HomeMy WebLinkAbout020-1221-50-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER nd r, , o
ADDRESS ~jr~~ ~r~~►,~_.R ~
SUBDIVISION / CSMj_pj}{-K V (e17,) LOT
SECTION-1-7 T N-R_J~_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN IEW
SHOW EVERYTHING WIT N 00 FEET OF SYSTEM
t M.
tti.
rs
t t4l) 1 CATI' r,orzTli r1P}iOW
Provide setback and elevation information on r~~v~>ISe of this form.
Provide 2 dimensions to center of ~~e~~tir trinF_ m<3nhOl(l r<~vc>i
f
BENCHMARK: - ~P 31q ~O0
ALTERNATE BM: 2-tAo/✓l CO✓'~~/ S !C~ tv~Q t d , 5 y
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: NAUJ4E priP r-A + Liquid Capacity: 000 p
Setback from: WelI- House Other
Pump: Manufacturer !p/i'►A4 Model#6( 033 Size-v,?
Float seperation ( Gallons/cycle: (~a,s
Alarm Location &bn43g, PLAMn p1-1
SOIL ABSORPTION SYSTEM
Width: Length O Number of trenches
G i
Distance & Direction to nearest prop. line: 2D i
Setback from: well: 90 , House 3(P I Other
ELEVATIONS
Building Sewer !99,&6 ST Inlet. S`1' outlet
PC inlet PC bottom ,(0 O Pump Off
Header/Manifold o? Bottom of system %,67a
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER: (7) vPe 77 3r?
INSPECTOR:, dntp ~1
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village p Town of: State PI
GEBERT, ANDREW X
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
v 7
Dosing i _233, d 5
Aeration Bldg. Sewer
Holding - St/,,Wt Inlet 99, X42
TAN-K-S1=TBACK INFORMATION
Ventto
TANK TO P/ L WELL BLDG. Ai Intake ROAD pt4l1fet'-- 1
Septic rp NA Dt Bottom y
r
2:5~ 60
r
Dosin
1' NA Header-
g
AeratioYr-- NA Dist. Pipe 99- ,ex
Holding Bot. System 7io,~ 52
-
PUMP/SNNR
SN INFORMATION Final Grade /
dam, 3
Manufacturer C'cU-~
v
Model Number4 5 r~ 33 ~;UGPM
TDH Li Friction System TDH Ft
oss Head
Forcemain Length 5 Dia., Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length/ No. Of Trenches ply- No. Of Pits Inside Dia,,- Liquid Depth
DIMENSIONS ~ (N a DIMENSIONS SETBACK
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING r r•
INFORMATION Type Of e « f5-/~ p i ~r CHAMB Moe Number:
System:Cr;d: f,=rc - OR UtldfT
DISTRIBUTION SYSTEM
Header / Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length -11L Dia Length Dia. Spacing \
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade s Only
Over Depth Over xx Depth Of ,-xx Seeded / Sodded [Depth
$gd / Trench Center .2 /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.).5-~ e
LOCATION: Hudson.17.29.19W, NE, SW, Lot 127, Brookwood
L
_ _
b'" r~.f-- , it pd_ /r~ ~ .1 ~ - r/~ /i. -l'Y,~;~ ~ ,.C_✓
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Plan revision required? ❑ Yes ~o
Use other side for additional information. /
SBD-6710 (R 05/91) Date Inspector's Signa re Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
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 Cou t
than 8 112 x 11 inches in size. ci-I
&4AAK-
• See reverse side for instructions for completing this application state saAnitary Pe~~ r umber
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
Propert wne Name Property Location
(SE,. EllA "1/4, S )r T , N, R 1 (or) W
Prop w r' ailing A dress, O dl- Lot Number Block Number 12,77
Sta Zip o Phone Number Subdivisi Name or CSDA Number
( >
C Ir
L) IR4~~
1. YPE OF BUILD G: (check one) ❑ State Owned El City 9Nealrest Road
yy ~ C
❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town Village OF 1T J Lno~
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo CPO QC;) 0
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. ® 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 E] Seepage Pit 43E] Vault Privy
14E] 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-) Propposed (sq. ft_) (Gals/da /sq. ft.) (Min./inch) Elevation
~ 00 o Feet -7 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. CoSite n- Steel Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank Q®o O O U filklAl ® 1:1 11 1:1 1:1 1:1
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
i
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PI ber's Name: (Print) Plu ber's$ignature No Stamps) P PRSW No.: Business Phone Number:
,Gc> ffVl ~4 O 71S ~-~S - ~ .
