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HomeMy WebLinkAbout032-1005-40-001 C01 RCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.S 12091/01 PAGE 1 ST. CROIX COUNTY REPORT DATES 10/11/91 COURTHOUSE DATE RECEIVED** 10/08/91 HUDSON, WI 54016 ATTNS THOMAS C. NELSON -lob 31.1 OWNERS David 6 Therese Renck I, LOCATIONS 628-230 ve., omerset COLLECTORS N.Jenkins SOURCE OF SAMPLE! Outside faucet COLIFORMS TNTC /100 ml. INTERPRETATIONS Bacteriologically UNSAFE NITRATE-NS 7 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. TNTCS Too Numerous to Count. Coliforo Bacteria/100 ml Nitrate-Nitrogen: mg/L r I f f V LAB TECHNICIANS Pao Gane WI Approved Lab No. 19 p►pEPE 4s V g < Means "LESS THAN" Detectable Level. Approved by; p4* ~T ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 p Iai - ql ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street Hudson, WI 54016 ~j Telephone - (715)386-4680 he St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. ~Na r nitrates and coliform bac eria WATER TESTING FEE: $127.00 (For VOC'S) 0. 11 NAM e ermines if system is properly functioning at ' me o inspection) Property owner's name -David P, Benck and Therese M. Benck Property owner's address 628 230th Av. Somerset, Wi 54025 Legal Description SE 1/4 of the SW 1/4 of Section 2T31 N-R 19 Town of Lot Number Subdivision Name FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house? If so, list firm: ADDRESS 28 2- ' v YOU MAY CALL THERESE AT 247-5653 to set time to _ st.° 4Q25 take water test PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: RANK OF SQMFgSFjj. Arlptng MMdr~inn. Telephone Number 247-3348 REPORT TO BE SENT TO: BANK OF SOMERSET ATM: AR~F~NF ~ pQM PO ROX 220 SOMFRSFT WT 54025 Closing dat Signature ,t Y NORTH S0M , 11 FOLK-STCROJX POLK COUNTY l Ra. IL 8 p~ ✓ e/ rv s G E CA2rei/ce A", r/ i a Cur P N ~ ~aJl Mah/e C ~ o.~ v r Nhr/en S/vric ,Y ~ 4Kr th fFior. 9/a-e oncer.9 7G a Uorda / H kriPai ~ orta o//e, Nk.// W ti - ~ o- ELON RO. ~ ~ 44..t2 PeterSO// Hd'l3e fro: k B) Dair• s./ v.i:/ as ton 76 rrJ J2 .3:5 '✓.l U~ Far-y v f = FER v r~~r v 1 h 'C A+r LAN N k pan f7 `shFC/' 131 tl u5/u5) ® p • ~SC elbe//l, /Gne -ins J49 \ d V InC.® 5 `-o ao ~(ly /eo • /e e vela/ H 7 - Edwards ~I. 41W~ /.l1ro/ ,JY o - tL/,/dyed Fh /65 van ~Terr MaiYu 7.9 rho so ,b/cry ~ r are t •T j b R.cJi. La I/enfure .d o ~ o. ' Sit /oW ✓ryy .t , ro J hr ~iwr acht/Jer , y • fFior. ~J u. . s F LY rQ y4 o f lfli e r ` „trrcF; /54/ 3• bill wh y m PorJ.nqq 'b nd/ K N cnJr !S n7 F)r fY p_ 3.h 0 ~SOW°J US ~ y J LorrYFine C 40 ~ - h [}.J b ~ W ° o s Kro man c3/o5.63 s. 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I l r~ w Cn ~ w _ unolatted lands owned_by_ohers GUEST LINE-SE1/4-SW 1/4 1 Soo027'26"W . 522.72' I~ 33 00' 489.72' rt IN N W W Ift NNtij OtI I(D N X ti o s I (D On p oo~n 1 I!✓ > lz] cn N o y y O In - I,- Oy :3 to A~ O o (D rCj y UI nU)\ N K C19 \ Di c t C) (4 - N FQ z o ('1 I m 0 irt 171 Irf. N I _ 10. O O 1:4 N) I(D ft o a 0 En ::Yl (D 0 (D (n W IW ri t=i H '33 J00 ' 1 ~ H 489.72' r~ H 10 I N00 27'26"E 522.72' i~ tYi C6 X) 0 I~ O .lift In . 0 (t V b (n i¢ 1 711 y o I unnlat.ted lands owned. by_plLttter in rr _ . ST. CROIX COUNTY WISCONSIN ZONING OFFICE : ST. CROIX COUNTY COURTHOUSE x~, 4 911 FOURTH STREET • HUDSON, WI 54016 _ (715) 386-4680 Oct. 8, 1991 Arlene Reardon Bank of Somerset P.O. Box 220 Somerset, WI 54025 Dear Ms. Reardon: An inspection of the septic system on the property of David and Therese Benck, located at 628 230th Ave., Somerset, WI, was conducted on Oct. 7, 1991. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is 'the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. erely, Mar(' . Jenkins Assistant Zoning Administrator cj AS BUILT SANITARY SYSTEM REPOR,:,! OWNER ADDRESS I i r d LOT SUBDIVISION / CSM SECTION _CZ:,2T~N-R W, Town of ST. CROIX COU Y, WISCONSIN PLAN VIEW SHO EVERYTHING WITHIN 100 FEE OF SYSTEM ~kfl i INDICATE NORTH ARROW Buses Provide setb ck and elevation information on rTeerse f this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 2 Z g~s A AA' - ,JLj1Z4~/? ALTERNATE BM: „ ~~'S e J Sf1~'~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well House Other ELEVATIONS Building Sewer ~LZ2 ST Inlet. 9~ y~Q ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system- ~2,f2? Existing Grade A~l Final grade DATE OF INSTALLATION : - PLUMBER ON JOB: LICENSE NUMBER: Z INSPECTOR: 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) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI BENCK, DAVID P & THERESE M X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T ,a7 110, 4d 1-11 o-.5.~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark / o / Dosing' u14LI .4. Aeration Bldg. Sewer Holding St/,W Inlet ~9Q~ TANK SETBACK INFORMATION St/ Outlet S 9S. TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosi ng- NA Headers.- 7 l Aeration Dist. Pipe (o 9-1Z Hold' Bot. System ' yZ PUMP/ SIPHON INFORMATION Final Grade M rer Demand's x-, s ~or l~ Model Number 1~ PM TDH Lift Friction Sys a Ft ead Forc ength I Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length / No. Of Tr riches PIT No. Of Pits Inside Dia. Li uid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING ufact r: SETBACK INFORMATION Type O r/Zc4.,x ~ CHAMBER - ° e Number: System: /'Ct 7(. ' " ~/~o, (po~/GD/ OR U DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) , x Hole Size x Hole Spacin it Intake Length Length I Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At, y nl Depth Over Depth Ove xx Depth O xx Seeded/ Sodded xx Mulched /Trench Center L~~p B~LTrench Edges 31 - r~ Topsoil E] Yes I'D - No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET,2.31. 9.28B,SE,SW,2 TH AVE, /VZ 30 ti UL/Plan revision required? ❑ Yes Use other side for additional information. 9 67 (R 05/91) Date inspector's Signature Cert. No. q _ rCY 1 ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: DID. R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY ~.e°.,....,.~...,. STATE5W ITARY ERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ a a ~p 3 8% X 11 inches in size. - Check if revision to pr vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. - 11-117 PROPERTY OWNER PROPERTY LOCATION '/a, T , N, R or 5-1 5A ) PROPERTY OWNER'S MAILING )DR SS LOT # BLOCK # ;~/4 CITYSTATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ^ VILLLLAGE : "T ),E ICI Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms- PARCEL TAX NUMBER(b) ill. BUILDING USE: (If building type is public, check all that apply)' /pas' ~Df,~J 1 ❑ Apt/Condo 20 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 0 Office/FaetopA 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.9 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 M 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./i ch) ELEVATION Feet 9A ' Feet Vil. 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 strutted Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the un rsigned, assume responsibility for installati of the onsite W sage system shown on the attached plans. Plumber' Name ( rint : Plumber's Si atu S ps) MP/MPRSW No.: Business Phone Number: - J ? Plu 's ddre ree , City, State, Zip de): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sa i ary Permit Fee (includes Groundwater Date Issued Issuing Ag nt Si ature (N tam ) Approved ❑ Owner Given Initial ~C Surcharge Fee) 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 renev, a.i 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 Fori i S"-3) 6399) to be submitted to the col-nty prior to installation. 