HomeMy WebLinkAbout038-1170-30-000
C c 3 0
a O
o
a
v
I
o I
0
v
o I
L
a I I
O
O
C
~ p
L cfl
X
N
_ y0
a O C
C Z co ~
LL O 0)
O O
a
I
M
3
00 E
Z
i2 U) a
z m a~i
C F w a m
c
o I
c f9 -o v
O Z C -
u a o
d o
W H ? a Z
c E 'a
-o r)
p) O"
I~j C
N
• ly ' a u) .C r- I
0 cu
Q O m Q O
Z co z
'Ni
'a c)
"Its m 't
> L CL m (0
0
c -p c c a c ~ N
w N
O H F- ~ -co
U m
E E 3: 3: I IL
Z C)
a 3 I
a~
~ o N
) C) aNi
to U rn rn y
o 7: 00 o Q
1 N CO 0
O O O
'o pa 2 I
co CD
p N Q )
co
*l~ C3 ~2 V)) (a I
r.+ p O J N N O = c)
O L" O N ~ C O C C O CL O) O
Ce)
Sw O C C N 00 00 00
N
'12 a)
~r d N (O N
nr M M m a) 0 Co Co
O ~
a.
~ E N
a ro y a
c a a Y
r~• CC a m U d w c
r 0 L c
A u IL 2 0 00
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER f } LLEM U lei s
ADDRESS_ ~S27X (~8~ ~~R(~P I~DQESS /3/cl S%tlR QUS)C)
!S ME
SUBDIVISION / CSM# _ Lua- 1\Ac-,\gD -5 LOT #
SECTION ) ~ T 73N-R /C _W, Town of ~3-jftC, j~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW STAR 0d67 ORIVC
SHOW EVER THING WITHIN 100 FEET OF SYSTEM
~A~2AC~ NOI~S~
3p' 3~
275
~RP~ ~e JSE
0\
0 18,
IDr 5~ -C
/ Sq j
j
i2 x~p $E~
3c~4.b0 INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t 6}. . r
BENCHMARK: ! 9~ lPRC) t` I P5 bN We-ST PL
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: V&--i'<S Liquid Capacity: )nOO 6PL
Setback from: Well House AbP/ Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 1Z Length GCS Number of trenches
Distance & Direction to nearest prop. line: 5y ( WEFT
Setback from: well: House PO Other
ELEVATIONS
Building Sewer 3.04 ST Inlet, Z l ST outlet Y. ~Z
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system 9,55
Existing Grade )3 Final grade -0 /-j
DATE OF INSTALLATION: 4/96
PLUMBER ON JOB: W)LOL)M PrANhIC-S
LICENSE NUMBER: L~?~
INSPECTOR:
3/93:jt
"Wi~c3r. nDe'partmentofIndustry, PRIVATE SEWAGE SYSTEM County:,. CROI
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
259469
Permi H er's N ❑ City ❑ Village [ Town of: State Plan ID No.:
=E
STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:.
Q Oo , / ' t .r ~ y,...: /..l £A< .,-J - A960
- 0031
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /o0 r
35
Dosing to-- i1v 94,3
Aeration Bldg. Sewer /
95'
~.y 9ff.
Holding St/Ht Inlet 3 g qg„
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic ~/d NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe /5
Holding Bot. System g_95~ qa, y '
PUMP/ SIPHON INFORMATION Final Grade 6, 8 S' 9s" S" '
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width I I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS o' DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK CHAMBER
INFORMATION TypeO Model Number:
System: `7 -ttf J"f' 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 _30" Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION : STAR PRAIRIE.13.31.1$W , SE, SW, LIST 6, STAR DUSK DRIVE
/3
d~
Plan revision required? ❑ Yes PI/No
Use other side for additional information. ` u ' ; + • . ' ' -
SBD-6710(R 05/91) Date nspector'sSignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH L-T-
SANITARY PERMIT NUMBER:
I r
^ RM.- Safety and Buildings Division
~~■~r■r,t 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 > N
than 8112 x 11 inches in size. ~5L , C roI
• See reverse side for instructions for completing this application State Sanitary Permit Number
9
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)j.
