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HomeMy WebLinkAbout038-1085-80-000 1 7 STC - 104 fC" .'-r AS BUILT SANITARY SYSTEM REPORT' 4~ . t AQ OWNER~~-Q.Lt~Y`- ADDRESS c~~/Oq SUBDIVISION / CSM 1 9 ~ ZP-, LOT SECTION 2V T N-R / W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVF.RYTHTNn WTTHTN 100 FEET OF SYSTEM 98' of 3039 line has 2" of insulation due to insufficient frost s depth 1200 Gal o z y S- Proposed 9 Bed House u, 3G \ c J Garage o ®B9 eB2 s /X~p y2Ctic,~~ s Each trench has w 75" of Perf Pipe ®B5 D ®B1 qV'~3 r k~~err' o South Lot Line 819.56' e r k 172.37 Provide setback and elevation information on rev,- Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: /00 -~cl e r ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 42c) G i Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length a-CJ Number of trenches Distance & Direction to nearest prop. line: Setback from: well: H u ~L eer' ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: /,R -13 PLUMBER ON JOB:J _ cl/V& L,ICENSE NUMBER: INSPECTOR: 3/93:jt ✓ ® ® cn cn Ul W fU bo U) -a CO t3:1 LO r+ m O W O (D O C7 ❑ o M U7 v V 'WV v m C0 ° CD b ° CD t- _0 m CD O T m U7 < Will tJt in O ' 3 0 ❑ rU CD N =r p y m Cn C) C ~ s ~ < t ~ ~ O W 7 O ❑ CD. -1 W 7 r'. p p O Z U) o y p ~ l"f N .r ❑ S m 7 b co I North LO 0 c T Ilk, o r- ❑ d 0 COD O S 0? -0 _ m t0 CD CD rn ~ T o p CL CL S -bL rn CD c ❑ E- T r. rv 0 CWW ® e 00 00 (A . Ln c~ o CD D :D r+ I 0 ,~O r+ li I 0 O 0o I _ CD r o m N Lfil O p p 77, d -O w 0 co b CL o V ~ Rl = CD W G7 o CL V ❑ U) CD t❑ ~ CD ❑ (n i~ N d Z Ill ro tim rn r o xvAixm m bD ~i °~D ~M ~m Z Z ~4 East Lot Line Wiscongiri Department of Ind `y, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety ancl;Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 21 C)044 PerWnlder_'sNarne: WILLIAM ❑ City ❑ Village EkTown of: State Plan ID No.: Star Prairie CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ~ "1 ~d 1"d 1 j 'r TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic JC 0 :J Benchmark , zoo" Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Oq q jr' I Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Septic ya5' i >/5 NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe 7~ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand1 P, I. ;I: 97, yg Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. Dist. To Well H SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt © No. Of re es PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer: SETBACK INFORMATION TyspO f ~ OR UNIT CHAMBER Mode Number: yte DISTRIBUTION SYSTEM Header/Manifold Distribution Piggg...ggg- x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. ff Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over ~.14." xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench EdgQW Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Star Prairie.20.31.18W, SE, SE, Lot 2, 100th Street Y1, a.1 e OtP Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date spector'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 ~7COUNTY . STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 0.1?49 8% x 11 inches in size. Check if revision to Eprvlous 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 f .VSP4- 5e r t/4SE 1/4,S R T?j N,RE(or) PROPERTY OWNER'S MAG ADDRESS LOT # BLOCK # 00V CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD TOWN OF: ILLAGE ❑ State Owned ;PARCEL V ❑ Public LN1 or 2 Fam. Dwelling-~#of bedrooms" TAXNUMBERO 2 III. BUILDING USE: (If building type is public, check all that apply) 3 1 ❑ Apt/Condo ! v 2 ❑ Assembly Hall n 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 9 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 b6o REQUIRED sq. ft.) PROPOSED (sq. ft.) (Gal ay/sq. ft.) (Min./inch) q ELEVATION F Feet ` ; 3 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New fisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank / CAS CYiVC . Lift Pump Tank/Si hon Chamber El El 11 1 11 Ll VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber'sf ame (Print): / umber gnatur : (N Sta ps)~ MP/MPRSW No.: Business Phone Number: d e "4b12~ 7 71s' 7 333 s' r P mber's Add ss (S reet, City, State, Zip Code): © x .3 f0 es eR- 1 .-(4cCl IX. C LINTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ary Permit Fee (includes Groundwater a e Issued Issuing A nt Sign a ps) Approved El Owner Given Initial Surcharge Fee) Adverse Determination ~~QO((~J //G cY X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 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 y1 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. 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) Ln 0 O] Q1 d O_ Z W U CO 4z1 L-i c::) ICE LO ~ o w Z J LL = Q W_ 3 Q : rr, • ? W Z J O Q Q ~ ~ '..~7 O J J Z O U QL W W Cn e~ y r1 ' C CD OD (1;5 ICZP U5 O Z ~ ~ (-D U U L-3 LLJ (I- dWd.W r F- Lr) c::) LO z z L1J cn LLJ CD z o C7 ~ IT z = Ln Q CO L = W 5 Ln Ln W C7 N C ¢ C'7 o z o rc*~winwLn C +-i Lf] W ) CI7 N Cf] Lf7 Z In cn r'1 1- 0 > L O Q O CD -C a_ O N - d. E v 0 ~ W L , LL- cC:? a ~ u Z Zo Z N wY I~~vf I C7 Cc M Q _ ¢Z~MM LLJ O 3 `W-"¢ (n X 0: a CAwih o N LLI A~ cc 01 rn a IL i M N, East Lot Line oa `Um Q~ D a~ L I Q (U o' A ~ ~ as y a~ L U Q] c 6n F- Ln CO Qa Qa 0 a C? E o t O Y O L U ~ N O C-0 to C ~ Ol Z7 y Q [A co O L CL N U) O O m O 0) w aI;rS 3d 41-~oN ~ q C 3 O C, d O N O Z O ~ N C~~ U7 1 Y d I- m to L N d U) p L W O 0 L W cn cn L 2 ,G E W O Co Ln Ln C7 J N U O O C7 N CO h+ r- I- r- ci W mm C7)O'1m Q L C y L Q° ""o o a~ o~ M o = W ' cn m M F- :~w cn cu mw Ln LL- a cn cn Z O Z U7 LLJ O~ Y w O [D C O Q lLf7 m U:) CO LU p N Lil CL Lr) Ln 0 3 rn LLJ LJJ LLJ m Z Lr7 m Q7 C 2 cm CD Q cl 0= CL C O c Y C C N C7 LLI U E yN O 4 y ~ T ~ N Ln CTS O ~J ~ Ol 4 F-1 O. Ch CD J- V_ A O y a O Ch U N C1 7 4 aO X C CU d 0 Ln cu L CLJ Q] 3 4 d Ln OC] t N C C 3 O Z O y C ~ F j N CU ®.L 4- CU d Ln Ln L F= w~ D d LL- LLIL,~r) ~ 2 Z LO W E Y z p Z¢gMM1~~r~pp. ~ LLJ 5 0= W = cn x 1f~ti 0 0: a 12 LLJ ¢ ca w th > d O ww wti (.n z o w U 0 0~ o:: F- W S Z CJ7 Q W O 0= 0_ O_ Q J J LL. CLJ J U CD W z L' w ~r U) w o ~ W~ F- O Er J U Z C7 Q Z • W 7 p O J cu Q LL. CO ~ LLJ Q z w O W Q CD O W co CD M __j t i J Z cD 3 U7 3 U o ¢ o W W LAJ ~ ¢ G LLI W cu ZD LO :z GG \ cn O C7 CU F- W N = 17- J J r r-1 En CDL U ¢ Q V / C7 • s \ Q Z r n RJ (D = O Co 0= ~~yy 111 W O O L1. m 0 CD O U C!7 p= cr O U- L.t_ W J Z Z Z F- CD O Q m Q Q W > 7 W co w U Q W O = X U F- U W X O Z W W l.t_ m O_ O O O W Q_ CL.I S S Z O O c n co -C 7 F- W q A C 3 L ~ J = J O :z O W F- cn F- N~ N ~C~fJ Q X Z n Z Q MO.L C] Q +JN O Ln CJ7 L- E LLJ O O r LL. LL. 3~CJ7 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page-/ of 3 Lat;or and Human Relations Division of Safety Buildings in accord with ILHR 83.05 AMs. Adm. Code COUNTY Plaq mu§linclude, tut Attach complete site plan on paper not less than 8 112 x 11 inche/a not limited to vertical and horizontal reference point (BM), directio % of slope;scgle or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest r APPLICANT INFORMATION-PLEASE PRINT ALL INFO~VATION j REVIEWED BY DATE PROPERTY OW ER: PAOPf-TTY-LOCATIOpL, e 6C~1/. L r/4 1/4,S