HomeMy WebLinkAbout026-1094-30-110St. Croix County Planning and Zoning
Tuesday, September 18, 2007at 4:50:35 AVf
Detail Sanitary Information Page 1 of 1
Computer #: 026-1094-30-110 Sub/Plat: NA Section: 32
Parcel 9: 32.30.18.498810 Lot: 2 TNIRNG: T30N R18W
Municipality: Richmond, Town of CSM: Vol. 22 Pg. 5355 114 1/4: SW 114 SW 1/4
Owner: Ray, David 8 Nancy 1006 County Road E New Richmond, WI 54017
State Permit: 240756 Issued: 08111/1995 POWTS Dispersal: Non -Pressurized In -ground Permit: New
County Permit: 0 Installed: 11/08/1995 POWTS Detail: Trench - Seepage Bedrooms: 4
POWTS Pretreatment: NA
Notes
Issuerllnspector As Built Plumber Other Requirements
Jim Thompson Yes Schumaker, William
Mary Jenkins Signed Off. Yes
Maintenance
Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification
11/811998 04/20/2006
8/11/2007
WI Fund:
Additional Notes Money Owed
acreage minus CSM 11/3168 - issued when part of $0.00
119 acres. Midwest 1200 septic tank to 1000 gal.
dose tank to 2 trenches, 5' x 75'
Parcel #: 026-1094-30-110 09/18/2007 04:45 PM
PAGE 1 OF 1
Alt. Parcel #: 32.30.18.498B-10 026 - TOWN OF RICHMOND
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
12/20/2006 02/13/2007 00 0
Tax Address:
Owner(s): O = Current Owner, C = Current Co -Owner
O - RAY, DAVID C & DONNA J
DAVID C & DONNA J RAY
1006 CTY RD E
NEW RICHMOND WI 54017
Districts: SC = School SP = Special
Property Address(es): = Primary
Type Dist # Description
' 1006 CTY RD E
SC 2422 ST CROIX CENTRAL
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres:
0.000
Plat: N/A -NOT AVAILABLE
SEC 32 T30N R18W SW SW EXC PT TO CSM
Block/Condo Bldg:
1113168 & EXC AS DESC 841045
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
32-30N-18W
Notes:
Parcel History:
Date Doc # Vol/Page
Type
12/20/2006 841046
AFF
12/20/2006 841045
OC
07123/1997 1213/597
OC
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations:
Description
Class
Acres
Land
Improve
RESIDENTIAL
G1
1.000
12,000
126,200
AGRICULTURAL
G4
21.200
2.500
0
UNDEVELOPED
G5
8.680
4.400
0
Totals for 2007:
General Property
30.880
18,900
126,200
Woodland
0.000
0
Last Changed: 08/09/2007
Total State Reason
138,200 NO 00
2,500 NO 00
4,400 NO 00
145,100
0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code
Category
Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
STC 4 104 vy'
AS BUILT SANITARY SYSTEM REPORT
OWNER %�c �/ /f e• �/ ! `r`
ADDRESS_G D AO
tfoA6ev 7 w,'
SUBDIVISION / CSM# 71T ire o LOT
SECTION T N-R W, Town of n�6-p JL
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATE NORTH ARROW
� h 1
— Fe xd t`_; --- --- ---- --
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
� � o, .,�,_ • .
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: /)/,�oG�s fe, Liquid Capacity:,6600
Setback from: Well S D House Other
Pump: Manufacturer Ja%,!a y Model# Size el-3
Float seperation 9 n Gallons/cycle:
Alarm Location 'A"_
SOIL ABSORPTION SYSTEM
Width: -15-- Length 7 S Number of trenches 2
Distance & Direction to nearest prop. line:_
Setback from: well: /°G .. House 6 f Other
ELEVATIONS
Building Sewer ST Inlet.
PC inlet
Header/Manifold
Existing Grade
PC bottom
ST outlet
Pump Off
Bottom of system
Final grade
DATE OF INSTALLATION: Z/ j—
PLUMBER ON JOB: �1�
LICENSE NUMBER: % �1
INSPECTOR: %f o
3/93:jt
Wisconsin Department of Industry,
Labor ortd Human Relations
Safety and Buildings Division
GENERAL INFORMATION
RAY, DAVID
TANK INFORMATION
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
TYPE
MANUFACTURER
CAPACITY
Septic4er9&Jzv&xa4lJ
o
Dosing
p pD
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG.
