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HomeMy WebLinkAbout018-1037-20-100 a-°i °o N ^p °v3 I O O ~ c N O 5 O N ~'1 N 1 ~ Q a fi rn X N ~ Y I h ~ ~ I ° (D z ti c co 0 0) a ° °o Cl) 3 I v ~ z ~ w E z w 0 z y y N w a m 0 c C7 0 z C v mz v ° ~ o I C E a M y _ 0 a~ 0 V.IJ N C v N (D CL N d U O N C~ "a © O N Q N Zmz z I 00 O O N E c 10 V L N y ` ` O d O N = Z j i0 I- F- a ao = O 0 0 0 Z ° •N CL IL IL m 0 c a 0 g N 1~ 7 O N E ~ 0 w U ca a) am *V o c0 e) o o N (V m a v Gi O ap u=1 N p 00 c LO y C ~V + 3 O E 7 C..) O c c W co © O T 7 U °`O. c n 0 IL 'o) M n o CN co p P,: Z c E E (U N O. _O rn E ° r s a E ^ c ~ ~ N • o m ? v Ni E E csi -7 O Lr O 2 of N O N -n C6 E E E n a c a r`I~i n v 'c °a' C cu E 0 0, STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~UQl ADDRES >fj mss/ , a^*^ onnnc) Lj.I' C r SUBDIVISION / CSM#q LOT # SECTION- T o? N-R W, Town of_ o n 44 ~~rn ST. CROIX COUNTY, WISCONSIN ' PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1S V 15 115-1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. A BENCHMARK. ALTERNATE BM: SEPTIC TANK / PUMF-CTrMMER / HO TION Manufacturer: _1Ah e's er• Liquid Capacity: 4000 Setback from: Well N/,4 House 1.157 #1 Other Pump: Manufacturer Model# Size Float seperation N Gallons/cycle: Alarm Location ~)4 SOIL ABSORPTION SYSTEM Width: 'L/n /11)_ Length _ Number of Distance & Direction to nearest prop. line: (o I 11 Setback from: well: AJ,4 House .,3D Other ELEVATIONS Building Sewer C),?, IZ ST Inlet. 9Q, 4(v ST outlet 9a o~a PC inlet /V PC bottom Pump Off Header/Manifold Bottom of system 81, ~ Existing Grade Final grade DATE OF INSTALLATION: 9S' PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3 / 9 3 : j t Wiswrisin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety an? Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI IVARD NANCY X CST BM Elev.: Insp. BM Elev.: BM Description: a Parcel Tax No.: 140, / ✓ S ~,n~ as TANK INFORMATION ELEVATION DATA / 30 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic _ Benchmark / Dos' Aeration Bldg. Sewer i Holdin St/WInlet ANKSETBACKINFORMATION St/bl't Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic U NA Dt Bottom Dosi ng ' NA Header 8' a-9' 90.~v -77 Aeratio Dist. Pipe olding Bot. System g pj' PUMP/ SIPHON INFORMATION Final Grade Man , Demand 7 47 Model Number C, RDA TDH Lift L ction System TDH Ft Forcem Length Dia. H Dist. To Well L ABSORPTION SYSTEM BED/TRENCH Width Leng No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DI N I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC Peffiufacturer: SETBACK ' INFORMATION Type Of CHAMB Mo Mbe[_ System: kzEc✓ (~~~ta } ?`t OR U DISTRIBUTION SYSTEM i Header/Manifold Distribution Pipe(s) x Hole Size x HOIe Spa " Vent To Air-intake Length ~O 7 Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S em Depth Over Depth Over xx Depth Of Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hammond.17.29.17W, SE, NE, Lot 170th street a-"~ j~ r 4V v Pan islon required? Yes Use other side for additional information. 77(. s- SBD-6710 (R 05/91) Date Inspector's Signat a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ► I i SANITARY PERMIT APPLICATION r.~iILIIn■'>t In accord with ILHR 83.05, Wis. Adm. Code COUNTY St" G>~o\K STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 02il77~ 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE TY OWNER PROPERTY LOCATION S %4 '/4, S Tar/, N, R or) W PR OW R'S FMLING ADDRESS LOT # BLOCK # / CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Adolim And 01: 1,jy61_S 7/C- 0 . c5 P~~- II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD State Owned VILLAGE N OF: mit rid ❑ Public X1 or2Fam. Dwelling-##ofbedroomsa PARCEL TAX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) /03 7 - Or b 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground- 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. P OF PERMIT: (Check only one in line A. Check 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 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 