HomeMy WebLinkAbout040-1215-20-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
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OWNER llj r' i) FA
ADDRESS 1 ~~^)C
SUBDIVISION / CSM#__ A LOT #
S ECTION_1 bTCA5 N-R W, Town of_ ro
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 00 FEET OF SYSTEM
9."M 7t Eke, i 6?
1 I
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK: box k!
ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well 75 L1 House C" Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length_ Number of trenches
Distance & Direction to nearest prop. line: S✓U f~115
Setback from: well: House }lam Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
I
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
I
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Hyman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
BATES MARVIN X
CST BM Elev.: Insp. BM Elev.: M Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 4 C'~ v . 0/ t Benchmark jQje Ob
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet ILV O
TANK SETBACK INFORMATION St/ Ht Outlet y 100V7
Vent
TANK TO P/ L WELL BLDG. A
irito ntake ROAD Dt Inlet
Septic ? a NA Dt Bottom
Dosing NA Header/Man. gS
u,
Aeration NA Dist. Pipe ~5-i
Holding Bot. System Q 94,3
~
PUMP/ SIPHON INFORMATION Final Grade J''Zg g8,yy
Manufacturer Demand 5T
Model Number GPM
TDH I Lift Lricti n System TDH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length _ No. Of Trenches plT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ° DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O f CHAMBER Model Number:
System: jri, V cS~ /,(U tc /V IA OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) 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 ~l1 y Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center ~EJ l V Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy.16.28.19W, SW, NW, Lot 42;lSoo 'ne Road
3
10
A_ -We
rn
Plan revision required? ❑ Yes ❑ No LAI() Use other side for additional information.
SBD-6710 (R 05/91) Date pector's Signature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
SANITARY PERMIT APPLICATION
In accord with ILHR83.05, Wis. Adm. Code Cod
STATE SANITARY PER IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than Pol 44 1
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.
PROPER NER PROPERTY LOCATION / ~j
n ~t3(I eS t/4 ~'/4, S Tq`" N, R E (OI 1f~
PROP TYINER' AILING DRESS LOT # BLOCK #
e
6 _A
SI PHONE 0 NUMBER 3~'y SUBDIVI IOly6NAME Ue OIr d RCS`M q~R Add,
cCITY, S~ Z CODE
II. TYPE OF BUILDING: (Check one) CITY J NEAREST R D
❑ State Owned ❑ VILLAGE to S t
W TOWN OF:
PARCEL TAxNUMBER( )
❑ Public 1 or 2 Fam. Dwelling--# of bedrooms 4(
Ill. BUILDING USE: (If building type is public, check all that apply) 6 0 ^ /a / ~ _0`0
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~j 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 / ~rtn CeS' 43 ❑ Vault Privy
14 El 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
L REO IRED (sq. ft.) PRO OS ED (s q. ft.) (Gals/day/sq. ft.) (Min./~in7ch) QY ELATION
~ i 4x,5 Feet ..`5 Feet
® 0® 5® f
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank a -ft
Lift Pump Tank/Si hon Chamber El El F] F] I F1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
) M Business Phone Number:
Plu er's Name (Print): Plu e s Signature: =S
~ / ~ / ^
Plu bens Addygss (Street, C State. Zip C de): , 110 kA
IX. COI(/U`-NJ,TYIDEPClAJ1RTMENT(U/SE ONLY l/ v'vJ S eyJ
Disapproved Sani Permit Fee (includes Groundwater a e ssue Issuing Agent Si n o s)
d$ Zj,
Approved ❑ Owner Given Initial G Surcharge Fee) n
Adverse Determination
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
submitted to the county-prior to installation. I
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 hne 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)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3
Labor: and Human Relations
Q:tvision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 i Jude, but
not limited to vertical and horizontal reference point (BM), i' and % of slo r PARCEL I.D. #
dimensioned, north arrow, and location and distance to n a road-.
APPLICANT INFORMATION-PLEASE PRINT A ORI14,ATION REVIEWED BY DATE
PROPERTY OWNER: r PROPERTY LOCH 10N
C • w'\• Ci4L, riKib ~LSI`1h-11 S L~ Si 1/4 NW 1/4,S ) 6 T Z$ N,R 19 E(or~l
PROPERTY OWNER'-.S MAILING ADDRESS i BLOC # SUED. NAME OR CSM #
RllA
7 10 N. "R-I AJ ST• G\..oukz Si"(Yu -2-11"
CITY, STATE ZIP CODE PHONE NUMXiP/ LAGE RYOWN NEAREST ROAD
R\U v- ~tLIL S, W I lst4o Z' Z ►S) 147-S p soo . LtuF RvhrD
[AQ New Construction Use [Jq Residential / Number of bedrooms V Addition to exisfing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 60tn gpd Recommended design loading rate o -1 bed, 9pd/ft2 o - $ trench, gpd/ft2
Absorption area required VS 8 bed, ft2 Z trench, 112 Maximum design loading rate n • 1 bed, gpd/ft2 0 • P trench, gpd/ft2
Recommended infiltration surface elevation(s) %(ZE V'P GZ 3 of 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material %LnX M Q-U'r W J L~ kkr~ g Gant UfsL. Flood plain elevation, if applicable • A • It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem KS ❑ U ®S O U ®S ❑ U as ❑ U RIS ❑ U ❑ S Cad U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color . Mottles Texture Structure Consistence Botrdary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rench
Ct-v ~ b • S b. (o
I l n-LO 1o~t~ it Z - s, Z ~ sblr< w► V `~1~
` Z to-i] Ir3 cS o•`t b.5
Ground 3 ?-I-SS I n y 1?_1 31` S O S q C s b •l 4• b
elev.
