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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER rGr~ p
ADDRESS
r
SUBDIVISION / CSM# LOT #
SECTION 2 T e ~_N-R ~W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF ST M
r 3~~
✓ IL~?Y .IYE i
g9 IPA I N D I CA f ,~1~~"
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
(~EPTIC TAN/ PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: GzrzJ
Setback from: Well e ouse d r Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: / Length
5S Number of trenches
Distance & Direction to nearest prop. line: ge
a
Setback from: well: ,26--verouse fir/ Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold _ Bottom of system
Existing Grade,-0A jr Final grade _15
DATE OF INSTALLATION:
n
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin D- ~-partmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safgty and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit NO.:
Permit Holder's Name: ❑ City ❑ Village f L Town o : State Plan o.:
DOUBEK, GARY X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 6--OT, Benchmark /00 1
Dosing _x 6,Lk 8&, /00,
Aeration Bldg. Sewer 5,a q,7(~
Holding StH W1nIet (,,07 qff. 4 7
TANK SETBACK INFORMATION St/ Outlet 7 /
Vent I
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header /I\n. `7,81 97,A3
Aeration NA Dist. Pipe '7 6 97, 0 g
Holding Bot. System %.9 96,1q
PUMP/ SIPHON INFORMATION Final Grade
V,5
Manufacturer Demandy
Model Number GPM
TDH Lift Lricti System TDH Ft
Head
Forcemain Lengt Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Len th , No. Of Tre hes PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER Mode Number:
r r 'Y~
System:® OR UNIT
!ta
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipes x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, e .U.)
Gc4_~2-
21
LOCATION: TROY.7.29.19W,NE,NE,LOT 2, RED BRICK RD.
i A)1 Q_ fi_,_
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 1// 107[;~]
c a (p 6
L
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH i
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
f, Gr ~ ~
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than S a 4/700
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side ions for completing this application. STATE PLAN I.D. NUMBER
for instruct
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
ril-e-A Y, VIP k e~ e_,11- &F '/4 '/4, S TO;Z5, N, R / E (or W
PROPERTY OWNER' MAILING DRESS S-7-- LOT # BLOCK #
3 9.
STATE ZIP C D PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
-3~
('.G- S` 23'r 4
0 CITY
11. TYPE OF BUILDING: (Check One) State Owned ❑ VILLAGE NEAREST ROAD
❑ Public 1~41 or 2 Fam. Dwelling-# of bedrooms PAR ELTAX NUMBER
III. BUILDING USE: (If building type is public, check all that apply) D d 3
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. ❑ 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 DdSeepage Bed 21 ❑ Mound 300 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
76;'0' Q 0 - % Feet 4rMS `Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's a (Print): Plu is gnature: (No Stamps) MP/MPRSW No.: Business Phone Number: y
Plumber' ..Address (Street, City, Stat , Zip Code)•
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Stary Permit Fee (Includes Surcharge Grou Fee) dwa r ate Issue I i g Agent Sig ure Stamps
Approved F-1 Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBM398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) allsizing information.
GROUNDWATER SURCHARGE
j
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`sorcharges are used for monitoring groundwater, ground- -
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLAN
PROJECT_ ADDRESS CO~.z~i-~ G4u r ll~,'
0 1/4//~~ 1/4/S ?/T,-z$N/R !W TOWN COUNTY _ G , j ~~86g
MPRS Byron Bird S. 3318 DATE -
BEDROOM
CLASS PERC CONVEN _
TIONALXIN- ROUN RE
~ SSURE
CONVENTIONAL LIFT MOUND HOLDING TANK
SEPTIC TANK SIZE `'LIFT TANK SIZE
DOSE TANK SIZE
HOLDING TANK SIZE
ABSORPTION AREA 6-6~"PERC RATE -_7,-= BED SIZE l /e~,&~z
\ Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark oe.~
* H.R.P.
M Borehole Q Well Scale Feet
0 Perc Hole System Elevation
Uent
12"
GTade
TYPAR COVERING
t 2" 1
12" 3' 4 6' O 3' 3' O 3'
, Sewer Rock
6
12' 18,
_ an
S~
~y~
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 -
.ST. c R o t• K
Attach 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
'S1' M Wow? P u f GOVT. LOT 1J f= 1/4 N 1/4,S 7 T 2 N,R 19 E (or) IL
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
4-7 7 C_'t Rn Z. CSM ?a %.3 uia G--
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (]f9WN NEAREST ROAD
RUPSoa Gc9(S . SL4010 (715) 384-2111 TRoY Rs-x) f3Rt'Ck RdQ .
