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HomeMy WebLinkAbout020-1048-01-300 y o (D M 1 ~ ~ 1 M y N 0. O i O ~ > C N O fO N > > f6 N O ° L O Y O C N 3 N ~ y ~ ~ ~a a C O N v U ° _ 0 3 c~Qy y ~ Ci y o> O v <0 O m c ' moo c m ON X N byh` Or-~ X O _N ~CO~ Nw ° y X O C Z W a) C l0 .0 U 3 t6 N .O y N 0 Co C n C '`O' CD CD E Q co~ O ~w m a a~ U (0 Lo CL 0) UJ E Z +O° i N W a co o z c O z d c fA F- I °7 N Z c o E -v Na O Q m ~ C O o z~-z o N Z N d N C E a d - N y d i N O OO (D 0 0 0 a = m N LO (n F- F- 1-- ° O oN O 0 0 0 d LL Z O •rv o a a a .0 LO LO 7 O V) ° to -j U Q 0) rn ° } O r- Q N O o o _ E a m 1 m N «s~ .2 U m 2 Q~ U) co C = 0 C) 6 a c © O o `n 3 v c c B rn o co 00 0 I~ ~ C C C N N ;nw ~ C N N N i..n O N j 7 (D co W Z3 M (6 • y' O c"I 2 m N O N US O ~ w k L N d O d y a 0 a STC - 104 AS BU T SANITARY SYSTEM REPORT OWNER u{~~ ADDRESS- 7 ,4 Lit >r~ 4/7- 1~6ti Gy% f Y~l~ SUBDIVISION / CSM# LOT SECTION 20 T L l N-R1-f W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _z ir-i (ot 0 Q O=rP,~Z ~hrfs Z 9 /a • c cry wr/~ utn~ z # 1 ^f+ ~1 r JAH A l7 /8" d3 X = 6u if va Cvc I l~ 123 r 8M hex-( ~r t„<<(s 6 uH.o( u T~~%r tk7~,,,~,/INDId,ITE NORTH ARROGd Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. c L. BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid capacity: / 20O Setback from: Well >S_6 House _51 Other Pump: Manufacturer ~,eModel# j-_? Size Float seperation Z Gallons/cycle: Alarm Location 6 f,~,H f ~~tt~ SOIL ABSORPTION SYSTEM Width: Length 2Number of trenches 2 Distance & Direction to nearest prop. line: lj 10 Setback from: well: -"/of House f2 i Other ELEVATIONS Building Sewer / ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Qf j Existing Grade rpd,~"~~ Final grade DATE OF INSTALLATION: 5- Z PLUMBER ON JOB: LICENSE NUMBER: i ~f INSPECTOR: 3/93:jt Wisconsin Departmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo.: Perr it H I r's Narrle VlD ❑ City ❑ Village C] Town of: State Plan o.: ll 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 Dosing ~c 50 Aeration Bldg. Sewer Holding St/ Ht Inlet 0 q2' TANK SETBACK INFORMATION St/ Ht Outlet Verit TANKTO P/L WELL BLDG. A irito ntake ROAD Dt Inlet Septic -50 ' NA Dt Bottom X7,15' 5y 0 t Dosing NA Header / Man. (_37 4 S3 L4, Z/ Aeration NA Dist. Pipe &17 ,8 ~ - v 7 7 2 q Holding Bot. System io PUMP/ SIPHON INFORMATION Final Grade - 97. f u~, Manufacturer Demand 95-. 7~ Model Number / GPM TDH Lift~j'3~ Friction System TDH fl, 3~Ft I oss Head ( I 7_ Forcemain Length MID( Dia.,)" Dist. To wel SOIL ABSORPTION SYSTEM BED/TRENCH Width L No. Of Tre es PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS T U !3_) DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O Model Number: Systems OR UNIT CHAMBER 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 El Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.20.29.19W, NE, NE, County Trunk A Plan revision required? ❑ Yes No Use other side for additional information. a SBD-6710 (R 05/91) Date I 'sp ctor's Signature Cert No. SANITARY PERMIT APPLICATION Bureasafetyu aofnd Buildiildiinng Water gs ter 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 81/2 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 I r'f evision to pre w s application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope wner Name Property Location 114 1/4, S Zp T Z , N, R/ E (or)V Pro rty Owner's Mailing Address l~ B Lot Number Block Number vqv G ` - - City Late Zip Code Phone Number Subdivision Na a or CSI VIA ~sd* l J-,Yo/,/, (J~ > GI GS II. TYPE OF BUILDING: (check one) ❑ State Owned , 0 city Nearest Road Villae Public 1 or 2 Family Dwelling - No. of bedrooms 3 a To wn OF ltKc~OS~ C rz y 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 4 -,,-O - O 'y 7 - 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 ❑ 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. 