9e,ft. 3S4y )O7ft Yl - S O s9
Depth to
limiting
factor
Remarks:
Boring #
~~.K.,<.Y 1 0-a ~0~,2. z!Z ~ s 1 Zt,.lsbk wtv~„ c s - o.s 0.6
Z ` Z 8-Zo )otiV- 3/6 - S $GH o 9 w, CS - o n•
.~~.:v<>
Ground
elev. 3S- cl 3 ► 0 7 IZ Y/)f S v S 9 wj J - a o•$
q~ ft.
Depth to
limiting
factor
> g 3''
Remarks:
TName:-Please Print Arthur L. We erer Phone: 715-425-0165
erer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
ge
Signature: Date: CST Number:
q 3 -Z9 3- 2~ - y M00576
PROPERTYOWNER 3`-tE - SCbtv~TZ SOIL DESCRIPTION REPORT Page FZ of
PARCEL I.D. # O q O - ~Z 5 - ZD
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ll LO zl'z - s5bk Go.S o.6
F-LL -).SVR 31 S ~e-Sblq-NJ rQw 0-Y o,S
Ground 3 Z6 -3$ 7 • S `t2 31 _ S d S9 vh C S 7 0.
elev.
S. I ft. -9~ Lb-IrL (l - S cz~ sg ~ ( - 0 7 0•Q!
Depth to
limiting
factor ,
Remarks:
Boring #
C5 -VZ 10 ~t 2 z Z.
Gh S l \ C-SbOZ vn v 'F~- e g o. y o, 5
0.8
4 CL Sly - \s \ e sbk w► i~ as
3 3~-yy 1,o`~.1z. 31b - S ~ Sq w, ~ c S - et 0.8
Ground
elev. qv- 8$ 1 V `12 V S O S-5 q3.3 ft.
Depth to
limiting
factor
~ QC ti
Remarks:
Boring #
)ZMV- 3 lZ S~ Z`Q ~bk Y`n~~ CS - o-S 0•L
54w€ Z 8-z~ tib~~Z 316 S ti Z'~'3bk m`f~ cS - e• S o b
Ground 3 s yR ~/6 _ S o g r~ 1 ~S - 0 8
elev. y{, .9l l 0 y R Y! - S g m 1 - o .7 a, g
92 ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground '
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Page
PLOT PLAN 3 of 3
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
h Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
• COUNTY
. ST• c2
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but u ix
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. oq0- \I\ S-IQ)
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWEDBY DATE
PROPERTY OWNER: PROPERTY LOCATION
C •'f'1- C34 L P%Kib 'Z~~Q1-JQ \ S S cldtj L'tL Q=-.• SW 1/4 NW 1/4,S ) 6 T 28 AR 19 E (ore
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # ►,d
-)1o N. "A-I KI Sr. qz - Gl.oo~ s`1" W Z mr)
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE NTOWN NEAREST ROAD
R\Ut_M uS, WI S401, Z 015) 1IZS- 8xw `C'20 Soo LWF P-.ohb
[JQ New Construction Use [JC] Residential / Number of bedrooms y [ J Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived dally flow 60O gpd Recommended design loading rate c--) bed, gpolftt2 u -'Strench, gpolft2
Absorption area required %S9 bed, ft2 Z SD trench, ft2 Maximum design biding rate 0.7 bed, glxW 0• P trench, gpd/(t2
Recommended infiltration surface elevation(s) S IM TACSF 3 0,= 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material %int M'I 13l" - Oy (M Std 'q Gti.r} U6L Rood plain elevation, if applicable • A It
S = Suitable for system CONVENTIONAL MOUND "ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system KS ❑ U IRIS ❑ U ❑ U ®S ❑ U ❑ U [I $ (?U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Corisisberice Bound3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rertcttt
b-LO 1z`-tQ. ZI Z S 1 Z u\ Sb12 Yn CL" - b.S b. (o
n 31i 2 t6-Z1 )OytZ 3/4 - s ~ \C.slb\Z yn U °•y 0.5
Ground 3 21-SS I D y t2 3/L - S 0 5 C s t'_) 0-b
elev. 0~7 4n. ~
9 b_ ft. 3S / )1[37R V - S O S1 ] -
Depth to
limiting
factor
~~yr
Remarks:
Boring #
I o-8 ~o~t2 z!Z s~ Zw,sb~ rHVf1• c s - C, a.6
2 Z 8-ZA %'1z 3!6 - S G4• o 5 w►1 Cs - o d.S
3 Zo-3S I o ti R ~/6 - S wt
Cg - 0 7 o
S
Ground
elev. 3S_93 10 71- Y/y, - S o s q wi 1 - o• ° $
Aq1. ft.