(-rNew Construction Use ( Residential / Number of bedrooms 3 +o y [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe r
Code derived daily flow &ov gpd Recommended design loading rate y bed, gpd/ft2 ✓r trench, gNSC= C
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, g$0
Recommended infiltration surface elevation(s) 5 ak p 9 • 3 ft (as referred to site plan benchmark) law
Additional design/ site considerations u S E? R, e u 5 o a Ly.
Parent material 5C S 73 SA rTRE 13 u Rk 1 A#eor Flood plain elevation, if applicable N• A . It
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U =Unsuitable for system Q'S 1:1 U ❑ U 2S E3 U C ❑ U CTS ❑ U 1:1 S 2-T
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ~
O 0-12 1 eYR 2./2 SO. Z f 5bk /w%f R 5 1 . S
t ~y
Pte, 12- 20 10 YR 3 Si 1. I f sbk nN►f R s l f 1.5
Ground 132- o. 28 10 Y R `f/(e 54K /vA`~ i c,5 1-F . 5
elev.
100,-5 ft. C, •yP -1.SYR Y/4 IS /.AM, ,%Uf►~ CS •0
Depth to C tr 9- 110 5 YQ 751116o S.
• S Ge
limiting
factor u
7110
Remarks:
Boring # 0 Si ( X f 5 bk nM -F R
13 ti (01'.10 /0 `lIZ y y - St I f s bk iw, f 1~. S I `F - Y • S ~
f3 2, • )-f /o Y /e y/(, of sd,~ n -f 2 c s f 4f • S
Ground
elev. C t y • 53 ~.S yR y~~ 5 1, r►M, 12 dp CS i • '1
J b l -1Q ft.
i l~r~r -Depth to C Z 3 '9 7•S `l R S/y . 5, SQ- 7
limiting
factor a
- Wna~l septic yst
Remarks:
CST Name:-Please Print (Z o 13 E R. T- LA L(3 (Z'i C k T Phone: -1 l 5 " 3 p _ O&S
Address: (05.5, 0' .A-)A.i l Rd H V DSoa (,V I. 5 y0t co S/- 18- ` LI C ST',At 2yP2.
Signature: `'1`✓' J , Date: CST Number:
rvoTE f3E-c~vS,E wall Dh~ili;vED
/rwa~. S . cf o f2,'zc,,~ S L r• rte- o E'E p C J-fow q " ~4 6w ss Ao sr
IQL' TP-r5 r Ak r= h A- bt-s cy N I oAD,%oc- kArc- OF ,
"tom2 P-13 c4le 5> c,4"' Net -us E D 0A3 Ly t' r= 10 S f h 0 EX 24-'S'E s A_co R E tea... I a„ a
C • oTl .w
° F ~ Sc~ 12~ CrhT Td co.,-t r ~ f to t d2.- ~ z•-t+(Z 83A3 ((e) r'SE'
SyST~ ,,~,ovLv ~ v 7-0 vEs~'~,~FO z>!'s.- 6-
G-A•L ~ p,+y ~ • 2' ~ S /o fiOl -v Cr- ~~-cT-a/2
i
PROPERTYOWNER atn ~oo~R~~~ SOIL DESCRIPTION REPORT Page Zof 3
PARCEL I.D. # Lo+ 2 c .S m
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 .v 0- 12 /o yl2 2 i o~p ~-re - to 7777 s K Zf R s ( ,.S Co
Q 1.31 /o y2 3/Z Si I. I SbK.f~ o s ( . . S
Ground 6 L y -s Y 2 Y s 1 q,e A% v-F 1~ Cs . s
elev.
10 It. -,,Sys y s O's d~
Depth W
limiting
faacloo
Remarks:
Boring # L 0 or2 rrka i o
v to /o y)e / I S. I z f s6k~ s I-F , s .