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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/day/sq. ft.) (Min./inch) ELEVATION 11as 609. Y Feet 9'Y Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App. Tans Tanks Septic Tank or-Holdin Tank W B_4AA__ F1 El I Lift Pump Tank/Si hon Chamber 7~7_H I I ' El I El I L1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name ( t)t): Plumber's Sign re. o Stamps) II~VMPRSW No.: Business Phone Number: C n i o r !S 7/S aiyL S1415" Plumber's Address (Street, Ci tate, Zip Code): 994 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued nt S' a (N Stamp ❑ rcharge Su Fee) Approved Owner GiveInitial 0 aAdverse 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 tt< 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. It. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. 111. 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 v 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) so I-A f 46, La~ i~ SIC / wil J n i e r o' i i f PAGE OF C.rO_SS S Ion pr SySre~'1 V / 76 Fresh Alr Inlets And Observollon Pipe Approved Vent Cap Minimum 12' Above Final Grade 20-42"Above Pipe 4" Cost Iron To Final Oradi Vent Pipe Math Hay Or Synthetic: Covering Mtn. 2" Aggregate Over Pipe - Olitribullon -Tee Pipe - 0 0 0 0 6" Aggregate o Perforated Plpe Below Beneath Pipe o -Coupiing Terminating At Bottom 01 System 9 ~~cJnl' toil SOIL. FILL DISTRIBUTIOU PIPE APPROVED $Ij,lTl{ETtC COVER • ° ATrRU~I- OR 9" OF STRAW (~ARSN HAy e o \~1 fe OF l2 -fiAGGREGATE DISTR19UTIOW PIPE TO BE AT L6.A5T INCHES BELOW ORIGINAL GRADE AQU AT LEASTLO INCHES BUT 1.10 MORE THAN 42 INCHES BELOW FINAL GRADE MAXIMUM DWN OF EXOavAT100 FROM ORI&NAL 6RAoF WILL BE mdb INCHES MIr11MUM A£Prit of EXCAVATI(DW f.RoM. CW141WAL OR49E WILL BE INCHES SIGUED: LICENSE NUMBER: DATE: DEPARTMENT OF SAFETY & BUILDINGS INDUSTRY,' REPORT ON SOIL BORINGS LAND DIVISION LABOR AND PERCOLATION TESTS (115) N P.O. BOX 76 MADISON WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION:SECTION: / TOWNS~IIP/MUNICIPALITY: LOT NO.: BLK. NP.: SUBDIVISION NAME: .SZ / N/R/ E COUNTY: OWNERS BUYER'S NAME: MAILING ADDRESS: r!~f D `s G Sr ~a' 5 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER 1 L DESCRIPTION: (PROFILE DE CRIPTIONS: PER O ATION TESTS: ®Residence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: HOLDING TANK: RECOMMENDED SYSTEM: (optional) [OS EjU ZS If Percolation Tests are NOT re DESIGN RATE: If an q uir ~ any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: DA4 FT PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH AV. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) - - B- / r B- 93 B- 7 7 B- T PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 4"eHff, AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIO 2 P R PER INCH I I 117 - P- p P / I P-3 -3.4 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 I~ O rn~ all borings and the direction and percent ~ /ill of land slope. ,SYSTEM ELEVATION S9's ~4 • ~~i I j__ j / E f z i i 3 1 i ~ ~ ~ 1 ~ i N p SS . • - 1C ~i --7, I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisc nsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME rin : TESTS WERE COMPLETED ON: Q AD E . CERTIFICATION NUMBER: PHONE NUMBER (optional): - ? CST S ATURE: fDISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - J 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 section must clearly indicate whether this is a residence or commercial project; 1 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; 0. PLEASE use the abbreviations shown here for uniting profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; . Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, place N.A. in ti box; 11. Sian the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED ' 'JH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols St - Stone (over 10") BR - Bedrock cob - Cobble, (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone s - Sand HGW - High Groc ter cs C- )rse Sand Pere - Percolatiorr rued s - C _um sand VV - Well I's - Fine Sand Bldg Building Is - Loamy Sand > Greater Than sl - Sandy Loam < - Less Than 'I - Loarrr Bn Brown sii - Silt Loan) BI Black Si - Silt Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot Mottles sc; - Sandy Clay wl - will) sic - Sil y Clay fff few, fine, faint *c cc; - common, coarse pi mm - Mary, rnedrun) rill - Mc•.