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HomeMy WebLinkAbout040-1214-30-000 pp~ ST. CROIX COUNTY ' WISCONSIN - ZONING OFFICE Y Y N II N p e n■ NNNR ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 October 12, 1994 Mr. Daryl Bjornstad 713 7th Street North Hudson, Wisconsin 54016 RE: Septic Inspection for B & H development Lot 34, Glover Station Dear Mr. Bjornstad: An inspection of the septic system for B & H Development, Lot 34, Glover Station, was conducted on September 27, 1994. This property is located in the SE, of the NE; of Section 16, T28N-R19W, Town of Troy, 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. (in,ce,rely, mes K. Thompson Assistant Zoning Administrator St. Croix County, Wisconsin mz STC - 104 BUILT SANITARY SYSTEM REPORT WNE-,,6 ' " p.d rn e.~ .T~.✓ f~Ar~l/~G?'S'o..(~ ;`kDDRESS SUBDIVISION / CSM ~~arr~y S7c~7`sro e~ LOT_ SECTION 2 Town of yd ~z ST. CROIX COUNT"',' WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r reams 3 N IND TE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: S'~y ywe- a-5 l ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ed Wesfef.,,,d Liquid Capacity: / Setback from: Well House ` Other Pump: Manufacturer Zd,, /for Model# 1f7 Size Float seperation Gallons/cycle: Alarm Location IYa a_s G- SOIL ABSORPTION SYSTEM Width: S Length 6-7 Number of trenches - -Distance--&- Direction--to--nearest - - nearest- -prop _1i-ne---e;'~ - Setback from: well: I&V_ House Other 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: 1911. 01/ PLUMBER ON JOB: , LICENSE NUMBER: mo G3 P.2 INSPECTOR: T~ 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.: 218913 PeErOj~FioldNa~ne: DARYL ❑ City ❑ Village K, Town of: State Plan ID No.: CST BBM!Elev.: tA~/UU Insp. BM Elev.: BM Description: Parcel Tax No.: 8 ~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic L` Gclfe Benchmark 7 Dosing rim b~r,a~ a. I4~x A OS Aeration- L Bldg. Sewer Hol St/Ilk Inlet 9991 TANK SETBACK INFORMATION St/ Jet Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 36 1 NA Dt Bottom z' 96 ~23 Dosing > NA Header t s~ gZ A2, <e 7 70 7,' L~99 Aeration NA Dist. Pipe Holding Bot. System g7s~ 98.7s~', PUM / SIPHON INFORMATION Final Grade o .36 ' Manufacturer Demand T°~° s. T Model Number 9o GPM ~Fs-6OS~ d/.54 Coo otda'-\ TDH Lift Friction System /LLLTDH Ft Loss mead /91T Forcemain Length &/Q/ Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length , No. Of Trenches p1T No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 S 7 DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manu SETBACK INFORMATION Type Of L)o se CHAMBE ou/` t Moe Number: System: ~r5 Sd`C ~/3 O T DISTRIBUTION SYSTEM Header /-9anftd Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length S~o Dia. Spacing ~1 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ove 3 Depth Over 'J xx Depth Of xx Seeded/ Sodded xx Mulched QAeg4Trenc enter 3O y?Bed/ Trenchges J(p Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Tr Y. 6.28.19W, SE,, NE, Lot 4, Souther _ Paciflic, RZads / {d OK CLc s tf[~ t' COX C~ . -cam Cc t n revirNo Pla Use other side for additional information. f 71170/ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COUNTY t~'aLr■R In accord with ILHR 83.05, Wis. Adm. Code Cdr STATE SANITARY PER T # -Attach complete plans (to the county copy only) for the system, on paper not less than P Check~~ 8% X 11 inches in size. 