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HomeMy WebLinkAbout032-1055-60-300 -0 0 O ~ o0 O a 0. 0 C O I N N N C i ~O N I r O CL E c o~ S 0 N N N N N L N z 3 0 C (6 ~2 N CO (n U. N Q N O z E rn z = o v p M a m N F- Z 0 I 0 z v 'Z c o CD ~ z rn ~ ~ I c E -o I N C0M 3 N N ~ C C 0 ~ Ili 4 o N zF-z o z ~C N E E V N 0 N N - > CL ~l ~~~VVV O N V 't G y C O O W d ~ CU ~ O B I C c CL c N z , > m 'R FL CL 0 --t O O O Z ° cc IL IL CL Z5 EL E -1 ~ U) u' 7 p N N fA J 0 C } Q O N N 00 CY) O O O_ m CL Cl) 'O 0 Q } N 1.1 N N W Q) N a+ 0 O N N U) ICI ` ' Y N C d.+ _ 1 3 O 'C S C 00 N O O U C gg C O C f3 d O ~ N ! ~ N N C ~ I to N C N 2 0 y -OO N` N wk3 .O N CV M E C O Cl) y',~' O N U) Y N O N z Cn O ~ w rr 4; E CC rn ' o as 0 a@ ~ d a c "~1 A U d 0 in U Parcel 032-1055-60-300 06/06/2007 04:38 PM PAGE 1 OF 1 Alt. Parcel 21.31.19.274C 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - HENNESSEY, DAN R & GWEN M DAN R & GWEN M HENNESSEY 413 210TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 413 210TH DR SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 6.626 Plat: N/A-NOT AVAILABLE SEC 21 T31 N R1 9W PT NW NW BEING LOT 2 OF Block/Condo Bldg: CSM 10/2874 6.626 AC EZ-U-1163/212 INC 032-1055-60-200 (274B) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 21-31N-19W Notes: Parcel History: Date Doc # Vol/Page Type 08/19/1998 585326 1349/464 WD 07/23/1997 1131/362 WD 2007 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 10.312 84,500 301,800 386,300 NO Totals for 2007: General Property 10.312 84,500 301,800 386,300 Woodland 0.000 0 0 Totals for 2006: General Property 10.312 84,500 301,800 386,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 132 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STC - 104 W a~ AS BUILT SANITARY SYSTEM REPORT ~d r, OWNER MIKE" V nLAIJLCRiM'AAj ,ls ADDRESS IZO Qj/,AN LAJUC 150ME9516r VIT 4/0Z5 SUBDIVISION / CSM# LOT # Z SECTION Z_T'?)_N-R 19' W, Town of ~ry~c ~15'j" ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Q 1~V i ~t~'' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ' Or S7AV- 3, S7 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: WEEKS Liquid Capacity: D GA Setback from: Well ~ House Other Pump: Manufacturer r Model# Size Float seperation Gallons/cycle: Alarm Location ':SOIL ABSORPTION SYSTEM Width: Length l Number of trenches Distance & Direction to nearest prop, line: r :0 -S Setback from: well:& 4=~4,! E _ House ~Q _ Other ~ ELEVATIONS Building Sewer ST Inlet, ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 9y'lCr~! PLUMBER ON JOB: rL~` X LICENSE NUMBER: (mZ2 INSPECTOR: ~grj,y ~~',Jkfn~S 3/93:jt Wisconsin 'Department of industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPerm itNo.: Permit Holder's Name: ❑ City ❑ Village Town of: State PI AVN704 KLANDERMAN, MIKE CST BM Elev.: Insp. BM Elev.: BM Description: -et Parcel Tax No.: i TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic f~ ~C11 Benchmark X03,5 d0. Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet x,75- g~ ga ' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake q NA Dt Bottom Septic y S 05 Dosing NA Header / Man. 6, 6 a 9` , f5 Aeration NA Dist. Pipe 7y' qc b 3' Holding Bot. System Sa ,6,L) 5 " PUMP/ SIPHON INFORMATION Final Grade s c' yq, o 7' Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft ead Forcemai n Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS g y~ 17 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu acturer: SETBACK INFORMATION Typeo CHAMBER Moe Number: OR UNIT System: ;t&4 A, 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 ^ I xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 30, Bed / Trench Edges a 9- 3U Topsoil El Yes I-] No C] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Somerset.21.31.19W, NW, NW, Lot 2, 210th Avenue Plan revision required? E] es E] No Use other side for additional information. 