HomeMy WebLinkAbout032-2031-50-000
s
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER,a DW A R X X47 5
ADDRESS L//Q r U~
SUBDIVISION / CSM#_ LOT #
SECTION 8 T,?,0_N-R__,[2__W, Town of___{5O/17"g,=7-
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N
SGRLG ypi
/8X 63
S~ef1Ao-E DC-p
weu-
Uri
E X15 rlAfC-
ON P//JFs
140usi
E~sri~c-
/Dod c-c. st,
Q
~G 5 T' '4Dt INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
T D o S E~ /Od
ALTERNATE BM: Q/E CO Pk~2 nF &,AeAt Ar ~L /d6 Z.S
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: /O1j0
Setback from: Well House 0` Other
Pump: Manufacturer Model# _ Size AAA
Float seperation &A Gallons/cycle:
Alarm Location NA
SOIL ABSORPTION SYSTEM
Width: Length 6 3 Number of trenches
Distance & Direction to nearest prop. line: Y2
Setback from: well: House_L/O Other
ELEVATIONS
Building Sewer /i/# ST Inlet. 1)(i4 ST outlet
PC inlet PC bottom .&4 - Pump Off 1&q
Header/Manifold 57S,32_ Bottom of system
Existing Grade /0/, 5- Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 3,ZQ~
INSPECTOR:
3/93:jt
nsi* Department of Industry, PRIVATE SEWAGE SYSTEM County:
La Human Relations INSPECTION REPORT ST. CROIX
Safety, and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
PeWgder' ffMZD ❑ City C] Village ( Town o : State Plan o.:
qwii -5c)-c)
S0MF.RSF.T 12
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax o.r
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic - J Benchmark ~o a /00,
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet (D 77 o,)
,
Verit
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic ~,;S'/ !00 ct/O NA Dt Bottom
Dosing NA Header/Man.
Aeration NA ' Dist. Pipe 3
Holding Bot. System I1.73 g 7, 5_3
PUMP/ SIPHON INFORMATION Final Grade 7,26
Manufacturer Demand /I 3 y
Model Number GPM
TDH Lift Friction System TDH Ft
ead
oss
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width} / Length6 3 No. Of hes PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS L DIMEN I N
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Mode Number:
System: ~(~i //0
r 160 //t OR UNIT
I` DISTRIBUTION SYSTEM
N Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
V ` 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 ❑ Yes ❑ No
COMMENTS: (Include code; discrepancies, perso present, etc.)
LOCATION. SOMER !i 8.30 1~._88A,SW,NW,165TH
f vl
Plan revision required? ❑ Yes ❑ No /
Use other side for additional information. o &aLtkx, (Q
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH t
SANITARY PERMIT NUMBER:
jj~ SANITARY PERMIT APPLICATION
coin
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 9L, & g3
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 LOCATION
t/a jVW %,S T N,R E(Or
levwmo PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
D 16 5 7W 14 U 164
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
A
-171
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) ❑ State Owned V
TOWN OF: ILLAGE : ~ , _
49
❑ Public 1 Or 2 Fam. Dwelling Of bedrooms PARCEL TAX NUMBER(S) 4r
III. BUILDING USE: (If building type is public, check all that apply) , 0 ~~Q
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. ❑ New 2. LANLReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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
9 3 i~o Feet O 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 structed
Septic Tank or Holdin Tank /Q X F7 F1 1 171
Lift Pump Tank/Si hon Chamber Ej F-1 F-1 El I Ej F]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Name (Print): Plu s Signature: (No Stamps) MP/ RSW No.: Business Phone Number:
-y
lu bar's Address (Street, City, State, Zip Cod :
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanit ry Permit Fgp (Includes Groundwater Date s us Issuing Ag t Signa No S ps)
/y) rcharge Fee)
pproved ❑ Owner Given Initial l G
e, /
A~~P) dverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
J
SBD-6398(R.08/93) 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.
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.
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% 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.
'I
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 (R.11/88)
30"
14P/ OVe?-b ca~~2
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O G C 6a
5 ysrem
F' cNC~/ 3
132-
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tll E~ ~ . ~ ~ s~eph~E /~e0
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~s T.N
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~tou s L311
y / o
C XISTIMG
/000 G-L Si81,7, i o~ o F S%~cL
165"t Atl&t
/?,4 WIN 6- FO
z/10 165-7-# Ave /
<S41`~/E2S~%, G!1/. 5 y0o7s cSorr~2SET GU/` . y0~s
W
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the ~/~1d1 /t~Gl 1J). . AnS residence located at:
S1/4, /VU.1 1/4, Sec. 8 T W N, R_L7 _W, Town of
c oyytE jeSEr 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: /,000 (;-L.
Construction: Prefab Concrete-Steel Other
Manufacurer (if known) : PO(Ver:2S
Age Tank (if known):
~N,4ai~ ~C /err T %
(Signature) (Name) Please Print
Rsw i ds
(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 to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle). /
Namen4y AUAI c~ Y11911~ r Signature P MPRS 3,1 (7J
5/88
P. 02
w1 ' ' PINKY'S CROMAND
SEWER SERVICE INC.