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 9c t ~„e s,rJ ,v E t E t/a '/4, S if T.Or, N, R E (or g PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # i s+c' i av!✓l -.7 d-1 I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISI NAME OR CSM NUMBER y .~c •C ST ' II. TYPE OF BUILDING: (Check one) ❑ State Owned O [3 CITY VILLAGE NEAREST ROAD S'!.c / ~'c 4 G 17W TOWN OF: ❑ Public 141 or 2 Fam. Dwelling-# of bedrooms vp PARCEL TAX NUM13FR(SV 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. R1 New 2.E] Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.0 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 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./inch) c7t~ S ELEVATION 4~.S' O 2. S f -7 O e'er 1~ Feet 1 -663 , 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 Septic Tank or Holding Tank QOB ' 2 -OK - Lj Ej 1 0 0 1 Fj Lift Pump Tank/Si hon Chamber X+ lJ7~d G eeA,, VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system s0. on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number: <1< s~ 3P~ -7M pG - 3f 1 - Plumber's Address (Street, City, State, Zip Code): IX. C UNTY/DEPARTMENT USE ONLY ❑ Disapproved SanitaryPe it Fee (includesGroundwater water a e ssue Issung Ag t Sign re (No S ps) ZJ'Approved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber -Attach complete laps (to o the county copy only) for the system, on paper not less than fn ~7/'~ size. Check if revision to previous application 8% x 11 L~ -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 a .Ce ,sit 7s,eJ //,da~eys~i!/ e '/4,Aje- 1/a, Sl< TaF, N, R E (or o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # .Se o c /,,Ci G *,ew t~I~d-Sv t/ < 4/ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVIS NAME OR CSM NUMBER t~kc ®v W % g /Ot' r _ ' cr er .57-.a- 7`11 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned VILLAGE 7% /y... ~r y - Pi 4OWN OF: fZ i - ❑ Public 01 or2Fam. Dwelling-##ofbedrooms PARCEL TAXNUMBER(S III. BUILDING USE: (If building type is public, check all that apply) 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. 1 New 2. ❑ Replacement 3.0 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 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./inch) fit, S' EL~VATION G7e.S-O r Feet , . < Feet Vll. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Ta ks Tanks structed Se tic Tank or Holdin Tank QlJG Lift Pump Tank/Si hon Chamber X. GSG /°l?a(jlL Gc^' 6 F1 El i VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number: GJ .`ll; SGT u d~~lv Gr/ ` G .3P.2 7~s' 3PG - 3t.?/ ~I Plumber's Address (Street, City, State, Zip Code): / 7e7 sc,z - GG d s ,GJ S dl6 IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved ISanitary Pe it Fee (includes Groundwater Mate Issued Issuing Ag nt Sig a (No S mps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ✓ _ Ile SBD-6398(R.08/93) DISTRIBUTION Original to County, One Copy To Safety & Buildings Division, Owner, Plumber r a:-....r s a r-r r s x t y.. i.- r r . , ,s.. << •,'t ! t 1 4. `e 't 4 1 4-i . 4:{~4~f.f,Y. #~1 f<Y'i't.