Plu ~be 's Address (Street, C tt~ State, Zip Code)-) Dn 1Af
IX. OUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sarvtary Perm t Fee (includes Groundwater ate Issued Issuing Agent Si ature Nos mps)
)(Approved ❑ Owner Given Initial J~~7 Surcharge Fee)
Adverse Determination ~
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SHD-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 may be 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 tanks and
manufacturer's name, indicate prefab or site constructed and tank material Ccrnplete fo- all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experiment-1 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. CountyDepartment Use Only
not smaller 8 1122 x 11 Inche-, r,Ii, 0r. sij, lir`f S t'; _ _.Jnty The 'tans must
v 1 G of drawl] C.., c,.Jle, of vlllth cornplet: `_ank(s),'i!ptic
a ors] non
epla, _ ,,c.n ys,, rl < Iding served;
Q c.-' , et~ Dr rl x S, rIGSE' VOIUnIt;
')h
Clots se(tioil
I,1`5; .7._rnp CC'"forr on( ] U Jrd Ir 1f, r•, D)
Sy`•tert, it ;e'qu ..J •..i~„'li',, SCE. Lestdata on u I .;rrn ul!: j ti '-,IZlni Information.
GROUNDWATER SURCHARGE
1983 Wise n',Ir, Act 410 included the creation of surcharges ("ees) for a number of rec~ _ lated pr,3cti, e, .vhic h can
effect groundwai-er
The mr~.iie,, :_u'1:_~ ted th( se'Ali-charges are used for monitoring groundw -]ter contamin<an investigations
and estabkshrner,t of standards.
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VEAIT CAP
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4"C.Z. VENT PIPE WEATHER PROOF APFROVED LOCKINIG
JUIUCTIOU BOX MAMHOLE COVEF.
25' FROM DOOR, wiiRr►~a
WINDOW OR FRESH I L AQ ~L
AIR IAITAKE
L GRADE I 4~~
10 1
COWDUIT--
\ \ 1~1
PROVIDE I
AIRTIGHT SEAL I III
T I III
73 C(
Cs-R" , <LBS l?R.y LT " I III APPROVED JOIWT-,
I I III W/C.I. PIPE
y I II ALARM EXTENDING 3'
ONTO SOLID SOIL
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14, b" I
PUMP -
OFF
BLOCK
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OEM L= Performance Data
Pump Characteristics
Pump/Motor Unit Submersible
Manual Models SW25M1 SW33M1 24
R 1/3 HP
Automatic Models SW25A1 SW33A1 W
x
Horsepower 1/4 1/3 U 16
Full Load Amps 8.0 10.0 It 1/a HP
Motor Type Shaded Pak (4 pole) °
a
R.P.M. 1550 8
Phase 0 1
Voltage 115
0
Hertz 60 0 10 20 30 40 50 60
CAPACITY-U.S. G.P.M.
