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HomeMy WebLinkAbout036-1040-40-200 Q G 44, > 0. C C C N `a C a N O L O LO ~X ~ I r y ~ ct, ~ U N o a d Z c (n c - U. C co O O) a O Cl) > N > 3 z E _ O V T LO Z N N a m z c 0 c ° m o z ~ z c co P N z c E 'o O @ co O O O N Q1 N N N N N a O O N a U Z M Z o N z c '0 ~ a, c co E O N I~ N _ (D j n1 co Z O) O It y 1- m n CL - U (0 T i i O O O G a (D N c` C O 7 O o o o a s z O O ra ' ° CO 3 0 0 N N J U Z 0) 0) } N CO A`l a O O - O N CD C> N O ° r O O G n N 1w LO co 7 N U) c LO In CL- V o V ~ N c O O CO ~i O p ~ M rt; L L UO I\ n O CO W N f F- U • ~a M O CD C? U) E E U it O (n O N O z cA =3 - U) eO ~ N V ~ D M a • ca a 'y :u y a r r~ a 0 M c c o `~1 A 0 a O 2 Q) co -STC 104 AS BUILT SANITARY SYSTEM REPORT OWNER I r r C-_-Z4 f Y, ADDRESS bar 5 o 0 SUBDIVISION / CSM# LOT # ~r SECTION T3/ N-R_L?_W, Town of ST. CROIX COUNTY, WISCONSIN / ;L:t • P J~, rvc PLAN VI W fIN , SHOW EVERYTHING WITHIN 100 FEET OF YVrEM -15 1r • ~I INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: /j~ litJ C,'ovr~c MCI S ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 1A) (o ~n_ Liquid Capacity: , Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM I Width: 42, Length Number of trenches Distance & Direction to nearest prop. line: :PQ' f'('ut-*l Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: 04,S ST outlet: Z PC inlet -r-le PC bottom - Pump Off Header/Manifold 165,3 - Bottom of system /oil Existing Grade 7, Final grade Aok `W DATE OF INSTALLATION: 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 68635 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DOOR, TERRY STANTON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A96003341, 10f l~P6 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic lj ESQ/ Benchmark Dosin Aeration Bldg. Sewer r H ng St / Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. ventto ROAD Dt inlet Air Intake Septic -"5-0 O 3 NA Dt Bottom Dosing NA Headed-- ~O 6 Aeration A Dist. Pipe 7,w p Holdi, Bot. System 8; 5 D 1,3 PUMP/ SIPHON INFORMATION Final Grade Manufac Demand SCE 6,3' Model Number PM TDH Lift Lriction System TDH Ft For, ain Length Dia. Dist. To Well Head SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~o? DIMEN I - SYSTEM TO P/L BLDG WELL LAKE/STREAM LEAC acturer: SETBACK CH R INFORMATION Type of p~ r Model Number. System: o?//(o 0 UNIT DISTRIBUTION SYSTEM Header / WjtMWFd- Distribution Pipe(s) e x Hole Size x Hole g Vent To Air ke ~ Dia. Spacing Length _ Dia. Length J z f SOIL COVER x Pressure Systems Only xx Mound Or At- de Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Tqawr' ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STANTON.17.31.17W, NW, SW, 150TH ST o 0,z Al /j, J1, G' Plan revision required? ❑ Yes Dliglo Use other side for additional information. ley 4 SBD-6710 (R 05/91) Date Inspector's Signatu Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: f Safety and Buildings Division ~~~~r■r. 