T~ ' N,R E (o4g PROPERTY OWNER':S MAILIN ADDRESS 0T # BLO SUBD. NAM OR CSM # STATE ZIP CODE PHONE NUMBER OCITK- VILLA MOWN NEAREST RQAD ~Q New Construction Use pC] Residential / Number of bedrooms [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow M _ gpd Recommended design loading rate bed, gpd/ft2_,,3__trench, gpd/ft2 Absorption area required 9,5-9 bed, ft2 ,7= trench, ft2 Maximum design loading rate -_-'7 bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material 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 ®S ❑U UaS ❑U IVS ❑U ®S ❑U ❑S ®U ❑S 19U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. S . Cont. Color Gr. Sz. Sh. Bed Trer& Ground _ Ad '7' elev. ,9,W ft. -Aw Depth to limiting factor I Remarks: Boring # z)=42 /2 4-iZy 4 '5 _ 7 Ground elev. 274ft. Depth to limiting factor~ Remarks: CST Name:-Please Print Phone: Address: r Signature: Date: CST Number: v PROPERTY OWNER SOIL DESCRIPTION REPORT 'Pag@~.of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench ~1iQ~ ~4 v: J -L J Ground elev. R ft. d Depth to limiting factorf Y Remarks: Boring # : it Ground elev. - . 2 42 Depth to limiting factor Remarks: Boring # Ground 71 elev. Depth to limiting factor Remarks: Boring # r:4 4v Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ~Ga 3 ter- 3 c- ~L9~~diJ j 0 ~Sa ti Cfl •1994 0 JAMES O'CONNELL 519922 Register otDeeds St• CrOIX Cb- IA/1 X1 N ~ ° N Cn O CD UNFLAT TED~PPROVED ao co O ° cn c LAI'lD M 0 N ' N O ° rn to m AVG 5 '941 0 rt* ° -m4 N01039'53"E N a ° 344.50' a'r. . CROIX COUNTY :3. ;a cn o o (D ::J C C-Ornprehensive Plannir Zoning and Parks Committee co co ~ ri' CD 0, If riot recorded 0 0 ~n ►-n within ~O days of = y 0) approval date (WD ~ I r. r• u,° x w }eproval shall`bo cD 1 P, rn 1 _Ztl All $ void 0H. En ,:2 o 1.1 0 0 ~mc IT I > > ,o cn ro N > N O iv ~o -co °-0* ° o '-I sw}-sE} -I-I Coto °(m 0- rt ° pl SE} - SE} a A - 1C7 I- (D I r co -n N T H s H N n 1,o I) ~o I r H. w m w? I.z w I] C, Lo Z 1-3 rt °a rb I W ti ~7 W ro - r'r ~ ~ cn I l!) Z fi s ~c CL H rt r') ~ z o rn rt ° ° 'd 0 n A a o N► h -I ° _ -1 co 4 °i Lnn n cf9o tt T O l., v (D rn `n ;uV A0 0 !n rt ti a ; V ti e`!' C 0 O < d rn rt, rn ° "i !0?aar, ? 501003' 41" rt ~ rt _Ir 3 W 10 C_ r Dy s~•tt"~y 326.60' ° a (D r . 'r ^ cn c o, rotz1 ol 40,', (D w co tzj G) 0) 0'. ~j,kj co z (11 It (31 CD E o o I z n O (D , e4 C, pF1:" L" 11i N O _ c o o c 0 rA.. O M 1-7 cn a ' 14. n (D C/) rt If rt H. C!} ( S L1 f I a.. I> n c* co rt N A I~7 ° 1nj N U1 00 0 w Ir~~ ° it x L,. P) - T s n ~ r• co Oa G tt R1w S0~00301_1111W O O f"t 01 a 18-021 co -ro a East line of the NE}, Section 29\ ° East line of the SE} Section 20 H. -L~ S0200711 7 W O N /SOl 03 4 n O _ 48.01'_.. O 0) UT-18. 01 ai rt 0i Eq H. - 1E) I H S I I Bearings are referenced to the P. (D ! _7_T 2 _ X Cn South line of the SEJ of Section 0 20, assumed to bear N86051'20"W. CERTIFIED DIED SURVEY MAP > I N '07 V0' 4 , PG. 1114 I ° VOLUME 10 PAGE 280C r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Bi `7 d 7'., e J01 ev e, AX r MAILING ADDRESS ®o y /oat/ S'y~ -So • s e,~ &'Cs- 5'f'-Pa s I PROPERTY ADDRESS S'Ah► e / 4!24 12 b o le o "'le - .y o c' ,e, `s Q c (location of septic system) Please obtain from the Planning Dept. CITY/STATE SO ^ e • s r,-rz PROPERTY LOCATION _11/4, E 1/4, Section 740 _W TOWN OF S ~A • /de A s ~ < , : ST. CROIX COUNTY, WI SUBDIVISION A- , LOT NUMBER CERTIFIED SURVEY MAP , VOLUME /6 , PAGE a8 609 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, tf 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. SIGNED: DATE: zz&V9 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 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 /;I,, ~ 7"W10'e Location of property_&!j~_1/4 Ala 1/4, Section ?J9 -,T,Z/ N-R /8 W Township Mailing address „7D a 4/ /o o S you s 1'y • So Lr, S 6 T f Al" s Address of site Subdivision name Lot no. 