Operation Interdttent
Temperature 120" F Ambient Total Neod (feet) 4 6 8 10 12 14 16 18 20 22 24
NEMA Design A 1/4 NP 44 41 36 33 29 26 23 18 12 6 0 -
Insulation Class A GPM 1/3 NP 47 45 43 40 37 34 30 26 22 16 10
Discharge Size 1-1/2" NPT
Solids Handling 1/2" Dimensional Data
Unit Weight 30 lbs. I. AN dimensions in nslm
Power Cord 18/3, SJTW,101 std 3.1/2 s-~/e 2. component dimeesioes may
(20' optional) 4-1/2 vary for - 1/8 coninch
T 3. Nor 1a sonsuWtion purpose
1-12 NPT Unless « ailied
aterials of Construction 3-1/2 DISCHARGE q Dunemionsand wiphtsam
app(oxuuote
5 011/011 level adrysk"
Handle Steel 6 We (nerve the 101 to
3.1/2 mu4e mvnums b oW
Lubricating 09 Dielectric 017 p,odum and rheN
Motor Housing Cost Iron speckotuMs Wadw notice
Pump Casing Cost Iron I
- -
Shaft Steel
Mechanical Seal Faces: Carbon/Ceramic
Shalt Seal Seal Body: Anodized Steel
Spring: Stainless Steel r r „ I,, rs
Bellows: Bun-N PUMP
ON
Impeller Ther stir 10-1/e 9.1i2
Upper Bear' Bronze Skew Bming DISCHARGE
v. HEIGHT
Lower Bearing Single Row Ball Bwri
3-1/2
Strainer/Base Plastic g PUMP
OFF
Fasteners Stainless Steel -
AURORA/HYDROMATIC Pumps, InC. 0.
1840 Baney Road, Ashland, Ohio 44805
(419)1299-3042
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pagel of 3
Labor and Human Relations
Oi.is~bn of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY i
St. Croix
Attach complete site plan on paper not less than es in size. Plan must include, but
ce~f$Iiii c nd /o of slope, scale or PARCEL I.D. #
not limited to vertical and horizontal referen
dimensioned, north arrow, and location apd'd sf S4o rie lrs$ 020 - 1221-50
P REVIEWED BY DATE
hL INFO ON
APPLICANT INFO RMATION-PLEA9.t,0R T
PROPERTY OWNER:. PROPERTY LOCATION
James Krueger CA GOVT. LOTNE 1/4 SW 1/4,817 T 29 N,R 19 Z-(or)W
PROPERTY OWNERS MAILING ADDRE LOT # BLOCK # SUED. NAME OR CSM #
573 Co.Rd. #J 127 na Park View Acres
CITY, STATE ZIP 61 PHONE E ❑CITY E]VILLAGE MOWN NEAREST ROAD
Roberts, WI. 54023 71 7 72 Hudson Brookwood
( New Construction Use [x] Residential / Brooms 3 [ ] Addition to existing building
j ] Replacement [ ] 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 6 4 3 bed, ft2 5 6 4ench, ft_ Maximum design loading rate ' 7 bed, gpiiiit2 ' 8 tfCitCl,, gPQA
Recommended infiltration surface elevation(s) 98.60 ft (as referred to site plan benchmark)
Additional design / site considerations n a
Parent material o u t w a s h Flood plain elevation, if applicable n a It
S = Suitable fors stem CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for svstem as ❑ U I Em ❑ U I Is ❑ U E56 ❑ U I ❑ S $$U ❑ S tau
SOIL DESCRIPTION REPORT
Boring# Horizon) Depth Dominant Color Mottles Texture Structure ConsistencelBotrtdary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
1 0-12 10 r 3/2 none 1 2msbk mfr aw if .5 .6
2 12-2 10yr 4/4 none sic) Ifsbk mfr gw if .2 .3
Ground 3 24-9 7.5yr 4/6 none cos Osg ml na na .7 .8
le0e2L . §.5
Depth to
limiting
factor
+90"
i
Remarks:
Boring #
1 0-12 10yr 3/2 none 1 2msbk mfr w if .5 .6
2
2 12-3 10yr 4/4 none sicl lfsbk mfr gw if .2i.3
3 30-9 7.5yr 4/6 none s Osg ml na na .7.8
Ground
elev.
102.5.