5. Onsite sewage systems-must be proper lymiiint&ied. Thl* septic tank(s) ?gust be f!urr!(.16_-d o 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 Fan?ily 01welling. 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, econnection, or repair. V. Type of :system. Check appropriate box depending on system-type. Vl. Absorption system information. Provide aP information recuest--p-j in r_11-7. VII. Tank nformation, ill the capacity of new and/or exec ;n,, t .°)k, ,ist ti,.P- *lc)!-;! of tanks anC' iTia.nsfacturer's name. indic ale prefab or ;iite consti d 4kank male, i,il. C si _z:,,(., ur all sept.s C.F.ir; ?srph~~n and holding Oar?ks for this system. Check expe,'m,.,, ! :~prava. c .i~ if :auks received exppt,,Y-:; , .al prodr.ict approval from DIi-HR. VIII. Responsibility statement. Instailinq piumber is to fill in name, licer!se n-or,be, with appropriate prefix (e.g. MP, etc.), address anC phone number. Plumber must sign application f(:,-m. IX. County/Department Use Only. X. County.'Department Use Only. Comp'sele pl ,-i ar I sper`ificatior . Smaller than 8'/z x 11 is?c' ::1 .submit? t~ -ounty. The in rn!,s! ,+G L fe the followi g plot plan, drawn to scale ?r vritFr 3wr{, , * pn of tank(s) cr ; Vier treatment tanks, huildirg -t?` service; sireani& IaKies- pump or Sipht-) tanks; distribution boxes; so!i ^-A;i -rueA system areas; and the location of the bJil ing served, 3) horizontal ar? viC,,°,i:' i iG ..i;I !r tf=r~> r`c n, 3; C) complete specifications for pumps and controls; dose volume; elevat -jr: differences: fricti _ i-, loss; pump pertormanc:e 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. - - - - - - - - - - - - - - - - - - - GROUNDWATEIV SURCHARGE 1983 Wisconsin Act 41(C, included the c. cation of surcharges (fees) for x; num~>)er of regulated proctwes whirl, -a7• ;etfect groundwater- The monies co'.` cted throug s thr, cs s?irch >,r :it`.c, 1 veeitC a: ;fie- water uontaminrtion ii15r(sSiir~ttPi?P1SanY~ t?Stclblt }hFr h;:i of ian,iardb a SBD-6398 (R.11/88) T~r96E ~ 6F i 9-,a w ~e,,o of 4 /57 6 Pid - ~f~ 0 b o 13- p Q/ 6 a3~ O © ~ f7 ~~N✓JL,o S ,Y'S~0 a0 ~ d ~ b Sl /?/i~S~ G3aS9 30 G~.r~~ hsus.~ ZMdwWn~y PAGE C-~-? OF CroSS Se_c~lol'1 o~ A Zco Sy,Jeln • ~ 1 flesh Alf Inlsl► And Ob4srvollon Pipe C~ Approve Vohs Cap MMlmww 12* Above final Glode 20- 42' Above Plpp _ 4' Cost lion To flnel Gr9de Veal PIP• -mash Hoy Of Synlhelk Covellnp 2* Agg,ag4lo Over Plpe Olsulbvllon Pips 0 0 0 Tee Ayyleggle Beneath PIPS ° Pulof9led Pipe 6619, o ~Coy01012 Twmin91109 At Bollom Of System Ina. ~Ic.~•.~' ton ~ / f SOIL FILL DISTRIBLITIOI.1 PIPE APPKOVEO S41JT14ETIC COVCR ATER14- OR. q" OF STRAW 2" OF AGGREGATE -fir - oR MAlcs►+ HAy E F EEY-1•1 f~,OF!/Z-21/2 AGGREGATE DIS-rRiF31JTI0W PIPE T(U BE AT LEAST _ INCHES BELOW ORIGIIJAL GRAOE AI,IU AT LEAST LO IUCHE,°, BUT Al0 MOR.C THA)J 42 IAICµES BELOW FINAL GRADE MAXIMUM DaPTF{ OF EXCAVATIomi FXoM OKI&WAL (59AK WILL BE INCHES nalmUM 9EPr11 OF EACAVATIOW f AOM 04~16INqL CIRAPE WILL BE T y INCHES SIGUED: LICEUSC DUMBER: DATE T i o Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 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. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 5 1/4 114,S T AR ~ (or) 01 -C 9E~'z PROPERTY OWNER':S MAILING AD RESS LOT BLO K# SUBD. N7 E OR CSM # CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD t~ N New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement bCf Public or commercial describe Code derived daily flow ADD gpd Recommended design loading rate , 7_bed, gpd/ft2-,_,L_trench, gpd/ft2 Absorption area required , 82 bed, ft2 / S trench, ft2 Maximum design loading rate _,I_bed, gpd/ft2. , trench, gpd/ft2 Recommended infiltration surface elevation(s) ~3A ft (as referred to site plan benchmark) Additional design / site considerations Parent material,ga ,,--,V ).,err _9 4- DJ a- 4k -by,,,.C-, L Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 1Z ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ❑ S ®U ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourbay Roots GPD/ft in. Munsell Clu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench J7- Al Ground S u~ elev. 21,L ft. , C - - ;V ~7 Depth to limiting factor Remarks: Boring # / 'i{4 }t• fT Ground elev. 2SA ft. Depth to limiting factor q Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page,~) of-2- PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 7 Ground A,'14 1A '7 elev. ft. Depth to limiting factor Remarks: Boring # nvi\titi+:: Ground elev. ~g ft. /1-" VIC '7 i - Depth to limiting factor Remarks: Boring # l -/2 IvI4 Ground Y n ' elev. ,aL ft. - - Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 3 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations November 18, 1993 2226 Rose Street it La Crosse WI 54603 I K 0 CONSTRUCTION RR 1 BOX 105 STAR PRAIRIE WI 54026 RE: PLAN S93-41307 FEE RECEIVED: 110.00 BENCK, DAVE SE,SW,2,31,19W TOWN OF SOMERSET COUNTY OF ST CROIX NON-PRESSURIZED IN-GROUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, #erard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 2902R/ 1 SH11-6423 1 H. 0"1) Wisconsin DepartmgQt #~i t ry. 0 VATE SEWAGE SYSTEM Safety and Buildings Division Labor ar~d Human t - 1 3 Bureau of Building Water Systems REVIEW APPLICATION Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1053A E. Green Bay Street 401 Pilot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 P.O. Box 434 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606 Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614 Fax (715) 634-5150 Fax (608) 267-0592 Fax (715) 524-3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans/information. Your submittal must be received at least one working day prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. 1. APPOINTMENT INFORMATION -if ou have scheduled an appointment, fill in the information requested below to save time: Appointment Date Reviewer Name Number Plan Identification 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here:` J Project Name ❑ City ❑ Village ® Town Of: County Project Location GOVT. LOT 1 /4 1 /4 S T N .R or 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type I (include new and existing tanks) A At- Up To 1,500 gallon septic tank $110.00 41,6- 1,501 Grade - 2,500 gallon septic tank $120.00 H ❑ Holding Tank 2,501- 5,000 gallon septic tank $160.00 M ❑ Mound 5,001- 9,000 gallon se ti ten$200.00 N ® Non-Pressurized In-Ground (convenuotuo 9,001-15,000ga W $300.00 P ❑ Pressurized in-Ground Over 15,000gallonseptictank ..3 $500.00 pp~~ nn vv O ❑ Other: Up To 1,000gaIWUselArnber1~y S 70.00 1,001- 2,000 gallon dose chamber Div........... $ 80.00 Building Type (check one): 2,001- 4,OOCM"ff -o$ $100.00 4,001 - 8,000 gallon dose chamber $120.00 D ❑ Dwelling,1 or 2 Family 8,001-12,000 gallon dose chamber $140.00 P ® Public Building Over 12,000 gallon dose chamber $160.00 ❑ S State-Owned Building Up To 5,000 gallon holding tank S 60.00 5,001-10,000 gallon holding tank $100.00 Code Derived Daily Flow /2a gpd Over 10.000 gallon holding tank $150.00 ❑ Check If Replacing Existing System Experimental System (additional one time fee) $300.00 Revisions To Approved Plan 2 $ 60.00 Petition For Variance: Setback $100-00 Site Evaluation $225.00 ❑ Petition For Variance Plumbing $225.00 . Revision $ 75.00 ❑ Groundwater Monitoring Groundwater Monitoring - Per Site S 60.00 (other than a proposed subdivision) ❑ Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 Subtotal: ~Jn Priority Review: Enter same amount as Subtotal: 116- MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: 5. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Compan ame 7Cont7 Pers n ( ) No. & treet Address Or P.O. Box City, To n or Village, State, Zip Code r, Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. SBD-6748 (R. 03/93) OVER S 9 3 413 U 7 1~f 6E ~--2 el 9~v a , -Y /s h~ - F~/GkJ•o #~c@u~e ta~l4~~#drt / .i ~6 's~~,e t aria V, lumbMg- ; oy,_ s ~'s" 6 O o b i e I .5,~ Pry 7-*~ve- 75 p asp d p ~ b O b b sl ' Nov 1 c: .i 30 , e`n WETY & . G~,rwt S# Vti4,SWAGE STEM , d ition Y PpjjOVEn 8tpy LABOR HUMARI F.:.~'~~'FUWS DES, DIVI O N OF p 6U1L SEE 0 SPoFw': S93 41307 PAGE or CroSS S~cc~IV1-1 of A ~r17 S• 5~~~ Fia►A Ali Inlal► And Obi,sivallon pipe C~ ADpiorsd Vanl Cap Mlnlmwi 12ALOr• final Giad• 20- 12' Above Plpp 4- Cost lion To final Giod• Vaal Pipe F~ ,:tier` SEWAGE SYSTEM s' gf~• • ~ 1ta•e 11•► Or S/nlM"k o•ulnu 4! f ~ti`~ nf/iSbv um 2" AyQiapol• . . Oval Pipe EiilCrllo~- i Plp• 0 0 0 T•• APPROV 6 AoOi•oal. 8•n•alA PIp• ° P6116144d Pipe 6•lar mugm ~ 3TIOF~s o --Carping To minallna Al / ~~•1~RYUn~i'`V` Galleon 01 si►lam DEPT. OpF1 VIOUS7AY- L~A~~~M DIViS1 N Or i/ai Fa a s SEE CO R N0'_:; :.E P, ID Pins.1 i SOIL FILL DISTRIBUT101.1 PIPE • APPROVED S41JT11ETIC COVC ---tIATERP,1- OF, 9" OF STRA 2"OFAGGREGATE Ott MA1cs►+ HAS F OFlz-21/a AGGKEGATE aP R ELEV. OF FEI;Y DIS-l"RIF~UTICOM PIPE TO BC AT LEAST IIJGHES BCLOW ORIGIUAL GRADE AQU AT LEAST LO IUCHES BUT 1.10 MORC THP%Q 42 ILICVIES OELOW FINAL GRADE 53 M MUM DEPtH OF FXCAVAT100 FK011 OK16WJAL 6F AK WILL BE IMCHES rimmuM OEFrH OF EACAvATION FPOJh 014WAL- GRIpf- \4ILL. BE INCHES SIGUED: CE 6'19ELD LICEUSC uUtABEIt: L2,s=- NOV 15 1993 DATE: SAFETY & SLDGS. DIV. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa e of - Labor and Human Relations g Division of Safety 8 Buildings in o ILH 0 Code T a0 7. COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in sizeaP ude, but not limited to vertical and horizontal reference point (BM), direction an , k or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 1~~3 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMAJ46V 1 REVIEWED BY DATE PROPERTY OWNER: #R~f of ION $PFE OVT. LOT s 1/4 - J 1/4,S,_ T N,R fE(or& PROPERTY OWNERS MAILING AD RESS LOT BLO K # SUBD. NA YE OR CSM # r ) 'o7 CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN NEAREST ROAD ()Q New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement bCi Public or commercial describe Code derived daily flow JDD gpd Recommended design loading rate , 7 ed, gpd/ft2__,e_trench, gpd/ft2 Absorption area required 82 bed, ft2 kZ~r trench, ft2 Maximum design loading rate _,_I bed, gpd/ft2__,Y_trench, gpd/ft2 Recommended infiltration surface elevation(s) 93_l ft (as referred to site plan benchmark) Additional design / site considerations Parent material E,•~ ✓~Floodplainelevation,ifapplicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE aGRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ®S ❑U ®S ❑U ®S OU ®S ❑U ❑S ®U ❑S ®U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxtctaly Roots GPD/ft in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench e~_17 1A Y4, 7A 11/1 0 Ground 5- a Lai elev. 21L ft. < Depth to limiting factor Remarks: Boring # I t 1,7 round G elev. ft. Depth to limiting factor Remarks: CST Name: Please Print Phone: Address: Signature: ~Z, Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REP RSECEIVED Page ~of~ PARCEL Lb. # S( V 3 L " 1 30 N 0 V 1 5 1993 Depth Dominant Color Mottles Texture $ Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color G . h& Bed Trends Ground elev. Depth to limiting factor Remarks: Boring # 4Z X-M 1 41Y Ground elev. ,9,U ft. Depth to limiting factor Remarks: Boring # &A 11,e Z~--v 2414 Al 1,4 4 i Ground elev. -ell AL ft. - Depth to limiting factor 7/aR Remarks: Boring # Ground elev. ft. Depth to limiting factor - Remarks: - - - SBD-8330(8.05/92) S 9 3 4 1 3 0 7 of 440E A-s/ja ! REC II~E e~ X28 a_3o f~~9~~ s,~'/5,/ Say S~~a, 7-~i,✓, ,t'i 9~~ N 0 V 15 1993 SAFETY & BLDGS. DIV. A So,~ ~o,C'~~S ,z Ju. ~.tBie ,Oil ` aso ' e P x 75 ~ . O 6 . ® ~ i y I i ~ c I 0230 * T7 ® 6 ASA, !~8^ a a ~ oZ~ PI / ~ 36 3C' 30' G.~r~.~ tlaus,e X28 a-3of~i9~,~ s~~~s~~~~; s~~a, ~i9~ A Sno,` ~~s T ° co 7s' i ti l + r ~ 0?30 ° e e Th ~ ~ ~ ~ t 3s CkA ~ m a 6. 30` 36 ~if6,~ tlar~s.~ Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division Labor and Human Relations REVIEW APPLICATION Bureau of Building Water Systems Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1053A E. Green Say Street 401 Pilot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 P.O. Box 434 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606 Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614 Fax (715) 634-5150 Fax (608) 267-0592 Fax (715) 524-3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans/information. Your submittal must be received at least one working day prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. 1. APPOINTMENT INFORMATION - If ou have scheduled an appointment, fill in the information requested below to save time: Appointment Date Reviewer Name Plan Identification Number A4,17- 9& CZX54 /-10 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here. Project Name ❑ City ❑ Village ®Town Of: County 'i Project Location GOVT. LOT 1 /4 1 /4 S T N R 91 or 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type I (include new and existing tanks) A ❑ At-Grade 1501-2500 gallon septic tank $120.00 - H ❑ Holding Tank 2,501- 5,000 gallon septic tank $160.00 M ❑ Mound 5,001-9,000 gallon septic tank $200.00 N ® Non-Pressurized In-Ground (cornentionao 9,001 -1 5,000gallon septictank $300.00 P ❑ Pressurizedln-Ground Over 15,000 gallon septic tank $500.00 O ❑ Other: Up To 1,000 gallon dose chamber S 70.00 1,001-2,000 gallon dose chamber S 80.00 Building Type (check one): 2,001- 4,000 gallon dose chamber $100.00 4,001 - 8,000 gallon dose chamber $120.00 D 0 Dwelling,1 or 2 Family 8,001 -12,000 gallon dose chamber $140.00 P ® Public Building Over 12,000 gallon dose chamber $160.00 S ❑ State-Owned Building U To 5,000 gallon holding tank S 60.00 5,001-10,000gallon holding tank $100.00 Code Derived Daily Flow gpd Over 10,000 gallon holding tank $150.00 ❑ Check If Replacing Existing System Experimental System (additional one time fee) $ 300.00 Revisions To Approved Plan 2 $ 60.00 Petition For Variance: Setback $100.00 ❑ Petition For Variance Site Evaluation $225.00 Plumbing $225.00 Revision $ 75.00 ❑ Groundwater Monitoring Groundwater Monitoring - Per Site $ 60.00 (other than a proposed subdivision) 0 Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 Subtotal: J)~o - Priority Review: Enter same amount as Subtotal: MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: 5. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Compan ame VConla Pe n ( ) No. & treet Address Or P.O. Box City, T n or Village , State, Zip Code I Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. SBD-6748 (R. 03/93) OVER 5 L N p = e0 ar C c c a, N 4- O n +r O Ri L d f e~ s. >e ea p N 1- J2 c ve iA. of-- u a, i+ C L L M Id c C >1 .O E n a► L A eO ar u ~ C r- ' E eV a~ E 4j ea 4+ 1- E O O ar C C 3 +4 cyt ep - N as L Of to r fV fa 4J C36 N N ar N 4- N N 4A 4j N '0 d = Rj +-t 40 r- n u L n f n= M" c .r ea • ea e0 x E c N - =1 ar #a E a •r s ar O n ar C 1- f- O L 3 v m ar v E 4J 4J ar O c eO L > > > eef L +-0 ar c L C I-"- v► C E c IT O N t so N d a p 4-j ea a c E E .i+ ~ c t O ar EE C s_ 10 E d N.0 N 4j v L O JO rt 4-0 0) 4) L 7 u > c s. W E 4-0 C u n'C O c x .r 00 N N 4- ar '0 O L O •M.