HomeMy WebLinkAbout040-1218-10-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1'i P 1'
ADDRESS
SUBDIVISION / CSM# LOT 3
l
SECTION___:~_T -)(5 N_R~ 1 W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW E RYTHIN WITHIN 100 FEET OF SYSTEM
I
q ~9
9 0' f 1
4
PAN
/v
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / TZrTM H MBE.R- / HOLDING--TAIx JJTn 'L'ION
Manufacturer: Liquid Capacity: acv t'?1
Setback from: Well N o ! no House Other
pUm S--
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from:. well: l House Other
v
ELEVATIONS
LU~
Building Sewer ST Inlet. U`,) • l/ ST outlet
I J U
PC -in7 PC bottom Pump OTT -
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: j
LICENSE NUMBER:
INSPECTOR:
3 / 9 3 : j t
LQQhTJM~61tT&QyM§us;0-19 SW, 1Vk?t SWVA8NY 4 V' Road County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
ev.: BM Description: Parcel Tax No.:
v.: Insp.
WR'p
TANK INFORMATION ELEVATION DATA A9400076
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
(~o
Dosin t l ✓K, -D, /06-2 7
Aerat Bldg. Sewer JCCr !
Holding St / Inlet F6 Cv, W
TANK SETBACK INFORMATION St/ Outlet 66 <,O
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic {U NA Dt Bottom Y
Dosing NA Header >
33' '
Aeration Dist. Pipe 9 ~z ~3 997 /F7~
Holdi , Bot. System # OS'
e97
PUMP/ SIPHON INFORMATION Final Grade
Manuf r Demand C- "
Model Number GPM
TDH Lift L Ion edem TDH Ft
Forcemain Length Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width I Length I No. Of Tlenches PIT No. its Inside Dia. Liquid Depth
DIMEN I N 5 'L DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Man
SETBACK CHAMBE
INFORMATION Type0 raw t<:,j --Model Number:
System: go, 44-- T
DISTRIBUTION SYSTEM
Header /AAa Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length _L Dia. Length 71_~ Dia. > Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys my
xx u c e
Depth Over Depth Over xx Depth Of xx Seeded/Sodded
J~Ore Trench Center Rs*/ Trench Edges - 7 Topsoil E] Yes E] No El Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOrCATION*& Troy.5.28.19 SW, SW, Lot 13, Red Bri)Qk Road
- G y%.+''"i c.~ ?',.4.--'~ . j'.., / /3 !/J%~)// ~ "~Y ~.l.~ri~d ~(~-~Cj7•-~~ _1.
Plan revision required? ❑ Yes [r.)-fdo
Use other side for additional information.
SBD-6710 (R 05191) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
. 7DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ao g'q s-3
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
DAV D cl L95 eN N e 5 LJ '/4S W S 5 T) 8, N, R J? E (or)
PROPERTY tN~'StAIYNG DDf~SS LOT # BLOCK #
to I
qQ9
CI , STATZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NU rJR
r v► h'p3otJ 1~' s c S V o) b N C rev tw ) I 410
II. TYPE OF BUILDING: Check one CITY Q NEAREST ROAD
( ) 1:1 State Owned VILLAGE : R ~C A BK ~ G
❑ Public a or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(ST
1111. BUILDING USE: (If building type is public, check all that apply) "1/14 O
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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 90 Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.4RNew 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 ❑ 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 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
O REQUIRED 750 ft.) PR 7 s D(sq. ft.) (Gals/y/sq. ft.) (Min./inch) 91. VO 9 .F\(AOTION 00 v 9 Y, Feet S Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New lExisting Gallons Tanks Concr t glass App.
Tanks Tanks strutted
Septic Tank or Holding Tank PDD 2Q S
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
ou es e 30 38~~ao
__TI M F- I
Plumber's Addr (Street, City, State, Zip Code):
t)~ C \`J s b
S.(.
I DSvly
IX. CO NTY/DEPAWrWIENT USE ONLY
10 Disapproved Sa i ry Permit Fee (Includes Groundwater Date Issued Issuing Ag t Signature (No
Approved El Owner Given Initial Surcharge Fee)
Adverse Determination 2~
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 re,ne-o .al any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisio is -to permit must be approved by the permit issuing authority,
4. Changes in Jirrrf.-ship or plumber requires a Sanitary Permit TransferiRerrewal Forir „?I} 6399) to be
submitted to the -_,oonty prior to installation.