0 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 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation SD o P!W D 9~. to Feet . S- Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank Od pm e Z. ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Z41> "0 ,--5,L m ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY ATEMENT I, the undersigned, assume responsibility for installation of th onsite sewage system shown on the attached plans. Plum er's Name: (Print) Plum is Signature: (N s) -ARP/MPRSW No.: Business Phone Number: ! ♦ 2 - ~j ~ i . e e ZJKf P umb Address (Street, Cit , State, Zi Cod 0.2 IX. COUNTY / D PARTMENT USE ONLY ❑ Disapproved r ry Permit Fee (Includes Groundwater at Sign re (No am Approved ❑ Owner Given Initial fj Surcharge Fee) f/ Adverse Determination / G~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original rn County. One copy To: Safety & Ruildings 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. w 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. 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 applica'ion form. IX_ County / Department Use Only. X. County/ Department Use Only. Compete plans and specifications not smaller than 8 1/2 x 11 inches must be subs' itted tc the cc unty The plans must include the following: A) plot plan, drawn to scale or with complete dimensions loca'_ion of ioldincl tank(s), septic tank(s) or ocher treatment tanks, building sewers; well,;; water mains/water serce; stre,, rns lakes; pump or siphon tanks; distribution boxes, soil absorption systems; replacement system areas, a+the loc,:,tio~ c f the building served; horizoni_al and vertical e ev,ition reference points; C) complete specifications for pumps a-c ontrols; dose volume; elevation differences; friction loss, pump performance curve; pump model and r .,mp r E mf c' -,rer; D) cross section of the soil absorption system if required by the county; E) soil test datcron a 1 15`f')rm, al;c: F) al sizirq information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 4.10 included the creation of surcharges (fees) fora number of regr. later practice; which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. s ~ h w g Z~r f~ C ~ y ~ it N Il ~ ~ Is 13 Ilk) ~ 'hn 1 e S h `D ~ ~ a ? /too S ~ I V I ~ m 4 m ~ W1 gz ~C ti W i ~ 1 PAGF GF PUff\P CHAMBER CROS5 SEC T IOIJ AND SPECIFICA-r►0K!S 3 CAP `1'~C.I. VENT PIPE VEIJT WEATHERPROOF APPROVED LOCKMIG 25' = RO.^1 DOOR, JUIJCTION BOX MANHOLE COVER 9 WINDOW OR FRESH 12"MIU. AIR IMTAKE GRADE I 41 I I y., MIK1. CONDUIT 18 x1m. 18"MIKI. ~ 11~ INLET PROVIDE AIRTIGHT SEAL ► f I III A I III I ilk I I !ALARM I *APPROVED I i ow . JOINTS WITH I I ELEV. FT. APPROVED PIPE I 3' ONTO PUMP --i OFF D SOLID SOIL COAICRETE DLOCK RISER EXIT PERMITTED OKJL9 IF TAKIK MAMUFACTURER HAS SUCH APPROVAL f SEPTIC E SPECIFfCATIOUS DOSE TAWKS MAKIUFACTURER: NUMBER OF DOSES: PER DAy TANK SIZE: r 2mr) GALLOUS DOSE VOLUME /f'/ ALARM MAKIUFACTURER: /PL y IKICLUDING BACKFLOW: ,243 GALLONS MODEL KJUMBEK: Z: rS CAPACITIES: A= ys IMCNES OR f10 GALLONS SWITCH TYPE: 13 = Z INCHES OR _ 9 GALLONS PUMP MANUFACTURCR: 7;~9P C=1_IUCHES OR 216 GALLOI•IS MODEL )LUMBER: ;;ltr7 D-- V INCHES OR _ 2 GALLONS SWITCH TYPE: _ Glut-e4ct~g _ MOTE: PUMP AMID ALARM ARE TO DE MINIMUM DISCHARGE RATE-_ 3o GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEREKICE DETWEEU PUMP OFF ARID DISTRIBUTIOM PIPE.. - FEET -T + MII~AIIMUM NETWORK SUPPLY PRESSURE , , , , , , , , , _ , FEET +FEET OF FORCE MAIN X Z1 _FY F,FRICTI0LJ FACTOR_.FEET TOTAL Dy1JAMIC. HEAD = 4 FEET IMTERNAL DIMEIJSIONS OF TANK: LEKIGTH ;WIDTH --e-C~;L.IQUID DEPTH SIGNED' LICEOSE KJUMBER'_-1'-221 g DATE:- HEAPI LL 115 34 CAPACITY 32110 105 CURVE 30 100 - 95 28 90 26 85 EFFLUENT 24 80 MODEL and a 75 MODEL 189 70 165 DEWATER/NG U 22 V 20 2 65 Z 78 60 p 55 16 50 MODEL Q 163 MODEL F- 14 45 188 12 40_ 35- 1 10 MODEL 30 71MODEL 137, 1,39 65 6 25 SEWAGE and , DEWATER/NG 