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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ` FOrpi
ADDRESS_ 6~ l /~*11 QQ .
l l~ 4
SUBDIVISION / CSMP LOT ~j
SECTION-NO T'S E N-R(93 W, Town of ~D
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~0.
ta\
8, b'1 ~t
~1 O IDQa~ ~ '
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tan}; manhole cover.
s '
f
/ l
BENCHMARK'
ALTERNATE BM: J
SEPTIC T PUM~PC CHAMBER
/ HOLDING TANK INFORMATION
Manufacturer: `~I,J~C tr~~~ S ( ~a6b
~ Liquid Capacity:
Setback from: Well House ad` Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length J~ Number of trenches
Distance & Direction to nearest prop, line:- S ~a
Setback from: well: House >D 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 INSTALLATIQN:
U 96
PLUMBER ON JOB:
LICENSE NUMBER: j
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Safety Labor and
arrndd Human Buildingss Division INSPECTION REPORT ST. CROIX
` (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 262381
Permit Holder's Name: ❑ City ❑ Village X Town o : State Plan ID No.:
FERN GREG & DONNA TROY 1~
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
A9600191
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic rJ, O Benchmark 3, j 3 !OD
Dosing Ali }
Aeration Bldg. Sewer vs 9,/-
Holding St/ Ht Inlet i q / i
TANK SETBACK INFORMATION St/ Ht Outlet 9:5- /q '
Vent
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic ya S -NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe S- i/ i~ ~a a-/'
Holding
Bot. System 17, q° ` ? Y,
I 10,1s-
PUMP / SIPHON INFORMATION Final Grade
Manufacturer
Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Wei
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches L PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N 70 3, DIMEN IONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O irr~,J CHAMBER Moe Number:
System: wt qp ' ,{J 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 El Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCTION: TROY.9.28.19W, NW, SE, LOT 6, BRIANA LANE
k, 3
Plan revision required? ❑ Yes 9?~o
Use other side for additional information. I YL 1.2 L
SBD-6710 (R 05/91) Date sp of~s-Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: `
~ SANITARY PERMIT APPLICATION Co
In accord with ILHR 83.05, Wis. Adm. Code a
ANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than SI)kTt
8% x 11 inches in size. El c 4v.. o to pre u application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNE PROPERTY LOCATION
e y1 6- Frek? ~'/a' E7%, S Td4 , N, R E (or W
PROPER OW ER'S ~LINGe~DRErS$n LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM E
a bV
II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE: k4b NE EST ROAD
PP14A4 Aer
❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER (S)
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo (J l vv
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 in line A. Check line B if applicable)
A) 1. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit 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 X~G 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
r 14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3, ABSORP. AREA 4. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
R QUIRED (sq. ft.) PROPOR(sq. ft.) (Gals/day/sq. ft.) (Min./inch) td P ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New isting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank }C !aa 7 rc.5 Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the ched plans.
Plumber's Name (Print): Plu Signature: (No St m s) MP/ RSW N Business Phone umber:
s /
Z,_~
Plumbers r7?treet,City, Sta Code)G~ x 1e U Ply' ' G~/', ~ d~
IX. COUNTY/DEPARTMENT USE ONLY
nitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature No Stamps) c.
❑ Disapproved ln~
Approved Surcharge Fee)
❑ Owner Given Initial AdversoX. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: V I/
SBD-6398(R.08/93) 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 the 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 & 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a//
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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Builcings in actor 83.05, Wis. Adm. Code
it COUNTY
10 I s~t--. cR o lx
Attach complete site plan on paper not less th 11 inches in ~D must include, but PARCEL I.D. # -
