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HomeMy WebLinkAbout020-1019-00-100 z Sys Tt'-Al' WS 7 ~MCo s T' Z - y c.~ STC - 104 AS BUILT SANITARY SYSTEM REPORT SYS I-eAj - OWNER ~11'/~'l 3 C ri ~'cl• S be R (is E (I IS 4 ADDRESS 7 P(P M C (v RupSo.3 &it. syo Uvl . ~ v SUBDIVISION / CSM#_ S ~(S 0 S ' 2 7~ Z LOT # SECTION~T Zf N-R 17 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM s sue,,, P14AA-- INA'~ OR1G INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. f BENCHMARK: c6)eAJt1L- 100-0 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION ~EE~rS Liquid Capacity: /6,0 O Manufacturer A/O to,( / 4zou ' Setback from: Well House Other Pump: Manufacturer Model# /Size Float seperation /Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM c~ Z Width: J Length Number of trenches i Distance & Direction to nearest prop. line: WAS7- Setback from: well: 'moo House (-P t ' Other / Lt9~ ELEVATIONS r r (f ~ Building Sewer ST Inlet. /~J • F / ST outlet 600 PC inlet PC bottom Pump Off S~ Header/Manifold Bottom of system 44,4,U 404 1-0a-A-, p/bT Ex4jj& Final grade 11~a7 AAA s /07. Z y DATE OF INSTALLATION: e- ZG - Y / 9- I PLUMBER ON JOB: y ( EP- 4 t'b R 1* 64-1-T LICENSE NUMBER: MP PS 33 D~? INSPECTOR: 14AX i b s 3/93:jt /5 7- pro Sc•~L~ . / - 30 T 7_4A*. sT~c - ~a /57- (//~f .44O /SOX 194 -E, 'Af 0,ez- ~ G~ . ~ 71 f► DiSTi~i;EQv T%a,~ ~gUSscvt,., ' ro L -1 J ~2 O~PD~O /3G1( /03.36 IfR, EA) $ STEM Td~ T9 pf- PA / I I' 12 Pa 14 /D 2 /02. 1,02-Y(, /O,Sp Zrr,. c,, ~ o a,r it 13 /D/, Q /02.0 I /02,.1O /40 1y ~i ~I ~C C Post-it" Fax Note 7671 Date pa°ses~ TO S U r) From' f Y/ AOd Co./Dep . Co. r JJ~ © T Phone # O Phone # Fax # p Fax # O 47- fEivCE_ rbp °f z ,oosr ~ p - , iDt~•~ ~ItL1ATWA) Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor ancLHumanRelations INSPECTION REPORT ST. CROIX Safety and'Buildings Division GENE RAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitlV 3 Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI KRUSELL, JIM & CHRISTINE X CST BM Elev.: Insp. BM Elev.: BM Description: HUDSON Parcel Ta r r /OD • r, TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /00 Dosing (Wj l 10U~5 /()0, Aeration Bldg. Sewer 104, Holding St/ Ht Inlet /OS, TANK SETBACK INFORMATION St/ Ht Outlet S,ff 3 /v TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom ~2S-U~Iu1/o - Dosing NA Header/Man. q'05 ioa.'6 P 5 Aeration NA Dist. Pipe ~7 6.;? Holding Bot. System 9,06 /0/, 94 ,Uel O PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand /i - 106,7 .S 1 ~.u1C ~ U' . J Model Number GPM 103,;?~' jq~ 7,6q TDH Lift Friction System TDH Ft tie Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / S e, DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Moe Number: System:41(pi /1)1A OR UNIT 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 ~I Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 4.29.19.91B,NE,NE,LOT 5,MC CUTCHEON RD. J. r ! 9.0 e~ly Plan revision re red? ❑ Yes ❑ No / U se other siclfor additional information. F I''ivk _.o 62 1911 1~ SBD-6710 (R 05/91) Date In 6ector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i I SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 5r Polly STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than I / 116 8% X 11 inches in size. 1:1 eck 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 Of L Q PROPERTY LOCATION cA,et S Pvc- /e U54_11 E '/4 /1 & /4, S Y T , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 333; SA 5'7'• • S CITY, STATE ZIP CODE 7PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: