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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER oC d' L4 . e. Ka1 L~.
ADDRESS_ 1& AmA Lpw-
G1oyeR [Ai (Is
SUBDIVISION / CSM# G(ok) I LOT _
SECTION 9 T 018 N-R. W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Note. n1w, Wh If
B~vrzoo a np- outle f &Offk
Nom
• tae ~~1
3y, ay S~p~ ~
0
59, /yr Y8' C, 7a'
a "raQ ~v Cke S-
N
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: UZ4 Liquid Capacity:-a u a
Setback from: WellORK 3() 1
House ~ Other
Pump: Manufacturer ~
Model# Size--."
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 15 Length 7:5 S Number of trenches
Distance & Direction to nearest prop. line: ovem 50'
Setback from: well:6YCKSol
House-_ Other "
LaweR, NeA at (Z 93, IRUNc~, - NQ.~~, 1`9-S7
i m D '13. ! ELEVATIONS i N 0 `Y CoV tit
Buildin
g Sewer ST Inlet,- l4• ST outlet 9(, a9 97
PC inlet PC bottom Pump Off
Header/Manifold
Bottom of system p p
Existing Grade Sy _ I y O
Final grade 1.04*t,(Z - 75, to s
U?pit - ?(#.9 8
DATE OF INSTALLATION:
j+
PLUMBER ON JOB:
LICENSE NUMBER: 3 yo y
INSPECTOR:
3/93:jt
• Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT - GRCII
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
P kff6 YERNa XCcy & LAURIE ❑ City ❑ Village R Town of: State Plan ID No.: Irpriv CST BM Elev..: K Insp. BM'lElev.: 7 BM Description: Parcel Tax No.:
/ 16 66 5( A96001190
TANK INFORMATION ELEVATION DATA 71,51 '9,
CAPACITY STATION BS HI FS ELEV.
TYPE MANUFACTURER
Septic Benchmark
Dosing -
Aeration Bldg. Sewer
Holding St/CPC Inlet
TANK SETBACK INFORMATION St/pt Outlet S/
Vent A-
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic NA Dt Bottom
/ 93. ,
Dosing Header:-
Aeration Dist. Pipe ,3V
Holdi Bot. System /v 6S y? 3;) r
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift LFiction System TDH Ft
Me
Forcemain Length Dia. Dist. To Wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length r No. Of Trenches No. Of Pits Inside Di bqui pth
DIMENSIONS S --2 DIMEN
SYSTEM TO P/L BLDG WELL LAKE STREAM LEAC
SETBACK C MBER
!?v~vC'(*ntF 0 model Number:
INFORMATION Type Of
System: 4,,re_. d 7 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spa n 67S trinttake
Length Dia. Y Length ~ Dia. Spacing
SOIL COVER x Pressure Systems Only xx ;eepth un t-Grade Systems
Depth Over Depth Over xx, Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ ~No
COMMENTS: (Include code discrepancies, persons present, etc.)-Y,/p5 f t-ce
LOCATION: TROY..9._28.19W NW SE BRIA1dA LANE
C'C
p /
Plan revision required? ❑ Yes R No
Use other side for additional information. 310
SBD-6710 (R 05/91) Date Inspector's Sign. ure Cert. No.
i,
Safety and Buildings Division
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 State Sanitary Permit Number
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
jeerty Owner Name Property Location
an.!~ Lie N~1/4 s 1/4,S T ,4, , N, R If E (or) W
caner' ailing Address Lot Number Block Number
City, S to Zip Code Phone Number Subd ision Name or CSM Number
T 5 ( >
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City N st Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms 54 Town OF Lila,
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Numberf(s) n
1 ❑ Apartment/ Condo ® w
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. b?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 410 Holding Tank
12 CKeepage 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/da /sq. ft.) (Min./inch) See 5Aef ElevatiPn
(000 ?50 5 g QtFG Feet Feet
VII. TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks y
Septic Tank or Holding Tank QQ1 ❑ ❑ ❑ ❑ ❑
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 Nam int) Plumber's Signa e: (No Stamps) MP/MPRSW No.: Business Phone Number:
03 5- - U
Ames C&LIL
Plumber's Address Stree , City, State, Zip Code):
49 do / S
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signat a (No Stamps)
$Approved 171 Surcharge Fee)
Owner Given Initial 4 Igo a y
Adverse Determination
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 necv c-iteria 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.
ll: Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwel!ing.