not limited to vertical and-horizontat referent M 'r on and , scale or
dimensioned, north-arrow, and location and a to ad.~ -
_ \ q u
APPLICANT INFORMATION-PLEAS NT 4' 'kINFON REVIEWED BY DATE
PROPERTY OWNER: S A V-B" r' `j,jjN. 4 ERTY LOCATION
~ON~L~ 2D 44 NW 1/4 WE 114,S 9 T Z8 N,R I'l E( W
1~ lti~
PROPERTY OWNER'.S MAILING ADDRESS ~t # BLOCK # SUBD. NAME OR CSM #
4 S O M, C~' ubvk R.0 > ' - ro - GLC)\)EjZ.
1`x'1LlS
CITY, STATE ZIP CODE P E []CITY []VILLAGE WrOWN NEAREST ROAD
1~IVDS ON, W ] S Y Ol ` C1t S) `T-a p g2l'Pf~R Lf~f.1~
Dd New Construction Use N Residential/ Number of bedrooms r--~ ►vw r~ [ ] AdditiQn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived dairy flow \.So gpd/e ®itoo" Recommended design loading rate - bed, gpd/ft2 0 • f3 trench, gpd/9
Absorption area required - bed, ft2 trench, ft2 Ma)amum design loading rate bed, gpd/ft2 o - 8 trench, gpolft2
Recommended infiltration surface elevation(s) 5~ t-JoTtr- oQ Ply&e- 3 , It (as referred to site plan benchmark)
Additional design / site considerations C~ ~~►'tt~t~
Parent material s ~'~O` I o S RS N Flood plain elevation, if applicable N_ K. ft
S = Suitable fqr system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem ~ S ❑ U 0S ❑ U INS ❑ LI ®S ❑ U IRS ❑ U ❑ S MU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rends
~ lo4 7- ` u o.S o.
Z . l2-1$ Lts 9-t 316 - S 1 1 CS Db t VA \]I J ~ 0--S - 0.'4 0.5
0•-1 0 $
- S Sg rn
Ground l$-~3 Lo `11Z 'VA'
elev.
9a ft
Depth to
hM g
factor
Remarks:
Boring # I _
0-9 ~r,~2 ~tZ L Z+nsblrt >»~c- es Z,v~ o.so_6
Z S u 311. - s 1 cSbk c g _ o.\/: o_ S
z ~ ~R 1
Ground
~3 3•~ ft.
Depth to
limiting
factor
Remarks:
T Name:-Please Print Phone. 715-425-0165
Arthur L. We erer
ress:. _
l:-Testing_&_Des :,gn Service P. 0,. Box 74-River _Falls,WI 54022 _
n j,..
PROPERTYOWNER GnSM-XIEZ - FOiZD SOIL DESCRIPTION REPORT Page Z
of
PARCEL I.D, #
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft !li : i.
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots
Bed ITMrICKI
-3 0- 9 1n l Z _ 1. Z,,►.~ s b1Z ►n A Zs Z j Z g-~ ~o~t~ 3t~ s 1 ~sbk vhu~. e.s y a
Ground 3 V -`tZ l0 4 R WL - S 0 4 g n~ 0.7 0• % %
elev.
Depth to,
limiting i
factor i
7 °1 ZK
Remarks:
Boring # p_ 9 do "11~-3 l Z L Zrngek 1~,'~1~ GS ZuO'S E3 Z g-lb lu~t~ 3l6 s csbh -
:j
Ground 3 16-8$ LO`'LR y16
S O s9 `M I _ p,7 o.g~ia
elev.
Depth to
limiting
Remarks:
Boring # i'
-°I ~b~tQ 312 L 7-M36k ~S ZU~ b.S a6!i'
Z 9-2 t3 tukn 31b - s J 1 csbk w,v O-S V•
3 y tZ W16 _ S O 9
Ground ~~-9 ~b`-t s y►, ~ _ a,~ in.~af
elev.
~
c•-5 ft. i!
