/ ,cJ_c.(dQ
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CERTIFIED SURVEY MAP
Located in part of the SWa of the SWa of Section 34, T30N, R19W,
Town of St. Joseph, St. Croix County, Wisconsin.
CURVE DATA 1-2 AREA OWNER
Radius 1839.86' Lot 2 Malo Duden
610 County Highway "E"
3.38 Central Angle 01045'28" 147,Acres Inc. R/W
147,325 Sq. Ft. Hudson, Wi. 54016
Chord Bearing S880531091IE 3.05 Acres Exc. R/W
Chord Length 56.44' 132,789 Sq. Ft. N
Cn ca
Arc Length 56.44' Lot 3 r
Tangent Bearing S8800012511E 4.30 Acres y s -3.
187,186 Sq. Ft. N
Tangent Bearing S89045' PARC L; L%-s89 , ,~_L O LAND
VC)L. 54 7 , l-jG. 306 c 33'133 5'5! 17!1W, 726.20'
y N 7-32.78-~ 347.39' 346.03' 34.03' 3
s I c r cl- o -380.061-
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Section 34 N9000010011E
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LEGEND 962.54 I . H. "E7
Aluminum County Section Monument Found South line of the SW}
• ~ Iv
V
FILED
OCT 1 9 1994p-
JAMES O'CONNELL
522628 Register of Deeds
SL Croix Co:, WI
CERTIFIED SURVEY MAP y
Located in part of the SA of the SWa of Section 34, T30N, R19W., -
Town of St. Joseph, St. Croix County, Wisconsin.
CURVE DATA 1-2 AREA OWNER
j
Radius 1839.86' Lot 2 Malo Duden
610 County Highway "Ell
Central Angle 01°45'2811 3.38 Acres Inc. R/W Hudson, Wi. 54016
147,325 Sq. Ft.
Chord Bearing S88°53'091IE 3.05 Acres Exc. R/W
Chord Length 56.44' 132,789 Sq. Ft. N
C03 W ca
c m
Arc Length 56.441 Lot 3
er
4.30 Acres °i
Tangent Bearing S8800012511E H r-
187,186 Sq. Ft. H
Tangent Bearin S89°451 31 L PARCEL 1° w
9 PARCE~ OF LAND
`✓7L . 54_7_, PG. 3_78_
35! CI. M
-8'89°5'5! 17"W 726.20' CD ~
,
y N -32.78'. 347.391 346.031 34.031
r 1c: Cf.
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Section 34 a, ;iN90°00100°E o
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LEGEND _ 962.54' Z I . H.
Aluminum County Section Monument Found South line of the SW}
CERTIFIED SURVEY MAP
Located in part of the SWa of the SWa of Section 34, T30N, R19W,
Town of St. Joseph, St. Croix County, Wisconsin.
CURVE DATA 1-2 AREA OWNER
Radius 1839.86' Lot 2 Malo Duden
0 3.38 Acres Inc. R/W 610 County Highway "E"
Central Angle 014512811 147,325 Sq. Ft. Hudson, Wi. 54016
Chord Bearing S88°5310911E 3.05 Acres Exc. R/W A'
Chord Length 56.441 132,789 Sq. Ft. N
W N co
Arc Length 56.441 Lot 3 r 0 w
Tangent Bearing S8800012511E 4.30 Acres d s
187,186 Sq. Ft.
r- (A
Tangent Bearing S89°451 3' L-S89 PARCE L OF L r1"Jv^ a f0
33133 5'5! 171'W 726.20'
N (A -32.781 347.391 346.03' 34.03' x
I_ 'r ° N -380.171- -380.061- 1n to 14- n
M
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SW Corner v ~ a)L
Section 34 N9000010011E
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LEGEND 962.541 ° l . T. Aluminum County Section Monument Found ZSouth line of the SWk
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERIBUYER o h yq 7-A o ekin es L~ I SJ S~ 9 - 5-;t;97
MAILING ADDRESS 1 aS~ ~8 57. N c~so-~ ► , yO16
PROPERTY ADDRESS 5T_
(location of septic system) Please obtain from the Planning Dept. -3B6 -Y6 7y
CITY/STATE Ht, J5 o n l t> 1
PROPERTY LOCATION S 1/4, S W 1/4, Section 3 y , T- o _N-R~W
TOWN OF S_ t7d, s eJ+h ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
~oa6a$
CERTIFTEDSURVEY MAP L ,VOLUME
D , PAGE X1831, LOTNUMBER & 50 2 Z2~
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:
DATE:
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 ~ ^I A.". 5-y9-S-2- 97
Location of property 5(k) 1/4 5 1/4, Section 3q, T. 3a N-R / / W
Township 5% D7ose,4"- Mailing address 11Sy- yg rt ;57- I -
H' Jso n it; S-1106
Address of site /CR/7 ('D 7tN 5-F
Subdivision name C5rA 2W3/ Lot no. a
other homes on property? Yes ~C No
Previous owner of property GVOfd(C- 61AIIJQdS "ENG.
Total size of property AS 339
Total size of parcel AR 3.3$
Date parcel was created
Are all corners and lot lines identifiable? Yes - No
Is this property being developed for (spec house) ? Yes _4 No
Volume 10 and Page Number a 931 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. 5'0-26-28 , 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.
~DZG Z 8
~`L~jyJyc.~
S' nature of Applicant Co-Applicant
Da e f signature Date of Signature
oc,ICUMENT NO. WARRANTY DEED THIS SPACE.RESERVED FOR RECORDING DATA
• i STATE BAR OF WISCONSIN FORM 2-1.982
545542
yo _118 5 PA~F 162 _ _ _ I REGISTER'S OMM
t ST. CROIX , M
Nordic Builders, Inc., a corporation,
' JUN 19 1996
j, at 9:20 A M
conveys and warraults to John D. Thoennes~,4,.,. ~to{ti,
~I ReerofDeeds
e
the following described re:ll estate in St..--.Croix County,
State of Wisconsin:
Tax Parcel No:.030-2008-95100
Part of the SW1/4 of SW1/4 of Section 34, Township 30 North, Range 19 West,
St. Croix County, Wisconsin, described as follows: Lot 2 of Certified Survey
Map filed October 19, 1994, in Vol. "10", Page 2831, Document No. 502628.
This 1.S...XL0.t_......... homestead property.
)CKKK (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
8 June , ~s96
Dated this _ day of - . . . . - . . . . .
Nordic Builders, Inc.
_ ............•••-••----............(SEAL) !._Z!(................................ (SEAL)
,Anthony all, President
(SEAL) By:i%L^'%Gi~ SEAL)
-Mark A. Arneson. ,..ViGe..President..
AUTHENTICATION A CKNOWLEDGIzIENT
Signature(s) STATE OF WISCONSIN
SS.
St Croix
County.