6 20. MODEL 15 MODEL 161 4 97 10 y MODEL W 2 F U. 5 53, 55, W 2 57, 59 0 i GALLONS 10 20 30 40 50 60 70 80 90 100 110 24 80 75 LITERS 0 80 160 240 320 400 22 70 FLOW PER MINUTE 20 65 p 1g 60_ MODEL- 295. W 55 S 16 U 5o Q 14 MODEL Z 294 12 40_ I ~ p. J 35 MODEL 14 293 10 Q 30 MODEL - - 284 8 I - 25 MODEL 6 20- 282 15 10 MODEL - Z ELLE/~ O_ 2 O 2 267, 268 5 - 0 3280 00 Millers Lane GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 P0. Box 16347 Loulsvllle, Kentucky 40216 / LITERS 0 80 160 240 320 400 480 560 640 720 (502) 778-2731 CFLOW PER MINUTE Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page Labor and Human Relations L of Division 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 PROPE OWNER: PROPERTY LOCATION < e GOVT. LOT 1/4 - 114,S.Zo T N,R E (04ty PR RTY OWNER': MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # r - - CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE [MOWN NEAREST ROAD [ ] New Construction Use Residential /Number of bedrooms [ j Addition to existing building Replacement [ j Public or commercial describe Code derived daily flow 7S-o gpd Recommended design loading rate -,Zbed, gpd1ft2 . J' trench, gpd/ft2 Absorption area required /,o 7S bed, ft2 ~F JV trench, ft2 Maximum design loading rate Z_bed, gpd/ft2 . / trench, gpd1ft2 Recommended infiltration surface elevation(s) 93.6 It (as referred to site plan benchmark) Additional design/ site considerations cw¢ 6ores if-3,V 2 jg ' o/ '6 /c # z Parent material 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 m S 1:1 U ❑ S JZ U 0S ❑ U S o u ❑ S m U S m U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Motes Texture Structure Consistence Botxtclary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& -.2 7 S 0"t At r .5 Z r ~~.6l Ground elev. _ i ft. L -5-f lo - - c K K. t7- s o'. S Depth to limiting r factor 3 Remarks: Boring # Z/ C.C Ground elev. o _ c c /DO.'.rft. ~ +a r o S Depth to limiting factor lop -Addl Remarks: CST Name: Please Print Phone: - 1 lP zyf Address: V o e3' OlP r w o.i Signature: of D ta: CST Number: PROPERTY OWNER j2e~• 114,ef el SOIL DESCRIPTION REPORT Page z of 3 PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Botixl~y Roots Bed Trench ; i / - ZZ 6- i c l .2 Jrr L k ht 41 7Z CS _740 Ground elev. f. 2 ft. Z. 2 -S 0" c/ c S C 4r S c o . S' Depth to limiting factor 3 - 9 s- _ s e / - Remarks: Boring # .2 ji 4 ti'Lvti•:vi•.t4.5 COY a)' Ground elev. ZZ re P. ~r co .Y . S" ft. Depth to limiting factor Remarks: Boring # Lk-:v.-n..-.. Ground elev. ft. Depth to limiting factor Remarks: Boring # inlM1. Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) CIS °=w IINJ ZC~, C y 1 CC ~ W ~ ^ N w Z' w H ~ V -C O ~y X Iv ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certi that I have inspected the septic tank presently serving the Ice -e 44 le / residence located at: 1/4, Pt 1/4, Sec.~0 , T_,MN, R_[g__W, Town of _ z Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes!/ No (if no, skip next line) Approximate volume or length of time: gallons -minutes Capacity: J paO Construction: Prefab Concrete t~" Steel Other Manufacurer (if known): yi Age of Tank (if known): 4101~ b/ per/ ~ (Signature) (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform the requiremen of ILHR-83, ;Wis. Adm. Code (except for inspect o opening o let baffle). Name Signature MP/MPRS 32f~ 5/88 TRI-COUNTY SANITATION, INC. 507 5TH STREET HUDSON, Wi. 54016 Mr. Dave Bluemel 491 Cty. Rd. A Hudson, Wi. 54016 Dear Mr. Bluemel A inspection of the septic tank at your residence of 491 Cty. Rd. A Hudson, Wi. was conducted on 06-15-94. The septic tank was pumped at the time of the inspection. The septic tank has been maintained by Tri-County on a regular basis. It was noted that the septic tank is a 1000 gallon tank and that the exit baffle has been replaced. Other than that the tank appeared to be in working condition