13535 33rd St; South
AFTON, MN 55001
Phone 439-4847 436-5788
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RECEIVED EV oO
1594
`Thank `You
All claims and returned goods MUST be accompanied by this bill.
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Wisronsin Department of Industry, S OIL L E E V A L U AT I O N REPORT Page 1 of 3
L° and Human Relations eA,'~Iord r i ian of Safety & Bui ldings p acb- th, 83.05, Wis. Adm. Code
COUNTY
A- St. Croix
Attach comPisle site PIan on PaPer 1 inch s i e. Plan must include but
T e s
PARCEL I.D. #
not limited to vertical and horizontal TAt1h A), di tio
me n'paid Vo of slope, scale or
dimensioned, north arrow, and loca ance tofiehiftl road:` 032-2031-50
APPLICANT INFORMATION-P tNT ALL;:-tNFORfi AJ ON REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT SW 1/4 NW 1/4,S 8 T 30 N,R 19 xxE (or) W
Wilbur Green ,
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
410 165th. Ave. na na na
CIS STATE WI. ~ PHONE NUMBER ❑CITY ❑VILLAGEAJfOWN NEAREST ROAD
165th. Ave.
( j Somerset
(J New Construction Use [x ] Residential /Number of bedrooms 3 [ J Addition to existing building
Replacement [ J Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • _4 bed, gpd/ft2 - 5 trench, gpolft2
Absorption area required 1125 bed, ft2 900 trench, ft2 Maximum design loading rate • 4 bed, gpd/ft2 - 5 trench, 9pdj
Recommended infiltration surface elavatlon(s) 97.56 it (as referred to site plan benchmark)
Additional design / site considerations na
Parent material ground moraine Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for svstem i ®S ❑ U ®S ❑ U ® S 1:1 U ®S El U I ❑ S ®U ❑ S 13U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. I Bed Tien&
1 0-10 10yr3/3 none 1 2mgr mfr cs 2f .5 .6
2 10-24 10yr4/4 none sil lfpl mfr gw if np .3
Ground 3 24-51 7.5yr4/4 none is Osg mvfr 9w na .7 .8
elev.
101.5(1, 4 51-55 7.5yr4/4 none sl lmsbk mfr gw na .4 .5
Depth to 5 55-98 7.5yr4/4 none sl 2msbk mfr ; na na .5 ::.6
limiting
factor
+98"
Remarks:
Boring #
1 0-6 10yr3/3 none 1 2mgr mfr cs 2f .5 .6
2 6-21 10yr4/4 none sil 2cp1 mfr gw if np .3
3 21-4 7.5yr4/4 none sl 2msbk mfr gw na .5 .6
Ground
elev. 4 47-5 7.5yr4/4 none sl lmsbk mfr gw na .4 1 .5
101.45
5 52-92 7.5yr4/4 none sl 2msbk mfr na na .5 .6
Depth to limiting
factor
+92,
Remarks:
CST Name:-Please Print Gary L. Steel Phone' 715-246-6200
Address: 1554 2 th. Ave., w Richmond, WI. 54017
Signature: Date: CST Number:
7-22-94 cstm 02298
PROPERTY OWNER Wilbur Green SOIL DESCRIPTION REPORT Page 2 3
ol_
PARCELI.D.9 032-2031-50
Boring # Horizon Depth i Dominant Color I Mottles (Texture structure. lCorsistencelBourrby I Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. I Bed ITrendi
3 1 0-6 10yr3/3 none 1 2mgr mfr gw 2f .5 1.6
2 6-20 10yr4/4 none sil 2cpl mfr 9w 11f np I.3
Ground 3 20-88 7.5yr4/.4 none sl 2msbk mfr na na .5 .6
elev.
101.9 ft.
Depth to
limiting
factor
Remarks:
Baring #
1 0-6 10 r3/3 none 1 2m r mfr 2f .5 .6
4 2 6-18 10yr4/4 none sil 2msbk mfr gw if .5 .6
3 18-60 7.5yr4/4 none sl 2msbk mfr gw na .5 .6
Ground
elev. 4 60-84 7.5yr4/4 none sl lmsbk fr na na .4 .5
101.10 ft.
Depth to
limiting
+8~
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. 1
ft. ~
i
Depth to
i
limiting ~
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Wilbur Green 1554 200th Ave.
CSTM2298 SW4NW4 S8-T30N-R19W New Richmond, WI 54017
MPRSW 3254 town of Somerset (715) 246-6200
4
N
1"=40'
BM.= top of steel pipe at el. 100'
alt. BM.=NE cormer of walk at el. 106.25'
~.2 3 Vo
G ~I l
0 r 070 su
Ova
5Lq
18~j' r
Gary L. Steel
7-22-94
SIf C 105
SEPTIC TANK MAINTENANCE AGREEMENT
St Croix County
OWNE
MAIIJNG ADDRES4
S Q
PROPERTY ADDRESS
(location of septic system) Pkerisx : ubh.aiu from the Planning Dept.
