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HomeMy WebLinkAbout042-1040-10-000 ~I a) q a) o0 a o oo o° h ti n G Q) 01 4i :OE ~ I I °c 0 N N y c a> m g E w m CD U c c i 0 ~ j O O 't3 rn 0 •0 L N O L 0 N o rn o 3wCD o Z ch E I z€ c o o c o -0 lL C C_ '0 LL. 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CROIX Safety and buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI QUILLING, JAMES X CST BM Elev.: Insp. BM Elev.: BM Description: "'L -L ell Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet Air l Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM t Loss Friction System TDH Ft TDH Lift Head Forcemain Length Dia. f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Mode Number: System: 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 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Warren.15.29.18W, NW, SW Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I~, SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code c1 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a-A y/~ I 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 PR P RTY LOCATION a61%NRi 1 pyi y"S N T ,N,R E(or)W PR ERTY WNER'S MAILIN,%ADDR SS LOT # BLOCK # 3 at I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER STAT ' ZIP CODE, W C t7 1015 -092' II. TYPE OF UILDING: (Check one CITY NEAREST ROAD ❑ State Owned VILLAGE KPublic ❑ 1 or 2 Fam. Dwelling- # of bedro s - P R EL AX NUMBE (S) 111. BUILDING USE: (If building type is public, check all tha ply) 0yt `j~ ~/5 1 ❑ Apt/Condo 7 lCCJJ 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 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.E1 New 2. ❑ Replacement 3. ❑ Replacement of 4. LN 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 N 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 140 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 REQUIRRED(sq. ft.) PROPOS D (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION D( Feet 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 Tan structed Septic Tank or Holding Tank 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: (N tamps) MP/MPRSW No.: Business Phone Number: LfttADA ~ ~X_~ (7X,5 lumber's Address (Street, City, Sta e, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si a V Surcharge Fee) Appro~Yed ❑ Owner Given Initial d - lD - 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. 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) 10% g J T ` T~ ~ VIII J O ICJ m Q O ~Q d© DUS RY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION BOX LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION N ME: Ill 5J/a !_5 /TAgN/R/8E (o W CL,, ae,, IIIFl N UNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE ,,~,~NO.BEDRMS.: COMMERCIAE IPTION: PROFILE DES RA ONS: ER ATION STS: L(,dResidence ~lew ❑Replace I 7t7f ! RATING: S= Site suitable for system U= Site unsuitable for system CONVSTIO❑NAL: MO__Ulyp:❑u IN-GROUJ)1DPR❑ESSURE:SYSTEM-I LHODLDINGTA R~O/MENDEDSYSTEM:loptio 1 19 I -S ED If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: I~Floodplain, indicate Floodplain elevation: A IA A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- j - 7U > D ~l ~ n t 5 fig'' S 3_ le 4 11 B-0 1 375' ZZ,67W, 7" 10'6k Basil f r ~ l~ ~ ~3 s 5io a► ?I r/ 9 B X5 > 8 i I nk n y s~ i 0" 55 Q B- 17 7'97 # > ?3 1 E 1-11-18 rl 5 11 K` PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN H S AFTERSWELLING INTERVAL-MIN. PERIOD 1 P IOD2 RI D PER INCH P- 10 /Y -ebN ::M P- 10 1 (11 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION Tole-PkdA"P, Ac~ g O Ott a .5a 13_, 4 irv a T N 3 A 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS W RE COM ETED ON: 6 1 C_ 6.v- 0- d / yq ADDRESS: CERTI ICATION NUMBER: JPHONE NUMBER (optional): CST ATURE: ION: Original and one copy to Local Authority, Property Owner and Soil Tester. '395 (R. 02/82) OVER - ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at 1 1 1/4 1/4 Sec. ~5- - T a • • . R W Town of ~ 44_~ I t~~1 Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No_4(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ~(e(X_- c~rc' Construction: Prefab Concrete Steel Other Manufacurer ( if known): Age of Tank (If known) : y(-S ZA(Signature) (Name) Please Print (Title) (License tuber) /0 (Date Form to be completed by licensed plumber (s.145.06, wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle). I Name Signature MP/MPRS 5/88 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. ~ R~W ADDRESS ST. CROIX COUNTY, WISCONSIN I i SUBDIVISION / LOT -4/ LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Q e~ - LL)a s r.s e u t INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: ':~X9B SEPTIC TANK: Manufacturer: iquid Capacity: /©C7(~) G~Z 'Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front.,0 Side 0 Rear , feet From nearest property line Front,O Side, Rear, O feet Number of feet from: well building: _ (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: _ Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X, Trench: Width: A~ Length: Q Number of Lines: Area Built: ~ Fill depth to top of pipe: , 3 let 1 Number of feet from nearest property line: Front, Side, O Rear, O Ft Number of feet from well: Q ` Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits:Diameter: Liquid depth: Bottom of,\ seepage pit elevation: ti Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 'oooo'7 i1 S License Number : M/1 49~ 3/84:mj I J l` S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property lVbl/4 S~J 1/4, section T_-)j N-R_W Township L~/La ; ems, Mailing address 3 9 /;2_6 s7_ _-.,7- //Address of site 4-~ Y i r_'~ ~i /1~ 5~:~~ 7vZS, 6-4/c7~ Subdivision name Lot no. Other homes on property? Yes /1//:) No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all cornersband lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume ( c_'L~c and Page Number V4L- Yy6as 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. '3 R6017 , 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. S gnature of Ap scant C6-Applicant Date of Signature n itPn+ nr,at „YA STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER u-rn. t W e G.. MAILING ADDRESS l p z ~i -t z T _ ob < ,S ~f Q 2 PROPERTY ADDRESS e Y O (location of septic system) Please obtain from the Planning Dept. CITY/STATE v Q ~s S PROPERTY LOCATION G- 1/4,~ 1/4, Section T N-R W TOWN OF L4/ a n ST. CROIX COUNTY, WI SUBDIVISION 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. at 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 syste , which was in operation prior to July 1, 1978. St. Croix County accepted this program in August 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees o submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeym plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposals stem 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 w th 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 STC-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 ~n delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), thenla 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 TAiln Location of•property 1/4 _1/4, Section T N-R W Township Mailing address 73 d~Z y 5 .R µ r Address of site x subdivision name Lot no. Other homes on property? yes--L&-No Previous owner of property Total size of parcel Date parcel was created 'Are all corners and lot lines identifiable? ~s 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 DEhD which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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. 3 5,~, & 0,27 , and that I (we) own the proposed site for the sewage disposal system orrI e(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 County Register of deeds as Document No. G1~ ? . Signature of applicant` • -c~licant 17 el Date of Signature Date of Signature. DOCUMENT NO. STATE BAR 01"_ S'C,ONSIN FORM 1 - 1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED ;VOL 668 PAGE264 - - R~STiRS OFFICE D Kingsley E. Hawkins _ - and , WIlth h11~1 made wen ST: CllO , Coset e I~e aw&s , J c~a Cosette _'M Rasmussen , liusbancT - - . gee d. for ReaOrd and wife as tenants in comron - Grantor, day of- July A.D. 19 83 and James .A._ Qm _nq. and--Debra_L,- uillinq-,_.husband_-_-_. at 4 :00 P M - and. wi fe. as- .jo-tenants - - - i t Grantee, M DNds - _ i - - - - Witnesseth, That the said Grantor, for a valuable consideration of one dollar and other valuable consideration • RETURN TO conveys to Grantee the following described real estate in St,-- CrQi.x.....-_. County, State of Wisconsin: Part of the NW 1/4 of the SW 1/4 of Section 15-29-18, Town of Warren, St. Croix County, Tax Parcel No- Wisconsin being Lot 1 of Certified Survey Man filed on July 7, 1983 3:15PM , in Volume , page 1308 of Certified Survey Maps, as docum t #385952 . THIS WARRANTY DEED IS GIVEN IN PARTIAL SATISFACTION OF A LAND CON'T'RACT DATED DRCETIBFR 1, 1982 AND RECORDED DECEMBER 15, 1982 IN VOLUME "656", PACE' 4 4 7-4 4 8 , AS TYn- D'IENT_ #381646 AT THE REGISTER OF DEEDS OFFICE FOR ST. CROIX 001NN, WISCONSIN. ~q. 0 J. This 1S..X1Qt homestead property. (is) (is not) Toget;4 with all and singular the hereditaments and appurtenances thereunto belonging; And..K1n461ey_ X....HaAinS.. nd-CQSE'.-tt:e..M...Hawkins_,_fA/rL.Cbse.tta.M...R ismssea......---.. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except l recorded protective covenants, easements and restrictions of record, if anv and will warrant and defend the same. Dated this 2A A day of Jay---------- . 