5. Onsite sewage ? `~>ms must be properly maintained. The ~..r:~ptic tank(s) ~.n:.°_`° be licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you-have questions concerning your onsite sewage system, contact your local code radar ffistrator 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 ri, rnber(s) of
where the system is to the 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.
V! Absorp:; ,n system information. Provide all information reques'ed in ##1 7.
Vli. Tanti :1,=rr =?ticrn Fill in the capac'ty ct every new z,na or +=x ,ns rk list t'-e tol<al -,is-giber of
tanks am fnanufacturer'ts name. Indicilo,~ prefab or site c: ns ,;~~te'd and tank material. ar-r i- ~ for all
septic:, pur p..s'phon and holding tanks ru•f this system. Che ci oxpprirnerital approva: ,f ar),r,, received
experir ie.wal product approval from
Vill, Responsibility Statement. Installing piiln,h-?t is to file in n:aine, li=,-f-ose nuimber with appn:rpri 4 re rrefix (e.g.
KIP, etc.), address and phone number. Pl~,rnber must sign applicat on form.
IX. County! )cpartment Use Only.
X. Courit`w ;lw'a -$rtment Use Only.
Complete riians and sper.itic;ations not ri-- iller than 8% 11 inches t,e submit`:e~l `'a *I- - ,.:.r..,nty. The
p,~a"js r at include f1,e toi:owing: A) ploy ,l:_ n, drawn, to :~,.._.a or with T? dime ( :on of
hold rig septic. tea-kis) or otho,, c t")lf'nt tanks _ din- )v,.,,! 3 wia'E ii-, r, ,Mef service.;
r7~cn, :iistribUtOn Soil - -s(roiil,-, systewr,nl system
StfG'3 arid lakes, pUf+'t1 oi SIpht~rt tt4
area anC the location C!I 1he bill ";C served: B) horizontal and 'v`t , rP -at'or reff'r('.n-(', :)1 nts .
C) complete specifications for puwps and controls; Jose volume; Qi8 c:';;)r dMerences: trlctan`r loss; pump
- performance curve; pump model and pump manufacturer, D) cross sec: on of the soil absorption system if
equired 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 c:rf surd`a= !e;s (fees) for : rum; er c;f
regu!ated pf,:ct ces wrlict' car affect g oUndw t=.,,
The nion,es co, eced throug' these si:rchargc,,s ati- used for momtori'j r ia,at a r_ ; .z
water contami+sation inve4Pi9Htif)ns anti establishrnf;, standards.
w..
SBD-6398 (R.11/88)
C 7 PLO41 A 1111) 1 \1 u z)
.N...M >
rn e S
3 ~ME m
Q pv', le i e e w N 1
FT-
U
3
~ 0 A. 10 M L. I-C E N IS E?.i7--- L) A T EL
NI"
S
~aa p~~ too ~
A`Afka~~
c~
a-
_ g 9t,.od Vie' ~ S ,~l
IVA 30• 1 od ~e~ } ; c
Iyp .
e o yn ~ 1:' ~ .r l
is fP
u!a StBI~ SJ ~r1 •reom ~e~fi,G~
S
Prn
y
- r~C?2UoM
O - gl~Ct~hOf 1 i~5
k
RoAn
FRESH AI1; INW,-rS-AND OBSERVA'I FIRE
CI;OSS SECTION
Approved Vent- Cap
minimum 12" Above I p
Final ,raslo-_ I 3 C'
Mai
4" Cast Iron
Above Pipe Vela Pipe
To Final Grade,-
,
Marsh flay or ~Synthetic Covering
Min. 2" Aggr.cglaI
Over Pipe
i
r Tee
Dis tribu ti24>.
I
Pipe
.Op Aggregate I'er-forated Pipe Celow
qv "~~e>vc~,e Beneath Pipe le, --Coupling Tcrminad.ncj r
.
. I h OD -S ~ - . Bottom. of System..
. I
Cuti>rZFR TEST- chc---, S - G/eAR • 40° f 1205 rt- .
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pag. ar 3
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
sr- G,eo/`,C
At complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: , PROPERTY LOCATION
° GEsll;v- l~tiEy GOVT. LOT Sw 114Sdr> 1/4.S f T2,9 N,R If E (41
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
V O 2- 577 cu . i3 elel P v.Ezv .50t3D.- v .
