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HomeMy WebLinkAbout020-1019-40-200 M O v> c o p' O ~ I ~ I O I N it I n r y X Y O c r ~ ~ N N z° ~ I LL c m 0 m pp a ° I Cl) Ul z E z o z ~ a m I v ~ Z c c zv' ~ o I fn F- p a) z [~~N^ n N 0 wv ` cn _ o 0)) Q O U z co z o N Z C ~ N E N [w! N 1p Y V) - a w 0 ID D O a. o Z co > LO ~y o I O O O Z • a. a. a. is c a o ~ I N :3 0) m (D vi J U 2 rn m > - LO ~ I M„y o N o op n 0 N c p p E O m N N U N N d - ❑ U m M~ U N N O " g C) r C) p cD (A o c c E W N N c Lr) d a 3 o o r N m °o o a s' a v o o0) m E E 42 c o o m N b o p a) H m n • cps ` 7 T pv E E U y O 2~ N O - ~ CA ~ I x# a ti a w • CL y d c r`i~V +j E c o I I STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_ SIIIW ADDRESS_~®,r Z flc/ D S o SUBDIVISION / CSM# S 29 1-7(- LOT SECTION / T Z'7 N-R-L,--~Town of /'1aP10A1 ST. CROIX COUNTY, WISCONSIN B. M. ToP o r Nw [BT PLAN VIEW srq SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I k F -F 1z l00.00' /60 3s~ - o 1 ' pT " G `i $cI LF- fly i i ~IrfQNg7E A 0 f A q0 ti14 3 et' ~~~°IX3z SS ~ r i INDICATE NORTH ARRO~d J Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: To P o F Lo T STA&,F #T 1V4.) CoOe A(, R J6/- 2 = /00, 00 ALTERNATE BM: TmP of $IDLk F6v#0,4 /ON F/= O.s SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: WFI S eA Liquid Capacity: /ODD 6A~, Setback from: Well SS House 2a.6' Other Js To 1vu/CaeA'~.eoFflvv3`c Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ~/O - Number of trenches Distance & Direction to nearest prop. line: 3s to V1r57 4v7' Zlez Setback from: well: 13s House qo ' Other (o ' To S T ELEVATIONS Building Sewer ST Inlet. b•12 ST outlet G,1- I PC inlet PC bottom Pump Off P 1}, I z, SO Header/Manifold RNIz,7o Bottom of system (p S- Existing Grade °j, V& Final grade y', g0 DATE OF INSTALLATION: PLUrIBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County- Labor and Human Relations INSPECTION REPORT ST. C'ROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: PuTit Holde;s Nm ❑ City E] Village ) Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / /GO. Cj c- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Aeration Bldg. Sewer Holdi St/ IMP Inlet 0 9h'' TANK SETBACK INFORMATION St/ VOutlet jv 7, TANK TO P/ L WELL BLDG. V#___NA ROAD Dt Inlet Septic > SGl?<` f NA Dt Bottom Dosing Header ! /a 33' /D/i Aeration N~ Dist. Pipe" /p/ Holding Bot. System l~U r: PUMP/ SIPHON INFORMATION Final Grade c M facturer Demand t D, Y" Model Number GPM TDH Lift Loss Iction Syestem TDH Ft Forcemai Length Dia. Hf Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia iqui h DIMENSIONS ' M SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHI anufacturer: SETBACK INFORMATION Type O z J r~_- go / C UNIT R Model Number: System: ' DISTRIBUTION SYSTEM Header/ 1b1 Distribution Pi e(s)~ „ x Hole Size x Hole Spac Vent o Intake Length ~o? Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulc e Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.14.29.29W4 NW, NE,~MCCUTCH:FN ROAD i'-cJ' :ti .1' :~'i G: j"' o ,''(.:,G~s' ~C;/~~ , ~ - ~.r) ~.C_~Y' .l ~y'~Q.C~--~ G ~_k:c~^, J Plan revision required? ❑ Yes Use other side for additional information. 17 11 1 / 1j'9 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. Illr~ry Safety and Buildings Division ~~■Lr■■~ 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 s1` than 8 112 x 11 inches in size. -L t • See reverse side for instructions for completing this application State Sanitary~rmit/dNNumb~er The information you provide may be used by other government agency programs ❑ Check if revision previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 54 Aet 11A r4 L IF/Z_ NKJ114 /YE 1/4, S /V T Z 9 , N, R /q E (or Property Owner's Mailing Address Lot Number Block Number SD " t$ z__ City, State Zip