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. -1 . Cr 8 t • See reverse side for instructions for completing this application State Sanitary Permit Number 0/ _ 35 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 ProQtirty Owner Name Property Location r) W v fi'r' /U(u1 /4 ~SL 1/4, S (7 T , N, R/ Property Owner' Maill Address Lot Number Block Number ~D S Cit State Zip Code Phone Number Subdivision Name or CSM Numb r 11. TYPE OF BU DING: (check one) ❑ State Owned ❑ Clt~ a est Road ❑ VII age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF a h'A ev. III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 636 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. sril 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 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 SD Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Feet / 6 $3, Feet VII. TANK Ca in 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 r"SDU w l+v'-~^~ ❑ ❑ ❑ ❑ Septic Tank or Holding Tank X I lift Pump Tank /Siphon Chamber I I - H-4 ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name:nt) Plumber's Sign ure. (No tamps) MP/MPRSW No.: Business Phone Number: S/b 19, 4!;-_3 7 ( S'-o) Q~r ;,4 a~~.rs ~ Q4:~t=~ Plumber's Address (Street City, St te, Zip Code): 6 lam-- AJQA~J 9 C.- w 6 IX. COUNTY/ DEPARTM N USE LY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A dent Signature (No m s) A roved Surcharge fee) - pp ❑ Owner Given Initial S~`~ p Q Adverse Determination I~/,(9o 1 _4z~ 7 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 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 administrat:)r 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-- ' t t ~ 1 + 1 1 ~ t t I t i- • _ I I I I i i i I I~ I ~ I I I ~ q~ I I , I I I ~ _i I I i ~ I I , I I 1 ' I i f I I I o12 I -f I 1 I - I ~ f I I ~ , I I I ~ I ~ i I I I I , I II gi, - t j r ~ I f t - 1 - - I I I- E - t - ile C I i ' I I I , ~ ~ _ I I ( I lid i _ - f - I - t - E I- - , I ! I , i I I I I ~ I 4 I ' I o. ' I , , _ I ' t I 1 i ' I f i i I I , 1 ; I I , • I I ' 4 I ( I I ' j I , i I , I , , - 1 r C I ~ 1 I I , I I . j t 1 r ~ I , r i I , i ; ~ t i E ' f I ~ I I i i 1 t I I ~ i , 1 i I ~ r j ~ I I' ' ; 1 i I I I i t I I I f t I , I i , 1 ~ ~ I ~ I I , I ~ I : C :I I I I I i i I I I I t I i I ! I , I i ! _4 I I I ~ i : II ~ + ~ 1 I I i i I i I I I t 1 ~ , i I I I I ! ~ I ~ ' I ~ I I I I ~ ~ I I - ~ i 1 I I j i - a i r+ --F t i I - - I ~ I I I I I I I I ~ I i I I I I I I I ' - - I II _ I I I I ~ I 1 y 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 I I i I _ I I I Ih ~ F 1 I I I Y I ' I I I I I I I ~ j I a t i 1- I I ' II I I I _ 1 i { I I i I ~ I I I li i { j I ~ ~ { ~ I I T i ~ t t I _ ~ i I I I i f I I ~ ~ ~ I I I I I ' I i i i I I 1 i I L I : ~ I I I i t I I I i l i - _a - 4- 41 -i i I, I I h ~ j ! ~ I I : I I i I I ' ' ~ ; i I I li ' I I ~ t i I ~ I f } I I I , I I I I I , I Te Z)OO~ V- JS PAGE OF cross eel u n o SYs terms froth Air inlets And Observation Pipe v~ , Approvad Vaal Cap ulrjmum 12' Above final Grade i ' 20. 