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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
01)or and Pluman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
DULLINGER, ARNIE M.
Vn"
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
F ding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
irIto ntake ROAD Dt Inlet
TANKTO P/L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss
ead
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 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: Eau Ga11e.29.28.16W, NW, NW
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION CO TY
In accord with ILHR 83.05, Wis. Adm. Code .
` STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 094 3
8% x 11 inches in size. El Check if revision to~vious application
STATE PLAN I.D. NUMBER
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRQR PROP RTY LO~CA1TION
OPERTY OWN
M G(.~/a (N/a, S N, R W
70 ` ~ ~ LOT # BLOCK #
PROPERTY OWNER'S ~ MAILING AD WSS
Z~- t'
NE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY, gTATE ZIP CODE 7(7
~ 3t
fbaldt0l 0, 1 lt)1 , _2002, 5 6g
CITY NEAREST RO
02
II. TYPE OF BUILDING: (Ch ne) ❑ State Owned ❑VI E ~z
❑ Public 1 Or 2 Fam. Dwelling-# Of bedrooms --PARCEL TAXNUMBER(S))pp~,
~,~/r~~-1092•Sv - Lf1 ~_4
III. BUILDING USE: (If building type is public, check all that apply) (JVO
1 ❑ Apt/Condo ❑ Outdoor Recreational al Facility
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 11 El Outdour Recreation
3 El Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash
4 ❑ Church/School 8 ❑ Mobile Home Park
9 ❑ Office/Factory 13 ❑ Other: Specify
5 ❑ Hotel/Motel
IV. TYPE OF MIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2.E] Replacement 3. ❑ Replacement of 4.0 Ex Reconnection 5.0 ERepair x sting System
System System Tank Only g System
B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
. Other
Non-Pressurized Distribution Pressurized Distribution Experimental
11 ❑ Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El Holding Tank
42 11 Pit P 'vy
12 ❑ Seepage Trench 22 ❑ In-Ground 43 ault Privy
13 1:1 Seepage Pit Pressure
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
ER GRADE
1. GALLONS P AY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. EFINAL LEVATION
QUIRED(sq.ft.) PROPOSED (Gals/day/sq. ft.) ( )
Feet Feet
CAPACITY Prefab. Site Fiber- Exper.
VII. TANK in allons Total # Of Manufacturer's Name Concrete Con- Steel glass . Plastic App
INFORMATION New xisting Gallons Tanks structed
Tanks Tanks
Se tic Tank or Holdin Tank
Lift Pum Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP/MPRSW No.: Business Phone Number:
Plumber's Name (Print): Plumber's Signature: (No Stamps)
917 t 6~y 3/7
11 `
Plumber's Address (Street, Ci , State, Zip Code):
"'170 227."'x'i
IX. CO TY/DEPARTMENT USE ONLY
E] Issuin A ntSigna No
Disapproved S,a ii tary Permit Fee (includa g rFeej Water ate Issued g
Approved ❑ Owner Given Initial
aC/
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
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 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% 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)
6 ~ I- I in accord with ILHR 83.05, Wis. Adm. Code COUNTY t
~u„7.ur.r.uw+,.u n..¢J
~ r d ►r~Y
Attach complote silo plan on paper not loss than 8 1/2 x 1' 1 inchos in sizo. Elan must includo, but ~ PAACELLD. N k
not limhad. to vortical and horizontal roforunco point (EIM), direclicn and % of slope, scalo or ;
dimensionod, north arrow, and location and dislanco to nonresl road. '
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY LOCATION
/ T29 N,R I ~ (or ~ 411
i ii GOVT. LOT NW 114 1V V114,S 2q
r\o1 Jt C tv -
PRQPERTY ONNER:'S MA IN ADQ 5Zr S - u(~t 1.0T M BLOCK rr SUM NAME OR GSM N
CITY, STATE, ZIP CODE PHONE NUMBER ❑CITY' ❑VILLAGE J1QWL NEAREST ROAD
p~ l~CS16`6 1 222nd Sve~~ -
3
D New Construction Use (k~ Residential / Number of bedrooms
j J Replacement u ( J Public or commercial describe
Code derived daily flow 15 gpd Recommendo design loading rate bed, gpd/ft` trench, gpd/ft2
Absorption area required 3q5- bed, tt2 trench, f~2 Maximum design loading rate bed, gpd/tt2 trench, gpolt?