CITY, STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE N NFJIREST ROAD
~vSEMCv uT /l'Iiuv sloe F 1&44 /i3-5Sa? _r c oy 13erc t-
[ New Construction Use [ rJ'Residential / Number of bedrooms y [ ] Addition to existing building
[ j Replacement [ ] Public or commercial describe Iv,4--
Code derived daily flow 4 0 ° gpd Recommended design loading rate T bed, gpd/ft2 ' Ltrench, gpd/ft2
Absorption area required 12-Se bed, tit 75U trench, ft2 Maximum design loading rate ' 7 bed, gpd/ft2 trench, gpd1ft2
Recommended infiltration surface elevation(s) S- 3 ft (as referred to site plan benchmark)
Additional design /site considerations WS-' Til°E~ s~5 oN ~o•c~ roo a sv~' D~Po p B O K- 1)t' S T It' CI3
Parent material 5C45 95~ - /3VWA^,fDT ~ ssi T~A'F Flood plain elevation, if applicable It
~c ou s
S =Suitable for system CONY TIONAL 1MOU91-5 ND IN-GR NOD U ESSURE AT_GRAa U SYST IN RLL HOLDING TANK
U= Unsuitable for s stem 9 0 U 0 U ~0--~5 O U ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouidery Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mrK:h
~srk.\SL E
/0YtP 3/~ /o,~M 1.~; sbr ,►„tuf2 S -F • y .S
15-15 /0 yR x
31,41 sloe '-Jwff 3f , Y • 5
Ground S- 28 7 5 yk X/6 S C~, C, S Ae S i . 7
elev. ft. ~L JP 9~ io y~ Spy t ^ O, C,
Depth to
limiting .l i
2 ~
factor „
r, d
r
Remarks:
Boring # 0-/s /O yR ~-~I o Gar S6,C ~iP f y S
2pn
2 /5-21 /o YP, 31q !o rErt / , f, S bk- t►N. -F R C S 3 , .5
C 2.y-34 -7.5 yR 31yR d e CS •06
Ground
elev. C L G -/0 7.5 y1e y~4 s 0, c, S Gl ,Q . 7 `
ft.
Depth to
limiting his test it8 APP OVL -
factor It
C8° .
>/00
Remarks:
CST Name:-Please Print 12 o QE P. 1 'U L R R 1 G ',17- Phone: 7/S - gl 0 S
- t 3 c57' 1~~
Address: (055 iVE►-L Ra- h{uDSoa 4~1. SY614 /10 0. 11
Signature* .~~1c • ~ Date: CST Number:
DD t
ORIGINAL
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2- of 3 .
PARCEL I.D. # D f (3 - C(e-~vr2 V E C c i
GPD/ft
Boring # Horizon Depth Dominant Color Mottes Texture Structure Consistence Bounclary Roo
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh.
Bed rend
o 4 3 X
Y F/3
0,?&,4.~t•c 5 io y/2 3191 A04" sb~ 2-f Ground 7. S yR y S' O, elev. ~C, ft. • ~G /O yR /
Depth to ,
limiting
factor
Remarks:
Boring # 0-/-S
i2
rTd /o 013 S b k ~-f
/3 3• 11- /o Y/? 3116",.r, S bk c S 3uf S
El
c, iZ• 7,5 yR 7 S a w r~ de- C.S •0
Ground
elev. C'i D l o /0 Y A ' s D S e~
ft.
Depth to
limiting
factor
7 /OD
Remarks:
Boring # O- /O O C ~o~1rt SGK iw+ -F i2 S 2rt . S
}
5 f3 /o y~ 31C 5 ~-F
'Y2 6 7.5YR y16 CS
Ground _C -
elev. i o9,0-/&1 /O c,
GQ - 7 •O
ft. S p
Depth to
limiting
factor
Remarks:
Boring #
r.gg
r:
I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
COIN 00"10 nemn%
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f
f
o-
~ C° T _ X30
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10
lot 7so to. FT.
9 a. 34 Acnes
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103. ?so so. ff.
11.30 .Cats l eb,
13
118.484 to. R.
1.05 .CRCt
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got, fto to. FT.
14. 93' "W ucoo"to of t ..o .cast
\ ___....210.114 r~ • / UW141 / tCCT/0a t~0i~•
CI S09.31~30~W rrv 11L 11wr• W t(CT1011 a tY (♦8
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° 39.47' 1w.oo tt7,ts' ur.s•'
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a 1 ~8
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132,826 SO. FT.