Ventto
Au Intake
ROAD
Septic
7/4) "
'dS'
5 '
NA
Dosing
NA
Aeration
NA
Holding
PUMP / SIPHON INFORMATION
Manufacturer 14Demand
Model Number GPM
TDH Lift G1 Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
j I
LTION DATA
County:
ST. CROIX
Sanitary Permit No.:
State PIHn o.: ra
Parcel Tax No.:
STATION
BS
HI
FS
ELEV.
Benchmark
/00
L
/0 0 '
Bldg. Sewer
7 ,_ e
93.3
St/Ht Inlet
Qa,y3
St/ Ht Outlet
Dt Inlet
Dt Bottom
Header / Man.
a z'
7.35
q s z
y 39'
Dist. Pipe
z S-.L
1;7,4"'
7'
Bot. System
a 3 q'
of T. 3 c'
Q. 55
Final Grade
y�� y,
I o A. 5-'
BED /TRENCH
Width
Length
'7
No. Of Trenches
1
I
PIT
No. Of Pits
Inside Dia
Liqu d Depth
DIMENSIONS/
a _
DIMENSIONS
SETBACK
SYSTEM TO
P/ L
BLDG
I WELL
LAKE/STREAM
LEACHING
Manu acturer:
INFORMATION
CHAMBER
Type /L
Model Number:
System: %
g0'
�s'
> Ocl'
OR UNIT
DISTRIBUTION SYSTEM
Header I Manifold
Distribution Pipes
x Hoe Size
x Hole Spacing
Vent To Air Inta e
Length Dia
I Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
a�
xx Depth Of
xx Seeded/Sodded
xx Mulched
Bed/Trench Center 6
Bed/Trench Edges
Topsoil
❑ Yes ❑ No
❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Richmond.32.30.18W, SW, SW, County Road E
116
/JL . �!'� / 1�'tt (alitCCa-az 6 c.�2. e� I' • a.�9 S. 5
i w o �^%► i S ' 11aJ . Z::7,a� -�-c)-
d
Plan revision required? fYes ❑ No
Use other side for additional information. [//=0� 6
SBD-6710(R 05/91) Date or'sSgnature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
dr Safety and Buildings Division
ILHR SANITARY PERMIT APPLICATION Bureau of But
Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P O. Box 7969
Madison, WI S3707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less
Count
'
than 8 1/2 x 11 inches in size.
9.
• See reverse side for instructions for completing this application
State Sanitary Permit Number
���
0?46The
information you provide may be used b other government agency programs
Y P Y Y 9 9 Y P og
[]Chock i1 reason ID ple9rDu9 epplicallOn
(Privacy Law, s. 15.04 (1) (m)l-
State Plan I.D. Number
1 APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name
AOLV1/4Sd�
Property Location
114, 5 T30 N, R E (or6l
Property Owners Mailing Address
Lot Number
Block Number
V,rs
City, State
Zip Code
Phone Number
Subdivision Name or CSM Number
IL TYPE OF : (check one) ❑ State Owned
C'tY
Nearest Road
Public Ig 1 or 2 Family Dwelling - No. of bedrooms
❑ Village
Town OF o
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
d2 C
1 ❑ Apartment / Condo
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 online B, if applicable)
A) 1 • M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ I] Repair of an
------System -_------ System ------------- Tank Only_------------ Existin(_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 ZSeepage 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 7a7l 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/da /sq. ft.) (Min./inch) Elevation
� 9�� s7
Gaa� 75,40 7 S0 r �� Feet ,07 Feet
VII INFORMATION
Ca cft
in gallo^s
Total
Gallons
of
of
Manufacturer's Name
Prefab.
Concrete
Con-
Steel
Fiber
glass
Plastic
Exper
App.
New
Existin
strutted
Tanks
Tanks
Septic Tank or Holding Tank
Y,
Idd
®
❑
❑
❑
❑
❑
Lift Pump Tank /Si hon Chamber
❑
❑
❑
❑
❑
❑
VII(. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print)
Plumber's Signature: ( Stamps)
P PRSW No.:
Business Phone Number:
3
1A
Plumber's Address (Street, City, State, Zip Code):
141'74
IX, COUNTY / DEPARTMENT USE ONLY
❑ Disapproved
[]Owner Owner Given Initial
Sa itary Permit Fee Ontiudes(I,wndwaier
Date Issued
Issuing ent Si nature ( Sta ps)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
S60-6391I N 0S1114) DISTRIBUTION: 0r4"f 10 Couniy nee rupy To: Safety A Beilkhoo Divio". (XeM . Muiribe,
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:
I 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 depenc ing on system type.