Recommended infiltration surface elevation(s) 94- l02 ` ft (as referred,lo site plan benchmark)
Additional design/ site considerations MoutJ F T R P
Parent material 104$S Flood plain elevation, if applicable fl
S - Suitable for system CONVENTIONAL MOUND C~GROUND RESSURE AT-GRADE SYSTEM W FILL HOLD i NG TANK .
_OS _
f7LLJ ❑ U ❑ S U C3 S U ❑ S ❑ S Dru
U= Unsuitable toes stem O S
SOIL DESCRIPTION REPORT
t
~Depth Dominant Color Mottles Texture Structure Consistence Bardary Roots GPDIft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trawl'
111 J-1.2 I 0-3 io wZ s l2 J 3 EC I__ c w i o, s
1x
~ S
2 f ab4 r► ~r w ~ v~
ra.~ 2 3-'8_ to Yi 5/2 _ 5;1
Ground 3 L7-2S t o YA k l'6 5+ '1 2-PCA M Pi w I v4. 0.q
elev. P 2E roY Y/6
i ~tf I vf 0,2
g$ ft. 2lr" 2 10 YR S 6 14-- 2- S R b i c) _ 4 yn fi Vj
- d' 2
Depth to 32- YO 9,5 YA & 12 m Q;2) P 515-18 al m a rh w
limiting
factor YR 5~6 S YR61g C, P
, - 0 r"
Remark's: - -
6ortng # 10 YR 313 ipt V4 0-5-1
So 0,5-
3 13-2q Iv Yee sI °-s
, 4.2
P
Ground elev. 1st ygf 2d ,2.5YRS18 . ~I I w, a64 v
It. -
p
Depth to 3S 3U 9.5 YI25 ttj F rg 2 SYR NL9 - --C I-- ! g b 0'2
- -i-- -
limiting
factor - I
H I
Remarks: -
CST Name:-Pisase Print n Phone: 30g'D r
t)duc2 Alto., S9q
Address: R r 3 Boy ;-3 F !f Ur A
-
Signature: / Date: CST Number,
, /'!19' < r LO 9/9 (n S T /90 ~L
r
7-
SOIL. DESCRIPTION REPORT
Depth Dominant Color Mottles Structure' : GPD2. '
Boring # Horizon Texture Consistence Bourr}~ay Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sir Bed Trand
3 ,oyR_wr - S~1 a i o•r
Z H-1b Iv Yk y 13 grI 2 ~aLk v fr I vf. .S' 1
Ground 3 Iv - IS 715;11 ~Y S 2 ~4~~ wI ~r t ;0015 il:
iloo, n. 9 Ir-fit roYt2
Depth to 26-32 !o YR ~-/y j d 9,SYJP9/ 14/
limiting
factor 6 3a- Ny t o YR S S YtR bh ' C Q r►~ C i i
26
i~
Remarks:
Boring #
,i
Ground
>elev
Depth to
limiting
:,factor 3
Remark's:
Boring #
i
Ground
elev. ft. #
r ,
Depth to
limiting
factor
Remarks:
Boring # -
Ground - '
elev.
It.
Depth to - {
limiting
factor - - -
Remarks:f M L e✓ R~Or -lc~_,c~%. ~
N /w a4- NW 'rK s
~acetitt~ ' ~
~~yy 4f r
' jocatp~, eta Rd+s4rt' ~aehe~v,,r,v✓ C~Ym ~ti„
v
flora ~
y s ° 7o
N
66 i
vlt
S _
t9- s°f e ~ Y
1
►•3 5►akr iv P of Oak, e1tweWO ►
hot 1-0 k,voo~ lat~ ~ Wry mf ~`i
Zhrs vc(trCwce ~o►K1' c vavi affly L* 76-
/
1 'i'~G W
p
RDq~rtg YbetJ SP_trQvitvS
'TI Ste ?9 -r 24N R ~6 s"'i ikfr: 4 Ste .