Check one CITY NEAREST ROA Q ) State Owned O AGE ~ # al~~d,~ ~!C ~ 'A N OF ❑ Public 1 or 2 Fam. Dwelling-~# of bedrooms PAR EL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) d Z~ f ' Q 1 ❑ ApVCondo 2 ❑ Assembly Hall 60 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 120 Service Station/Car Wash 5 ❑ Hotel/ otei 9 ❑ Office/Factory 130 Other: Specify IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 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 Beck 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure _ 430 Vault Privy 14 ❑ System-In-Fill 5 VI. ABSORPTION SYSTEM INFORMATION: Q 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.) PROP( ED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION V • y 4dD~ 5 Feet Q2• r7 Feet 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 cted Septic Tank or Holding Tank 16M r 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): Plumber's Signatu e: (No Stamps) /MPRSW No.: Business Phone Number: 'k,fT- 2ij6R ~T Mq!~~n~ 3 ® 7 0>049460P. Pis Plumber's Address (Street, qty, State, Zip Code): N . / G(,1.o9 . /,0/: S D A ~e rG U ~ ` SC IX. COUNTY/DEPARTMENT USE ONLY 0 Disapproved Sanit#p Permit Fee (Includes Groundwater ate ssue Issuing Agent Signat re (No StampB) ,Surcharge Fee) Approved ❑ Owner Given initial D(/ Adverse Determination tj/ 5n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS f a 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 Sanillary 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, 603-266-3815. 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 muss: 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 for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (8.11/88) - ~ of ~ 3 m /vv. Lor. L d Cl. i ~ J p w 3 ~a s fs L3j \o lee. 00 o 02_ 0 as piee-Chs r GS S~sT , M,3-0 s Fecwn ~ svpuFyoR's X00 • ~ - s~ rop °g F l~vhTfoa~ ' r /02.30 fb 4 /0 2. 3 ' 43 /09.0 13y /07. GO' ti 107 '30 I i b /t~l G Cv •fG~i e o,~ X17 . - ~ ~ SuG~~sTED T~kac~,. ~.tevhTro~s Ow -t eeAJ C,4, 163.0 SCALE % I 30 1*11 Wi onsin DepartmRent of Industry, SOIL AND SITE EVALUATION REPORT P ( 3 Labor and Human elations-a Division of Safety & 601dings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5-r. C. R d 1' 7L Attach complete site plan on paper not less than 81/2 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. #I dimensioned, north arrow, and location and distance to no r 1 APPLICANT INFORMATION-PLEASE PRINT A REVIEWED BY DATE PROPERTY OWNER: PR LOCATION PEIPR y ~ Nf}•N C}/ ®Li /Y~ Go s1a L GO NE 1 /4 NE 1/4,S /7 T 2.9 N.R /I E (or) W PROPERTY OWNER':S MAILING ADDRESS RT # LOCK p GSM OR CSM #1 A T of 7q 10C ~'efctiE'viv Yt~: N1P1'AJ <i-- 2/ 4015 CITY, STATE ZIP CODE P UMBER" - ❑CI ILLAGE N NEAREST ROAD &L"Pso"i SelG!6 (7 ,3, R f hN VsOti ~.t c co, I e- 14 & 4"-j j New Construction Use ('If Residential / Numberedrogms ' ` [ ] Addition to e)asting building j I Replacement [ I Public or commercial desci e Code derived daily flow 69 °d gpd Recommended design loading rate bed, gpd/ft2 trench, gpdM' Absorption area required bed, ft2 trench, ft2 Maximum design loading rate / bed, gpd/ft2~ Trench, gpd/ft2 a Recommended infiltration surface.alevation(s) S-e-e- Pa • 3 ft (as referred to site plan benchmark) Additional design / site considerations W-c - 7-1?