HomeMy WebLinkAbout038-1085-70-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER c /i~ q ir1 r A< o
ADDRESS
Ocl-
SUBDIVISION / CSM# LOT #
SECTION_<20 T _y / N-R /gr W, Town of Slxxr 6~ ,r r e,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
D
3 6z~ rov (x;e jl
A> w se.
s~~ ra
I~
II
iI
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: f on-P (J 1 4cj. -e-,
ALTERNATE BM: T 0 an PT IC / PUMP CHAMBER / HOLDING TANK INFORMATION /
Manufacturer: Liquid Capacity: I M67 d l
i
Setback from: Well O e House Other
Pump: Manufacturer Model# r Size -
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches 1 ,P CJ
Distance & Direction to nearest prop. line: 150
I
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet:9 , ST outlet
PC inlet PC bottom - Pump Off 'r
Header/Manifold..2-2_3 4 4& Bottom of system
Existing Grade 2,x Final grade 1LL~LM emu, X -le- 9~s
S
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and HuTan Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary PermitNo.:
GENERAL INFORMATION Aggic)
P U'AMI3WC~`M:, JOHN ❑ City ❑ Village IR Town of: State P13 1113 No.:
CST BM Elev.:Insp. BM Elev.: BM Description: Parcel Tax No.:
d , , Q. G.
TANK INFORMATION ELEVATION DATA 47
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic te,< T7 d)6 Benchmark
i
Dosing
Aeration Bldg. Sewer -6
[Holding St/K Inlet g 199 56
TANK SETBACK INFORMATION St/ Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet '
Air Intake
Septic NA Dt Bottom
Dosing NA Header /-Mook_
Aeration Dist. Pipe
Holding-_. Bot. System ~2 33
PUMP/ SIPHON INFORMATION Final Grade
s Manufacturer Demand -P
Model Number
ti
TDH Lift I Friction 5 TDH Loss I ,
t
Forcemai n Length 'I a. Dist. To Well
SOIL ABS PTION SYSTEM
BED /TRENCH Width Lengthy j No. Of Tr riches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~7L DIMENSI N
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEA G Manufacturer:
SETBACK
INFORMATION Type Of Ti/ 5 ,t CHAMBER Number:
System: 064C 6~_ OR
DISTRIBUTION SYSTEM
Header/ N1a7rffodd rA Distribution Pipe(s) x Hole Size x Hole Spacing it Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste my
Depth Over s Depth Over xx Depth Of x eded / Sodded
Bed /ICenter __00 Bed /TrM Edges - Topsoil ❑ Yes I-] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: St r Prairie.20.31.18 , SE, SE, Lot 1, 100th,Street
`1,
y
_ "Ic
4261
74
Plan revision required? ❑ Yes( o
Use other side for additional infor ation.•---
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY ,
SNIA$Y§,RMIn
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE v~ yx CC~~
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
fE%%,S o T_3/, N, R E(o
PROPERTY OWNER'S MAILING A FtESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER
,04 sx 1-1 y o Z7,66
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE v ,Q p!! ARVEST ~ L~C
❑ Public X1 or 2 Fam. Dwelling of bedrooms - PARCEL AX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) - 0 76
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. ❑ Replacement 3. ❑ Replacement of 4-E] Reconnection of 5.E1 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 430 Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
_ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
' ~ i~ d Z/ 6 er 7 Feet 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 pp'
Septic Tank or Holdin Tank G~ + El I El I El I Ej 1 0 F]
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumbs ' Name (Print): r PlumStam MP
/MPRSW No.: Business Phone Number:
^D~ $l
Plumb s Address (Street, City/, State, Zip Code)-.--
IX. COUNTY/DEPARTMENT USE ONLY
Y❑ Disapproved Sam ary Permit Fee (Includes Gr undwater Date ssue W g g Agent Signature (No Stamps)
Approved El Owner Given InitiaSurcharge Fee)
Adverse Determination
2LL&::~L
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.
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) rrlust 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'dnly one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic., pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement, system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, gound-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLAN
PROJECT John D,Ambrosio ADDRESS 6438 Stillwater Blv. Oakdale Mn 55128
SE 1/4SE 1/45 20 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MFRS BYRON BIRD JR. 3318 5/21/94 BEDROOM 3
DATE
CONVENTIONAL XXX IN OUND PRESSU CONVENTIONAL LIFT HOLDING TANK
SEPTIC TANK SIZE 1000 GALS LIFT TANK SIZE DOSE TANK SIZE
MOUND
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 ft BED SIZE 12'x 54'
BENCHMARK V.R.P. Top of Red Stake ASSUME ELEVATION 100'
❑ BOREHOLE (Z)WELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 97.1
12" GRADE
VERING
U3'
12;' K
747' Property
50' P.L.
