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HomeMy WebLinkAbout032-1072-95-100 a. o h p Ocn o (D N 0. 0 a I o N ~ O ~ ° I y CI. vY o ° CL I D m c io ~ 'a I c °''C N a Z 0.0 3 t5 h ti c 4) M o a E ¢ ° ti Z v N M a v z v d co z a co c O z c m ~ = z 'O N N a a~ y I Q) c a> ID • Al a m L g I p co O z m z N ° M m I E E N M e6 w y Un a ° c v v N d .yQ C O N N c Q a 0 z j t3 = U o 0 0 0 0 d 0 Z o 0 N A Naaa y IL EE 0 0) 0) co N v IU) 0) CD z ~l O O N O j M M 0 Q O O .00 E = ) C N _ w y f~ a M a Q ~1 N d Q Z Fn y in ~'V O O co y C (D 04 V r- Q N O H N C C C a - 0 0 LO r M € 'Yp N N N V 04 Oj N C C y C N lA E 00 M 'D y~ 00 ~ f7 E ~ ~j .w 7 Z' C N • ~`V) O N U) 2 N O 2 N Z ~L fn v~ N a a y L: IL ~1 A ciao 0U 0 r 8 9 STC - 104 AS BUILT SANITARY SYSTEM REPORT,.` OWNER -Su 4-)7 .5~- ADDRESS SUBDIVISION / CSM# LOT # SECTION_,.2,~_T_--!~j N-R_4~?_W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM hJ._1l ib INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: hLA Liquid Capacity: JeA Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location -.SOIL ABSORPTION SYSTEM Width:' Length_Z~-" Number of trenches Distance & Direction to nearest prop. line: A~,/ ~ Setback from: well: 11~5r House' Other ELEVATIONS Building Sewer ST Inlet ST outlet g~` y7 PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade 2aX Final grade 9y C " DATE OF INSTALLATION: -PLUMBER ON JOB: LICENSE NUMBER:' 9 i INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Pep it H Ider's Name: ❑ City ❑ Village ❑ Town of: State PI SUB 3 Y~N9 CLIFF PARTNERSHIP/HART N, X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATAa TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S / aw Benchmark Dosin Aeration Bldg. Sewer Holdi St/ Inlet TANK SETBACK INFORMATION St IX Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake wv- Septic NA Dt Bottom Dosing NA Header 7 Aeration NA Dist. Pipe 7,171 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION S 1 SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Moe Number: System: 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 Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET.26.31.19W, NW, NW, 200TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. TI I SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION Safety and uillngWater Sn Bureau o off 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 P The information you provide may be used by other government agency programs E] Check revision tb pevious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT L INFORMATION Prop Owne Property Location , J W 1 /4 1/4, S T , N, R /21 (or Propert Owner's Mailin Ad ss Lot Number Block Numb Cit ate Zip Cod Phone Number Subdivi ion Name or CSM N tuber II. TYPE F IL DING* (check one) ❑ State Owned ❑ it Nearest Road Villae Public 1 or 2 Family Dwelling - No. of bedrooms ~ ❑ Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. ❑ New 2.,g 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 10 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./i/tch) Elevation Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i stal ati n t onsi sewage system shown on the attached plans. Plu be ' Nam . (Pri ) Plum er' gna a s) MP/MPRSW No.: Business Phone