3.05 ACRES
SW CORNER OF ~.tij^ 2s
59„W SECTION 5 AND ~~6 0
~S30.00•
X31 SECTION 8 C9
210.24' SWI/4 OF THE SWI/4 OF SECTION 5
S89°31' 30"W NWI/4 OF THE NWI/4 OF SECTION 8 k'
~ S
+ h\ \ 00
8
59„W 6
20'
LOT I OF CERTIFIED SURVEY MAP IN VOLUME 8. PAGE 2292
5 Q N00017' 18" W N 15
40.00'
N710 53'59"E N890 31'30"E 41
W 190.00'
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State of Wisconsin
County of St. Croix
1 hereby certify that this instrument is a full;
true and correct copy of the document on file
and of record in my office and has been
compared by me.
Attest April 18 ,19 94
James O'Connell
James O'Connell Register of Deeds
I
STC-105
j
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
r~ I
OWNER/BUYER
MAILING ADDRESS
c K
PROPERTY ADDRESS ~ 00 ru> 6i)
iln o septic system) Please obtain from the Planning Dept. R ,p
CITY/STATES-~
PROPERTY LOCATION lL 1/4, l 1/4, Section T aj N' W~
TOWN OF ST. CROIX COUNTY, W1
SUBDIVISION LOT NUMBER
_t,C -
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/NVe, 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.
SIGN
DATE: C-7
St. Croix County Zoning Office
Government Center
1101 Cann ichael Road
Hudson WI 54016
11193
S T C - 100
,.h? <Jpplication 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
Jo el.opment 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.
•n~r of ~ rir ~ ' ~
property
Location of ro ert 1+% '
P P y j 1/4 S -')1/4, Section
Tcwnship
i,;aiiing address Re BdZr~~~ ~d
Addy ss of site Subdivision name-(,-- r 1l .
Lot no.
Other homes on property? es
Y No
Previous owner of property o
Total size of parcel 3 ,
Date parcel was created
Are all corners and lot lines identifiable?
Yes No
Is this property being develo ed for (spec house)? Yes No
S
Volume
and ~
Page Num
of Deeds. Le as recorded with the Register
INCLUDE WITH THIS APPLICATION hAI'RANTY DEED which includes a DOCUMENT NFOLLOWI O
NU?- BEI & THE SEAL OF THE REGISTER OF DEEDSS.. , inL ddi~tion,AGa
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified surve
hall also be required. y Map, the Certified Survey Map
PROPERTY OWNER CERTIFICATION
certify that all statements on this form are true to the
Lest of my (our) knowledge that I (we) am
the property described in this information form, the
virtue (sof of
'arranty deed recorded in the office of the County Register of
:'eeds as Document No._~
the, and that I (we) presently
proposed site for the sewage disposal system or I (we)
twined an easement, to run the above described property,
the construction of said system, and the same has been duly
recorded in the office of county Register of deeds as Document
_I' natur of ap cant r
-appl cant _
L
C91 ature
Date 9'f S ' gnature
L
%
S• • ,
DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING, DATA
WARRANTY DEED
513, 1251 : STS BAR OF WISCONSIN FORM 2 - 1982
Yoe ~~SS~ x.75
REGISTER'S OFFICE
ST. CRGIX CO., WI .ry
David R. Knighton Recd for Record
JAN 3~ 1994
8:45 - A:
A~ M
conveys and warrants to David M. Henney, single e• IF
tteglsta or Deeds
RETURN TO
the following described real est-Ate in St. Croix County,
State of Wisconsin:
Tax Parcel No: -
Lot 13, Clearview Addition
Subject to Declaration Establishing Protective Covenants and other _
easements of record.
rR.A.
FEE
"Q
This is not homestead property.
(is) (is not)
Exception to warranties:
Dated this 6th day of December 19 93
(SEAL) (SEAL)
•
David R. kxdghtq
(SEAQ (SEAL)
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) STATE OF yX996%& MINNESOT
Ss.
Hennepin County.
Personally came before me this 6th day of
authenticated this day of ,19 December ,19 93 the above named
David R. Knighton
•
TITLE: MtMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who executed the
authorized by 1 706.06, Wis Slats.) foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED 13Y
David J. Butler, Attorney at Law
' LZYL[C~t/Lg(~7~~
6625 Lyn dale Ave o, Suite 526
Richfield, MN 55423 NotaryPublic 12-26-96 Hennepin County,gs.MN
(Signatures may be authenticated or acknowledged. Both My Commission is permanent (If not, state expiration
are not necessary.) date: )
' Names d persons signing in any capacity should be typed or printed below Their signakm H NENrNBt A ,
ENNEDIN COUNTY
W OOIWISSION EXPiK467 t2."
WARRANTY DEED STATE BAR OF WISCONSIN ORSe ASSOCIATION
FORM No. 2 - 1982 480( Hayes Road, Madison, Wisconsin 53704
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