&-A-16A eS m u S/o~aF wI'A Arelo 13oX D~STRi (3 v rio J Parent material -"C5 5'9 l3 u,? eti .f-4pDT Flood plain elevation, if applicable ~11f • ft S - Suitable for system CONVENTIONAL MOUND IN-GR UND PRESSURE AT GRADE SYSTEM IN FIl HOLDING TANK U = Unsuitable fors stem ❑ U ❑ S ❑ U l ❑ U ❑ S ❑ U 9-s" ❑ U ❑ S &b-- SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bot rd3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mnch 13- o - ~ /V yR 3/2-- 2- f Shk r►+, of /e S 2 f 5 . G Z • 20 /o y/e 3/3 1.0,4M I- f 541 f 5 If . S • G Ground 3 a 3 /o yR Y1,11 Si f shk /m f R C;- I ~ Y. S /o e12~ ft. y 9 7. S '/R 3 /y ~i7A d , S . - -7 Depth to limiting factor > 2 Remarks: Boring # 1 p_ 00 /o y/e 3/.z - /oq,H 2 f 564- ,bti, v f R S Z~ .3 • G Z L /o yR 313 f 56e /M -F R S • S • G • S 3 /4/ /6 /t~ Y Si/• If she CS Ground 7 ~ Y elev. y yp 7 5YR S/G S 7 ' cP ;17 * 16 z. 33 ft. o_ 9 7 S y S. 0 Depth to ' `s 7 -ao limiting factor Remarks: CST Name:-Please Print R03E-PT 011 h e1* •G ti 7- Phone: -7/ S - 3,P G _ oo/S S Address: 0 All 7/. L I VD • #V j0 'D..-, -41 2l0 ' J C5* Ply 2 `/PZ. Signature: Date: CST Number: ORIGINAL This test Site App A01/ED for a conventional ssptlc system. PROPERTY OWNER An" ~~s SOIL DESCRIPTION REPORT Page -of 3 # C'S~r - /a ~.v D r .u (r- PARCEL LM Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rench 169-k /6 it' 3/2- /o,},,4 2.f 5 ht- A-,, foe CS I f .5 • G 3 z 30 io ye y/y 5-11. 2 -F She fR Cs r f -S Ground 3o-so 7• S yR 31v %e?,ove//y . S. 0, S f~ C S . 7 • elev. f° ft o y0 /o y G S. D s d,2 Depth to limiting factor > D Remarks: Boring # / 0-F 16 YR 2-11 5~ . Shy f R e z go-Z7 !0 yie 3/ es Y S 3 27- 56 7•Sya Y16 o .7 Ground /0 7. 6 ft Depth to limiting factor Remarks: Boring # C~-Co /p yle 3/2- s/ S~,ev Its, v7w G S /7G Y 5 v4 Ground elev. /0 7 It Depth to limiting factor ~r Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: 0011 OOOfl/D AC M7\ I A ! 1, • a . p ~ • 3 of 3 • a ~d - 0 ~y N .J (U SCE AI 6;<-s ce, 8 Goy i o GS aS~ ~o /3M I N 1 Feu,,,d ~ Sv~puFyoR'S boo , l3Z - Tor of /02-30 ~p~RoX• ~bo d~ /02-33 43 0 C3y /07. G0' B S /n7. 3a' /t9G fvfG~iEo~✓ SVGCPEsTED TVeA3c - F-lk~-uhTI•oA.~s Kv t,(, TRe,3c.L, "y D " low -t ReA.5 CA, 103.0 SCALE % ~1" 30 ' Fresh Air Inlets And Observation Pipe J Approved Vent Cop Minimum 12' Above • Final Grade "Above Pipe _ 4" Cast Iron 1o Final Grade vent f047 Synthetic: Covering Min. 2' Aggregate Over Pipe Olslribution pipe --*'LO- 0 0 0 0 - Tee s • Cr A99regate ° Pertbroted pie Below Beneath Pipe _ P o Gauping Terminating At S 57•'• 2-9 Bottom Of $15140 Fresh Air Inlets And Observation Pipe Approved Vent Cop ~/P~.UC l f Minimum 12" Above i Final Grade 36 "Abort Pipe _ 4 Cast Iron "fo Final Grade Vent Plpi Synthetic Covering • Min. 24 Aggregate Over Pipe Distribution Tee II Pipe --"o 0 0 0 0 Aggregate o Perforated Pipe Below Beneath Pipe o Coaplint Terminolinq At 2 Bottom Of System sy ~T 5-o o FILED ~ J U L 2 6 19948-- 3 6 JAMES O'CONNELL Re91ster Of Deeds 4 519505 S` Croix CO., Wt CERTIFIED SURVEY MAP Located in part of the NE4 of the NE; of Section 14, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin. U 1Tr-- AI I c J L,\NDJ S89°04'23"W North line of the NEJ 33.00' S89°04'23"W S89°04' 23"W 695.00' NE Corner Section 14 Nk Corner 1917.72' 1.5' SOUTH OF FENCE 0 NORTH OF FENCE Section 14 N r a O A O N , d + Ct IF- I~ N 7 N F+ {G C N• N LOT 4 Irk Iw ° I ~l1 w O o I -I 17.01 Acres Inc. R/W p d ~ TI_ p w_ 740,792 Sq. Ft. Inc. R/W m Ir- r~CJ 0 16.72 Acres Exc. R/W o b c co 728,278 Sq. Ft. Exc. R/W oC, -ti s c. O o I +S a cn ~a N N fl Ch Cr G :m If = E`, y r N LL C. I IG L4 y I G7 I tV o N M. • r07 I l~ 1 t If ° O I- S89 1215211W Fi00SC?t'", I> 'j CD I ~l 300.00' Wis. I~ < ~q~.:•` 0~`-I to I _cr, m Co s- `7- a ~~~®1~9~4i4~`► ~ v 4- o v ~ o o Ir- CD 