~k d - distinct p - prominent HWL - High water Level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP Vertical Reference Point E OWNER: Ti - .,ort is they in securing a nitary permit. The cou! y Department- may request s soil i - pric° --trance. A c, of pl ; f -')e private P ion r tied to the 01" order to J mu i and posted prior f any J FJLFD 44,2 . 01986 r l* Co /,L, aft CERTIFIED SURVEY MAP Located in the SE 1/ 4 of the NE 1 /4 of Section 17, T29N, R 17W, Town of Hammond, St. Croix County, Wisconsin Owner: John & Marcella Rivard Surveyed for: Ed Rivard 170th Street Hammond Hammond, W i . 54015 This map is hereby appr ved by the T w f Hammond. Rate Town Cler UNP ATTED LANDS NE CORNER SECTION 17 2.25' North line of the S 1 /2 of SE -NE N89o56'54"W 293.84' i 33 _ i FENCE II' 255.44' 33' i 5.40' I ' 1 I LOT 1 I LEGEND i 87,121 Squard feet or 1 2.00 acres including Section Corner z l right -of -way I I F- Q I monument found a, Q) WI o+ I W z 1 "x24" round iron (n 0 aI 76, 151 Square feet or N I I ~I ~aI pipe weighing 1.68 I 1.748 acres excluding I I N o1 I lbs. / ft. set 00 I Z1 (J)QI ,tttgpllflq~, WI N right-of-way cd I I 4 1 -4 NI W GOA1S►~41 x o M1 W Z off APPROVED 41 ° i W I ~ A NI o ► dal I O i f- I_ 1 z i 2 U z -4 JUN 181986 I POINT OF BEGINNING I W 1 H i I ' .50' Q 0 w) ST. CROIX COUNTY S89056'54"E 293. 84' SU 2 5 8.24' Tino COMPREHENSIVE PARRS PLANNING AND ZONING COMMITTEE I/ 4 O R N E R also 0UNPLATTED LANDS SECTION 17 /"3 .29 N. R.17 W. (SCALE IN FEET) 0' 25'50'.1 100' 200' 300' DESCRIPTION (111Z 100, 1 A parcel of land located in the SE 1 /4 of the NE I /4 of Section 17, T29N, R 17W , Town of Hammond, St. Croix County, Wisconsin, described as follows: Commencing at the E1/4 Corner of said Section 17; thence NORTH (assumed bearing referenced to the East line of said NEl /4, bearing assumed NORTH) 362.51' along said East line to the point of beginning; thence continuing NORTH 296.49' along said line; thence N89056'54"W 293.84' along the North line of the Sl/2 of said SE1/4 of the NE1/4; thence SOUTH 296.49'; thence S89056'54"E 293.84' t0 the point of beginning, containing 87, 121 Square feet (2.00 acres), more or less, and being subject to Town Road (170th Street) right-of-way as shown on the attached map, and also subject to all other easements, restrictions and covenants of record. I, James E. Rusch, registered Wisconsin Land Surveyor, hereby certify to the best of my professional knowledge, understanding and belief, that I have surveyed and mapped the above described property; that such plat is a true and correct representation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Section 236.34 of the Wisconsin Statutes, the St. Croix County Subdivision Ordinance, and the Town of Hammond Subdivision Ordinance . Vol. 6 Page 1668 486-986 TC-10,5 S ' SEPTIC 'TANK MAMFINANCE AGREEMEN'T St Crone County , MXMG ADDRESS PROPERTY ADDRFSS pcation of septic system) Please obtain from the planning Deft. CITY/STATE Oct''' T N-R 7 W S ~ 114, 1/4, Section pROPERTy LOCATION ST. CROIX COUNTY, W1 TOWN OF' LOT NU'bMER SITBDMSItJN ME PAGE ~S~ LOT NIINTaER CERTIMD SURVEY M VOLU AP ~ ure to handle and maintename of your septic system could result in Y or sooner, if needed proper use jos of out the septic tank every wastes. Proper maintenance'cons -pumping affect three the function of the septic tank by liccused septic tack pumper You Put into the system can as a treatment stage in the waste disposal system' ' t for a maximum of 60% of the cost St. Croix County residents may be eligible to receive a gran lacement of ti failing sWem+ which was in operation prior to July 1, 1978. St. Croix County °f rep is August of 1980. with the requirement *111 owners of all new systems agree to accepted this program 1 stained. keep their system pmper Y the owner Tie property owner agrees to submit to St. Croix Zon'nB