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name ropertrtl' Location
T1~l~N 1/4 J W 1/4, S 13 T 31 , N, R / S E (Or)e
Property Owner's Mailing Address Lot Number Block Number
ftD
Cit , State Zip Code Phone Number Su ivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned o ityage Nearest Road
Vill i~
❑ Public K1 or 2 Family Dwelling - No. of bedrooms Town OF Q
rvp ~ _ X115 Q
T>12 )
911. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0,31-, 1170 ` 30-
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. ❑ 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 43E] 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
1-150 1 -77-0 -72!n Feet Feet
VII. TANK Caacit
in gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App
New Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank
k: ❑ ❑ ❑ 1:1 1:1
ooo - IN
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb 6 Signature: (No Stamps) MPS: Business Phone Number:
Plumber' Address (St et, City, State, Zip Cod
~5 G 51
IX. COUNTY/ DEPARTMENT USE ONLY
VApproved ❑ Disapproved San ry Permit Fee (Includes Groundwater ate ssue Iss ing Agent Signature (No Stamps)
E] Owner Given Initial Surcharge Fee)
U
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION; Original to County, One copy To: Safety & Buildings Divi ion, Owner, Plumber
INSTRUCTIONS
1 . A sanitarypermit 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 lic _nsed 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 D,rrelling.
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, r( onnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers throug"
VII. Tank information Fill in the capacity of every new/or existing tank, list the tote: gallons, > >r of tanks and
manufacturer's narne, indicate prefab or site constructed and tank mater,al Cer 7plete 'or , 1, .•ptic, pump/siphon and
holding tanks for this system. Cf,eck experimental approval only if tanks received experirne -i I product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropi a . (Prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County / Department Use Only
X. County / Department Use Only.
Co ,plete p! a!v a-, :?('ci flcat!Olls no: srnalier than 8 1%2 X 1 c r r, -,,uSt be sU .._nty. The plans must
A/ plot plat i,I_]Iuwi!toscale orwi0, -o, Lank(s), septic
b ~rmvers; vvells, pulrnp or siphon
o I)~ > I ,...>c I s! nls, repla-em~. m are_ic> ;the ."luilding served;
L11 V~CiO;e JC~lurlc,
0,'.~ r "F_rlC.. S, friCtl .)`l r^r'r..: -1n( 'J°T;I~ _..,rer, D) UJss seC. tlOn
f i pie It IcQUI'ed I c i'r; 5 i`ri Inforrnatlon.
GROUNDWATER SURCHARGE
1983'vNis(onsir Lci 410 in6uded the creation of surcharges ife,-) for a number of recl~-lated pr. which can
effect aroundwafer..
The Lhi eft these surcharges are used for neritoring groundvjater contarn investigations
and establishment of standards.
( e
Ro ) L-5to
ST C,zott FAcu, W ~tozy
5Cy15W ~ :5137a 1UR /P
~ woe Tul-,P
1-67 4, Cov ~v N~4P ;4"S
~a~sro
o
ti
o
)tom Cpl, WAS
yl
IZXIcd v~"Q'
n~
s
j , ~ ~
Q~
fo
3~ ~ 3,
y „
~--12'
~I .f EtZF (~j~
~...Z„ ~
2~
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
~wy4 _--w y ~ (ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/ NICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
/s~-► l~ /T31 N/VfE (or) W n ~ (o
COUNTY: X AILING ADDRESS:
M. C!'24 ba-at, M LGJ
6 '6?~ L
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: PER O ATION TESTS:
.Residence - ~ New ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:lopti nal)
®S ou ®S ou Qs ❑U DS Kul ms DU
ISI~ RATE: If Percolation Tests are NOT required DESIGN If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: / Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
j 9/ - RP
327 - 6161
/8-
B- Z_
B- 3 8D ~J~ OS ~4j- d .a3 a D " Bi><T
B- 41 '60 '9j7- 2- 3 Z_
B- ,r 9Z- 9~. 7 > g Z- 6-Go'GtQ~J e-e7/ "
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P_ ( S Z
3 4_1
P- z-
~69_
P- Z- Q 7 w 4, 1'7
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. i Gz (>it.e_a`
05-
SYSTEM ELEVATION E
z Y
2
i
i
-70
~4-rcn
12 -
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 soction 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;
6. 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
mod s - Medium Sand W - Well
is - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand < - Less Than
'I - Loam Bn - Brown
'sil - 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
CEP DUSTR NT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
DIVISION
ABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
UMAN RELAAIQNS ` J MADISON, WI 53707
--l' `°"-Sw -may (ILHR 83.09(1) & Chapter 145)
OCATI N: SE TION: TOWNSHIPWL~NICIPALITY: L ~NO.:BLK. NO.: SUBDIVISION NAME:
C ySw 1/ ~3 /T 31 N/R/8E (or) W r .