42" Above Pipe _ 4" Catl Iron To final Wads Vaol Plea Meth Hoy Or Synlhella Covering I Nla. 2' Apprea'ole Over Pipe Olildbu11an - Tee = Pipe o 0 0 0 t 6' Aaareaale 11 na aI Plpe 0 Perforated Plpe Below o -Covpllna Tarminotlna Al Bottom of 3161484 P~D~oseD ~ink1: 119re,~1{ o~ - .SOIL. FILL DISTKIBUTIOIJ PIPE APPROVED SCfW HETIC COVE OK 9" OF STRA Zu 00 AGGREGAI~ OR MARSN II `d° le~.OPl~-zt/Z AGGREGATE ;p ~A tLEV. of FEET-. DISTRIg~JTIUIJ PIPE TO BE- AT L:EA5-T INCHES BELOW ORIGIIJAL GRADE AVU AT LEASTZO INCHES BUT.,1.1O M RE THAIJ 42 IUCHES OELOW FINAL GRADE 1`1AXIMUM MrH OF E%CAVATI00 FROM .bRI&NA'L 6X&M.WILL BE - IIJCHES 1' immum 9crr" OF EXCAVATION F•ROA.0 I14IWAL. GR49E WILL BE INCHES SIGIJED: . LICEIJSE iJUM6ER: DATE: Wisconsin 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 St. Croix 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. pending APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: r PROPERTY LOCATION Terry Dorr GOVT. LOT NW 1/4 SW 1/4,S17 T 31 N,R 17 kqr) W PR 6RH OW W MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Hy- 2 na csm CITY, STATE ZIP CODE PHONE NUMBER [:]CITY ❑VILLAGE MOWN NEAREST ROAD Osceola, WI. 54020 (715243-7014 Stanton 150th. St. [xj New Construction Use k ] Residential / Number of bedrooms 3 [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 104.25 ft (as referred to site plan benchmark) Additional design / site considerations alt. site system el.=102.431 Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑U ®S ❑U ©S ❑U ❑S CRU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Bartdary Roots Bed Trench 1 -20 10yr3/3 none 1 2msbk mfr gw if .5 .6 2 0-96 7.5yr4/6 none m s Osg ml na na .7 .8 Ground elev. 108.5 ft. Depth to limiting fact Reerl Irks: Boring # 1 0-9 10yr2/2 none 1 2msbk mfr gw if .5 .6 L2€_ 2 9-25 10yr4/4 none scl lfsbk mfr 9W if .2 .3 3 25-96 7.5yr4/6 none m s Osg ml na na .7 .8 Ground elev. 1101 108.5 ft. Depth to , D limiting ECv factor +961, Remarks: ST GR,00 CST Name: Please Print Phone: Gary L. Steel 715-246, Address: 1554 0th. Ave., New Richmond Wir- 54017 Signature: Date: CS um er: 8-2-96 cstm 02298 PROPERTY OWNER Terry Dorr SOIL DESCRIPTION REPORT Page ~Of PARCEL I.D. # pending Depth Dominant Color Mottles Texture Structure Consistence Bourxbry Roots GPDift Boring # Horizon in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tmrch 1 0-14 10yr3/3 none 1 2msbk mfr UK if .5 .6 2 14-27 10yr4/4 none sicl lfgr mfr gw if .2 .3 Ground 3 27-96 7.5yr4/6 none m s Osg ml na na .7 .8 elev. 107.25 ft. Depth to limiting factor +96" Remarks: Boring # 1 Q-12 10yr2/2 none 1 2msbk mfr gw if .5 .6 4k 2 12-25 10yr4/4 none sil lfsbk mfr gw if .2 .3 3 25-78 7.5yr4/6 none m s Osg ml na na .7 .8 Ground elev. 105.43t. Depth to limiting f+78 Remarks: Boring # 1 -16 10yr2/2 none 1 2msbk mfr gw if .5 .6 -5-` 2 36-32 10yr4/4 none sicl lfsbk mfr gw if .2 .3 3 2-78 7.5yr4/6 none m s Osg m1 na na .7 .8 Ground oleo. 105.3 ft. o limiting factor +78" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) A STEEL'S SOIL SERVICE Gary L. Steel Terry Dorr 1554 200th Ave. CSTM2298 NW'-4SW',4 S17-T31N-R17W New Richmond, WI 54017 MPRSW 3254 town of Stanton (715) 246-6200 lot #2-csm N 111=401 BM.= top of NW lot survey stake C el. 100' 5 aa e -I $.2 1 10 GAry L. Steel 8-2-96 6 FILED 8 AUG 3 0 1996 ► KATHLEEN KWAUN 548945 L sic° ~I Z.