Depth to i"
limiting
factor a ! i 111
Remarks:
Boring #
Ground
elev. ji
ft,
lk
Depth to H;
limiting
factor h'
Remarks:
PLOT P LAN Page 3 of 3
1-~crvC. SCALE 1"= SO'
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\
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~.S_ls b
(315 Y 424-D~ M00576_
CST Sis~nat~ire _ Date Signed Telephone No. CSF #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page Not
3
Labor and Human Relations
DK*ion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
' CGU'V?Y
Attach complete site plan on paper not less than 81/2 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. If
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: -SAa 1B IE71 S S. 11 1 6 t;-w PROPERTY LOCATION
~'S►ti ~~NRL 1'~1. FORD GGVT,t~ NW 1/4 SST 1/4,S9 T 77-8 N,R 19 E( W
PROPERTY OWNER':S MAILING ADDRESS LOTBLOCK # SUB LOUR CSM 1'}'Z lrl S
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
1' D S 01,3, ► J 1 S V 0 L ` CH S) 38 6- 13 1'1 't-R p 62t Pt>uR Lhi j R,
Dd New Construction Use M Residential/ Number of bedrooms U,,,jVdJ"oW r.1 [ ] AdditiQn to existing building
j ] Replacement [ J Public or commercial describe
Code derived daily flow ILSo gpd/8ED120or-t Recommended design loading rate - bed, gpcW °'g trench, gfdjft2
Absorption area required - bed, ft2 - trench, ft2 Maximum design loading rate -'--I bed, gpd/ft2 o . 8 trench, gpolft2
Recommended infiltration surface elevation(s) 5 f~oi~ OQ Pn-&e- :3* It (as referred to site plan benchmark)
Additional design/ site considerations Tz x~~p'►~.x~~U
Parent material s ~^~~t v,Pt81-1 Flood plain elevation, if applicable N_ P\1 ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem to S ❑U ®S ❑U INS ❑U ®S ❑U IRS ❑U ❑S Oil
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. BW mnch
0_~2 lo~tcz 3Lz 1. Zri1Sb~c YA cs Zu~ o.S 6.6
Z. t2.L}~ tA`tQ 3L6 - S )I CSb* YA\JJh e-S C•V 0-5
Ground 1$-~3 l~ ` I [Z 5/~b _ S O Sg m - o•-? a $
elev.
a~ fL
Depth to
limiting
factor
? q 3"
Remarks:-
Boring # }
,a,.-.~}~...;~x o-9 ~.~~12 3IZ L Z.wlSb12 }+~`~t., cs Zu~ ~.s€o_6
~':Z~~z,~ Z °I-1S ~u`~R 3l(, S~ 1 CSdk 1'''f~'~- ~-S - ~•Y€n-S
3 ~s=Sq to~,Q yl6 _ S ~ s~ wt 1 _ ~ 8
Ground
elev _
9 3-$ fL
Depth to
limiting
factor
9."
Remarks:
T Name:-Please Print Phone:
Arthur L. We erer 715-425-01.65.
ress
raSs~~leting &__Desii~ Box_ 74_River_Fa11_, WI _5402_
SxTnature _ : - __a1e - :cal ffttift 4
s "t-Z t `MUG-57-6
i
U.
PROPERTYOWNER GL1SS11yG~2 - FOiZD SOIL DESCRIPTION REPORT page ?of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bcurxiay Roots GPD/ft i~
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed T
to 12 sM
z, m T111 `LS Zvi (2)1S o bj•, S ` Q-SbVr W%31'* oLS o•y o.
Ground 3 L~-qZ 111 `-1R ~Ll6 - S 0 4 3 wt 0.7 0,
elev.
ft. ( r F~
Depth to
limiting i 61
,t
f-7 01 2.w
d
Remarks:
Boring #
1 0_ q ti0 `11Z~ l Z - L Zrnslb w,'Ev cs Zvi
.y Z -I I. ~o `tom alb s 1 Csbh lmv ~M - o. y' o,
C1
<,,7 S I.
i 1
3 16-8$ L~`t R Y~6 S D s9 `Nr I - 0,7 i0• iii;
Ground
elev.
013.3 it.
Depth to '
limiting
~ II
f 7 t Jill.
Remarks:
Boring #
. 1 o-°I ~,~`-t2 31Z ~ L Z►-►-~sbk WL'~ cS Zvi o.S ~o,~'~~.
5 Z °I-2~3 > v\-I 2. alb S 1 Csbk w v'~1. cS 'i
Ground
elev. k 4
Q9. S ft. ,F
Depth to
limiting q
factor ~ ' ~ it
Iii;=li ,E
Remarks:
Boring #
I CI': i
r
Ground
elev.
ft,
Depth to
limiting
factor
li
Remarks:
PLOT PLAN Page 3 of 3
SCALE 1 = ~o
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I d
L~~ b ~ ~ s A~q 26
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71,
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CST_ SignaWre: _ late 5ign d Telepho6eNo. CST #
c
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
)
OVVNF.R/BUYERr
MAELJNG ADDRESS C~ ~G> c•c~ S~Yv
S~.~ to a Q, 1~1 11
~ , rs
PROPERTY ADDRESS 1~ a/, t,
r ! S
(locatio septic system) Please obtain om the Planning Dept.