CITY/STATE_
PROPERTY LOCATION jW 1/4, 1/4, Section T ~ N-R W
TOWN OF •~C~M~ rSC'-_ _ _ ~N___. _ _ _ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTEBUDSURVEY MAP "'+rOl.AJ?*ffv,.._... 'PAf*I'`.__._. _..._,LOTNUMBER _
lmpropi r use aid. maintenan z of your. ep jc sr s~,>-m ~~dsesi rt--. alt i.a its prentature 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.
i
St. Cro° County residents may be eligible to receive a gj-ant for a maximum of 60%, of the cost
of rep ment~f a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted is program in August of 1980. with the requirement that owners of all new systems agree to
keep their system properly maintained
The property 0-mmc;r agrees to submit to St- Croix s-ou:jik o c unification form, signed by the owner
and by a iriater piumbt , jc='.it'n- '[rk an piux0 ber pit lrr" - r a Ala:,eased pumper verifying that (1)
the on-site wastewater disposal system is it, t,toper upeiatuig wnditiun 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 wid 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: bt-. curnpleted and returned to the St. Croix
County Zoning Officer within 30 days of the three year expira.ion date.
SIGNED: 04
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, Wl 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 su~jldtted to this office with the
appropriate deed recording.
owner of property
Location of property G1 h 1/4 `J y\/ 1/4, Section , T3_L_N-R__i9 W
Township ECSe~ Mailing address HNC) ~(Q
Address of site
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property UV 1 6y A *ytfly C-C-af
Total size of property l 4 &A/
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 _,V No
Volume JOR& and Page Number 5b as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOW C3:
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 OW:'. R CERTIFICkTI02d
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. i; 19a~'7 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.
4,1
F
S' azure of Applicant Co-Appl~a:it
Date of Signature Date of Signature
WARRANTY'DP.9S; THIt ^':E RESERVED Pon RECQRDIN4 DATA
1?0Gt1MENT NO.
STATE, BAIL OF WISCONSIN POR_M 2-1982
5JL9527 VOL i SPAPfc5Uc,) REGISTER'S OFFICE
$T. CR= CO., W!
Wilbur A. Creen and .Beverly M. Green,.. husband and Rw'd IN RBCord
wife,.. a$..joint..tenants JUL 2 x 1994
..sib.-1.e.
•
....=~sori....... at 10:20 AM
. Fdward ....Jams.Y -•a••• g .
warranty..to..
Conveys and
>rraaeo~
. ........._.._..i•-•-•-•--•-•--•_....
} . 5t • C-rOlX
the following, described real estate in County, -
State of Wisconsin:
Tax Parcel No:
Part of SW1/4 of NW1/4 of Section 8, Township 30,Range 19 described as follows:
Commencing at W1/4 corner of said Section 8; thence North 88 degrees 16 minutes fI
30 seconds East on South line of said NW66.27 feet to Plate fBeginning; `
thence North 2 degrees 54 minutes 45 seconds West North 87 degrees 57 minutes 40 seconds East 332.41 feet; thence South 2 degrees
54 minutes 45 seconds East 1323•glfeet
WestSouth
lineN332~45thence
said Southsaid
to
South 88 degrees 16 minutes 30 seconds
Place of Beginning, St. Croix County, Wisconsin.
TRANSI~ I~
This homestead property,
(is)
Exception to warranties: Easements, restrictions and rights-of-way of
rv record, if any.
July 94 ,
Dated this day of ld.......
' (SEAL)...._....'~/'--c1?-st, ..(SEAL)
Wilbur A. Green
..(SEAL) :.......e~?f..... (SEAL)
Waved M. Green
,
AUTHENTICATION ACKNOWLEDGMENT
s Signa.tureM STATE OF 3d`1
NNESOTA
ss.
•--Washington ...............County.
authenticated this ....,...day of-.---. 19...... Personally came before me this - ..day of
.01Y._ , 19.9 the above named
- - - - - Wilbur A. Green and Bever- M. Green,.
and.,Wlfez...
TITLE: MEMBER STATE BAIL OF WISCONSIN
(if not,
authorized by § 706.06, Wis. Stats.) to me known to be the perbon s. who executed the
foregoin • strument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED GY
_--------Kristina-.Ogland._-----•-------___•--------------•-••-.
Attorney at Law n I MA County, X434 MN
Notary Pu lie
(Signatures may be authenticated or acknowledged, Both My Commission is permanent. (If not, state expiration
are not necessary.) date: ) W490NUM mum
* 8tne6 of per Snns ?ixraing in aaY CBptcit5' 2hotild be tlp,-.d nr Printed below their signntur. W JoL cow E M:20
STATE BAR OF WISCONSIN -4 .5 Inc.
WARRAMIV