Depth to
limiting
factory
+9011
Remarks:
CST Name:-Please Print Phone:
Gar L. Steel 71 - -
Address:
1554 200th Ave. New Richmond Wi. 54017
Signature: 4-27-95 Date: c s t m 0 2 2 CST Number:
9 8
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PROPERTY OWNER J. Krueger SOIL DESCRIPTION REPORT Page 2 of 3
PARCELI.D.# 020-1221-50 '
Depth Dominant Color Mottles Texture Structure Consistence Bounciary Roots GPD/ft
Boring # Horizon) in. Munsell Gu. Sz. Cont Color I Gr. Sz. Sh. I I I Bed iTrench
3 1 0-12 10 r 3/2 n n mfr w 2f .5 .6
-oe
2 12-2 10yr 4/4 none sicl lfsbk mfr gw if .2 j.3
Ground 3 28-7 7 . Syr 4/6 none COs osg ml gw na .7 .8
elev.
101.6 ft. 4 70-9 7.5yr 4/6 none s osg mvfr na na .7 .8
Depth to
limiting
fa q0"
Remarks:_
Boring #
1 0 10 r 3/2 none 1 2 m s bk mfr w if . 5 .6
4 2 13-2 10 r 3/3 none sicl lfsbk mfr w if .2.3
3 22-5 10 r 4/4 none sil lfsbk mfr w na .2.3
Ground
100ev7 ft. 4 52-9 7.5yr 4/4 none cos osg ml na na .7 .8
Depth to
limiting
faCA2„
Remarks:
Boring #
1 0-10 10 r 3/2 none 1 2 m sbk mfr w if .5:.6
5 2 10-1 10yr 3/3 none sicl lfsbk mfr gw if .2!.3
3 16-2 10yr 4/4 none sil 2msbk mfr gw n .5.6
Ground
itt.gP 4 26-9 7.5yr 4/6 none cos osg ml na na .7!.8
Depth to
limiting
factor
+9011.
Remarks:
Boring #
Ground
elev.
ft. f
Depth to
limiting
factor
i
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel James Krueger 1554 200th Ave.
CSTM2298 NE4SW4 S17-T29N-R19W New Richmond, WI 54017
MPRSW 3254 Hudson, township (715) 246-6200
t lot 127-Park View Acres
N
1"=40'
BM.= top of NW lot stake @ el. 100,
fily, /+7
z 71 3
^1
5t 1`
Gary L. Steel
4-27-95
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S I C - 105
SEPTICTANK MAINTENANCE AGRI'll:;t' ENT
St. Croix <_ouctty
OWNEWBUYER 7t~4e-k~ -
MAD.ING ADDRESS _4/ ~'..2 `l C o✓ ~ G(ie oL~
PROPERTY ADDIMSS
location of Seines sec leascrObtain from the Planhin}~ I)cpt
I Y l~
C' CI Y ISTA 17:
PROPERTY LOCATION y L/4, 1/4, Section ! 7 , '1
TOWN OF ST. t_'ItOIX COUNI'1', WI
SUBDIVISION I.01' NUM131:1i 47
- -
CERTIFILD SURVEY MAP , N10LUMF-- , PACwF L0T NUNQ Flt -/;1-7
improper use and maintenance of your septic system could result in its premature failure to handle;
wastes. Proper maintenance consistsof pumping out the scptic tank every three years or sooner, if needed
by licensed septic tank pumper. Wliat you put into the system can affcc:t the function of the septic tank
as a treatment Stage in the waste disposal system.
St. Croix County residents may he eligible to reeeive a grant for ;I maximum (tf 60% of the cast
of repl:ecernent of a failing; system, which wbs in operation pilot to July 1, 1978 St Croix County
accepted this program in August of 1980, With the requiremcnl that owners (.)fall new system; a};tee to
keep theii system properly maintained.