a certification form, signed by the that (1) per ourneymar► plum, restricted plumber or a licensed p after inspection and and by a mater plumber, j is in proper operating condition and (2) the on-site wastewater disposal system pumping Cif necessary), the septic tank is less than 1/3 full of sludge and scum, UWe, the undersigned have read the above requirements and agree to maintain the private sewage system ~ accordance with. the standards set forth, hereinleted set by the Wisconsin D11K disposal turned to the St Croix Certificatioc stat'mg that your septic has been maintain must re tion date. County Zoning Officer within 30 days of the three Y Sze: DATE. ld /v 9S St. Croix County Zoning Office Government Center 11193 1101 Carmichael Road Hudson, Wl 54016 S T C - 10 0 This application form is to be completed in full and 'signed by the owner(s) of the propo rty being.. developed. Any inadequacies Will only result in delays of the permit issuance. Should this development b owner/contractor, (spec be intended for resale b Y 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-------i--------' owner of property an L~a v Location of property S6 1/4 1/4, Section ~7 jT_23_N-R_t7W Township Tvnm. orLo~ Mailing address Address of site 1 S Subdivision name nq. Lot no. other homes on property? es )C No Previous owner of property nn Total size of property - ~7 /a s© o~ 1 Total size of parcel . L • yf Date parcel, was created 61-20 140 Are all corners and lot lines identifiable? Yes No Is this property being developed for ('spec house) ? Yes --.>L-No Volume -!1Q4, and Page Number 5(a5 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTYtiDEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMSER•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. ,53030 7 , 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 Date of Signature Date of Signature :i ' DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA II STATE BAR 01' WISCONSIN FORM 3-1982 I~ l QUK~ DEED ii Mr ♦ a a' WOO- 0PAGED[)3 s" IF_ W` 9. GZ<~ C'3-i0icy i ~Qh - r I Marcelic A. Rivard JUN 9 11995 I; ii suit-claims to Nan.......K,_.~7.vd d- IL_. Qt $:30 A.Jed ~'y_ u / rR 0A 48 I: H ~ - the following described real estate in ......St.~.. KQa.x-------------- County, oc~ State of Wisconsin: RETURN TO r I' ~J Ty 11 ~I Tax Parcel No: 17...19..17..260C LEGAL DESCRIPTION: SE" -4 OF NE 4 OF SEC. 17, TWSP 29 N, R 17W Town of Hammnd Commencing at the E 4 corner of Section 17, thence N 362.51' along East line to Point of Beginning, thence continuing N 296.49' along said line, thence N 89'56154" W 293.84' along N line of the S 2 of said SE 4 of II NE 4; thence S 296.491; thence 89'56154" E 293.84" to Point of Beginning. °.ntaining 87,121 square feet (2.00 acres) rmre or less and being subject to Town Road 170th Street right of way, also subject to all easements, restrictions and covenants of record. CSM 6/1668 Lot 1~ A- EXETI.J.PT This i5...not:...... homestead property. (is) (is not) Dated this 21st June 95 , 19......... { ........................................(SEAL) - ...•L••'!.....4.. ......(SEAL) v ; Jl. H... Rivard.............. W ` (SEAL) SEAL) • Marcella A. Rivard i i AUTHENTICATION ACKNOWLEDGMENT i' Signature (s) STATE OF WISCONSIN as. St Croix authenticated this da of 19 Personally came before me this _ 2.1.S.t...day of June_ . 19.9`x.._ the above named ii ........................J....._..................._............_.......__....... JIQhn• H.._........................................................ rt i Mar':cal Ia.A...Rivamd................................... TITLE: MEMBER STATE BAR OF WISCONSIN I. (If not . authorized by § 706.06, Wis. Stats.) to me known to be the person ..S who executed the it foPe o1Ll i v ~ . g,ihstrurrient and ackno dge the same. ' THIS INSTRUMENT WAS DRAFTED BY ',ti 4 • • ` •r •i. 1 z ...............County, Wis. ~ (Signatures may be authenticated or acknowledged. Boll • ~5►bS- is permanent. (If not, state expiration are not necessary.) d'a~ ,........3 9 > 19....... QUIT CLAIM DEED STATE !IA.R OF \VISCONSIN Wisconsin Legal plank Co. Inc.