Code Phone Number Subdivision Name or CSM Number upso W I S-yo c3S > z 7 6y c.S M is, s -Z i II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF },<vl>SOPl /hcCuTeHFN Pochb III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo O ?,0 - /D / of o 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 8 171 Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System ---------Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade ysO Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation `F 3 7 Z0 • '7 /ad, 7S Feet /03. S Feet Ca act VII. INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic EAxper. Gallons Tanks Concrete Con- Steel New Existin strutted gb PP Tanks Tanks Septic Tank or Holding Tank /Od ~Z wc-- / S E ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' Signature: tam MP/MPRSW No.: Business Phone Number: NUKE 5L)0 E 4,t!_. Al?A5-o3soo 38'G-~~o9Z Plumber's Address (Street, City, State, Zip Code): y(-1 6RIE,E MILL 4X4115 fi~rJUSoar c,✓i SYo~L IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing ent Si nature (No a s} Surcharge Fee) Approved ❑ Owner Given Initial oil 1 51 711 7 Adverse Determination ley , X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SRD-6398 (R. 015/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Divi ion, 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 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 and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 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 to lks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all >e )zic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experiment. D-oduct approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate p efix ,e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. Compie,e ;p'alls an d specifications not, smal'e; than 8 1/2 x 1 1 inches mu s i-,,- ~I e nty- the plans must include the foilowing: A) (=got plan, drawn tc scale or viith complete dimension lucatw, ; Ic, linc yank(s), septic ;i<_rsl0l;2" Creatr72nitanks, bullding_•e,vers; wells; vvaterrnains/`,ti.i',:~- s.l:;~ce. str__ sakes, purnpor siphon t 31'k', d ;:,uutlon L,oxe,, a5sorptlon systems; replacement systen al-:r>, a c thel:ullding served, _ ~fizu";i.al f (i v,. on reference points, C.I complete spc( 1 l on, `Or pur,lr15 & unt: (,Is,- dosEvolume; elevDti;,n dif feren(- s n loss; pump perfor narn_e _urve, pump rT c w d .,:;mp rna-. r. r-r; t'), cross section - o J~e sc> absorptiol; _yst e ~ if required by the couOty, I_; s~ti! t>stda~.. vr: U lorn~, an:- _51 izinc Information_ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin .Act 410 included the creation of surcharges (fees) for a number of regulated practice which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination invest gations and establishment of standards. SAM M l«E2 LoT -71, 4 c S M FI44F Sg5TEM EI,: to-0.75' SGALE'Iy /O, (3,M, ToP of NW COT STAKE El.. loO.oo " .VokTH LOT L / KE z S/. 2a' f -B-L4 LoT (o LOT S S l°f~ ~ Z•7 3 ALRE S "o r ,q rT F A AIATF- ~ I I~ 70' -I ra4 EA o ni q" o s o' - - q5 I&I Ir ID o ~ o m 6 \ M - r & - WELL cl o ~2~`lE wAY - i 2ZQ j 1 i 1~JP~ V JE J37.S&• SevlH <c7 LiNE MSC U1-CHEN ZDA1) a/.! a, 7~r I ~y loo W LA' Ch I I ~ m 3 I i i i I' ( n m I I m rv*rn I ;u z I I ~ I ~ p LA ran I m t Z' j w I I rn I (A I ~ I I I ~ v m I I 1 d 1 r" I i I © 11~ ~ a I m j -u En • i z -n 02 I I "O fn I J y. r~* j 1 I ~.C) -d f i I m Z an w m AZ x oa -D1 0 I} o ~ Z0 Fn m~ x < AC) J m O z r" -i 4 z m -o `v T m o X os ran 4. Z m a u, Wi:nnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 ' s in size. Plan must include, but not limited to vertical and horizontal reference point , Q ti % of slope, scale or PARCEL I.D. # y dimensioned, north arrow, and location and dist 6) pending APPLICANT INFORMATION-PLEASE