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.
ROS'S ;A.;--. SLU I I I \ 4
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F'RESII Ail" AND OBSERVATION PL1?1
CI;O~S SECTION
Approved Vent Cap
Minimum 12" Abovc I f~
~i nal ,Y~f~4~__~
I '
Y~
px 4" Cast Iron
Above Pipe Vend Pipe
To Final Gradr- I"•
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buikings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
sue. c~,~ ~ x
Attach complete site plan on paper not less than 8not limited to vertical and horizontal reference point (Be a or PARCEL I.D. #
dimensioned, north arrow, and location and distance t . e road. _A v~
~ REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT NF0
17
PROPERTY OWNER: $AeV_,B r" R • G
S l ~e6 P,,qRPER ATION
0(
y`~ ~pN pt ~p 1/4 Sf; 1/4,S 9 T N,R I cl E ( W
PROPERTY OWNER'-.S MAILING ADDRESS LOT # ~W- K # SUBD. NAME OR CSM #
4SD (=,LOU 1 ILLS
CITY, STATE ZIP CODE PHON R ILLAGE MOWN NEAREST ROAD
`I~ups o>v, w l S Y Ol 6 (-It S) 3' t2,p 62twftvR Lkjt
New Construction Use N Residential /Number of bedrooms u r~ h~vvw ry [ j AdditiQn to existing building
j j Replacement [ I Public or commercial describe
Code derived daily flow SO gpd/8 El5tZ(3Q" Recommended design loading rate bed, gpd/ft2 8 trench, gpolft2
Absorption area required - bed, ft2 - trench, ft2 Makimum design loading rate o bed, gpd/ft2 0.8 trench, gpddtft2
Recommended infiltration surface elevation(s) 5ZE ►-►o-rtr eel Pn-&e- 3 • It (as referred to site plan benchmark)
Additional design / site considerations Tz c-VVQQ ~►-t►~ ~
Parent material s +~tioy o ~~vf~3 N Flood plain elevation, if applicable N_ A It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for stem [4 S ❑ U R] S ❑ U ENS ❑ U ®S ❑ U [as ❑ U ❑ S o u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bouixr Roots Bed h3xh
f ; qn-
' ) 0-11 Lo`1tZ 3t'2, - s Z1t. 5 'M U ~h ~S 2u`~ o.S a_
Z 11-93 lWlk Y16 _ S 035 wti ~ - 0.7 0. S
Ground
ab~ft.
Depth to
limiting
factor
Remarks:
Boring #
0-12 to`1 R 31 Z - s Z-.ns U WiU`t~. cs Zu~ 6-Si 0.6
Z Z 12 2,9 luKl23l _ S~ leSbk h1v~~ ~g - o.y`o.S
3 29-b'8 ) (IV 2 t.!16 S Ogg Yn
Ground
elev. -
92- aft.
Depth to
limiting -
factor
~ 88 y
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425-01.65
Veser_er,Soil Testin & Design-Service-P.O. Box 74 River Falls WI 54022
Qatei~,.7
r 4 ,
' III;
PROPERTY OWNER Gl:1S S 1 ~1G~i2 - F0 2D I,
SOIL DESCRIPTION REPORT , •
Page Z of
PARCEL I.D. 0
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft21,
In. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed T
3 0- \-t Z- 3l Z s Z~ sbk Ya u z!-S Z\ o, s a_!JJ'
Z 9-ZO ...~u`-t►z 3~y - s 1 csbtz It7 UcS o.~ o.~?f
Ground 3 Zu $9 l v `t 2 ~!6 - S O s 9 $°`1 !
elev.