VI. Absorption system information_ Provide all inf rmation requested for numbers 1 through 7.
VII. Tank information_ Fill in the capacity of every ew/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
VIIL 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 8 112 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 sped fi(aUons 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 contamination investigations
and establishment of standards.
°r_ • _I 0 Iff-IM&SEld lw�IIL cQ"w
Al-
12 ILA07//
Thl
Parcel #: 026-1094-30-110
10/0812010 09:02 AM
PAGE 1 OF 1
Alt. Parcel M 32.30.18.498B-10 026 - TOWN OF RICHMOND
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
02/13/2007 10/07/2010 00 7
Tax Address:
Owner(s): 0 = Current Owner, C = Current Co -Owner
0 - RAY, RETIRED
RETIRED RAY
Districts: SC = School SP = Special
Property Address(es): ' = Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres:
0.000
Plat: N/A -NOT AVAILABLE
SEC 32 T30N R18W SW SW EXC PT TO CSM
Block/Condo Bldg:
11/3168 & EXC AS DESC 841045 (CSM
22-5355 TAKES ALL)
Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
32-30N-18W
Notes:
Parcel History:
MADE NON -CURRENT 2010 FOR 2011
Date Doc # Vol/Page
Type
12/20/2006 841046
AFF
12/20/2006 841045
QC
07/23/1997 1213/597
QC
2010 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations:
Description Class
Totals for 2010:
Last Changed: 02/26/2007
Acres Land Improve Total State Reason
General Property
0.000
0
0 0
Woodland
0.000
0
0
Totals for 2009:
General Property
0.000
0
0 0
Woodland
0.000
0
0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code
Special Assessments
Total 0.00
Category Amount
Special Cho so Delinquent Charges
0.00 6.00
Wa nan Department "Industry- SOIL AND SITE E V
Labor�nd Flrxnan RNaoone
�ivisir .ur Safety a Bulcwvs in accord with ILHR
AM--k ww.wd-.- -:.- wA. --. A- -.L-- 0 . ^ ... —6-
'PION . RT
15, Vas. Adm. Co J�
St. Croix
Page 3 of 3
not limited to vertical and horizontal reference point (BhA'), direction of slope,`i�l0 o O
ARCEL I.D. 9
026-1094-30
dimensioned, north arrow, and location and distance to nearest ro IA f
�
EVIEwEDBY DATE
APPLICANT INFORMATION -PLEASE PRINT ALL INFORM
VS, ti
PROPERTY OWNER:
OMPY LOCAT
DAvid Ray
1u,S32 T 30 N,R 18 *or) W
PROPERTY OWNERS MAKING ADDRESS
LCNh&&&Wff
SUBD. NAME OR CSM IF
985 Co. Rd. #E
na I na
I 119 acres
CITY, STATE ZIP CODE PHONE NUMBER
❑CITY []VILLAGE®TOWN
NEAREST ROAD
New Richmond, WI. 54017 (715 246-5470
Richmond I
Co. Rd. #E
New Construction Use [xJ Residential / Number of bedrooms
4 [ J Addition to existing building
[ I Replacement [ I Public or oommercial describe
Code derived daily flow 600 gpd Recommended design "Ing rate - 7 bed, gpdA l - 8 trench, gpdfft2
Absorption area required 858 bed,112 750 trench, ft2 Maxinun design beding ram .7 bed, gpdAt2 •8 trench, gWt2
Recommended infiltration surface elevatieon(s) 98.57
It (as referred to site Dian benchmark)
Additional design / site oonsiderations alt . area 102.37-99.47
Parent material outwash
Flood plain elevation, if applicable na It
S ■ Suitable for System coNvEmnoNAI WAD
Ut El ®S ❑
IN-GRDLND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
EIS ❑ U ® S ❑ U I ❑ S E311 ❑ S iau
U • Unsuitable for system U
Boring #
s
S
1
Ground
107,
Depth to
limiting
factor
+84"
Ground
el".