Ilre ptopcrly owner agrees to submil tit .cit. ('.roix Lomq,, a ccrtrltc;mon firm, signed by 0w owner
mitt 1)yr:I mmut plumbci, jotirrteyrrtau pluntbr;i, rc! t(mtcd plumLet or a IILCILUCCl liurrrllw vclthat (1 )
(lic c,n ~;It, rlr:pn-;al system is m propcr oper.Ilnrr condition :Imd nfler I natrrtloll and
primping (if necrsswy), the septic tank is Icss Ilmn 1/3 full of ~Il dpy and Scoot
l/W(, the urtdcrsigned have react the above requirement-,, :ur,f ;rr ,cc to In;rtrttarrt the (,rrv:,tc sewfl} C
it,Inr,;Il ,ti .U:tn In ar,ccudanec with the. st:Indaid" r:e;t tunh, herein, a'. r,r-I by tilt- wl,r rrn"m 1?Nlt
rou
cry lr(allctn sealing char your -;optic has Ll4xn maIrimIriud must N. ccoTI l,lewd ;I)tl rctcrrnccf t,i the .`;t I,
('drily /.onntf-, ( Ahrer within 10 days of the three year r..x.plr;i11on dar~-
SIt iNl •l7
DAII:
`.t l tor:, r w1my /onln}; Ofl e
t iovCIIIm, III ( c rtlcl
1101 a ~11IIIlr lmcl P.kwd
EB'd Eb:SO S6. 91 wnf
~f 8 T C - 100
This application form is to be completed in full and signed by t
he
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 ib suld and submitted to this of£ieC with the
appropriate deed recording.
Owner of property _AnjOckA d- AfVNctiE 6&)Q, T _
Location of property 5N 1/4 w' 1/4, Section, T_N-R_J_W
Township +1U 6SP A/ Mailing address ~~Ok`r P d A y)
Address of si E 1' RC1A~, f 7c ~OSG/~? S~~f~/(a
Subdivision name Akk VET-LU 6jIA*r Lot no. Q
Other homes on property? Yes No
Previous owner of property AA,1,2 L t1,-J'6~
Total size of property Q ckf-S
Total size of parcel ( sac RCS
Date parcel was created 1
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes _)~--No
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. _ and that T (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-~+pp] ic;ant
Datc of Signature Date of Signature
b0'd bb:SO 96, 9Z wnf
f
•
State Bar of Wisconsin Form 2 - 1982
531491 WARRANTY DEED n MS L Q
DOCUMENT NO. VOI. 1.131PAGE346-
Sit 'x. 'MSOFF',QZ
Hadd We
Darrel Wert and Beverly Wert, husband and wife, JUL 0 1995
t
a
convas and warrants to Andrew D. Gebert and Annette S. rr°v
Ro~.~ter o9li8st.8
ebert, husband and wife, _
la
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix
County, State of Wisconsin:
(Parcel Identification Number)
Lot 127, Park View Estates Fifth Addition in the Town of Hudson.
TOGETHER WITH AND SUBJECT TO an easement for shared driveway purposes over and
across the above described property as said shared driveway is now laid out and
travelled.
C~" bl
This is not homestead property.
)OW (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
7 v~
Dated this day of Tttn , 195.
-42NzO C~ (SEAL)
(SEAL)
Darrel Wert rt
(SEAL) (SEAL)
Beverly ert aa Beverly A. Wert
AUTHENTICATION ACKNOWLEDGMENT
r
Signature(s) Darrel Wert, STATE OF WISCONSIN
ss.
Beverly Wert
V~ County.
authenticated this day of June '19-95- Personally came before me this day of
/ , 19 the above named
. Kristina gland
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina Ogland
Attorney at Law
Notary Public _ County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
necessary.) , 19
"Names of persons signing in anv capacitN should be tvped or printed below their signatures.
N', IZI?AN'1 DI I-'D CT.A1 E RAR 01: WISCONSIN Wisconsin Legal Blank Go.. Inc.