Depth to iF
limiting
factor
Is q''
Remarks:
Boring #
1 0-1~ tio`l62 3lZ g 2w►Sb1T vqu'~. Zug o-S,v
I ;I
Z l1-°tZ LO `12 ~f16 ~ S O 303
vrt 1 0.'7 afj
3 -
i I..
Ground
elev.
OL1•'1 ft.
II,
Depth to ;
limiting j {
factor
Remarks: „i
Boring #
v-t) ~~`1tZ 31Z S -M 361 voU` Cg Zu`F p,$ 'a
S Z 1 t -g3 l0`-t 2~/ 6 - S v g S m I - 0~ 7 o.
Ground
q~vI i 'a
ft. l
Depth to
limiting `
u
factor I
? 93"' ~ ~t4
i
Remarks:
I~ 1
Boring #
.4
# ih1 lr
Ground s
elev.
ft•
Depth to "
limiting
factor
Remarks:
PLOT P LAN Page 3 of 3
SCALE 1
lrjous 'TO BE P`T l.ls'f1-ST -?-S' FIw11 TtZ*)O rC -
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131. Z8' 331.3)
9.S_tS-S
17 15 ) 425 MO05~ 76
Signed phone No.
SST Signature Date Tele
Wisconsin Departrnent of Industry, SOIL AND SITE EVALUATION REPORT Page N of 3
Labor and Human Relations
Division of Safety & Railings in accord with ILHR 83.05. Wis. Adm. Code
f 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
PROPERTY OWNER: SP't B " J~ . C EjS S ! Xj G t'R PROPERTY LOCATION
r~~a SON pt LD w'1 F0 RD ( 8T MW 1/4 SLr 1/4,S 9 T Z8 N,R 1 `l E ( W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK it SUED. NAME OR CSM #
y S D N. Lo U~ ~kp t) - 6 LO U ER. 1'}1 Ll. S
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
`Auk )s Olv, LV I S (I 01 L S) 386_ 131-1 't-TL4 11 gCtlptYJR Lk je
DX] New Construction Use pQ Residential / Number of bedrooms U),.j r tvw r'j [ ] AddibQn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow VSo gpd/eEtizoowt Recommended design loading rate bed, gpolft2 8 trench, gp(W
Absorption area required - bed, ft2 - trench, 111:2 Maximum design loading rate bed, gpd/ft2 0 • $ trench, gpd/ft2
Recommended infiltration surface elevation(s) 5QlEf- ►.aoT>r OQ 1>11-6E 3 , It (as referred to site plan benchmark)
Additional design / site considerations -v-x2-- -)kt_ T ~E~b
Parent material S f4^~o~ o y~vfE3 N Rood plain elevation, if applicable N- A ft
S =Suitable for system CONVENTIONAL MOUND J IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem [OS ❑ U ®S El U IN S El U ® S El u [as ❑ U ❑ S N U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GP /ft
in. Munsell QU. Sz. COnL Color Gr. Sz. Sh. Bed mrx:h
0-11 l0`1iZ3~Z - S~ ZMS~ `Mv' ~g 2u`~ O.S Q_b
Z ~1-93 lr Ll12 Y!6 - S o 3'~
Ground
elev.
a6•U fL
Depth to
limiting
factor
~ g 3 ~Remarks:-
Boring # 1
o-~Z lo~tz31Z s -Ln >nU Cs z►,~ o.S 0.6
Sa
Z Z 12 29 } 011 rz3ly csblz Y o. S
NMI
C) 15 yn .9
Ground
elev. -
92.3ft -
Depth to
limiting
factoorprpp
CJ(J4
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425-01.6.5...
ress
eger-er Soil-:Te-sting & Design Service-P.O. Box 74 River Falls,WI 54022
;,iii;
PROPERTYOWNER 6ET.1SSlJVG~2 - ~0fZp SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
slc
Depth Dominant Color Mottles Structure GPD/ft l~
Boring # Horizon Texture Consistence Boundary Roots Bed Trerti
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ,
3j ~~~tcZ 31 Z s Z sb~r Yn v c Z\)
v. Z 9-ZO tu~ttZ qty - s lcsbk wiU`ft- cs o~ oS~''.