P ALIIF RMA REVIEWED BY DATE h PROPERTY OWNER: PERTY LOCATION Kernon Bast +g3 . LOT NW 114 NE 1/4,S 14 T 29 N,R 19 Dior) W PROPERTY OWNERS MA!i_ING ADDRESS # BLOCK # SUBD. NAME OR CSM # 948 LaBarge Rd. na csm Pending CITY, STATE ZIP CODE )BONE NU CRT- CITY []VILLAGE MOWN NEAREST ROAD Hudson, WI. 54016 X7'5)._ -77 Hudson McCutchen New Construction Use [4 Residential I Numbedr~ 3 Addition to existing building (j Replacement [ j Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2 R=te emTended. i;tfiltration surface elevaticn(sj 100.75 bed 101.35 trenidl~ as refer, ed to site plan beiichmarkj Additional design / site considerations trench if used to use area of B-1-3-4 Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system I CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for svstem ®S ❑ U I ®S ❑ U ®S ❑ U ® S ❑ u ❑ S 5 ❑ S ] U SOIL DESCRIPTION REPORT Boning # Horizon Depth Dominant Color Mottles Texture I Structure Consistence BaNxiary Roots GPD/ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmndt 1 -12 10 r3/3 none 1 2msbk mfr 2f .5 .6 1 °2 12-28 10yr4/4 none sil lfsbk mfr gw if .2 .3 Ground 3 8-84 7.5yr4/6 none S Osg ml na na .7 .8 elev. 104.75 ft. Depth to limiting factor +84" Remarks: Boring # 1 -12 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 h„ 2 12-23 10r4/4 2y none is Osg mvfr gw if .7 .8 ::kA+t•}}}}}}iiii 3 3-82 7.5yr4/6 none co s Osg ml na na .7 €.8 Ground elev. 103.85 ft. Depth to limiting factor Remarks: CST Name:-Please Print Gary L. Steel Phone' 715-246-6200 Address: 1554 20 . Ave., New R' hmond, WI. 54017 Signature: Date: CST Number: 5-12-95 cstm 02298 r PROPERTY OWNER K. BAst SOIL DESCRIPTION REPORT Page At PARCEL I.D. # pending /ft Depth Dominant Color Mottles Texture Structure Consistence Botr~dary Roots GPD Boring # Horizon) in. I Munsell I Ou. Sz. Cont Color I Gr. Sz. Sh. I I Bed iTrench 1 0-10 10yr3/3 none 1 2msbk mfr gw 2f .5 1.6 3 2 10-3 10yr5/4 none sil lfsbk mfr gw if .2 .3 i Ground 3 36-100 7.5yr4/6 none co s Osg ml na na .7 1.8 elev. 105.15t. Depth to limiting factor +100" Remarks: Boring # 1 10-16 10yr3/3 none 1 2msbk mfr 2f .5 ':.6 4 2 J6-30 10yr4/4 none sil lfsbk mfr gw if .2 .3 3 0-88 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 104.85 ft. Depth to limiting factor +88" Remarks: Boring # 1 -15 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 5 2 5-30 10yr5/4 none sil lfsbk mfr gw if .2 .3 M,:..... 3 0-78 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 103.25ft. Depth to limiting factor 8 11 i Remarks: Boring # Ground elev. 1 ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 NW4NE4 S14-T29N-R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246-6200 lot #6 N 1"=40' BM.= top of NW lot stake at el. 100, a r g ?-r7' ~r 130 ~ ` 70. B- f f-/2LNN H 1 ([S 130, R3.3 2 ~r 4 (2d- Gary L. Steel 5-12-95 CERTIFIED SURVEY MAP Located in part of the NW-4- of the NE--4, section 14, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin. a~ln~aa,. rs OWNER W. Ray Brown ` C/0 Kernon Bast LA C 948 La Barge Rd. P~ HAG r► Hudson, Wi. 54016 UDSON, Wis. a, ' IJInJ I D LA I D `r~~ VIJv Stj R, 16960 %4 M 494.50' _ S88054'22"W 44- IX II i -I J 251.20' 243.301 - I-11 I-I g I< I- N y~ G o Zc~- ~p l9 - 1/0 00 1 I r ~b I<IJ I C: r 1 Z I~J~ r '7 o I- ~I p IF- N I -p Iv) 1-1 Ic) ICz I_I Ln I:ta7_- - I~ 'c co LOT 6 N LOT 5 ir11 (-n ICO r F' s , tJ ~ 2.73 Acres Inc. R/W 2.72 Acres Inc. R/W N} Corner C2 ~ 118,894 Sq. Ft. Inc. R/W - 118,681 Sq. Ft. Inc. R/W 0 of Sec. 14 - Z. 51 Acres Exc. R/W 2.51 Acres Exc. R/W 109,431 Sq. Ft. Exc. R/W 109,434 Sq. Ft. Exc. R/W ILA jr- F_ C" 00 I-I Sit 00 00 -7 ko N r T p- r W n - - W r• m v ~ B 243.281 ~ j 238.71' co i- J N89037139-'E 481.99' I W W o N8901215211E 237.58' 243.28'_ - N89012152"E 480.86' 0 of 169.811 ( L -South Line of the