- c O =EarM 0 C CO CL Car - c N 4) 4- 4J c ar c. O c u 0 s- ar ar cr'o O L N a O N n 0 o 0 - a< L go d s- u L N~ ELar fO 4-c0 O++ ar 3=+00 = ~ O Nar 4J N f- 4- O 4J elf C c. E ar W .C N +e 0 c C CL C •r N u O A ar '0 N 4-0 N S- s. '0 &V it o L •r F- 4J d 0 lO ar L 10 0 C. 3 4J M, d +L+ E 0 4J .Q 0 0 L L 0 -'0 E > a, n ~ s_ ea ar CL 0 C Ae: s- C E > ar N ea p s. 1 E as L ea f-0 • u4-Oard ar Cd 4J n>C0 ar C a.CL NL O 4- > V E d L N '0 E 4,1 O E E o ar C dod tv= C~ea arm >,CQ>.N4- Oz a 00 Q s_ L cLn .r ME ix ea N to u n•r eO z - oc c to 0 00 00 J t F~~ Q ~ ~ Q ec HO ga$$at $$$$s$ gas as Sass $ g s~ ~ e~ z s~s~~~ s'ss~ss s8~ ~s B~Ns; s s ~ ~a ;H ~ SAN ` V NMNNNM MNNMMN NNN MM NNNN N N _ ! S3 v ~ N E fir Aft Jill 1 103 c 3 W ~~R ggggg aaaQ gpQ4g8Q as$ ~ ~ ~ R• ~E ~ # ~ W ` MNwNN »f.•~» Nee e► ~ ~ V ~ ~ ~ _ N N I~ ~ _ » f N ~ ~ N ~ W S ~ e► ~ t tt ~ < 060 loll am I'' 3 F _ era o 51 Sim !8 <t2 S•O O.N o ~ o - r-.; X- G S & N LAND SURVEYING HUDSON, Wi. 386.2007 NAME Bank of Somerset u ADDRESS Minnesota Title .502 Second Street Hudson, WI 5 - DESCRIPTION part of t ~S!hofthe Sw Section 2, Township 31 North, Range 19 - roix County, Wisconsin. Vol."5", page 1411. (David P. Benck) t PLAT DRAWING N This is not a complete Land Survey g; west _ 250.001 a, rw 36t N... .a n z ell _ 30 , ti ~ tp 28 ( N O p buried telephono _ Ea,at 250.001 3 ` "Cla' 250TH 'AVE. $ M vv 1 f the LOoatioh of improvements on this drawing are approximate and are based on a visual inspection of the reoisea, the lot'dimensions are taken from plats and deeds of county records. This drawing i6 for r ;ihformat'lonal purposes only and should NOT be used as a complete Land Survey. Sank of S, nersot . has agreed to waive these requirements of A-E7.02, A-E7.03, { 'A47.04, ArE7.05(1)-(5), AE7.06 1 - 5 and.A5RoQ7,„~~ The purpose of this paragraph is to comply with W n. A,E7 O1 2)• 91.-01-289Y;,pw",,.~dr~lrt"'~,, .,....lu . lihp No, r ALLEN C ar~,P Date 10/04 91 Prawn By B.C Scale 1 100' ` . HUpSUw, .t" W11U. 392424 S;rJ rn ~ ~ ~ ~ FiLEP +o APR 110 f~ a 0' i y Wider of be*& Grob I O( _ T Q , ii A'i1!., SOUTH, t~ LINE OF TH , ST' 1/4 ASSUE n To Z4,) I . ts] (n -J ~3 un°la -'-ee lands owned b o t:zers ,c - T, Sx' LIN:3-SEE/4-ST1 1/ 4 S00°27' 26"tea 522.72' 33,.00' ~'~89.72' fc) w 1 F, r. N I ri• l•Z N N t•<] O 1 I 1(D 11 L1 O•• i Ich O.~ C) O C: 0') n I r ^h N I- W t-J CJ N I F--' IFS ri o rt (D ,71 r, p & O P) (D 116, to 10 ' O I-h 1ri In IN O r} t.. O I(DD1 O (D O IN O I } (D W 10 1-! LJ hr (q ;..I uPii 33.00' 4.89.72' 1 rci rr F•I !0 e100 27126"E 522.72' 1~ 1 O Iri. C~ 0 1(D h Vi 1;-.~ y H un2lai-tec_la.nc.s_ownPC; _1)y_ ater Icu r C u O hr :11 IO N ~ c U: APPROVED rr I(D APR 0 41984 z 4 (n M. O y r S.- O!X COUNTY 'j rn C_ F- co . 7c;ZE. PAWS PLANNING G~ Ul j C) ,i--1;QNG COMAUTTEE I I n O APPROVED l-3 O~ W 1-h p~j ('f I LiJ -4 APR 0 41984 W U1 G7 ~v :-J ST. CROIX COMM I COUNWAB WS r/r.WS IIAIWWI►d O #M MUM COAUMM ~ r. n . i rl~ tD O O D - n L71 N Fi O ' (R J,1 b m CA O o G) rn w ::t P. rn W ri (D X y ` n a O I-i y (n rV Q-0 k.. RV~1 N• ~ `lie'' •~,`4W to 0 ~6 Vol. 5 Page 1411 Fj- (D z N tt SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER- 0 u , c{ 4- i)ler&5 e be tic ADDRESS: C oZ 230 ''h I40'' mac'/7IE~I sc'. f FIRE NO: LOCATION: S 1/4, _6L__114, SEC.--_T_,L_N-R 19 W,_._ TOWN OF:- ST. • CROIX COUNTY SUBDIVISION:_& LOT NO. 