Ground 3 Z~$9 l0 `t 2 ~~6 S O s9 1~-i - 7 I''
elev.
9z• S
ft. f
Depth to
limiting
factor
q ►1
Remarks:
Boring #
0 -1 ~ Lb `t 2 ~!Z g Z.kn %bk wt u'F<^ cg Zug o $ tt,
y Z ~1- qZ ~u `t tz Yl6 S o s g w, 1 - 0.7 • g''j
Ground
elev.
O •-1 ft. Depth to
limiting
i
factor
7-7
Remarks:
Boring #
v- t l u`'► 3 J -Z S) Zw, s b wr v CS Z u O. S b. b`':tj!
Z 1l-q3 fib`t t2 q/( _ S C) Sg r•► 1 - ~,7 i0'
Ground
gTv'1
ft. ,
Depth to
limiting s'r
factor l "'r
hit
Remarks:
Boring #
l
r,o,~ w,3,11
Ground
eiev. it f
ft.
Depth to
limiting
factor
r'1.If
Remarks:
PLOT PLAN Page 3 of 3
SCALE 1"=
1r USE '1r BE l) Lfl~ST ZS' FI?-OM Z tZ c1+CT -
i
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b ~ZY'111v -LS:iQC!I TL..EU PMV )U S WIF TM 1~7- of COhI T T"CbOAJ ,
131- Z8' 331.3 j'
9.S_lS-S
1400-57-6
S-T
SST Signature _ Date Srgrled Telephone No-.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER a k V n r La v ri c, ~d S i ~k
MAILING ADDRESS N6 SO Z -7 T~ O r h ' S 8
PROPERTY ADDRESS _ l ri Q n Off, Lra ('1
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Trb T is c6n 5y ~l
PROPERTY LOCATION N v~ 1/4, S / e 1/4, Section 9 T_25 _N-R_13--W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION Moy cz LOT NUMBER
CERTIFIED SURVEY MAR'S_~ 1, VOLUME (0 , PAGE X59 , 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 xperation date.
SIGNED:
DATE: Zd - 9 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.
Owner of property_ o ,k si 4 L Q u r ia_ o51 c k
Location of property t(LO 1/4 5/j'5 1/4, Section C) T ~S N-R-W
Township f Y6 ~I Mailing address N-0 SO2:7 -Z-kOrn FJL kd
-Ladq m i h i. 5 ~l 8 ~f
Address of site gr i a na Lan
Subdivision name G Ip v E-- y f5 Lot no. 8
Other homes on property? Yes No
Previous owner of property rjya P, SS I nGa~Y 4 Dona)_~ M . (0yJ
Total size of property
Total size of parcel q 3
Date parcel was created SE'pf . 1., )995
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume 1I HQ and Page Number 6( 9-5 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. '-3 4/010 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 eds as Document No.
C/
4ture of Ap li.cant c pplican
2-0 -
Date of Signature Date of Signature
g a0 V" -7D
1
$ 2. OT ACRES •.,a~ , c`o.
90, 151 S Q. F T. •
t '
ti I R'
~ f s8 . I ~
66.00' \
2. 41 ACRES, f
100, 138.90. FT.
3.93 CRES ato
y~.. 187 -SO. FT.
3.41 AC. E . A 1 VE wA r EA$EA*NT
' 14 z 0. F T.
DOCUMENT NO. I WARRANTY DEED THIS SPACE RESERVW FOR RECORDING DATA
!ISTATE BAR OF S O SIN 2-1982
53401.0 Vol. ~~~~as~ ~QRM 65
REGISTER'S OFFICE
ST CROIX CO., WI
!
BARBARA A. GEISSINGER and DONALD M. FORD, as tenants Recd for Record
in C...'mon SEP 1 9 I9yo
ntors -
at 11:45 A. M
conveys and warrants to ROCk~! A. Kostick and Laurie A. Kostick
husband . and • wi.fg
Register of Deeds
Grantees.....