g
>20% Slope
13. M. 25 200'
20' 6% 10' Pro 3 Bed
B-2 House
15'
Ven 10'
B-5
55' 15'
60' o Well
10' Rep A B-3 B-1
B-4 4% slope
200'
747' P.L. N
Wisconsin Department Industry,
Labor and Human SOIL AND SITE EVALUATION REPORT Page
Relations _ Of
Divisior.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 Gt~o
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 1/4S~ 1/4,S,42 T N,R - E
PROPERTY OWNER':S MAILING ADDR SS LOT4, BLOCK # SUBD. NAME OR CSM #
CI Y, STATE ZIP CODE PHONE NUMBER CITY ❑VILLAGE 3FOWN NEAREST ROAD
~l
r _l^c r, p
[ANew Construction Use [ Residential / Number of bedrooms [ j Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow y~:ogpd Recommended design loading rate * Zbed, gpd/ft2 . Ss trench, gpd/ft2
Absorption area required 6 4 3 bed, ft2 trench, ft2 Maximum design loading rate gibed, gpd/ft2=trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations 3;~ el
Parent material 451--a- 1.44 Flood plain elevation, if applicable ft
r='U Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
Unsui
table fors stem IM S ❑ U as ❑ U EEFS El U imS ❑ U ❑ S S lit? ❑ S $U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-422
Ground
elev.
f t.
Depth to
limiting
factor
y12- 1 T
Remarks:
Boring #
Ground
elev.
i?X Y't.
Depth to
limiting
factor
2
o`-7~ Remarks:
CST Name: Please Print Phone:
Address:
Leo/
Signature: Date: CST Number:
I
PROPERTY OWNER f ,Jry ~/Dn-60IL DESCRIPTION REPORT Page 6f
#
PARCEL IA
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
izon
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring # O /o
42 Z't
Ground
el Pv.
ft.
Depth to
limiting
factor
2 71-A
ar / Remarks:
Boring # G
Ground
elev.
9~ ft.
Depth to
limiting
factor
a2 Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
I
Soil Test Plot Plan
Byron Bird Jr. ~.~-G~~"<<s ~r sTro
- Property Owner y
896 68th Ave. AddressZ 9-7
Amery Wi 54001 / .SG-11/4 -S~l 141S.zo lT.7/ N/R/aW s ro~s-
CST #3479 Township ~i`or~.-mgr.
DateJ/--Z,~ ::may . County
0 Boreing ► Benchmark H.R.P. System Elevation
SP.-..-
A
20 /
I y Irv
7Y 7 '
APPROVED
FILED APP 2 7,'94a
~,PI? P, 7 1994 ► 4
515899 ST. CROIX COUNTY JAMES O'CO,,NhELL
Registar W Deeds t5
omprehensive Plaid di 6 St. Croix Co., Wi
Zoning and
r-'!rIts Cornn ifto cb
O If notrecord6d Bearings are referenced to the
within 30 cJa~s of East line of the SE} of Section
°o ~ W 20, assumed to bear NO1°03'41"E
0 Ln x c a 0 3ppIOV8I31tiM
_ > > c Z no- & vow
c UZI _ rr
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co = < <
> c
co 7 UNPLA T T LD I-a~; U'
-n O. r+ - - -
v o ~c
r-
or c
CAP
N ° S01°03'41"W 350.00'
In er
co N
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V,
Existing Fenceline ---x- y t1
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Fh a
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nro
D roK
r n rr
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rr c ~
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to d r
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V1 C7 N >
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0 100' Roadway Setback Line
00
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A
N01°03'41"E w NOO°30'11"E 350.14' I
v ~ NOI°03'41"E
CAI Co m 762.15' - N01°03~41"E 350.00' 5 0.54'
z 0 East line of the SE-4 of Section 20. w 1
z i 0
om m
N~ 100TH STREET o M
VOLUME 10 PAGE 2750
UNID, AT I EG I_AiND
This instrument drafted by Ed Flanum Job No. 93-60
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS 6Q3 S7i~ T`- BG D6JfT Gal/p /VN _5T/ 2',Y
PROPERTY ADDRESS 2° T!1 .S 50MF~'.S c ~J/S& , 5~~~ Z.S
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
I
PROPERTY LOCATION S E 1/4, 5 E 1/4, Section, T__IL_N-R1 W
TOWN OF -S TCc r ,~~a.,'~ , G ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER I
CERTIFIED SURVEY MAP y) ] S ~ VOLUME , PAGEoj 5b, 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 ex iration date.
SIGNED --~C
DATE: 5
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 J D ✓ "'4' 4'
Location of property-5 _1/4 6E 1/4, Section 2, TN-R_W
Township : ,Q Mailing address 6Z~ 5j,'/,ri.~uvfdr ~►o
1Z ar
Address of site a02_Z /vv ?f/s% s~~"''rS~ f t~JisL s'✓O?-Y
Subdivision name %Moo Lot no.
Other homes on property? _Yes No
Previous owner of property r /y 3 rj,~-rslr,;,m
Total size of property 4'C`Q'5
Total size of parcel C. OEJ '4 d- -rte
Date parcel was created
Are all corners and lot lines identifiable? Yes No ,i
Is this property being developed for (spec house) ? Yes ~ No
Volume and Page Number 7- as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the Office of the County Register of
Deeds as Document No. 516 70 ,S 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.