OUNTY: ~fL MAILING ADDRESS:
'E DATES OBSERVATIONS MADE
Z0.N 7MS.: COMM R IAL ESCRIPTION: lpr S: PERCOLATION TESTS:
kiResidence R New ❑Replace ZZ
ATING: S- Site suitable for system Um Site unsuitable for system •J
JNVENT NAL: MOUND IN-GROUND RESSUR : S STEM- N-FILL HOLDING TANK: RECOMMENDED SYSTEM:lopti Hall
®S DU ®S DU ~S DU DS ®U ®S ❑U f
Percolation Teats are NOT required DESIGN RATE: I} any portion of the tested area is in the
,ider s. ILHR 83.09(5)(b), indicate: C~ Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
5RING TOTAL P HT R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
JMBER DEPTH IN. ELEVATION OBSERVED EST.
TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
8 I ~G . C?- Q// ic1-/<r ' .e' . +?~J,' S
s
g- - 1 q.s 9 P r
z 8~ 9,s L O~(o 451/, - , iB- Vd "e. 'ffoff , Vo -
_ 3 8d 9S- OS- )tad o-,a /a -z 3 ,e. B~ J, x 3 - 39 ',V. 4, 13
Bo yS.3 > D -//'6// -z 3',e,e4--T , z A7
If IF
9z-- 9 Z- W,670 04J.
>3
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES
JMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH
( SZ. G / / G Q//G
D '7 n w
- -
)T PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
tal and vertical elevation reference points and show their location on the plct plan. Show the surface elevation at all borings and the direction and percent
and slope.
(STEM ELEVATION
Ise
~ I
i
; - 101,
i I
. I
i
J1-% i
e0.
r-
y_
0
8 s
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
n / St. Croix County
OWNER/BUYER / y' 'I
1
MAILING ADDRESS 164,12 / S /~~~~r ~l . Sf C~Oi X /-i~/~5,, Lc.~r ~ .S"~d•~
PROPERTY ADDRESS sf R CY US h~ P12 t 'V e- l e '-L)
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ~eU-' Lip ~ Moxld ' ~r ~+I . J_`/6)/ 7
PROPERTY LOCATION .ACV 1/4, ~,e,-) 1/4, Section / T N-R_.ff W
TOWN OF ff~~ Rj/eI ST. CROIX COUNTY, WI
SUBDIVISION tJ ~~2 y e'gcloc c - LOT NUMBER <a'_
CERTIFIED SURVEY MAP , VOLUME /,9F5PAGE,7// , LOT NUM 3ER
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. It
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 exp. tion date.
SIGNED: ,~~1
DATE: / ' I1a R c GI t 7C40 -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, W1 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 ;/leas/ Z
Location of property_ 6J 1/4 1/4, Section _-,T3 t N-R_/S W
Township j A9 Peq Mailing address elf/
Address of sita IJ; d~~.e; ~~cti P~~~ D~~~ ~i,
Subdivision name rocl,✓~,ei~ Lot no. _6~11'_
Other homes on property? Yes X No
Previous owner of property
Total size of property 7:3 f1 c2~'S
Total size of parcel 17 3 ,q c K 5'
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? X Yes No
volume /wand 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 f Applicant Co-Applicant
2- 7
Date of Signature Mafia nf C i mnat;ira
oCUMENT No. I~ STATE BAR OF WISCONSIN FORM 3-198211 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED
Gary Brunclik and Allen L. Lunde d/b/a Homestead Rwd ~ r7 ii
Deeelop......t-••--------.•----• JUL _5 1994 II
quit-claims to .Al............................................... Lunde r 10.00 A.
-
•
Ii
the following described real estate in t.-- Croix County, _
State of Wisconsin: RETURN To Allen Lunde
P 0 Box 686
St. Croix Fa 1 WI
Tax Parcel No:
Lots 4, 81 61 13, 15 and 18, Country Meadows First Addition in the Town of
Star Prairie, St. Croix County, Wisconsin.
I
K
This ..-..-1S.llOt homestead property.
XXX (is not)
Dated this day of June 94
, 19.........
(SEAL)- (SEAL)
* r nclik
• ...-----(SEAL) .....--(SEAL)
4 u~.,. L . 4
.
Allen L. Luii e
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) ------Gary Brunclik- , Allen L STATE OF WISCONSIN
Lunde
_ ~ ss. 1
County.
authenticated this V day o------..June 19 94 Personallv came hefnre mP thiQ ,afl., f