Number: P u ber's ddress (Street, p S e, Zip Code . JJ~~ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved isaitary Permit Fee (Includes Groundwater ate ssue Agent Signatur (No Stamps)o Approved F1 Owner Given Initial Adverse Determination Surcharge Fee) 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: i 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. i 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 J 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. fir a~~~r ~®d ~Cl,/are,C-t!t L rdl may. , 2,9 //6 ~T~t use a is -21 -1A CIO 14nJonsin Department 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 COUNTY 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 PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PR ERTY OWI PROPERTY LOCATION f s GOVT. LOT 1/4 1/4,S 21 T N,R (ore RO ERN OWNE 'WI G ADD SS LOT # BLOC SUED. NAME OR CSM # CITY .51A IL ZIP CODE ;HON) NUMBER ❑CITY VILLAGE OWN NEAREST ROB [ ] New Construction Use J~ Residential / Number of bedrooms [ ] Addition to existing building (JQ Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _bed, gpd/ft2_,,'P_trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 17 bed, gpd/ft21,F -trench, gpd/ft2 Recommended infiltration surface elevation(s)ft (as referred to site plan benchmark) Additional design / site considerations Parent material fl&sw J / Flood plain elevation, if applicable ft S = Suitable for system COJVVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL 11 HOLDING TANK U= Unsuitable fors stem S [I U WS ❑ U QZ1 S❑ U J2~J S❑ U ❑ S f~ U El S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bax>dary Roots GPD/ft in. Munsell Qu. Sz. Copt Color Gr. Sz. Sh. Bed Trenctt k•.4 •+ii ?3 112 se, Z, 1~d ~7 Ground Jd 7C '7 2 elev. Depth to limiting factor >9 Remarks: Boring # tvy / Lf//j ~2 11-1.a In_-e_-WZ Ground s elev. Zdit. Depth to limiting factor __T >99 Remarks: CST Name: Please Print Phone: Address: J Signature: r 7 Date: CST Number: PROPERTY OWNER C SOIL DESCRIPTION REPORT Page PARCEL I.D. # Sh. Consistence Boundary Roots GPD/ft Boring # Horizon in. Depth Dominant Munsell Color Qu.Sz.Mottles Gr nt Color Texture StruSz. cture Bed Trends . Ground elev. y~ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # t Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) r 2- av 078°' / _A"'j cc • 9 ~c FILED JAN 3 1996 ► 11 KATHLEEN H.'-W&SH Register of Deeds St Croix Co,, WI 538111 CERTIFIED SURVEY_..MAP Located in part of the NWj of the NWj of section 26, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. N N z w d rr -1 N -1C C N Q co °1 O O ~ ct -h o = -h CD W 0 W -1 CD CO 0 *e W I r1 Previously recorded o - - - - as S88°54'39"E. OO O VOL. •-I P V V. :.2..~I Ct 200TI-I Via'✓c. - - - - m o _ 588°50'02"E North line of the NW>4-~ S8805.010211E 343.39' w S88°5 '02"E 420.36' ROAD DEDICATED TO THE PUBLIC W 1911.21' NW Corner S89°08'38"E 342.60' Cot Nk Corner Section 26------_-..-__ Section 26 ROADWAY 0D VISION O L Z TRIANGLE I 00 rl to Ln _y F 1 E L L. - I. N.. l l- v Cf m D V aIv In F✓ I-~ N Jr. N i Z N N y L 6- SEPTIC• I 1'-I g i b O n~ N C~ Q I VENT I nj W ~ G) ' 3.00 ACRES , :n ~C7 ni '961 a m 130,724 S0. FT. I o .A. ni Se ~ 2.74 AC. EXG ESMT. OUT N 3 Fr. BUILDINGS s A I m c.r t;f'.OIX CC1(1t(')''( If"' 119,261 So. f w w z ;y •?::1~3nsiv~ l'laru~u I N o N g h'aks Camrrlittee C7 I IU M Icn o » L. ICS z tp 7t recorded z i, V , j•:in 30 days of z ...13proval date I z ° sv yL . -roval steal,'be ( I y n (W f ' :N + . v.4! 