t:
Ytf{~t r'c'~ ~~ih'+ 0.PnrDYr v»Ottr O ! of T
Q 'C~7S a«a
J.` }p.~~ ~jaln t1'!°~G+c.Y'Q-~eS s~'ct'~OwS
Bow, 99 0
~ave.3 Io0• `I
R~ s sd"~ s, syo+f
GSA
k
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
DivisiQn 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
Z
PROPERTY OWNER: / PROPERTY LOCATION
CtG~(e r~ GOVT. LOT j j &j 1/4 t) 4ji/4,S T ;?8 N,R 6 W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILI GE OfOWN- NEARESI ROAD
( ) eakl 6&. ire ZZ,7- Sf. 71 e
[ ] New Construction Use [ ] Residential / Number of bedrooms [ J Addition to existing building
Replacement - [ J Public or commercial describe
Code derived dairy flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material ITr Flood plain elevation, if applicable 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 ❑ U
SOIL DESCRIPTION REPORT
B ing # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft
Consistence Bouxfary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trencft
v l~ S Z r lv~ i
(`>r
o-.~ 1t4...' ' ~ 1-10 1 J I i^n i • l7 1
l9 m S ' ~
Ground LLI [C Si I E C, 1^4
elev.
r
ft.
" h~SbK ry);
Depth to 2?"3`~ any- m z c~ 2 5"r C)
limiting
factor
Remarks:
Boring #
f.
Ground
elev.
ft.
Depth to
limiting
factor
m I G,55i~e
Remarks: P i,JJ ? c l<.:I.' e. ~CL
CST Name: Please Print Phone:
Address:
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boubary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
. ~:•t}tt:ti ii
Ground j
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. j 16 r
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Bog 7969
Madison, Wisconsin 53707
State of Wisconsin
Department of Industry, Labor and Human Relations
December ~11 , 199P
BRACE WEBSIUR DAN R .1AN DULLINGE_R
RT 3 BOX 231 1 1 1 ?Nlt 1
E l_L sWORTfi WI 54011 BA f!Wl N Wl SOO?
hear Sir or Madam:
Subject: Petition for Variance Approval
PLAN ID: 920:3248
There has been some confusion expressed regarding the status of petitions for
variance for mounds for new construction. On November 2:1, 11492, Judge Mark
Frankel of the Dane County Circuit Court issued a temporary injunction against
the Def)drtment prohibiting it from accepting or approvinq certain kinds of
variances. The injunction affected only petitions being pro(rossed on or
received after November 23, 1992. The variance,, that yoc_r r(-'+:pived for your
mound system was approved prior to the issuanc.e> of tho temporary injunction.
They Public Intervenor, who brought the action against the Dnpartment, raid not
request, nor did Judge Frankol grant, any order affecting variances, already
approved by the Department. It you havN nclt yet donr= so, you may submit a
sanitary permit application to your, county corfe administrator. Once you have
received a sanitary permit, your plumlcer may proico(ld w1th tho construction of
the mound system.
If you have, any questions regarding this owttwr flea-,j, fool tree, to contact
me.
`sincerely,
1
Bennette 0. Burks, fl,E., Chief
Private Sewage Section
6081266- 0056
cc: ~T CROIX
t.
SBD-88171 R. OI 1911
d ST. CROIX COUNTY
~y
WISCONSIN
r
ZONING OFFICE
x ST. CROIX COUNTY COURTHOUSE
x, 911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
Aug. 12, 1992
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
To whom it may concern:
An onsite soil investigation of the Robert Kachelmyer property,
located in the NW1/4 of the NW1/4, Sec.29, T28N, R16W, Town of Eau
Galle, St. Croix County, WI., has been conducted with the
assistance of Bruce Webster, CST# 1902. This site was located in
the NE1/4 of the parcel.
This onsite revealed suitable soil for onsite sewage disposal to a
depth of 17" while meeting the requirments of the A + 4" rule. This
site should be suitable for new construction using a mound septic
system having 19" of sand fill.
Should you have any questions, please feel free to contact this
office.
ince ely,
ales K. Thompson
Assistant Zoning Administrator
cc: file
PRIVY INSTALLATION AGREEMENT -COPY TO BE ATTACHED TO THE SANITARY PERMIT APPLICATION.
Property Owner(s): Reserved For Recording Data
Mailing Address:
176 s-
Location: 11
17 a)1. S T ;2-SN R Zi~ W
Lity iFiHage,.7ovy~ship o :
Parce Tax Num er:
Legal Description:
~Sa l-,.e
1. No plumbing will be instilled in the privy.
2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or
holding tank exists, or a valid sanitary permit to install such a system has been issued.