with on signs of cracks or the bottom heaving. incerelyl M V-) t'`r`_" Ben Morgan Tri- County Sanitation STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNEWBUYER MAILING ADDRESS ~IJC~~1~1 y 1 n PROPERTY ADDRESS l I Co ° l A (location of septic system) Please obtain from the Planning Dept. CITY/STATE G/Ci yy% Lh S " / PROPERTY LOCATION " 1/4, 1/4, Section 'I,?,>, TZTN-R ye TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT N MBER - 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 tl ar expiration date. SIGNED: U DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, `\Vi1 54016 1 1 /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. ------------------------b------------------------------------------- Owner of property. ~6IL/tYV\ 2 Location of property_AZrl/41v_F1/4 , Section 7.c , T N-R__2_7_W Township A ts' S&) Mailing address S,51 Drew , t, Address of site C-15 Subdivision name Mz Lot no. Other homes on property? Yes_s,-/ No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes N Is this property being developed for (spec house)? Yes No Volume -J-~ 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. 1 3 ."^/Z_, 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. _V S3 s 1'~ 1 signature of Applicant Co-Applicant L ld Date of Signature Date of Signature v DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1961 THIS SPACE RESERVED FOR RECORDING DATA QUIT CLAIM DEED 453518 Kathryn M. Bluemel J REGISTERS OFFICE ST. CROIX CO., WI quit-claims to navid .T_ Rluemal a/k/a David R1 em 1 Reed for Record at NOV 161989 a.~1...10+ the following described real estate in St. Croix County, I Q h0vof Dollith State of Wisconsin: RETURN TO J4&" C.5 $pf-TAct-o to P. C1• 1t3otc Z~ I! ~L!t_n_ScN . w . ~ 01 Tax Parcel No: Part of Northeast Quarter of Northeast Quarter of Section 20, Township 29 North, Range 19 West, described as follows: Commencing 368 feet West of Northeast corner of said Section 20; thence West 158 feet, more or less, to road leading to elevator formerly owned by H. C. Hanson; thence Southerly on-said road to right of way of Chicago, St. Paul, Minneapolis and Omaha Railway Company; thence Easterly on Northerly line of said right of way to a point South of Place of Beginning; thence North to Place of Beginning. Part of Northeast Quarter of Northeast Quarter of Section 20, Township 29 North, Range 19 West, described as follows: Commencing 521 2/3 feet West and 33 feet South of Northeast corner of said Sectoin 20, being 83 feet East of centerline track on WYE of Chicago, St. Paul, Minneapolis and Omaha Railway Company; thence Southerly parallel and 83 feet East of said Centerline 410 feet; thence Westerly 33 feet; thence Northerly parallel and 50 feet East of said centerline 410 feet; thence East 33 feet to glace of Beginning. This deed is given pursuant to.juigment of divorce; pending in the St. Croix County Circuit Court as Case No. 88-FA-189 i•t,Lt >f This i3 homestead property. (is) (is not) 9 Dated this S+ day of tg / (SEAL) ~V (SEAL) Kathryn M. Bluemel I (SEAL) (SEAL) I I AUTHENTICATION ACKNOWLEDGMENT ~I Signature(s) ~U-Q KAJe STATE OF WISCONSIN ss. Oq - County. authentic ed this-.day 0 19~ Personally came before me this day of 19 the above named J" I- s 2 t6m~, Psi c d i TITLE: MEMBER STATE BAR OF WISCONSIN (If not, 10 me known to be the person who executed the authorized by § 7006.06, Wis. Slats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED By Bartholomew Law Office 516 Second Street 'j -Hudson, WI 54016 Notary Public County, Wis ~I (Signatures may be authenticated or acknowledged Both 1.ty Commission is permanent. (If not, state expiration are not necessary ) data _ 19 ) n r ~s , ?•sons 9 gn-j n err cacao u P e •no„ y_ - . -j S83 NTF 17.6 1 , ,vPU n _ 9 d! .9 QUITCLAIM DEED STATE BAR OF WISCONSIN FORM No. 3- 1962 Neico Tax Forms, P 0 Box 10208, Green Bay, WI 54307.0208