CITY/STATE iU_-A
PROPERTY LOCATION 1/4, 1/4, Section o T~N-R-Z-2-W
TOWN OF O ST. CROIX COUNTY, WI
de LOT NUMBER
SUBDIVISION O U
15-:7 -j
CERTIFFIEDSURVEYMAP 1 &OL 'PAGE ~LOTNUMBER_
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 tTi`ts-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
8 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.
R
Owner of property C G U ptu
Location of propertyA/Wl/41/4, Section T ~2?N-R-Z_~-W
To ship Mailing address C~~ C
e a _ e. I
Address of site 111 a
Subdivision name V, / Lot no.
other homes on property? Yes _No 40x/
Previous owner of property 9A-K-94,0-
Total S~ NEE ~ !Lf f s,p ~
size of property ' rr-
Total size of parcel
Date parcel was created
Are all corners and lot lines Identifiable? Yes No
Is this property being developed for (spec house) ? Yes ~No
Volume and Page Number :3s 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 ewa a 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-Applicant
Date of Signature Date of Signature
Y • - I VOL 1151PE~ 5 6 7 71115 SPACE NESERVED FOR RECORDING DATA
' DOCIIMENT No. ~ WARRANTY DEED
I TATE BAR OF WISCONSIN FORM 2-1982
5_
I r
~ i
' - - - - -
`;"7024
1 1-1 1
BARBARA--A..- GEI_SS-I-NG.ER.--anal -DONALD M- ••FORDf__as I DEC 4 1995
a
ht,.-
I tznants in common and each in-their- own_.rig
Grantors I t 10:00 A- j,J
.
GREGORY B. FERN and DONNA ;4-.- _F ER a -urof D-:ad3
conveys and warrants to
husband--and- _.surv vors..IP_______--_.__
..........G.r. a lit a-e a------------
mar-ital...ProPert.y
0
ip consderairi9.O:.o-..$ Q - -
URN TO
i .........................................................ood ._..'_a _ and othe r nd Doe'
a.na J~ icf- porn
men Dr,vc 1 4,o 303
>_n_cons ide.rator~•-of_..$1.~ ................•----..........g..------- WT S~Fa~~
valuable-.con ~de.>r.at.~q.r1
the following described real estate in .:..--t-•---C-XO•~ COO°ty,
State of Wisconsin: Tax Parcel No:
locat
Lot 6 of the Plat of Glover Hills, a rural subdivisionWisconsdnin
Section 9, T28N, R19W, Town of Troy, St. Croix Cc;nty,
according to the plat thereof filed September office , 1995, inStolCroixf
~ Plats, Page 35, as Doc. No. 533327, in the County Register of Deeds. '
Sset fortn eptember in the
Together with and subject to the rights and obligations
Declaration of Protective Covenants and Easements dated 12,
t 1995, recorded September 13, 1995, in Vol. 1190, Pages 39-96, as Doc.
No. 533786, in the office of the St. Croix County Register of Deeds.
s T ` rsFER .
FEE
This _.__AA..TaQt•........ homestead property. !
(is) (is not)
Exception to warranties:
November t9.9.5
`
day of
Dated this .t
....1...(SEAL)
--.-(SEAL)
Ha ara A. Geissin er
' SEAL)
•
(SEAL)
.
.Donald--M-.-.Ford-._......
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN I
Signature(s)
?=--1/t--
ST. CROIX__. ---•-nty.
+S+ G
Q"•.• e S Persona Y camp before County. ne this ......__.----.day of
E}~?~ ' - --day of 19 T+ 19-9,5- the above name.!
Barbara A. Geissinc~er and
A er~ :-r Dona id
ATE BAR OF WISCONSIN M. Ford
9RL14tB~~'-------------•--•
- -
- -
I Futl~r<i+ ',~y 706.06, Wis. Stats.) to nm ape n who executed the
nt an ack a th ie.
•'•••w.,.,.,. fo is
. WILLIAIM J. Mr.