41~ 3 50 1 f S b,t All f R s l f . .5
13 I3 , o• 18 10
t3~ V3o /a yk YN Si I Z A-~ s bit
Ground
el v. C D V I. s m y/lo S 1J, I R •e
-7 "fir- 03=-It.
f 56,E n.,,, ~ R Qom' . y . 5
Jr1i >cfuRE
Depth to
limiting C Z 1.5 NR y~t!~ S. d, S elek •Q
factor y
'7-
Remarks:
Boring # 0 /o S/Ie Z/ ( ° 12CrAAM < s i I 2 , f sh.< IvA-f 1 'f • 5 . (o
y 5
.5..: l/- Z(a l b y)e 3 S i. f s b,e nom, C5
C, - yJ- -7 - S yR y/(- I s IJ, y' cr? S s • s
Ground C
elev.
y/ s s G(JL 7
Z .t -yG -7•s VP,
/vft.
Depth to
limiting
fac~„
Remarks:
Boring #
p p 'i
Ground ,
elev... k
ft
Depth to
limiting
facto
Remarks:
OWN ooonio ncinn%
: cRep BRiCK Irv. P5. 3 0f3
L07 Z
II
1
~ X5`1 SCALE
J
• ° l3.¢ Gtr~i of P~ TS
h
lod.50
C3z lol. !o
Q UJ
o w 133 1o 1. 3O~
0,
0
of 0
= fay 103. Coo
~s IoZ.go
M
+ + ► ` ► Su ~~ESTED
~ goo\+ ,
I-AyouT- AT-
►+139 5
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,yo C3 3
2~b ► I ,
R~?INCE7Kt& T A12C t-
i
f3Z 3q
tl
m I 3~9 So. ~.o-r
20'
TOP of Su Ru EyoRS I4
s P
AT' 514J LOT CORNER . F lr--Vhl'!Oa = /00.0
Su&&o ST&D S yS Tem G~ L VA-rl'aN 5
TREacQS) AT' 5 GPDI~F-F2' 9e•50
T RIJu C41, S A r G PD F •z
w itk. W, Rock ~R 2- g 7. 5
MORE To L-Ee:p 0CSTRi Q0T)aN P,'pigG-
c I OSM le `1 our- 3-L -F I?.o F c'N i s wa- P
Ct: x 1'5 rrNG-- tee
MAY-28-94 SAT 12:52 AM S&N LAND SURVEYING 386 2007 P.•02
FILED
MAY 2 5 1994 w-
g JAMBS OUNNELL
Flogisorof Deeds
-517034 This instrument drafted by Fran Bleskaeck Proj. No. 94-27 ti St Oro CO.,WI
g
CERTIFIED SURVEY MAP
Located in part of the NE; of the NE4 of Section 7, T28N, R.19W, Town of
Troy, St. Croix County, Wisconsin.
OWNER SCALE I FEE
James E Margaret Woodruff b ao - 00 - zoo
477 C.T.N. nF1'
L' ' • ' Hudson, WI $4015 I w i i 3
Iti V. 5 f P. 1282 UtiFLAT" D LANDS }1.. n^
~.L'ARVILc W Avg.
N} Corner of
Section 7 North line of the NE}
S90o00,00"W
S
90o00' 00"W , 350.27'.
NE Corner of
2303.411 J Section
7~
N89 52"W 235.14'
C - 1 4 CvI
I ~I
(JI
r M I
o \ 04 j
O
C a 6 6' LZ
!
,,IUD
n II old
u G - o L c
r of
L v o r`OilC7 _
CV ! 3.12 Acres Inc. R/W o I~
o ! O 135,708 Sq. Ft.
w O ? I
`a °o CJ j 00
2.70 Acres Ext. R/W co U)I
C d r 117,810 SQ. Ft. r
Ly d
o N a
ca
O [sl v
~ p
° I 7.77
a 341.431 o+ +
21 a N90000 1 00"E 3.49.20 1 _ W
O OR VE H o v C~ I
b 0 a
z M G31
c!> 1 o; ! C'J!
LOT 3 Io <>r
CCI
A 2.'26 Acres inc. R/W ; (2 QI
iYI-1A 98.582 SQ. Ft. i N U11
~ ,14 i JI
p X 2.22 Acres Exc. R/W C>I
~~1Q'VN, ~f 96,924 SQ. Ft.
