HomeMy WebLinkAbout020-1017-90-001
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERscl,n beklr7
ADDRESS/el/ow
SUBDIVISION / CSMJ LOT
SECTION-. T N-R W, Town of L~ c-•.c.c~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~f~~e-
9
a INDICATE NORTH ARROW
i
J"46:V~ide setback; and elevation information on reverse of this form.
~,~~f'rovide 2 d nensi_ons to cent<~i of -optic tank: manhole cover.
BENCHMARK: SG lyre Q ~l J''--
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: Liquid Capacity: /0 e, a)
Setback from: Well House G Other
Pump: Manufacturer 2o/it X a.t- Model# Size_.,~_
Float seperation Gallons/.cycle: /i;'d
Alarm Location ..R .t
SOIL ABSORPTION SYSTEM
Widt -L: f 2_ Length Number of trenches
Distance & Direction to nearest prop. line: ;2
Setback from: well: 6f1 House r Other
ELEOATIONS
Building Sewer ST Inlet: ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: ~T Q Jr/
PLUMBER ON JOB:
j✓,-_
LICENSE NUMBER:
INSPECTOR:
3/93:jt
■ r • s
L(i ri' n art b uQ- 29.19. PR1~A1'E SWAGE SYS M EWA PAT County:
• Labor and Human Relations INSPECTION REPORT C O X
Safety and Buildings Division Sanitary Permit No.:
GENERAL INFORMATION (ATTACH TO PERMIT) 199979
Permit Holder's Name: ❑ City ❑ Village ~ Town of: State Plan ID No.:
HUDSON
BM Elev.: 1=. BM Elev.: BM Description: Pa rcel Tax No.:
}
020-1017.90-000
ELEVATION DATA A9400009 ,~PY
TANK INFORMATION
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aerate Bldg. Sewer
/
Holding St/ Inlet 5 a7
y8 S. l~
TANK SETBACK INFORMATION St/yf Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake 9
5Z '301 t1A NA Dt Bottom
Septic
Dosing > So 7 ScSU~ G~ / NA Header / Me
Aerati NA Dist. Pipe 67
Holden Bot. System
PUMP/1U FORMATION Final Grade
Demand
Manufacturer
Model Number # -70GPM 47
TDH Lift&Erection pfi~ Syetem TDH 3 F
Forcemain Length /3/ Dia. -7 " Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of renches P No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIME Manufact
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA
SETBACK CHAMB Model Number:
INFORMATION TypeO
~o~(l~i Slb
System: !2&, O T
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. ~ Length ~J Dia. Sparing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst
Depth Over /7 Depth Over xx Depth of xx Seeded / Sodded xx Mulched
~7 Bed/ji& l dges oar / Topsoil ❑ Yes El No E] Yes E] No
Bed /Sccrt[I4Center
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 13.29.19.83A,SE,SW,LOT 2, CH,~PPEW ATH
r
Cr~vrt~il cw*i v
44 by S. (J.
f" T
p~
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Plan revision required? ❑ Yes 8_1q_0
Use other side for additional information.
SBD-6710(R 05/91 Inspector's Signatu e Cert No.
Date
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: a
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code oo IN
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than , L?
8% x 11 inches in size. ❑ neck it 112 revision" pre ions 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 LOCATION
Sot- "I c-0-7` '/a S T , N, R /Q E (orXjW
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
if V ellB.s7`v.-40 7-0A AeAL-
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
ad s o.~fJ O G e . ade Ali.
L:I
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VIL
LAGE : ~h ~GLV a 7'h
NO W:
❑ Public Yb.1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL A M )
111. BUILDING USE: (If building type is public, check all that apply) 04i20_/0//_ vod 1190,
10 Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory ' 13 ❑ Other: Specify
IV. TYPP~E1 OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L} New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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/day/sq. ft.) (Min./inch) ELEVATION
ysa 6' Qo CS 115- Feet ov--'geet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank IW
Lift Pump Tank/Si hon Chamber El F] F1 El I Ll Ll
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number:
s Q t
Plumber's Address (Street, City, State, Zip Code):
l0) 7e) LL 4 S .5e_ a 41
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved San' ary Permit Fee (Includes Groundwater Date Issued Issuing ent Signature (No Stamps)
rl-y Surcharge Fee) _
lT)(if Approved ❑ Owner Given Initial /l Jl s -
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
1 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 (SE30 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.