NWI 7- I rJjCrIJiCilPll Road the NEI of Sdctioo 14. I I a T w C3 I a N ° pr 11 I II~r1CIJ B .to iv rn ~ "III w I W o it co p LEGEND m I ei a ° o ro rr ? ° : I9 Aluminum County Section tr w C) :3 rr W•U~ Monument Found ° W W. 7 N W O N S} Corner R, • 211 Iron Pipe Found r Section 14 r O 1" x 2411 Iron Pipe Set, weighing 1.66 lbs. per m z ~ linear foot. B rl- ~ o a o re fi a Existing Fence Line SCALE IN FEET ° 0 0 100' Roadway Setback Line ~ rt 0 50 100 200 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER SAM M /I-1-4 /L MAILING ADDRESS 13 D X ' L g Z PROPERTY ADDRESS -7.!5o M G 1> Tc l 1~ iC/ Q o ,ff D (location of septic system) Please obtain from the Planning Dept. CITY/STATE J J .S o N W/ S yo / G PROPERTY LOCATION N (.t1 1/4, 17 E 1/4, Section / y T?-~N-R / 9 W TOWN OF 1-1 V D SON , ST. CROIX COUNTY, WI SUBDIVISION C- 5 M # S Z7 1 7 LOT NUMBER CERTIFIEDSURVEY MAP Sz 17 VOLUME' 1-0 , PAGE 2 / , 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 date. P SIGNED: 2:24AA DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 r. 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 :S A A t ^A ( 'LL'aZ Location of property , Y / 1/4 NF_ 1/4, Section 4,~lTAN-R / W Township H J D S o Mailing address Bo X, Z r L 1/ y P s a IV r,J Address of site ~S L /1'1 C cJ7 rHEiy X0,4 D Subdivision name C j /~I Z~ ~7G Lot no. Other homes on property? Yes No Previous owner of property bom4tDx T. 5-PE,ek-- BA-77- Total size of property -2.7 3 .4 c- Total size of parcel Z. 7 3 A e Date parcel was created co - S S Are all corners and lot lines identifiable? Jr Yes No Is this property being developed for (spec house) ? X' Yes No Volume /1Z,/ and Page Number S8S 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. .-S-27 7 yf- , 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. - 9?y` All Zt"" Signatur of Applicant Co-Applicant 7- Date of Signature Date of Signature 06/27/95 10:52 $603 785 1685 FIRST FEDERAL HUDSON 0002/002 S DOCUMENT NO. WARRANTY DEEP Tmm -,oweE nr:EnY ED FOR gECUwDINq, n.T• STATE BAR OF WISCONSIN FORM 2-1082 529'7 VOL 1 ,frg.iGis3~~es~A~ "T. CR3D' C-J,.,W1 Donalda J. Speer-Bast, a married woman li~C'u1iorF:~:~. D ~ , JUN Jr 1995 Zt 8:00 A. 'T)1 conveys and warrants to S,aPI..E,,...Mi I I I... r~L rU I.N TO ~ the following described real estate ill St.,_CTo•i%....................... Councy, _ State of Wisconsin: Tax Parcel No: I A Parcel of land located in part of the NW's of the NEk, Section 14, T29N, R19W, Town of Hudson, known as Certified Survey Map Lots 5 and 6 recorded May 22, 1995 in Volume: 10, page 2921, Document Numer 529176. ;~.i't1''•J•v J tl This is• not.----•-••-•• homestead property. (is) (is not) Exception to warranties: Easements, restrictions and rihts of way of record, if aHY. Dated this day of .......dune 19.95... (SEAL) 'G6-.. dll~ (SEAL) Donalda J. Speer-Bast ..............,...................................................(SEAL) ......(SEA 1.) AUTHENTICATION t ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN as. .S.t.. Cr~o.iY ....................Count authenticated this .....,,.day of 19 Personally came before me this Ilay of ....June 1%5 the above named • I : TITLE-. MEMBER. STATE BAR OF WISCONSIN " . . (If hot, ;i:; ~I authorized by § 706.06, Wis. Stats.) . to me nowh 1'tl~,'~ie2 who executed the fore oingr i aNc~ a tho le. THIS INSTRUMENT WAS DRAFTED BY , .............IIonaLda--Spaar•••Bast.............................. S ST.. c/o Edina Realty ::ity s (1 1},~...._..--R-• ..County, Wis. Notary Pub o';:... - (Sign atureps n~4i rr~C tCCff~'ffrt1~11Cpd or acknowledged. Moth AIy Commisslop•1ta•.permkttCn . (If not, atatc expiratin are not ft&w"ptb date: ....~~.'/l.'....., 18.... } ?lames of versom slynlne in any caDaelty should bo typed or printed below their siQnntures, I •v. n _