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 a 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. z/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 form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. l SIGNED. I. DATE : St. Croix County Zoning office 911 4th St. - Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by the okg11er(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 E • ~/I 7~. Location of property5G.5 1/4 SW 1/4, Section- e2 , T_N-Rj W .Township Nailing address _ 62 ?3C i3Ll6-' Sc9/YIP/5115 ' lv Syt~a2S Address of site X19 a 75 0 Subdivision name c.SH Lot no. / Other homes on property? yesNo Previous owner of property _ rkll /PS 7rc~~5~'0 Total size of parcel Date parcel was created ' Are all corners and lot lines identifiable? yeS No In this property being developed for (spec house)? Yes _i:::~."No volumet/-,?7 _and page Number as recorded, with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIWITY DEED which includes a DOCUMENT NUIWER, VOLUME AND PAGE, IIUI BER & THE SEAL or THE ItEGIST]hl 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(wc) certify that all statements on this form are true to the best of ny (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 Ho. , and that I (we) own the proposed site for the sewage. disposal system orreIe(we) obtained an easement, to run the above' described property, for the construction of said system, and the same has been dul recorded in y the office of County Register of deeds as Document No. ignature'of'ap~l cant Co-applicant Date of Signature Date of Signature °t)ocuM► NT No. Ir~ WARRANTY DEED I TMIO srACC Rcscevso FOR RccoROl«a DATA iI STATE BAR OF WISCONSIN FORM 2-1981. von 687PAGE542 _ 393:170__- - ~ W. 45 OfRCE . C~Otx CO., *16. Charles F. praiser and Mary Ann Traiser, St 7jeCd fo d Ifi { - r Reeor Is loth < ?E hu b nsi ..and... wxf.e..as...ls~i joint-_terants . 1 day of y AD. .19114 E` (I - I at •30 A M, conveys; and warrants to David P. Benek - and Therese M. s Traiser.r._-as..7ont...tenants lgYlet of Deeds 1, t I R.T... TO I - 1111, the following described real estate in .St.....-Craix .........................County, It I~ State of Wisconsin: i Tax Parcel No: i I; I Part of the Southeast Quarter of the Southwest Quarter (SEh of SW4), li Section Two (2), Township Thirty-one (31) North, Range Nineteen (19) iii West, described as follows: Lot One (1) of Certified Survey Map filed April 11, 1984, in Volume "5" of Certified Survey Maps, page 1411, as Document No. 392425. I i FEE i h I i i Thia ..-is..not..._...... homestead property. (is) (is not) I { Exception to warranties: ;i is i Dated this 19. $ 4 . --.9th day of X..-- ..................9th ' .L~~"~r~"",•~!--. (SEAL) :-IV) (SEAL) Charles F. Traiser tnn~Traiser Mar (SEAL) ---....(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN 33. St. Croix County. this day of ..........................119 Personally came before me this 9th........ day of. Mav 19.84._ the above named Charles...F.__.Tra e.X._and..Mar. __.Ann._. `raiser • - TITLE: MEMBER STATE BAR OF WISCONSIN (If not . -t authorized by $ 706.06, Wis. Stats.) to me known to be the person .5...._..._ wh<e*e d the fore ng instrument nd nowledge VAeltdne. _k THIS INSTRUMENT WAS DRAFTED BY ~.r 1 fr Reinstra, Van Dyk & Needham, S.C. Q . _ J , ..~'1. Ta a•_ L._..G.a ds_er........---- r ~ctttsrrteys at Law . .:i~~nty Vis.. , `Ie.w__Ri~kl?nOna.....W seo-•sin..... 54-017-0.127 Notary Public ....Str---Cr.QIX.............. '$tlEtci' eKpitiot) (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, 7 ~c( are not necessary.) date: 4-5-8 •Nanes of persona signing in any capacity should be typed or printed below their signatures. ~fnA STATE BAR OF WISCONSIN SfOCI( NO. 3002 H ~MdtMrCa+gry~ FORM No. Z - 1Y82