3. A privy vault / pit shall maintain minimum setbacks as specified in Table 1.
Table 1 Well Building Lake / Stream Additional County Setbacks
Open Pit 50 Ft 25 Ft Min. 75 Ft
Sealed Vault 25 Ft 25 Ft Min. 75 Ft
4. Privies for public buildings shall comply with ILHR 52.63, Wis Adm. Code.
5. Privies used for one- and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and
'other vermin. Doors should be self-closing and vault ventilators should terminate at least one foot above the roof.
6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall
comply the intent with ILHR 83.20, Wls. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes
and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code.
7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR
113, Wis. Adm. Code.
8. This agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the
register of deeds in a manner which allows its existence to be determined by reference to the property where the
privy is installed.
Printed wner s Naarne s :
Ar AA Z, , , ~k"evc r Subscribed and sworn to before me on this date:
Owner(s) Signature:
Notary Public
My commission expires on:
SBD-6432 (R. 05/91) NOTE: This document was drafted by the State Department of Industry, Labor and Human Relations,
Bureau of Building Water Systems.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER-
MAILING ADDRESS 17e 15LI 51"
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE g
PROPERTY LOCATION fi6) 1/4, 176d 1/4, Section/ T c'~Lf N-R A; W
TOWN OFu (gage- ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME -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 dates.
SIGNED:
DATE: 3 - G
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11/93
Hudson, W1 54016
e
STC - 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., ~Gr~C~Ci, q
Location of property)1W 1/4 Y10 1/4, Section T -;~-B N-R ~co W
Township E6UA Mailing address 170 ~ao~
Address of site
Subdivision name Lot no.
Other homes on property? Yes o
Previous owner of property i~z°~ ~a
Total size of property '~04 f
Total size of parcel 014 4~-
Date parcel was created O~
Are all corners and lot lines identifiable? Yes 1/ TO
Is this property being developed for (spec house) ? Yes L---'go-
Volume and Page Number 41e ;7 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 n 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-Applicant
3 -~q
Date of S ianature Date of S i anat ure
. pOCUMENT NO. WARRANTY DEED THIS SPACE RE•ERVED ►OR RECOaDINo DATA
STATE BAR OF WISCONSIN FORM id-i9a!
v 967PAGE 407 REGISTERS OFFICE
4'IP _ st ggq(OC Y4
Wd for RKW
........._..RQ.b-er-i<..~C~c.he.l,myer., SEP081992
: d 8:00 A. M
conveys and warrants to Ar..nQl-~••M~...D!)1.t1.n9-fit".,.... 4 ...I 11kg...0...
pe.r.son....::.................. Irc
sa,NR r soh C~~~'f him
-
,rit, v,dtA~-
.
the following described real estate ln ...St_zrmix
State of Wisconsin: Tax Parcel No'
The North Na1t of the NWO the Quarter
Southeast eQuNor
art~ereof
Quarter (NI of NWt and
the Northwest ion arten ofnine (29)hwand Quarter (SEi of NWT
NWj) , of Section
Northeast Northeas ofQuarter
Section Thirty
Northeast Quarter
(30),
All in Township Twenty-eight North (T28N), Range Sixteen
West (R16W).
i s
This homestead property.
.
A" (is not)
Exception to warranties: Easements and restrictions of record.
19..92..
r*A.M4
Dated this Q`l~wC- day of
(SEAL)
. .
. (SEAL) . .
- obe *tactimyer
` (SEAL)
(SEAL)
•
MZNT
AUTHSNTICA?ION ACENOWLSDID
STATE OF WISCONSIN
Signsture(a)i-1-L~~C1r as
- ..St'-- C4 am----------•----County.
•
anthentka -P-4A., or - - 1972- Personally came before me this day of
s 19.1? the above named
Robert ache 1 my a r-•---•-•-----•---••••----------•-
'uu x._s~t~~aSa'e C
TITLE: MEMBER STATE BAR OF WISCONSIN
-
(If not,
y .06,
atrthorized by ~ ?06.08. Wis. 3tats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Ih°ma5___A----MLcCnr_mack----•------•--------- e
8A~>i1N~n+ ~I•--54.0.02---------------••--.._.__ Notary Pnblie County, Wis.
My Commission is permanent. (If not, state expiration
(Signatures may be au'heaticated or acknowledged. Both
are not necessary.) date: . 19.........1
' .Names of persons signing in any Capacity should be typed or printed below their signatures. Wisconsin Legal Blank Co., Inc.
~YA8RAN7 r DESJ a7ATF09.1[ BAS No. OF a - 1982 WISCONSIN Milwaukee. Wisconsin
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