4 vniri C N8900-8' 38"W 335.42 a- 0m, Vi A •~cwu•vro. LEGEND - - '~w~ Np ;3tJ rZ'~ Q Aluminum County Section Corner Monument. Found - a 0 2" Iron Pipe Found nrauFU d . k S£O£ 828a TT 'TOA •aoTApp ao.4 paeog umoL ageTadoadde pup aoTjjO SuTuoZ Alunoo xToaO is auq qop''quoo tao.z~d Cup 5uidoTanap ab Bu'Tseuoand eaojag •(•ova 'Zaoaed o-a ssaoop 'azTs joT mruuTu-m 'spueZ:jaM. ' *a•-r) suot~Etn6as pup satna '.shpt dTUSUAO,L pup X:IunoO 'a:1p:IS oq' gp91gns :'Bt".d u sTUn uo uMO-qs ZaoaEd gopg -amps SuTddum- pue Su-rAe ans uT xToaD • qS go Aquno3 auq go eoupuTpao uOTSTATpgnS pueq eqj pup sagnivIS uTsuoosTM auj go VE•9EZ aagdprD go suoTsTAoad juoaxno 94-4 uTTM.paTTdmob ATTn3 aAig'u I :teu:t !pagTaosap pup p@A9Aans..Aappunoq aoTaagxe auq go ateos..oq uOTIEluesaadea :oaaaoo p sT d-eW- AeAanS pa-cypaao: sTUq :Ipu-4 Ajj gaao osTe I •paooa:x 90 squaui9sv9t1 9 01 jobCgns.ST Taoapd.paq-raosep aAogv • 4A ' bS viL l vT) seaw ZE • E suTEiuoo Zaoasd pagTaosaa- • SuTuuTSaq go quTod.. auk oq :19ag• Ob • L'ZI, 'Mu Zip ,ZT000i1 aouaqj gaaj ZfiI•SEE 'Mu8E,80068N.9ou944 :1999 9V•SZV 'M.uZZ,TSOOOS aouau:I ::499.4 6E•E:VE 'auTT u:Iaou pzes Suote 'SuZ0,09088S SuTnuTIuoo aouauq : SuTuuTSaq go juTod auq of jeej 9E' OZV "k1I i~I . qqq 3o auTT ulaou 944 5uoTp '$,.ZO.OS088S aouauq :9Z uoTgoaS ;o aauao0 MN gill qE SuTou9unuo0 :sMOZTo3 sp pagTaosep aeglang.uTsuoosTM• 'Aqunoo xToa: -.qS• 1-4as.19MOS 3o UAoL 'N46T2i 'NTE.L UT ' 9Z uO.T109S . 30 ' V/TM,N auk' JO V/TMN gun go lard uT paIpooq CONSENT OF CORPORATE MORTGAGEE Bank of Somerset, A Corporation duly organized and existing under and by virtue of the laws of'the State of Wisconsin, mortgagee of the land described in the Certified•survey Map,. - does hereby consent to the surveying, dividing, mapping, and dedication of the land described on this- Plat, and does' hereby :consent to the above certificate of Michael J. Hartman (D.B.A. Pine.Cliff Partnership), owner.- In witness whereof, the said Bank of Somerset has caused these presents to be signed' by J.H... Casey, President., and countersigned by Keith H.. Vardon Jr., Senior Vice President. at- Somerset, ..Wisconsin, and its corpora seal to be hereunto.. ;..affixed this_ day .01 ct 19 g - n the pres ce of Witnes Bank of Somerset 1,4 Witness :H.'Cas Keith H. Vardon r. Presiden Senior Vice President STATE OF WISCONSIN`) SS, - COMM OF ST. CROIX Personally came • ,before me this 8.7y°day of n6cE/ F2 ,19q5, J . H . Casey, President and Keith H. Vardon. Jr.., Senior., Vice President of the above named corporation, tome known to be the persons who executed the foregoing instruments ; and - to.. me known to -be such. President and Senior Vice President of said corporation' and acknowledged 'that they executed the foregoing instrument .-As such. officers as the deed of said corporation by hority. `O . R BR9- ~ MY- Notary Public Wisconsin my commiss M expilms' USLIC. 