'V Other homes on property? Yes___X_No Previous owner of property _ W.. r B I-o s ra.,, 61 Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ G~Yes No Is this property being developed for ('spec house) ? Yes __,Z _No Volume and Page Number Ys2 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. 503c4 '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. ~w ignature of A licant Co-Applicant e /is/9y Date of Signature Date of Signature W1~u Ic.,i~y , . A WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 S?034 7 Vol 1n P REGIS'TER'$ OFFICE w ST. CROIX CO., WI Charles H. Bor__gst_rom and Dolores Bor strom1: ReC'dfborRemird a/k%a Dolores S. Sorg-strom~ fiusharid.:EJc wife . A............... AUG 18 1994 10:30 /%/jeA• 1.1 f1 a.....mj`~.... 11, ~E - ~V conve s and warrants to1t evensOn anC~ ':7u lanne tev..enson,...hu band..a?ld. Wi,fp .o-••••••............••............................. awswOfDMos ~RN UjiTblorr.'F~wheanne S1-eDutsrr• 9004-) 0 O-h 3fi fit..ro-- 11x' ..I .............................Count So rse~- wx 5Vo the following described real estate in . County, State of Wisconsin: Tax Parcel No: Part of SW 1/4 of SE 1/4 and part of SE 1/4 of SE 1/4 of Section 20 and part of NE 1/4 of NE 1/4 of Section 29, All in Township 31 North, Range 18 West, St. Croix County, Wisconsin described as follows: Lot 2 of Certified Survey Map filed August 5, 1994, in Vol. 10, page 2800, Doc. No. 519922. Also, part of NW 1/4 of NE 1/4 and part of NE 1/4 of NE 1/4 of Section 29, Township 31 North, Range 18 West, St. Croix County, Wisconsin, described as follows: Commencing at the NE corner of Section 29; thence N86°51'20"W along the north line of the NE 1/4 of said Section, 1278.88 feet to the point of beginning; thence continuing N86°51'20"W along said north line also being the south line of Lot 2 of Certified Survey Map recorded in Vol. 10, page 2800 at the St. Croix County Register of Deeds Office, 463.62 feet; thence S01 '39'53"W 631.10 feet; thence S87°11'50"E 463.56 feet; thence N01D39'53"E 628.33 feet to the point of beginning. Subject to the Protective Covenants as set forth on attached Exhibit "A". ~NSA.^ C This ......iS- not..... homestead property. (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this ~ I.......... day of August....................................., 19.-94... ..(SEAL) • ....................................................................(SEAL) 4.~~~A!!~y.......4 0_e, Charles H. Borgstrom • ...............................(SEAL) ?r (SEAL) . Dolores Borgstrom, /lt/a Dolores S. • - Borgs trbm AUTHENTICATION ACKNOWLEDGMENT Charles H. Borgstrom, STATE OF WISCONSIN Signatu (a} y Bor strom a/k/a Dolores S. ss. "r t~ t ~I au this ................day of u ien awl _day of ....Auguat......... 19.94. Personally came before me 19........ the above rp.med . It 4*.r t bi,81~and I ESTATE BAR OF WISCONSIN ~(I~iiut 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 0 land Attorney a.. Law Notary Public ..........................................County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19.........) *Names of person Owning in any capacity should be typed or printed below their signature.. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc., FORM No. 2 - 1982 Milwaukee, Wisconsin