101. fL7
Depth to
limiting
tern
+84AA
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
Cons6tencelBounday
Roots
GPD/ft
Bed
iTmr&
1
711
10yr4/3
none
1
2msbk
mfr
Igw
2f
.5
.6
2
11-35
10yr4/4
none
sil
lfsbk
mfr
gw
if
.2
.3
3
5-84
7.5yr4/6
none
co s
Osg
all
na
na
.7
.8
P.cmar:c ;:
1
-10
10yr3/3
none
1
2msbk
mfr
gw
2f
.5
.6
2
10-19
7.5yr4/4
none
sil
lfsbk
mfr
gw
if
.2
€.3
3
19-84
7.5yr4/6
none
cos
Osg
ml
na
na
.7
i.8
Remarks:
Gary L. Steel Phone: 715-246-6200
200th. Ave., Ne wRichmond, WI. 54017
cstm 02298
PROPERTY OWNER David Ray SOIL DESCRIPTION REPORT PRW� . of 3
PARCEL I.D.# 026-1094-30
Boring #
;5
is 3
Grand
101,71 f
Depth to
limiting
facto
+96"
Boring #
C
v
Grand
105."371.
Depth 10
iftng
III=
Boring #
5
GGmund
105.77 ft.
Depth to
limiting
factor
+94"
Boring #
Ground
elev.
N.
Depth to
imili g
law
Honzon
Depth
in.
I Dominant Color
Munsell
Mottles
Qu. Sz. Cont. Color
Texture Structure
I Gr. Sz. Sh.
Consistence
Imo,
I
I Roots
GPD/ft
Bed iTwich
1
0-13
10yr3/3
none
1
2msbk
mfr
gw
2f
.5 .6
2
13-34
10yr4/4
none
sil
lfsbk
mfr
gw
if
.2 .3
3
34-45
7.5yr4/6
none
Ifs
Osg
mvfr
gw
na
.5 .6
4
45-96
7.5yr4/6
none
Co s
Osg
ml
na
na
.7 .8
Remarks:
1
0-9
10yr3/3
none
1
I 2msbk
mfr
gw
2f
.5 .6
2
9-30
10yr4/4
none
sil
lfsbk
mfr
gw
if
.2 1.3
3
30-94
7.5yr4/6
none
Co s
Osg
ml
na
na
.7 .8
Remarks:
1
0-9
10yr3/3
none
1
2msbk
mfr
gw
2f
.5 ;.6
2
9-22
10yr4/4
none
sil
2msbk
mfr
gw
if
.5 '.6
3
22-94
7.5yr4/6
none
Co s
Osg
ml
na
na
.7 .8
Remarks:
Remarks:
S8D4X10(R.05M)
STEEL'S SOIL SERVICE
Gary L. Steel David Ray 1554 200th Ave.
CSTM2298 SWkSW4 S32-T30N-R18W New Richmond, WI 54017
MPRSW-3254 town of Richmond (715) 246-6200
1
1"=40'
Bi.= top of 111 steel pipe @ el. 100'
Alt. BM.= top of 1" steel pipe @ el. 98.52'
W'/9d.-#C
Gary L. Steel
7-26-95
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS Al C G C C
6
of septic system) Please obtain from the Planning Dept.
CITY/STATE%
PROPERTY LOCATION S LO 1/4, -5-W 1/4, Section a T > (zN-R i 9' W
TOWN OF d1_ , ST. CROIX COUNTY, WI
SUBDIVISION
LOT NUMBER
CERTIFIEDSURVEY 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.
l/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.
SIGNED: �/ /.
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
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.
-------------------------------------------------------------------
Owner of property
J
Location of property c 1/4 5 1/4, section
Township L-, f;-, Mailingaddress 13�
S Yo i
Address of site
Subdivision name
Other homes on property?
Previous owner of property
Yes No
Total size of property y0 ckn--�
l
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes X No
Volume Gs2 and Page Number ij'.Z 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. 3 79 y 3 V , 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
Date of Signature
Co -Applicant
f5/5,/9� _
Date of Signature
RICHMOND T.30N-R.18W.
(715) 246.2017
MONARCH
IRINTING, INC.
New Richmond, Wisconsin 54017
QUALITY JOB PRINTING
IWb Off On Wedding Invitations
COMPLETE TYPESETTING SERVICE
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Swenby's, Realtor
"See Us Before You Buy, Sell or Burn"
REAL ESTATE • INSURANCE
214 South Knowles Avenue
New Richmond, Wisconsin 54017
(715) Z46-ZZZZ ❑ (715) Z46-ZZZ3
"WE SELL THE EARTH"