I E ;o
~~eJtl~v A/u S U~
rs~~sanw~o ,
N89o43 11."-E 348.43'
Putur&; road eesem¢n+
LEG E NG as per Zoning mce+tng 5/24/94.
i
- Aluminum County Section Corner Monument w
c - 1" x 24" Iron Pipe Set, weighing 1.68
Its. per linear foot, JiVPi__.A ITTEV «i o L AtiC'~
Existing Fenceline
• o
100' Roadway'. Setba Line
0 >
I'll„ a-- ° F Q Corner of
N',s 1C+ Section 7
r 4
0 VOLM E 10 PACE 2762
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
~St. Croix County
OWNER/BUYER CF ~
MAILING ADDRESS Cr~ L4qvt~
PROPERTY ADDRESS G &a1&7%D QL-/ Uk ~ C10 ~b
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
A' n
PROPERTY LOCATION ME 1/4, /V ~ 1/4, Section 7 T 2-TN-R 9 l W
TOWN OF v 1 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER Z_
CERTIFIED SURVEY MAP 170 , VOLUME /IV , PAGE~J6 , 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 co d return St. Croix
County Zoning Officer within 30 days of the three yea pii 1. ate.
SIGNED:
DATE: Z~
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - loo
-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 b owner/contractor, Y (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 o f property f~J L~ ~Z~C K
Location of property / 1/4 QCi 1/4, Section T21 N-R__L~_W
Township 1 C=Qq Mailing address 5'C~ C , C T
G L
Address of site- o (_-.K h
Subdivision name Lot no.
Other homes on property? Yes X No
Previous owner of property `J 1 N1ftf?Hlli W&DnR_Q~
Total size of property '3,) Z.AQCS IKV.. CIO cQ 2.70 kages yTC. Clyj
Total size of parcel
Date parcel was created ~T y!
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? X Yes No
Volume!` and Page Number 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. 7:r-
Z~F , and that I (we) presently
own the proposed site for the s6wage 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.
4S'gnatur ACo-Applicant
Date of Si nature Date of Signature
i. ,
. CrO V,UMENT NO. WARRANTY DEED THIS +PT:-E REiEn YCt, FOR REGORGING DA1A,
V STATE BAR OF WISCONSIN FORM 2-1982 p
_
James T. Woodruff and Margaret S. Woodruff, LT. C rZ C I
- - - -
husband-. and own wife and each in his and. her Ro^dltxt,f
-
lI
right--- - q
1i T 1994
- - -
conveys and warrants to Gary-S Doubek, a single man
i
t.1
4~w Olt 0"_
i - -
.
•
. _ uRN To~4Y y S
. . . - .
(~Ar),s le `t-lLs4~cs 93Yo
Ave. __FT I the following described real estate in - y, 3
$-t -~rO -
1X--•-- ------Count
State of Wisconsin:
t
Tax Parcel No: I ,
Lot Two (2) of Certified Survey Maps, St. Croix County Register
of Deed's Office in Volume 10, Page 2762, as located in the
Northeast Quarter of the Northeast Quarter (NE 1/4 of NE 1/4)
of Section Seven (7), Township Twenty-Eight (28) North, Range
NincLeen (19) West, Town of Troy, St. Croix County, Wisconsin.
I
II
This - ._1S not - homestead property.
jSW(is not)
Exception to warranties: easements, restrictions and rights-of-way of record,,
if any. ~I
II
I '
Dated this June
_.(0 day of . . . . .
- (SEAL) (S F,?T)
- l
James T Woodruff
- - - U -
- - - -
tIA~C~ A ~r ~T• Z.(S~,~L,I• •an•
- (SEAL) - -
.A Margaret S. Woodr f ~►'*~~...•sK }
i a
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss
- ------------Cou nty.
authenticated this 3^; of 119 --rsalsl'y rarac before this C! J_ n.
lay e
June _ 19.94- the above named
-
James T. Woodruf- an
i
-Margaret S. Woodruff
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not.
authorized by & 706.06, Wis. Stats.)
to me known to be the persorts------------ who executed the
foregoing instrument and acknowledge the satne.
THIS INSTRUMENT WAS DRAFTED BY
Leo A. Beskar; Attorney -vf..._.
RODLI , $E-SKAR_._&--SOLES-; -S C - - - - ".3 - -
9 t G
Ncrt Mair1 Stre Notary Public _-.County, Wis.
iv r Fat s, wit~02$ -
(Signatures may e al or acknowledged. Botl, Mti' Commissio!q- is~p/r'manenp. If not, state expiration
are not necossary.) date: GC~ K~!"- J Q 19_ yli-_.)
•Nam~ of Dersnn, signing in any capacity shun+d be type 1 r 1 r nt,M below t1,1, Cigna :ire,-
WARRANTY DEED STATE. BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. 2 1792 Mdwd_:kee, Wisconsin