~•t«.4,.`st,t.t.s.;..,`a's`s Js'i _ _ _ _ _ _ . . w • A. .a 3 k S 4 i F k 4 4'. i~. } } ^,1t 1`4'1`SYtS fi 4 S 1 a t. 5.~a 3 ,'ti 6 INSTRUCTIONS A 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, 606-266-3815. To be complete and accurate this sanitary permit application must include: i 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. 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. 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) PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4"C. I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 25' FROM DOOR, WINDOW OR FRESH 1211M"`~ AIR INTAKE i GRADE I `i° MIN. 4/611 IB"Mlu. CONDUIT _ I®"MIN. IAII_.f=l" PROVIDE I T AIRTIGHT SEAL I III II APPR.OVEG JOINT A I III APPROVED JOINTS W/C.2. PIPE. I III W/C.I. PIPE EXTENDIMC• 3' I (I ALARM EXTENDIwG 3' ONTO SOLID SC:1. B I I ONTO SOLID SOIL c oN I NIL, I PUMP-_ OFF D CONCRETE BLOCK RISER EXIT PERMITTED OMLd IF TANK MANUFACTURER HAS SUCH APPROVAL SPECIFICAT10KJS SEPTIC AMP yam/ DOSE TANKS MANUFACTURER: NUMBER OF DOSES: L PER DAy TANK ; IZE : 10,04) C b?7 : r'n-geGALLONS DOSE VOLUME ALARM MANUFACTURER: &,e_VeXr /l/.ev IvZ INCLUDING BACKFLOW: GALLONS MODEL QUMBER: , t~tG L1 CAPACITIES: A= aa,ro,S~S/. 'TAICHES OR GALLOAIS SWITCH TYPE: !21 -e-;,- t' B =INCHES OR GA'_LONS PUMP MANUFACTURER: :z'rf'_ /lt'Y C =_l_-,5flNGHES OR 7' GALLOIJS MODEL NUMBER: cZr D=XINCHES OR 130, GALLONS SWITCH TYPE: a7 e- Y'e-MOTE: PUMP AND ALARM ARE TO BE PUMP DISCHA.R4E RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEKENCE B'0IEEAJ PUMP OFF AND DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE . , , , , . , , . FEET + L4 FEET OF FORCE MAIN X ==F 00FtFRICTION FACTOR._ -1 FEET = TOTAL DJWA.MIC HEAD = 9.4'2 FEET INTERNAL DIMEWSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH 3 51GUED:~A LICEIJSE DUMBER: DATE: r1 -117- f/1 d' HEAD CAPACITY CURVE 0 MODEL 9811 7/e 6 1/4 f 8 4 5/8 3 5/8 m 15 0 4 4 3/16 10 0 1 LITERS CALLOW- 10 90 30 40 Sp 60 80 70 80 160 240 FLOW PER MINUTE l TFLOW PER W,WTE . EWATERIrq; . ' CAPACfIY ` 12 tlNtlS/MIN QALS LfRS 72;• 1 81 271 25 15 2S ~ CONSULT FACTORY FOR SPECIAL APPLICATIONS Electrical abernators, for duplex systems, are available and r: supplied with an alarm. • Mercury float switches are available for COMMON single and I : Mechahical alternators, for duplex systems, are available with or. • thDouble ree phase alarm switc Piggysystems. back mercury float swi he&• tches are available if << variable level long cyae controls. i, Standard all models- Wei ht 39 lbs. HA , I. lrrlvlal Ik>el o SELECTION oUIDE 110 S rl•r _ Petaled 2 pole rnochankal switch, no flxtorTtal co/1tr01 r (Model Yalu-Ph Control selection 2 iM9Y~dc rtlercury Goal switch or double Mode Am s Sim lox swUch.lluler to FM0477. Piggyback mercury, fbat 15 Ou lox 3. Mechanical akernator 10.0072 or 10.0075 9.0 1 or 1 6 7 4. See FM0712. for correct IF 098 a 3 4 6 5• Mercury) model W Electrical Alternator, '•E•p~„how • ~0 1 to 4.5 1 or 1 i 7 duple (3) soor tai) Ik m systorn 10-0225 used as a aorgfd sxtivator, swj), 230 1 Non 4.5 2 or 2 a 8 3 or 4 &5 B. Four (4)lwkr "J.Pak". juncyort box. Plex or duplex operalw^ 10-0m. for walelti(Ihl or "ad -in t Ytt r 7. Two (2) hole "J-Palk". for