Il. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. 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'/s 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; webs; water mairsiwater 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
e,gquired 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, ground-
water contamination investigations and establishment of standards.
i
SBD-6398 (R.11/88)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR
P.O. BO HUMAN NDATIONS PERCOLATION TESTS (115) MADISON W 7969
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS HIP/M4N+etPAttrY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
s/a~ ~3 /T,7 N/R/ E (0 2
COUNTY: OWNE 'S °"`s.-~;r~IAME: MAILING ADDRESS:
IF 41;V1 f w 5- B/
USE ATES OBSERVATIONS MADE
IND. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION
TESTS:
residence Dffe-w ❑Replace
I'd 1 o
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIElONAL: IMOUND: IN-GR JND-PRESSURE: SaSTEM-I L HOLDING TANK: RECOMMENDED2TT'EM:logtional)
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ~f
under s.H63.09(5)(b), indicate: Allolf- -7--- Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 100,3
/~Tk C } d b Ts 7, w
B- z SI/ 3r,91.19 6 > r/
'Ts w ~su~ .z
B- . 3 ins x /4/k V.
B- t q E6 I. r f .7 `Ts 11 -
z ,rd ,
Ra,25 &$Z 6e
6-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD PER INCH
P- Y 3
P-
P- y 3 7 wi
P
P- 3 S-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
f ~ ~ 1 ~ ~ I I I
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r~ ~ ray ~'sr_.~~ _ ~ ~ / ~ } ~-Y-✓E~'~t. f ~1L ~ll~ _ .L~ e ~U
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Licensed Pork Tester & Plumber y
ADDRESS: FO - die 3 RG CER IFI ATION NUMBER: PHONE NUMBER (optional):
ROBERTS, WISCONSIN
One 749.3656 CST SIGNATURE:
IBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
BBD-6395 (R. 02/82) - OVER -
II\"_, JCTIONS R COMPLETING FORM 315 SRD - 61395
To be. a cc; 1 accurate sail test, your report must include:
1. Co ption;
2. clearly i whethe r'fis is a residence or commercial
J bedre comm i use pla 1 ;
4. nr
5, is Sul] E FOR A HOLI TANK ONLY IF ALL
CI ASED ON S CONDITIONS;
6. F` here for vvritir ,.e clescriptio c(.inpleting the plot plan;
7. ~~ly locating y( r locations. I r xo scat ferred. A
I elevation a )oint a ~ ~)wn, neat;
bo>.s 's, nai; sses, flood i': t exemp-
} es not apply, riate box;
1 our u3" certification
s. ALL. SOIL.. TES ~ H THE
WITHIN - OMPLETION.
.r..T:VIATION S FOR CERTIFIED SOIL
hires Other
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Estel pi'jor,'to
. ~ SAFETY & P INGS
DEPARTMENT OF REPORT ON SOIL BORINGS AND VISION
INDUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, W1 53707
HUMAN RELATIONS (H63.09(1) & Chapter 145.045)
TOWNSHIP/ h4bNtetfhKCtTY: OT NO.: LK NO.: SUB DIVtS10 NAME:
LO A 1 SE TION2
'A'-W4 /3 /TN/R/qf E for
At N
COUNTY: OWNS '
~
I ES OBSERVATIONS MADE
rrff-Wl LE C! 1! ESTS:
USE p : CO
9nesidence [+}weew ❑Replace y
RATING: S- Site suitable for system U- Site unsuitable for system I •F1LL OLDIN TANK: RECOMMENDED 5Y TEM:Io tionatl
CONV£NTI~NAL: MOUND: iN•GROUNDR S
sou ~s❑u ~S,0U nS[N 0S MU -
I I Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63,09(5}(U}, indicate: Ftoodplain, indicate Floodpiain elevation:
PROFILE DESCRIPTIONS
M/~ L PTH T R UNOWATMINCHES CHARACT SOIL WITH THICKNESS, C LOB, TEXTURE, AND DEPTH
N. ELEVATION SE RV D S TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
1-joo 3 ant > 6 rr Ts ' R 1, *7
B• T- S y
B- S / 40.9 r 3 s .2
B- ~ r
leL
B. r 9
13-
PERCOLATION TESTS
0 iN ATER L V L•iN HE RATER }INCH ES
TEST DEPTH WATER IN HOLE TEST TIM
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. 1 0 EE 03
P_
P- _
A; 74
P. 3
P~
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori•
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM! ELEVATION
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2Z "4'
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y /per r/~/f ~i iG ~i>'•r~i~ll`Y1 !r d K+I . ,....i_ _ ..1..... 1
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in tha Wisconsin
Administrative Code, end that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
[AD E print : AWE-FOG TEST WERE COMPLETED ON:
Licensed Perk Tester & Plumber
RESS: CER' IFI ATION NUMBER: PHONE NUMBER (optional):.