9 k/ 6 SBD-6710 (R 05/91) Date In pe or's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - SANITARY PERMIT APPLICATION DILHR COUNI;I- In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA Y PE M T -Attach complete plans (to the county copy only) for the system, on paper not less than - 46 ~ ~T 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. PROPERTY OWNER PROPERTY LgQATION Axljkg- [ hJ Yh MAIN,, /INN., S ZI T N, R / E (or PROPERTY OWNER'S MAILING ADDRESS r /E LOT # ~ BLOCK # CITY, lox ,l /1H L- ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER om4Rser w 5yoz5 II. TYPE OF BUILDING: (Check one) El state owned VILLLLAGE NEAREST Si3A ~E ❑ Public 05 1 or 2 Fam. Dwelling-# of bedrooms A ELT NUMBER (S) III. BUILDING USE: (If building type is public, check all that apply) op 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. [A 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/da /sq. ft.) (Min./inch) q U ELEV LION C~ 6dd ~c~ i O S Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank ~if!S Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): PI er's81gnature: (No Stamps) MP/MWftSW-Ne- Business Phone Number: r L s .53 = bZ PlunMi"d ress ( r et, CW, State, -Zip CcAel' . ba -Y IX. CO EPAR T USE ONLY ❑ Disapproved Sani ry Permit Fee (includes Groundwater ate Nis g Agent Signature (No St~nps) Approved F-1 Owner Given Initial Surcharge Fee) ru Adverse Determination ~ = - X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 1 ' 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 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. 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 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 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 fpr monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) '6 II t - ter- i ~Ir t- Z - - I _ - O - - - 4- - T I _ t u - - - r-- - - + O~ rt rt + I - 1-p} - - _ - - j 71 - - -rt -I L - - I I - - it fi - fi ! r- --i - - - -t- I I I I, III I I ' ~ I I I }I I t- i I ~ I - I I I I i I i 1 T i I ! ' I I I I I ~I~ I ' I I I I I I : I I I , I I j ~ I I il T- II I ! i I i I I I i ; I I i I I I ' I .WiscE = n Department of Industry, SOIL AND SITE EVALUATION REPORT Page of LaL^~ :d'Human Relations - D~jis of*;Safaty & Buildings in accord with, J46-8 is. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 1 NtyCties mrsize. Pla clude, but not limited to vertical and horizontal reference point ( section t %r0 slop' s e or PARCEL I.D. # dimensioned, north arrow, and location and distance arest APPLICANT INFORMATION-PLEASE PRINT INF-QtlAT01 '{I REVIEWED BY DATE PROPERTY OWNER: 3 PROPE LOCATION GOV- tt@T/ AILJ14 Pj W14,Sa T 3 i N,R E (or) PROPERTY OWNERS MAILING ADDRESS LOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER-,_ ITY ❑VILLAGE [$rOWN NEAREST ROAD a I ( ) _ S ,-,A e✓ r ) d R v f, [K] New Construction Use W Residential / Number of bedrooms ; [ ] Addition to existing building j ] Replacement r' [ ] Public or commercial describe Code derived daily flow 7 SO gpd Recommended design loading rate . ? bed, gpd/ft2 trench, gpd/ft2 Absorption area required, bed, ft2 trench, ft/2~ Maximum design loading rate bed, gpd/ft2 + U trench, gpd/ft2 Recommended infiltration surface elevation(s) ! 