watertight connection or splice, at trMaslstlon ~ W 2osNer PraducO nlst to cater On Combin:.Wn Sauter, F • AIYRr PaCYEpe, fMO61J 77$twRp AdemNw, FModW: t"',~ MO514' All InNall~ CAUTION ° tied kwn"d eMeun, Controls, r y *k fja drW & w ojW W be done .e s r war • eeNnti FM0487; and S' unWeR control am. IRQ NN Moat Meant Na ' alaetrioaI end nNO et y ,do "d eAOUW be IoMr•.ed LW r Health Act (03liA). tel. F trk Code (NEC), and Irle poq,rPNLiorra Salary "d RESERVE POWERED ° DESIGN For'unusual conditions a reserve safety factor is neered into the ~ design of every Zoeller pump, { :'I MAI! T0: P.U. BOX 16347 ,n q sal p To.- . eo 40156.0347 Manulaclurers al... • , ~G~G sHIP ro: ,~~40 of n~,reys L" pt;13Y1ac; KY4f°16 tiirr Q....... L!..__ /nrieA' E.~JDILHR SANITARY PERMIT APPLICATION ) In accord with ILHR 83.05, Wis. Adm. Code co STATE SA ITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 19913 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 E Y %4, S l TO&% N, R E (or PROPERTY OWNER'S MAILING A SS LOT # BLOCK # C/ .T 7% s 7- DDR 1--- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ,r w' 3YalG ,4 e U e r d xicd II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD / ❑ State Owned O VILLAGE * 2 low ❑ Public U 1 or 2 Fam. Dwelling-# of bedrooms 3- PARCEL AX . E 'f III. BUILDING USE: (If building type is public, check all that apply) Q Q _ 2 41 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 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 1Z New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.0 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 Z 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./inch) &?Q/ r ELEVATION Feet 56.2JQ Feet "e 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 Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) 6PMPRSW No.: Business Phone Number: I`ll t4ln c ~..~.a/y Plumber's Address (Street, City, State, Zip Code): ZOO- /ff 7,64 -T c t a IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanita~~{{ Permit Fee (includes Groundwater Date Issued Issuing A wVi' I~ ` VCSyccharge Fee) X I Approved ❑ Owner Given Initial TTYYFFJJ~I L Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly 13115-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety ✓f< 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 renewai 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. 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 systern. 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'f 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) i i n ~ j T I. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of Labor and Human Relations g- Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY r Attach complete site plan on paper not less than 8 1 x°y 1 ~Z i I t ust include, but Sr. cj(J Ix not limited to vertical and horizontal reference poi ,direction and % o scale or PARCEL I.D. # dimensioned, north arrow, and location and dist e neat Oy0 _ jZ lq - 30 ~0 REVIEWED BY DATE APPLICANT INFORMATION-PLEASE P L MA O PROPERTY OWNER: PFIOPERTfY LOCATION ~ 1J 15 5 C1.1-~~ LTZ <a t F- St;. 