%Tuff" To LANDMARK BANK
ai?a..Oth~X.Yd~.Ludk.::~..CQ?1S~deraton P.O. BOX 808
HUDSON,WI 54016
the following described real estate in St....CroiaL------------------ County,
State of Wisconsin:
Tax Parcel No:
Lot 8 of the Plat of Glover Hills, a rural subdivision located in Section 9,
T28N, R19W, Town of Troy, St. Croix County, Wisconsin, according to the plat therof
filed September 1, 1995, in Vol. 6 of Plats, Page 35, as Doc. No. 533327, in the
office of the St. Croix County Register of Deeds.
Together with and subject to the rights and obligations set forth in the Declaration ,
of Protective Covenants and Easements dated September12, 1995, recorded September13
1995, in Vol. 1140, Pages 39-46 , as Doc. No. 533786 , in the office of the St. Croix
County Register of Deeds.,
Subject to a non-exclusive 66-foot wide common driveway easement over the northerly
part of Lot 8 as shown on said Plat of Glover Hills, for the purpose of providing
vehicle and pedestrian access, utilities and similar services to both Lots 7 and 8. k!
The cost of installing, maintaining and repairing utilities or similar services to
each lot, and of repairing resulting damage to any driveway and vegetation, shall be
the responsibility of the utility or service provider and the owners of the lot Y
receiving such ut;lities or services. :he cost of installing, maintaining and
improving any driveway within said easement shall be shared by the owners of both
lots to the extent they agree thereon, but the owners of either lot may install,
maintain or improve any driveway therein at their own expense; provided, howver, that
no lot owner or other person shall cause or allow, by act or omission, anything to
diminish or interfere with the rights of the other lot owners and their use of said
This s_ not------- homestead property. easement.
(is) (is not)
r~u'~iv5Fr2
Exception to warranties: Js
4UF.
19..95... s + z
r.........
Dated this 8th•-....•-• day of F------- temb
t (SEAL`
---..(SEAL) )
• ~bi3ra_A...Geisainge a
r
.............................•-••-...................-•••......(SEAL) - (SEAL)
Donald. M...Foxd......
fi
AUTHNNTICATION ACSNOWLBDGMBNT
Signature (a) STATE OF WISCONSIN
ae. - .
ST. CROIX
Coanty.
authenticated this ........day of..... _ 19 Personally came before me this 8th_..... day of
_ Pt r .....................I 19-.95__ the above named
e ~dra__Ar..issi3?9 anat........................
TITLE: MEMBER STATE BAR OF WISCONSIN -••_lkmald--M,.-.EoXS3
(If not,
-
authorized by 1706.06. Wis. Stata.)
to me known to be the person who executed the
foregoing instrument dge the same.
THIS INSTRUMENT WAS DRAFTED BY'
Wit 7 lam .T_ r-4 11-n►-1- _ of}nrnov x-•-•----••••••~►••r:f••. .
,
r '
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
w r w n ~i ! rrrri ST. CROIX COUNTY GOVERNMENT CENTER
- 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
September 4, 1996
Attn: Darin Heller
BankAmerica
1811 Weir Drive, Suite 145
Woodbury, MN 55125
RE: Septic Inspection for Rocky and Laurie Kostick
Address: 553 Briana Lane, Hudson, Wisconsin
Dear Mr. Heller:
An inspection of the septic system installed to serve the above
described residence was conducted on July 31, 1996. This property
is located in the NW; of the SE,, of Section 9, T28N-R19W, Lot 8 of
Glover Hills, Town of Troy, St. Croix County, Wisconsin. At the
time of installation, this septic system was found to be code
compliant for a four (4) bedroom home.
If you have any questions with regard to the above, please do not
hesitate in contacting our office.
Sincerely,
James K. Thompson
Assistant Zoning Administrator
St. Croix County, Wisconsin
JKT:pe