0F. WAS Vol. 11 Page 3035 k S£0£,a2Ed_ii TOA vlt;pI: 6:.. S,T,SSHS. Z J0 Z 1LagHS• l0 sAvr, Cl'e; c ' LL. :96, C , CD a-+ 4-. X-19-ED uMos a ~a 's.zouuOD aoiTK 0, •N •p.z-eog uMos ..gas.zauios atlg ~q ~gazau I ng pai~rT4a9D sT.gq gVug .AJT4.za3 panoatdd-e s:r- days. dan:C M do 1113 r) ? .6- saztdxa uoTSSTmmoD AN N i ucaszM' - !aTTgna 1LzaggH r Yl0 0• ~e •a o am-es aug paTMOUXOP PUP guamrLx:lsu•r `Buio.69aoj aqg pagnoaxe oqM uosa[ad aqq .acq... Og uMOux am og u2 u-4XeH • r TavgozW pamieu anogV aqq 6"" " WA9~ru, go .A2ps~L~ sTgg am as oiaq amvo ATTEUOS.zaa (X,[OaD ' is 30 AgunoD w _ SS ( uTsuoasTM -40 ag-egS d-rgsxau:z-ea ;;TTO 'au-cg •v•g•a 'uemq ,eH r, j a2 oT ssaugTM . ;o aouasazd aqg uI ~b 6T aC1 O Ep s-rgg„,.a<auMO PT-es go-was PUP Pig agg SSaUIM • gasa[amog TO uMos aqg pry aaggzanuo;D guamdOTanaa pu-e Bu-ruuETa AIMOO ' x oz, • gS : uoigoa CqO 20 TEnoidd-e ao; BuTMOT-10 agg og paggTmgns aq og..ZT.' 9•£ZS ao 0'£ • 9.£ZS Aq pea -mbea< s.T dEW AanlnS paT;TgxaZ sigg g2gg A-4TI.190. osTs I •.dp-W AaAang p9-c,Tp tao aqg uo pagueseadea SP p9190Tp9P pus padd M 40OPTATP 'paAoAans aq o~ dPW AananS PaTJTga 9D sTgg uo pagt.aosap puVT aqq pasneo I q 7q:4 A~zgatao ~gaaaq I 'zaUMo sv us a , STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _ AJe4 ~ Ix ~s~.' / ~ e ~~~i~ MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE L1lz ~~D S PROPERTY LOCATION 1/4, 1/4, Section f/„ T_N-R_ Lam/ W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIEDSURVEYMAF S-= VOLUME J1, 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: 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 2'.1 - Location of property.A(A 1/41/4, Section,T,„~LN-R~W Township-Mailing address Address of site Subdivision name Lot no. Other homes on property? Yes_ No Previous owner of property Total size of property Total size of parcel Zklaf Date parcel was created /--91 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number 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. Signature of Applicant Co-Appl' ant Date of Signature Date of Signature Tr r ~ *~p State Bar or Wisconsin Form 2 - 1"2 ~~~.t.9 S clrh l J.L0~3~I WARRANTY DEED ST. CROIX Ca., V J DOCUMENT NO. F4 3.1aIUfRr:~~1 MAY 91995 George T. Pennock, a/k/a George Pennock, tt 11:00 A.6•~ o,-s>,; D conveys and warrants to Pine C -Eartn I THIS SPACE RESERVED FOR RECORDING DATA - NAME ANO RETURN ADDRESS the following described real estate in St Croix County, State of Wisconsin: l (Parcel Identification Number) W1/2 of NW1/4; SEl/4 of NW1/4; NE1/4 of SWl/4; all that part of NWl/4 of SW1/4 lying Ely of Apple River and that part of SE1/4 of SW1/4 lying Ely of Apple River; all in Section 26• and all that part of NEI/4 of SEI/4 lying Ely of the Apple River of Section X17; All in Township 31 North, Range 19 West, St. Croix County, Wisconsin. This is not homestead property. w(is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of MaY , 19-1c t5 (SEAL) (SEAL) . George Pennock, a/k/a George ennock (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT cai' T. Pennock a/k/a STATE OF WISCONSIN I ss. County. sfl ' s day of may Ig 9- Personally came before me this day of 19_ the above named land TI < M1B$,R STATE BAR OF WISCONSIN (If no authorized by §706.06, Wis. Stats.) so me known to be the person who executed the foregoing instrument and acknowledge the same.