1/4 NF 1/4,S l6 T Zf3 N,R I 9 E (or)© PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ~r SLO CLC c' 1q. 6LuVL3lZ 91!t ON Z t~pD. CITY, STATE ZIP CODE PHO WI -Mb CITY LJVILLAGE (MOWN NEAREST ROAD ~lu~1Z RILLS, kJ[ S\j at: (71S) ~ g 4 _j ~ So PActfac~D• [4 New Construction Use 14 Residential / Number of bedrooms L4 [ ] Addition to existing building [ ] Replacement Public or commercial describe Code derived daily flow 10o0 gpd Recommended design loading rate o.'1 bed, gpd/ft2 0 % 8 trench, gpd/ft' Absorption area required ~'S*~3 bed, ft2 -1 SD trench, ft2 Maximum design loading rate 0, 1 bed, gpd/ft2 0, t trench, gpdtft2 Recommended infiltration surface elevation(s) 5 e~c tztrCE 3 oP 3 ft (as referred to site plan benchmark) Additional design/ site considerations SWi~j7 ] ►~'0 Irv sTM-L evIt- zhi Q+ti-GN 3 ot= 3 Parent material Sin 1 v~l C~ iT ou~Z S RKjig d G M V L3L Flood plain elevation, if applicable t.3 -A • ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable fors stem S ❑ U [3S ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ❑ 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 r nch ~ ~-lb lo`-tR ~'!2 - Sit ZtinSbk m'F~ cg - o.S o•6 l Z 16-3~ vwlfz 1/b s 1 1 Z J s~k >j cS o.S o. L Ground 3 3$-~Jy ~•S y2 3ly _ S I 1 0 S bk w,`f y es - o• y o. 5 elev. tom ft. ~J y Loy g '1Z 3 l y - S o s ry M o. 0.9 Depth to limiting factor ~ 1Q M Remarks: Boring # 1 o_1Z 10`12 z_1Z Si 1 Z>r.s bk w,`~~- cS - ~.s~• 6 Z . Z ~Z-Z7 10 %1 Q 3/L s 1 'Z s bk wt'F 1- ~S - o. S ? o. 3 z-1-sz ~.s ye 31- s l l c sbk ►yt~?r Ground elev. 52_lob S `I 31y _ S O 0.8 103 •q ft. Depth to limiting factor to6y Remarks: CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165 Address: Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: 43-24'3 4~-1_9Lf M00576 PROPERTY OWNER SC-VYU LTZ SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench \ o-\Z bo~R 31Z 5) 1 Z`Fs k 0-S G' L ,°k.'`x~~`~;~~``,s~;~ Z ~ • s ~ tz 312 - L 2 ~ s dk S Ground 3 29-31 ~•S yR- 31y - S 1CS~lz rn v~~ cS _ o.Y o•S elev. U. gg eft. 4 37-103 -7-S `9R 3/Y S o S9 , - Depth to limiting factor 71p3 Remarks: Boring# o z S) ZrnShk rn`~~ cS - O•S u•~ Zuyr 316 >qCS - o•S o- b 3 3b ~!B -)•S va 31y _ S 1 1 zsbk l`f~. 0- Ground elev. y A-110 ioy2 vA - S O S ki I io. \O ft. Depth to limiting factor 711 C~' -:::F Remarks: Boring # 5 1S-~to Doti R 3l6 - si I Z~f sbk w►~f~ CS - o. s u. 6 3 yO,So `tIZ 31y - S~ ~cSbrc 1~`fH CS o y'6•S Ground I elev. L/ Sd-°l q 7. S 7 2 3IS/ S O S9 wf 1 - i n' )01 ft. Depth to limiting factor ~q 4 I Remarks: Boring # '2Jyi1\{i Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 S0-^(.- k-Z -3 ~•C~D. No, X40- 1ZIy _~n ~'NUS~ D 3 NT L ~IkST ZS' F:;fw m S k s 1•`sq w~1L_ ~So' k s ~ a ~ a r .o 0 .o N 2 --T"v cite s 2 hT S'x75'le►.,G T S x'~ S Ljv B Z b' 13 F3 s `rte a eH ~s 6 0 " Q)E~ RT T'H e U p s uPE• J"! fNK lt"1 )M 1-4Z" CO uLR ova 'T?te 1~~S`T~2~R u j`1 Ur~J p1 ow.S SWC~ t=H1utS ltt G fr c-~tZ s~czcN bRMwe ~c f J h Sa 2 c IOU. Oo1J Sp1h-~ Z ` I b.ve GRovAJi, GLpU~ ~ D'k ~3-Z93 ?)S) yzs_ c) Mo13 S-76 signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page X of I Labor and Human Relations Division of Safety s Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S 1'• e-l?