6i, d ft (as referred to site plan benchmark) ,q Ze Additional design / site considerations 9 5 Parent material © Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM Irk~t FILL HOLDING TANK U = Unsuitable for s ste S ❑ U ©S ❑ U ® S ❑ U ® S ❑ U ❑ S ®U C1 S [dU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Botxxiary Roots Bed Trench /62)y~r 2/Z Ground" elev. ' l~~t• Depth to limiting f~or y Z Remarks: Boring # _ D - 'b Ground elev. /pa, 2ft. Depth to limiting factor S /d y, 2 Remarks: CST Name:-Please Print Phone:/~- h ~~(X b Address: Signature: eate: T Number: ~ 7 a? PROPERTY OWNER C/Z 40 S , / AC1- SOIL DESCRIPTION REPORT Page_-4of PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tw& S 4-1 :....l Ds / 19. Ground --elev. ~t. Depth to limiting factor Remarks: Boring # / Ground lev. ft. Depth to limiting factor 7Z 3 Remarks: Boring # , )OLir 211 r, Ground elev. ft. Depth to limiting for -72 3 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Soil Test Plot Plan Project Name Otto Silha Byron Bird Jr. Address 4900 IDS Tower . Minneapolis MN 55402 CS 3479 Lot 2 Subdivision Date 6/14/94 NW 1 /4 NW 1/4S21 T 31 N/R19 W Township Somerset Boring ()Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft.Base of White Stake System Elevation 96.0 *HRPSame as Benchmark 417' 5' P.L. ~SB.M. 15' 180' B-4 15' 15' 50' B-1 Pro 3 0 30' Bed House S/ooe B- Area. b 60' y y 0 B-5 30, -2 210th Ave Scale 1/4" = 10 Ft/ When dimensions aren't stated 525689 CERTIFIED SURVEY MAP Located in part of the Northwest Quarter of the Northwest Quarter of Section 21, Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin. Prepared for and by the direction of: Legend Otto Silha 0 Public Land Corner, found Aluminum Mon. 4900 IDS Tower Minneapolis, MN 55402 o Set 1" x 24" Iron Pipe weighing 1.68 pounds per foot. 3f z rn0 40 r80 O = 0 rn~ N ° M Z z N f o a C4 x 'TJ M 0> ttL-'' f) rm g $ ) 1 1 I I I 1 y o; r- c C. a rn D - . -1 i!1 = A O Sc4D V) 2 Ln ~P W W o. F- M rn f1 , N to M f N F On Un Ln j z I" / 3• .9" .9 \ Z 1 n N J J lJt ~P N z C7 E X X K` • pOZ I l- O 70C to J J In N J H C 2 O //nj0 j~ $ I = m Cn N N F-' W %o :z En Hj 10 N_ A (A 0 rn -1 OX N I I O\\ 9v 00 ~ r I W N N U1 W N t'' rJ tri z m /~a` 4d \0\ / / u Z O Co J 110 00 N co z N /C"' Y~4r; ' - / m = - yr~ rn O N N L1 In F aoz 8 ,s'°~' m= m Noo tswrn~ p= / 09 r 7c j ~f~ O N rn z zzEn En En In W0 u• f P J J In w W y~ ]C / > CI OCD4 wW nJ 7d~p - ,I 0 0 0 0 0 0 N N O O P W H m d ~o0m sJ~. a I co J%.0 0 0 1 Z CD X N n l N W W U1 F, .P M z z O~ Cn W A. O ko n p X. Uf N~'~ _ _ = s C tr ~CC oz z a I E £ E t~ rv I ~0' S0' 1_ a -~°o 1, 0 ` to' s g t3'~o (O Ln C) -j k.0 46 0% \ 100' Nm ONi~ 4 O to W N J J 14 0 ~ \ ~ 1 OD W N r~+ G) ~f H M a tOr ow~JF,o HC7~ a o N P %o .o ° pC r (A o o r' sy I p c~ ►n w ~ Fr r ;0 o= ~ z 0 8 N ~ In N J to Ja O~ ~ T v~ og IA_I~ IN rn . _ i i - • \ 01 O I Q) to F~ O 00 iA yy I_. \ ro N M, Frw arntrn x 10 \00 O N M- 1 K \ CO * P z En In En En V) 00 C1 0P N 'P n D 00 J O In C\ W IM m D. b- wwN~P W 00 O O O N ~.