Fn^grty Heiwhts Road
ROBE 1-110 AlSC- 656 CST IGNATURE:
nts7n_1--11•-1--'• e)f;,inal And to Local Authority- Property Owner and Soil Tester.
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PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
1°C.I. VENT PI WEATHER PROOF
PE APPROVED LOCKING
MANHOLE COVER
~ 25' FRCM DOOR, JUNCTION BOX
WINDOW OR FRESH 12"~ I
AIR INTAKE
GRADE
I `i" MIN
IB"MIN.
CONDUIT
18"/KIN.
IAII PROVIDE I -
AIRTIGHT SEAL
Ir I I \v/
APPROVED JOINT A I III APPROVED JOINTS
W/C.I. PIPE I III W/C.I. PIPE
EXTENDIAI(- 3' I II ALARM EXTEMI)ING 3'
ONTO $OLID SC:;. B I I ONTO SOLID SOIL
I I
I I ON
C.
I I
I
PUMP-~_
~1 OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED GWLy IF TANK MANUFACTURER HAS SUCH APPROVAL
SPECIFICATIOUS
SEPTIC AND
DOSE TANKS MANUFACTURER: i~W~ST.gC'Cc a57` IJUMBER OF DOSES: L~ PER_DAy
TANK SIZE: 7Sa GALLONS DOSE VOLUME
ALARM MANUFACTURER: l+ -e p-e 4 ,~u G4d^ Atli_ INCLUDING BACKFLOW: GALLONS
MODEL NUMBER: ~U CAPACITIES: A= a~'S INCHES OR yoy GALLONS
SWITCH TJPE: PJ'C 8 =IMC14ES OR ~ GA'_LONS
PUMP MANUFACTURER: -,Zo eY C = 6 INCHES OR GALLONS
MODEL NUMBER: D= 718 INCHES OR GALLONS
SWITCH TYPE: - Alara NOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHARVE RATE 33 GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE B" -wrzrA1 PUMP OFF AND DISTRIBUTION PIPE.. 13! FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . , . . AMC- FEET
+ FEET OF FORCE MAIN X;?,&15 F oofTFRICTION FACTOR..,2 FEET
'~t = TOTAL DYNAMIC HEAD FEET
r ~
INTERNAL. DIMENSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH
SIGNED:/ LICEWSE NUMBER:&,~2a3r2- DATE: Z
-117-
1ST.NATIONAL.BANK 17154259018 P.03
STC-105
SErTIC TANK MAINTENANCE AGREEMENT
St, Croix County
OW"JVRUYER _ !Vl Gt 11~!]:i L w
MAMWG ADDRESS
PROPERTY ADDRESS 02
(location of septic syste ) Please obta' from the Planning Dept.
CITY/STATE U DAD SGO l
W
PROPERTY LOCA'T'ION yw 1/4. J VJ 114, Section
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFUDSURVEY 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.
1`he 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) tion the on-site wastewater disposal system is in p o ~3 pull insludgeland
scum(2) after inspection and
1/
pumping (if necessary), the septic tank is less than
I[Wc, the utndersigncd have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards moust, herein, as set by the Wisconsin
completed and returned to the St. Cron
Certification stating that your septic has been xn
County Zoning Officer within 30 days of the three year a ration date.
SIGNED:
DATE: 11z_1r114? 0_
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11193
Hudson, W1 54016
1ST.NATIONAL.BANK 17154259018 P.05
,L,Q(;ftrED" IN THE 51ql/4 OF H4 `Wi/4 Ur 'I:UI JUDI 1.3, 1 . li„ r P yrr► t%ay ,,.x.
111B NW1/4 OF 5ECTION 74, TM,. R19u, TOWN OF HUDSON, S1. (;BrJ.t7:
COUNTY 0 WISCONSIN
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1,114E OF CHIPPEWA PE~tli ' u x co c~ A
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• 1ST.NATIONAL.BANK 17154259018 P.02
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STC -loo
' This applic4tion form iS to be completed in full and signed by
the owner(s) of the property being. developed, -Any, inadequacies
will only rosult ~.n delays of the p6rmit issuance, ,Should this
development'be intended for-resale by owner/contraetor,(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.
r------------r ..w--------------------------------------- s-----------
owner of property sI l~ ~,t) ~-SG T 118ZLY11
Location Of* property -§tL1/4 1/4, Section
Township . a ubSO)J
Mailing address
Address of site ~ .