~AIC o C71 N O _ n U1 C1 a Dc 0 P) O rt :J (D ° L1NPL/!JTED LANDS CA :r. En 0, 150 TH STREET c West line of the SWk of Section 17 F'S S00°26'0011E S00°26'00"E 400.00' CI S00°26'00"E 0 2016 471 CIL w 225.00' - Fh - \ S00°30'18"E 380.00' 0 (D M o 0 -1 *0 N ci i OD f AI-. V N Cf O Ak 1-h rt- O M fD (D n O Fw-I h O O O C-) I~ z = 1-h m M 00 v -1 Q rt \\!i S9 Iy :J w C 1.0 v Q u Q G Hy } '~j~ i try to > w ~ r W : tPPR V \ - \\\~O CA fD N W 0 C:) F I 110 (n 1 1 r- r- N CD O. N ScP 3 0,' -n x N I~,s I-i N v~ I~J C4 c~ Ct C~ N W I-- C= P ; ; v IN IZ m < -j I CO) M H ST. CROIX COUNTY 1 Vi w Comprehensive I(atu* ° 3 ~ z ~ 4,~ Zoning and -0 Parks Cotwwritteo a If not recorded witiirt ays8f 0 ~ y a al3woYa1 date p apprtlQVa,t~Zrsfi~ IL y t-' +W d~V01$ O CD 3 x - a O -n ht1 0 ;p to ri- a sm rn s 0 rt 0 cOr-0 o r~r, ' C 0 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMUYER. MAILING ADDRESS -sd y~3 S ~SG'e~'~• S~ PROPERTY ADDRESS (location of aseptic system) Please obtain from the Planning Dept. CITY/STATE A)i, PROPERTY LOCATION if 1/4, 1/4, Section 7 , T / _N-R /1 W , ST. CROIX COUNTY, WI TOWN OF LOT NUMBER, SUBDIVISION CERTIFIED SURVEY MAP 5~ 6 VOLUME A, PAGE LOT NUMBER LL) 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 0wner4;; 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 undersigndd 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: l 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. 'A Owner of property te_ r r-Z ~p r r Location of property/ co 1/4.S 1/4, Section TAN-R W Township ~r---~-~^ Mailing address Address of s to 1"U /S d Subdivision name 3Lot no. Other homes on property? Yes ,X No Previous owner of property_ Total size of property 3 16A Total size of parcel _3./b1+ Date parcel was created 30 Are all 'corners and lot lines identifiable? _Yes No. Is this property being. developed for' ('spec house)? Yes No Volume 119 and Page Number - Sao? 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. 1?090 , 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. ignature of Applicant Co-Applicant Date of ignature Date of Signature VOL 1198Pac[539 WARRANTY DEED 549090 Document Number REGISTER'S OFFICE ST. CROIX CO., WI Redd for P=d Return Address S EP 5 1996 `~~t.?5 ~ A M IC R i Sk-- ~ n A O I LP, n cQ at s 5o 4 L O G u S 'i dek. ' y Register of Deeds u- k f, 0 to Parcel I.D. Number: o O'~ fC'~ Richard L. Derrick, a/k/a Richard Derrick, and Robert J. Derrick, a/k/a Robert Derrick, conveys and warrants to Terry M. Dorr and Nancy S. Dorr, husband and wife, as survivorship marital property, the following described real estate in St. Croix County, State of Wisconsin: Part of NW1/4 of SW1/4 of Section 17-31-17 described as follows: Lot 2 of Certified Survey Map filed August 30, 1996, in Vol. "11", Page 3158. Grantors herein reserve a perpetual easement over the airspace located in the Northeasterly corner of the above described property for This is not homestead property. irrigation system purposes. Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of September, 1996. (SEAL) AL) e,- 0 z 1 0 Richard L. Derrick, a/k/a Richard Derrick Ro ertJ. Derr' , a/k/a RobertDerrick AUTHENTICATION Q SFER elo FEE Sign4t~1"re(si Richard L. Derrick, a/k/a Richard Derrick, a. r.kob"rt ",Derrick, a/k/a Robert Derrick, "t4eritic&ted this•.*4t*`" day of September, 1996. r. VAJ- Krist~ha O . ' ~ TITLEt- : c K ),viBER STATE BAR OF WISCONSIN THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristina Ogland Hudson, WI 54016