~ LsC 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. ,,jyj - APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Z)~EJtN S 5 Ctt LTA 40VT-L6 St= 1/4 NF 1/4,S ) 6 T Z~ N,R 17 E(or)O PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # S to ' 1LC 3y - 6 \-u v is S" r"OIV Z&%9L PtUD . CITY, STATE ZIP CODE PHONE NUMBER []CITY (]VILLAGE 91 170WN NEAREST ROAD Z10t 1 F LLS k)( S\i otL (715) yZ"5-ZL85 TZZO'-( lsoksytkew Pfar4CuD. f)t New Construction Use (JQ Residential if Number of bedrooms L4 (j AdditiQn to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate o. -1 bed, gfxi/ft2 0 • a trench, gp w Absorption area required ~'S"a bed, ft2 -IS 0 trench, ft2 Maximum design loading rate o,-) bed, gpd/ft2 0 _?trench, gpdtft2 Recommended infiltration surface elevation(s) S EE P-tKe 3 Q r- 3 ft (as referred to site plan benchmark) Additional design /site considerations sgiEi~ »olt 7o tw sTn-t t?R 15ki PkGr_ 3 ot= 3 Parent material Sin 1 wf ehiT queg S Mil 0 G ftA u 0- Flood plain elevation, if applicable N • A • ft S = Suitable for system CONVENTIONAL MOUND "ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDWG TANK U = Unsuitable fors stem 0S ❑ U [as ❑ U IRIS ❑ U ®S ❑ U IRS ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consisterxe Boundary Roots GPD/ft in. Munsell Qu. Sz. Cone Color Gr. Sz. Sh. Bed w& 0-11o Io~IR z! 2 - Si l Zm s bk m'F~ cS - o. S o.6 1 Z 16-38 lo'lR 3/6 - S t S Z Sbk 117 cS o.S o• L Ground 3 3$ - \4V S y 2 3~y _ S, l c S bh wt'F~ CS - o• 4 v. S elev. %b4-5 ft. -13`d2 31Y - S o s-j M o•~ o.$ Depth to limiting factor > IQ Remarks: Boring # 1 o_1Z Io~i2 zlZ si 1 Z~,s bk >~~H c S - ~.S c,. 6 Ell Z 12.-Z7 lo~V- 31L SZ~ Z g~k wr'~l- ~S o.S o• 3 z-)-SZ ').S `iR 31- S 1 c Sbk kn`f cg - o.y o, S Ground elev. 52-cob S YtL 31y s' O S9 M o.~ 0.8 l03-q ft. Depth to limiting factor to6`' Remarks: T Name:-Please Print Phone: Arthur L. We erer 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: a3-Z9'3 j,9 y M00576 PROPERTY OWNER SOIL DESCRIPTION REPORT Page? of PARCELI.D.# OSLO- \Zl~t- 3Q Boring Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft rrizon Gr. Sz. Sh. Bed Trends # in. Munsell Qu. Sz. Cont Color o_~z doHiz 31z si 1 7-`Fsek cS 3 ~ r k 1Z _Z -).S` a 3h - L 2`f Sdk ►+a~L. ~S o•S o. L Ground Z9-3'1 ~•S yR 31 y S) 0-% 'blot rn U f cS o.S elev. S O Sq o•~ U` $ qg~i ft. y 3~-ID3 ~•S `1R 3!Y _ - Depth to t limiting factor 71133 Remarks: Boring# si Zw~Shk ~►`~t cS iu•~- Z y $-3` 1u `12316 S)) Z`~Sbk ti''+`F~ cS - O.S lo- 6 3 3b•~!6 ~•s `72 3!y _ S 1 1 z s bk }n~ft- ° ! ° Ground o • 7 y$_ 1~o cry w/b - S O s - elev, v011 ,ft. i Depth to limiting i factor >1101" Remarks: Boring# ~.\S \O`'12 Z-LZ S~ ZwtSbk wi`F~ CS D.S 10.6 1. 1 s i I Z'f s bh ►~`f~ S 3 yo.sb -~.s~~z 31y - sl lcsbh S Ground elev. L/ 5d.°Iq 7. S y 2 31S/ S O S9 w► - o• ! u. 10 ft. I Depth to limiting i factor Remarks: Boring # I Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 0- /IN LL. 1~~ - 30 ►v~ s Sct~-vL~'z EL le D D r ~ J 0 .0 2 2. RT S' x 7 S ~ t_e►., c ~T Sex7Se Uw6 ~_~-yB.z 9 3 b' r b 1 ~.y ~ Bwl 9 A `1 \ s ~ B•1 `1 s.s _i ti 5~L 'c'Z ~v e~} s 6 0 " P-T T?} N: U Pa Lo PE' ap C. F ON- CR M~► tP~X L w1 UY 1 L4 Z CU U (ER ' C_11~~, ..'1-r}~• ' r ip ~ I _ ~ ~ v m O I C.) U) N cn W r o w iz o to m N !(A a p z a o m ~ rrl N 07.43.30. E 399, g1, ! H ~ ° 1H n w O . o ~ co o 6ti 9 •g2 O o N 07.43.30 E 309.68 ~ . 