Depth to
limiting
factor
> 3''
Remarks:
CST Name.--Please Print Arthur L. We erer Phone. 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: '3 _ 'Z 9 Date: 3 _ "L _ y CST Number: 0 0 5 7 6
PROPERTYOWNER - SCM~.'%-'rZ SOIL DESCRIPTION REPORT Page Zs of 3
PARCEL I.D. # O q O - %-Z-% S - ZA '
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # rri in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Boundary Bed Trench
o-LO zIZ - S' Z Sbk "'S~ CS - L
_z,6 S y R V S 1 O' S
Ground Z6-3$ 7•S `7R 31 S O s9 C S - 7 0-~
elev.
9$ 3 ft. -9$ 10 tz- Y! - S sg _ o, ; a. 6
Depth to
limiting
factor I
7 °f
i
Remarks:
Boring #
` 0_~Z l0`12 zIZ - Gh S1 ~cSbbt M v~~.. cg o,y ?p. 5
Z ~z.-3b •S ytZ 3l g e.sb1z v" v~I. CS o. #o•8
3 3b-4y ~o~,R 316 - S ~ sy Y'l )
Ground
elev. y, g g l b 2 y! S o SID
a3.3 ft,
i
Depth to
limiting
fa'dtoQrrc
~y
Remarks:
Boring # Z'Q ~bk
1 0_8 lo`iQ 3 It o•S l)•~,
a 6
S S
g-2$ tib`t ~Z 316 S 1 Z-'F 3 bk Yh `F1~ S - o,
z
Ground 3 Z8-~6 S yR ~/6 _ S. o s w,1 cS u o• 8'
elev. LJb-ql t0 `1R Y! S b g M
1 - 0,7 I o, $
9 ft.
Depth to
limiting
factor
7Ol-)' I
Remarks:
Boring #
i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05192)
3
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS and A711~f"At
PROPERTY ADDRESS b a Sob L, 111
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ~r0 ~V A
PROPERTY LOCATION S~tJ 1/4, / zj 1/4, Section ! b T e9"l N-R_Z~ W
TOWN OF D c ST. CROIX COUNTY, WI
SUBDIVISION C11(2Pfk LOT NUMBER
CERTIFIED SURVEY 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 expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
'This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/ contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-----------------ka-
Owner of ProPertYr~ S
Location of propertyal(i 1/4...~Y& 1/4, Section ,TAN-R__W li
Township 7t'D Mailing address ,C T l ~oX ~6
bb 1 j
Address of site 3 6 P SQO tN
Subdivision name Ctlebe)'^ 9101 Lot no. Y
I
Other homes on property? Yes No
Previous owner of property to f 'S
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? 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. ' alb 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 ~f of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
Date of Signatu e Date of Signature
r
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
II
STATE BAR OF WISCONSIN FORM 2-19821
518924---
Y _ 1.G86PA~E4..r3:. REGISTER'S QFFICE
Dennis R. Schultz ST. CROIX CO., WI
- Recd for Record
_ i~ JUL 13 1994
ae_--
~i conveys and warrants to - ~~M S.; Maryin__G.._Bates.-'Mary-A.--Bates., at
-husband..and..wife.........................
Roo WofDeedS
RETURN TO
.
the followin; described real estate in St,...Cr_Qix ..................County, -
State of Wisconsin:
Tax Parcel No:
Lot 42, Glover Station Second Addition, Town of Troy,
St. Croix County, Wisconsin.
~6
1
This 1S not homestead property.
( (is not)
Exception to warranties: Easements, restrictions and rights-of-way of
record, if any. June Dated this Z'1'0-------------- day of . 19..94... . (SEAL) (SEAL)
Dennis R. Schultz
- - .
- -----(SEAL) ................(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
SS.
County.
authenticated this daof 19---.-- Personally came be.forc -M this -----...davy -)f
June-------------------- 19.._94. the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ANN E. DOSTAL
Kristina Ogland QUAY-PUBU TA O
- ~x /
Attorney at Law Notary Public
. -•----County, Wis.
(Signatures may be authenticated or acknowledged. Both My Co ission is permaneht. (If not, state expiration
are not necessary.) 1 C
date: , 19.
'Names of persons signing in any capacity should be typed or printed below their signatures.
II WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. I;
FORM No. 2- 1982 Milwaukee. Wisconsin