Subdivision name_ 0T-Z-• C#/ -Lot no.
Other homes on property? yes V-11"-No
Previous owner of property _e::~:94P-LeS
Total, size of parcel 2~• -77V • eggj
Date parcai'was created
'Are all corners and lot lines identifiable? ✓ Yes ,,,i~No
Is this property ceing developed for (spec house)? _yes No
Volume~and,Page Number 3
as recorded with the Register
of Deeds.
: ..ter--.err----
INCLUDE WIT14 THIS APPLICATION THE FOLLOWING:
A WMUWaTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & rkHE SRAI, OF THE REGISTER OF DEEDS. An 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 eli statements on this form are true to the
k~ftf- nf TRV l Hurl knnWI NDAne 4..hgaf.. y i._.-% i , . _
the property doscrl,bad in this ~information 'f'orm, by virtue sok. a
warranty deed recorded in the office of the County Register ='of
Deeds as Document No. , and that I (we)
own the proposed site ;for the sewage disposal system orr I e(we)
obtained an easement, to run the above described property, for
the construction of said system, and the -same hays been duly
recorded, in the office of County Register of deeda as Document
No.
signature of applicant a-appli nt
----L ;V - 96Z
D e f Signature Da
ta of signatu e
l
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR, OF WISCONSIN FORM 2-1982
512265 VOL ~062PAm 37 REGISTER'S OFFICE
T. CROIX CO.; wi
Charles T. Berres and Dora Mae Berres, husband S Ree'd for Record and wife, as survivorship marital property -
JAN 2 5 1994
115 P.
conveys and warrants to Samuel--W.- Tal-bert, A MARRIED ai^~ M
MAN . - ' Register of CegdS
RETURN TO. NAL
I own lob
the following described real estate in - RIVER FALLS, YVISCONSIN 54022
. . County,
State of Wisconsin:
Part of SW-4 of SW-4 of Section 13 and Part Tax Parcel No
of NW-4 of NW-4 of Section 24, All in 29-19
described as follows: Lot 2 of Certified
Survey Map filed May 28, 1992, in Volume "9",
Page 2481, as doc. no. 483963, in the Office
of The Register of Deeds for St. Croix County, Wisconsin.
This deed is given in satisfaction of that certain land contract
between the above-named grantors and Samuel W. Talbert dated June
15, 1992 and recorded June 16, 1992 in the office of the Register of
Deeds for St. Croix County in Vo. 955, page 332, as doc. no. 484745.
.~0
This _..15_.n-Ot........... homestead property.
(,%:K (is not)
Exception to warranties:
Dated this - 24TH. - day of JANUARY is 94
.-(SEAL)..---...(SEAL)
Charles T. Berres
(SEAL) "~.U Csl~~ -----.(SEAL)
* - * Dora Mae Berres
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
St. Croix ss.
- --------------County.
authenticated this day of 19...... Personally came before me this _
24_._.__day of
JANUARY-•-_ _ , 19. 94. the above named
Charles T...... Berres anc) Dora Mae
Berres, his wife,
-
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
-
authorized b
y § 706.06, Wis. Stats.) to me known to be the persons who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
••---•___Alex_ _S_.._-Kosa,_ _Attorney
-._~-17T-• - .........Hudson, , WI 54016 COER
- - Notary Public .----------ST,-- CROIX
- ----County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: 4/10- 19__94__.)
JAYUE C. MOELTER
•Names of persons signing in any capacity should be typed or printed below their signatur* Con isSlOn Exr,*as Apr. 10, 1994
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
FORM No. 2 - 1982 Milwaukee, Wisconsin
it .~OSa✓!
(JAMEES ILED
n 2 81991
V O'CONNELI
crob co., W1
ster of Dodd s
483963
CERTIFIED SURVEY MAP
LOCATED IN THE SW1/4 OF THE SW1/4 OF SECTION 13, T29N, R19W, AND ALSO THE
V1~~ NW1/4 OF THE NW1/4 OF SECTION 24, T29N, R19W, TOWN OF HUDSON, ST. CROIX
M COUNTY, WISCONSIN
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w"wabdato VOLUME 9 PAGE 2481
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