0 N C N 07.43130` E 298.10 e a o. • n co r, ir. N a► NJ ~~`D• ' N CA N ru w W o. p;.Tl O (p µ O N CD > En tm Cl N 6~gN I 1 ~z ' .pub 5 Z Z Q 1> 1 E~ •g2 to s z Im m to I I c ly to I A IEn CA) CA) tU I ~ W ~d o a~ro'`o 0 u • aoo Z . gbh 3 m s oa'~• 6n ,pp W -4 G) H N 0 > u / H O• / / / N Z z --4 H Z 0 A 0• / / G7 Z IT! / O l iTH 512.76' ASSUME 1/4 SE ru rn ~ c3 a• * v Zia z N / SAC, mzn is 3c (III z m STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYERSo2~s MAILING ADDRESS fn / 5 t~~ 'SA .5-'10 / h PROPERTY ADDRESS LOT M G- loy e y_ S+o oy-,_,(2o J To L n ~ h i p (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, A'_ 1/4, Section T N-R W TOWN OF 0 y ST. CROIX COUNTY, WI SUBDIVISION [~~lle _S147-.1M LOT NUMBER .3 CERTIFIIEDSURVEY MAP , VOLUME , PAGE , 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 a iration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 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_ 0WX1 ~Tde~vS ~iYC e- Location of property _,2E 1/4 AL 1/4, Section 16 T 4 N-R__ZZ_W Township 7/2Q~ Mailing address Address of site p Subdivision name / Zoyel- S7`/~fi0~ ,ADD, -Lot no. Other homes on property? Yes No Previous owner of property _ ~W'V/S Total size of property , 9 a- a ne _g Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ Yes No Is this property being developed ~ff or (spec house) ? PC Yes ,_Yes No Volume ~D Yf and Page Number WY// 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. 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. Si atur of Applicant Co-Applicant Cn Z 0 Date of Signature Date of Signature DOCUMENT NO. WARRANTY DEED iI THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1988 I _ T ; 111 Dennis R. Schultz t2eda ibr f.wtvd MAY 2 5 1994 _ . I 8:30~}Y C_-_t A• conveys and warrants to ..-AAl7! ._.~1Q>~Ils s~ +-V , r GllOw~ R[TURN TO Stl,L y~.~ the following described real estate in O1X County, State of Wisconsin: Tax Parcel No: Lot 34, Glover Station Second Addition in the Town of Troy, St. Croix County, Wisconsin. s 2b D~ This .__.y..~..yU. AOL........ homestead property. I= (is not) Exception to warranties: $asemnts, restrictions and rights-of-way of 23rd. record, if any. Dated this day of May . 19... .(SEAL) . --(SEAL) nnis R. Schultz (SEAL) . .......(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St....Croix----------• -----County. authenticated this .-......day uf 19...... Personally came before me this ................day of Iky-.............. 19.94.. the above named Dennis-1,__Schultz • TITLE: MEMBER STATE BAR OF WISCONSIN (If not- person authorized by 1 706.06. Wis. Stats.) to me known to be the who executed the sspsssss.s42I egoinP instrument cknowledge the same. -•--THIS INSTRUMENT WAS DRAFTED BY ~aO~ Pf~ sa ^ ^ ^ Kris tina..~land a'~~+•?~ Attorney at Law N i Q..-'-- . - - ►.~1_i_ . . No blic ..__...-5._.. Q~!) County, Wis. (Signatures may be authenticated or acknowle Bq~h M. ission is permanent. (If not, state expiration are not necessary.) 'Names of persons signins in any capacity should be typed or Drin o+s! natums. WARRANTY DEED STATE BAR OF W TSCONSIN Wisconsin Legal Blank Co.. Inc. FORM No. 2- 1982 MilwaukRe. Wisconsin -aa:rcA:^,fta.'Ar~ia III~ 42l.-MaI>thu>I. &A?_."', IIA-w "k F.mrM :ff ~C JVC'4'Ik _ . 'A-