32. ma LOT 5 1> C* IL7 N A N A C- Oho I C'7 N N 41 Ut V co m N O' V1 O 1V 10 I(J) ,t n1 X -M ? CF n to f O I r i I J cn X co I> I -I o 0 0 CD House ZD _ : w • w w o W N ~O .....694.981 - ........._.tO_ N89025105"E....4, 299.99' 394.99' 300.00 395.00' w O1- N8901215211E 695.00' w South line o the NE} of the NE} --LEGEND I OWNER - Aluminum County Section McCutcheon _Ro_a_d Perry & Nancy Phillips Monument Found I 794 Mqutcheon Road HudsiW, dii. 54016 0- 1" x 24" Iron Pipe Set, weighing UN r' `A - I _ Lr--- Q 1.68 lbs. per linear foot. C- 0 N n 3~ 5' H .92 - < -x Existing Fenceline I A_ IND i ~ ~ ~ n Q w 50' Roadway Setback line K. 0 O' VOLUME 10 PAGE 2792 c o Well SCALE IN FEE $ O Septic CE[' I IFILQ SURVEY MAP 0 1" Iron Pipe Found VOL. 41 I] G 966 100 50 0 100 200 300 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT f St. Croix County 75 Y (AAL C VV~ aF `J K Ake OWNER/BUYER MAILING ADDRESS s- yo i PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE kkcjs~L L/u, l PROPERTY LOCATION_ 1/4, 1/4, Section, T_ZA_N-R l W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER S 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 three year expiration date. I i SIGNED: --~a DATE: J - 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 nuf~6n .3 d'14a5 +dLA-o- K4 A ~ac d IN& Location of property 1/4_1/4, Section T_?:j_tN-~R~W Township HvicDo Mailingaddress Address of site Subdivision name Lot no. Other homes on property? Yes No Previous owner of property elty' Total size of property_ 1 (0 ~ t l6 Total size of parcel LL A 30d Sgo Date parcel was created -qr li 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. 8 $'Z Z SZ 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 i 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. :5 /Q666-1 , 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 o ice of the County Register of Deeds as Document No. i atur of Applicant Co-'-Applicant /~-50:G / Date of Signature Date of 1gnature ` •DOCL MENT N0. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 519660 " T i~ REG, 61 Lk'S OFFICE VOL . CROIX CO., WI S r~r i p h I e?v~CI (~1'1C Y 1I Q5 Reed for Record - JUL 2 9 1994 ~I 4:50 P. IN conveys and warrant to h(5 e hu~Wc at ~shl Register of Deeds r RETURN TO the following described real estate in (0N County, I State of Wisconsin: Tax Parcel No: ~I Kok # 5 Of Ce4d ~Orv~{gyp recorde~~ ir, Uo~uxne I o ~SM~ P~. ~'79~ , bocurrle 5_ _95os , own i Hu.c(W) S~. CroiX Coinf~~ ~~U i~corksin, ;~e~ ~7uly 2~~ 99 , parc~~ L nl (,cX J i n pr~r k nF ~iuQE/4 a>C ,L 1\j~~/~~ o c~Ch'r)~ 14 , ?9~~ , fo r it This homestead property. (is) (is not) I C Exception to Warranties: ~c~ew~S YeSICho~S~ ~~r`~ Ot U(al~ a rQCOYC~~ ~'~~jUll~, 1- . Dated this day of 119 (SEAL) rzr" (SEAL) / (SEAL) (SEAL) li AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. l/6 County. /I ~J authenticated this day of 19 Ars nally came before me this day of , 19 the above named f,p5 F7Zr'tr ~T 779~1_ 6_4 TITLE: MEMBER STATE BAR OF WISCONSIN (if not, to me known to begtr on who executed the v wledge the same. max authorized by § 706.0 Wis. Stats.) foregoing i`sgtieM•A THIS INSTRUMENT WAS_AF Y 0 • E. Phil I Notary P IC County, Wis. (Signatures may be a t Gated or acknowledged. Both My CoMmiiiPPOP rrr9~'q~r~t ' I not, state expiration are not necessary.) \ date: 19 ~.1 of,i wt 'Names of persons signing in any capac~ty sKQvId be typed or printed below their signatures. SB2 NTF 0021 W A RANTY DEED STATE BAR OF WISCONSIN ° Nclco Tax Forms, P.O. Bax 10208, Green Bay, WI 54307-0208