S' nature of Applicant Co plicant
Date of Signature Date of Signature
STATE OF WISCONSIN )
ss. AFFIDAVIT OF SELLER
ST. CROIX COUNTY )
The undersigned Seller, being first duly sworn, certifies with
regard to the property described on the attached Exhibit:
That I have owned the property on the attached Exhibit
continuously for years past, and my enjoyment thereof has
been peaceable and undisturbed and the title to said property has
never been disputed or questioned to my knowledge, nor do I know
of any facts by reason of which the title, to, or possession of,
said property might be disputed or questioned, or by reason of
which any claim to any of said property might be asserted
adversely to me;
That there are no proceedings in Probate Court, no bankruptcy or
divorce proceedings, and that there are no unsatisfied judgments
of record nor any actions pending in any Courts, State or
Federal, nor any tax liens filed against me except as herein
stated;
That any judgments, bankruptcies, probate proceedings, State or
Federal tax liens, of record against parties with same or similar
names are not against me;
That there has been no labor or materials furnished to the
premises, described on the attached Exhibit during the last 120
days for which payment has not been made;
That there are no unrecorded contracts, leases, easements, or
other agreements of interests, relating to said premises, of
which your Affiant has knowledge except as stated herein.
The undersigned Affiant knows the matters herein stated are true.
Dated this '12th day of May, 1994.
Charles H. Borgstrom Delores Borgstrom
Subscribed and sworn to before me this
12th day of May, 1994.
Kristin gland
Notary Public: Pierce County, WI
My commission is permanent.
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
Charles H. Borgstrom and Delores Borgstrom, husband
and wife
_
-
convey.s and warrants to John V. D Ambrosio and -Janet
D--Ambrosio.,...husbandan
-d.taife,-------------- -
RETURN TO
the following described real estate in .................St. Croix .County,
State of Wisconsin:
Tax Parcel No
Part of SE1/4 of SE1/4 of Section 20, Township 31 North, Range 18 West,
St. Croix County, Wisconsin, described as follows: Lot 1 of Certified Survey
Map filed April 27, 1994, in Vol. 10, page 2750, Doc. No. 515899.
This is not homestead property.
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of
• record, if any.
Dated this v;?'p day of -------------------..-------------May - 19--.--94
i
I
L.%~i~C
(SEAL) •----!?!G~~ (SEAL)
* Charles H. Bor strom
(SEAL) xaoL-Ca - (SEAL)
Delores Borgstrom
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Charles H. Borgstrom, OF WISCONSIN
OF
- - - - STATE
Borgstrom ss.
-
I.~~,,~~}},,~~ --------------------------------------County.
authenticated this __Vtay of----------- AY.......... 19..94 Personally came before me this ________________day of
- 1 19-------- the above named
Kristina 0 land
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not- -
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina 0gland
Attorney at Law
Notary Public ------------------------------------._...-County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date:
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
FORM No. 2- 1982 Milwaukee, Wisconsin
DOCUMENT NO. WARRANTY DEED I T.I. SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
516703
Charles H. BorgStrom and Delores Borgstrom' husband
--if-------------
an we
,
- M AY 16 1994
John V. D . Ambrosio. .'am. Janet..... x 12:30 P.M.
conveys and warrants to - - - - -
D-'Ambrosio,. husband and wife, ` ~L'
r
RETURN TO
- Kristina Oglan
P. 0. Box 359
- .
the following described real estate in .................St-. Croix County,
State of Wisconsin:
Tax Parcel No:
Part of SE1/4 of SE1/4 of Section 20, Township 31 North, Range 18 West,
St. Croix County, Wisconsin, described as follows: Lot 1 of Certified Survey
Map filed April 27, 1994, in Vol. 10, page 2750, Doc. No. 515899.
This is not homestead property.
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of
record, if any.
Dated this day of -----.1"18y.------------ - , 19.... 94
Z,r
---(SEAL) . - - - - (SEAL)
* Charles H. Bor strom
..(SEAL) Q(-t (SEAL)
Delores Borgstrom
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) Charles--H-.---Borgstr:Om, STATE OF WISCONSIN
Delores Borgstrom ----------------------------------------ss.
-
-Wt--------------------- - - County.
authenticated this -.`.ilay of........... ay_---------- 19..94 Personally came before me this ................day of
, 19 the above named
-
Kristina 0 land
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina 0gland
Attorney at Law
Notary Public ------------------------------------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date:
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
ST. CROIX COUNTY
WISCONSIN
1 ` ti ZONING OFFICE
1111114 u x u r - ■,NO ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
September 26, 1994
FAXED TO YOU THIS DATE
River Valley Abstract & Title Company
206 Second Street
Hudson, Wisconsin 54016
ATTN: Roger Bevers
RE: Septic Inspection for John D'Ambrosio
Dear Mr. Bevers:
An inspection of the septic system for the John D'Ambrosio property
was conducted on June 23, 1994. This property is located in the
SE, of the SE, of Section 20, T31N-R18W, Lot 1, Town of Star
Prairie, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for
a three (3) bedroom home. If you have any questions with regard to
the above, please do not hesitate in contacting our office.
inc'o-,rely,
i
J es K. Thompson
ssistant Zoning Administrator
St. Croix County, Wisconsin
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