~j, \ O~ v N F~ Vt U1 'L; A F 11` O O J U1 F, 00 N O\ I S26• ~ W z O I En En En En W Z O En .P N N 00 J O 0. ON H 0 0 0 0 0 o z c C ~rar a I rt~-.o.wtoN G) FEB `~9yo ~ya\,D~ s J I w w o0 0 1c O In z RATHLEEN H. WADH S ► I v+ J ~n 1 ~ Co N Register of Deeds lpl \ E E E E E E SL Croix Co., WI 2 \ o w ' w /-+Wz a0 Arn wrn7 z 41 z 16 F. ,y N r1a m 70 ra ted by: D.J.Z. Z:v ~oNZ ~ g ~ A t tit fm Ln Vol 10 Page 2874 z A STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1 /1 /1 ~~lrlQ~ 111'1 /4 MAILING AD"1-Dl~(RESS IRO ~ X1xJe- Sor? r 13 PROPERTY ADDRESa/ e)eSet &A (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION A)OL) 1/4, 1/4, Section T_3 ~__N-R__L?_W TOWN OF 50- M eRSe+ ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER vZ CERTIFIED SURVEY MAP , VOLUME, PAGE 28}J , LOTNUM 3ER- ~7oc Improper use and maintenance o 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 Icss than 1/3 null 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. SIGNED: -gquq~' 2v, DATE: 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 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 A}1 e J A-W<lPRW,A )J Location of property 1/4 A)0114, Section ,4,Z,Taj N-R_ 9 W Township JO'm eI25e't Mailingaddress X-Ro 15;9 le)9 it Z-19-Ax" f'►') P S e Oyu Jt-' O Address of site p?lQ , Subdivision name Lot no. Other homes on property? Yes X No previous owner of property d7YjQ ✓ f~R Total size of property 6 g c,2~ 5 Total size of parcel 5 Date parcel was created .2-.3 /919 Are all corners and lot lines identifiable? XYes No Is this property being developed for (spec house)? Yes N4 No Volume and Page Number ~S 7 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 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. //rr U ~ Sign u4-piplicant Co-Applicant Date of Sianature data of Cir-rnati,rca ' 531495 !I STATE BAR OF WISCONSIN FORM 1 - 19821'i WARRANTY DEED i DOCUMENT NO. I- ^ ~ V01. 1-131PAGEe36-2- ' it S U L 2 0 1995 This Deed, made between Otto A. Silha ci 11:30 A.I~ Grantor, and Michael J. Klanderman and Cynthia K. Klanderman, - - - husband and wife as survivorship marital property Grantee, I Witnesseth, That the said Grantor, for a valuable considerationof one ID A IS SPACE RESERVED FOR RECORDING DATA dollar and other good and val a11 P co~is. d a i one NAME AND RETURN ADDRESS conveys to Grantee the following described real estate in St. Croix Carl~ on• Evergreen Agency, Inc. County, State of Wisconsin: PO BA Osceola, WI 54020 Lot Two (2) of Certified Survey Map recorded in ,W Volume 10 of Certified Survey Maps on pace 2874, ✓ r-CA1,A_(( ~«t /~sctaC as Document No. 525689, being located i of the Northwest Quarter of the Northwe _ (NW4 of NW40 of Section 21, T31N, R19W; )er) This is not homestead propert, (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations of record and will warrant and defend t e same ttLL Dated this i' Z day of July 19_95_. (SEAL) X. (SEAL) * * Otto A. Silha (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT fr\ t fJIJES 0-1-19 Signature(s) STATE OF W4&GG+J&W SS. County. authenticated this day of 19 Personally came before me this 1"Z day of July , 1945 the above named Otto A. Silha TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ■ authorized by §706.06, Wis. Stats.) to me know N e ted the ' foregoing ins n ~F'Lr 1Ty I' THIS INSTRUMENT WAS DRAFTED BY IIy^.OS IsalonEXp1mJY.31,2= LUDVIGSON & GALEWYRICK,S.C., Attorneys Osceola, Wisconsin 54020 Notary Public ounty, *AiS MP~ (Signatures may be authenticated or acknowledged. Both are not M commissio 's y permanent. (If not, state expiration date: necessary.) *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 1 - 1982 Milwaukee, Wis.