19..83... C/ ~ - -------•----------------(SEAL) . - • . - - - - - - - - - - - - - (SEAL) ley E. Hawkins yyf * -_--r--------------------------- (SEAL) - ...(SEAL) Cosette M. Hawkins f/k/a Cosette M. Ras pe ~ I AUTHENTICATION ACKNOWLEDGMENT Signature(s) 9TXTE 0F-WI5U0N5IN St. Croix ss. County. authenticated this day of___________________________ 19 Personally came before me this 7t~ day of J4Y 19..-83_ the above named Kin slew F. Hawkins and. Cosette M. Hawkins . * f/k/a Cosette M. Rasmus TITLE: MEMBER STATE BAR OF WISCONSIN - (If not, authorized b ~ y § 706.06. Wis. Stats.) to me known to be the arson ho cub the 0 1; foregoing instrument and ac4q; wtedgQ~hells V THIS INSTRUMENT WAS DRAFTED BY w . JJJG.LL.- J;-...lYF3.1..L. y% - Ip---- - ---t~--- J.Y522 Second Street, P.O. Box 151 Kal hleen _St ro r t _ - lt^ Wis. Hudson, WT 34,01 Notary y, (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not,. state .expiration are not necessary.) date:.-.. 19-6.4 - •Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE DAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1 - 1982 Milwaukee. Wis. c Form - S •T. C - 104 r AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. / T12 9 R~W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT /v LOT SIZE A PLAN VIEW Distances and dimensions to meet iequirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r f c~ '236, "De 0 e~ 0 1 1.~ 0a s INDICATE NORTH ARROW ICHMARK: Describe the vertical reference point used ,ation of vertical reference point: Proposed slope at site: C TANK: Manufacturer: /2 taCt~&j d' -&yS'7Liquid Capacity: /BV,) G',gz mber of rings used: Tank manhole cover elevation: tk Inlet Elevation: Tank Outlet Elevation: ier of feet from nearest Road: Front,O Side 0 Rear, feet From tea-rest property line Front,O Side, Rear, O~ feet of feet from: well /,90 building: _ 2z ~ his information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER Manufacturer: Liquid Capacity: + Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: L Gallons per cycle: Alarm Manufacturer: ~r Alarm Switch Type: Number of feet from nearest property.,line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: t Number of feet from nearest property line: Front, Side, O Rear,O Vt~ Number of feet from well: Number of feet from building: -3 8 (Include distances on plot plan). SEEPAGE PIT r t Size: Number of pits:'` f'. Diameter: Liquid depth: Bottom of'seppage pit elevation: Area Built: Has either a drop box O or distribution b x O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity:,/ Number of rings used: Elevvation of bottom of tank: Elevation of inlet: Number of feet from nearest property one: Front, O Side, O Rear, O Ft. Number o'f feet from 11: Number of feet from buildin Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: In o" l0 License Number: Mid 3/84:mj DEPARTMENT,OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LAIBOR & H.UMA,N RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOj( 7969 , BUREAU OF PLUMBING MADISON, WI,53707 CONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number: 11t ❑ Holding Tank ❑ In-Ground Pressure 1:1 Mound assigned ) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPE TON DATE: James Quilling R. R. 1, Hammond, WI 4/0-/9.-fy- 3.1O0 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NW SW, Section 15, T29N-R18W, Town of Warren Name of Plumber: MP/MPRSW No. FS'"t".1 Sanitary Permit Number: Lyle J. Myers 6219 Croix 49507 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER P OVIDED: PROVI D WAic~.~al.Y~ ~O I ! , U YES ❑NO8~ NO BEDDING: VENT Oil A.: VENT MAT L.: HIGH WA R UMBEROMof ROAD: IPROPERTY WELL: BUILDING: VENT TO FRE H J ALARM FEET FF~ LINE: / AIR INLET: ❑YES O C - ❑ E O NEAREST / Z `fS ! ~ DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUF URER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA L. NU BER OF PROPERTY WELL BUILOING. V NTT FFRESH (DIFFERENCE BETWEEN F T FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑N EAREST SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing JLEN(,TH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH: JNO,OF DISTR. PIPE SPACING. COVER J'NSIUE DIA.: #PITS. LIQUID BED/TRENCH TREND MA/ PIT DEPTH DIMENSIONS GRAVEL DEPT}1 FILL DEPTH DISTR. IPF 1011TR PIPE DISTR. PIPE MATERIAL: NO D R. NUMBER OF PROPERTY WELL: ;71N]G VENT TO FRESH BELOW P;PESL ABOVE COVERELEVI LET ELEVENJ PLINE: AIR INLET: 7 zI {I q FEET FRM L_ NEARESOJ /J I Z' MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAMWSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: ISCIDDED. SEEDED: MULCHED: CENTER: EDGES. ❑YES FIND ❑YES ❑NO ❑YES ❑No PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE IM ANIFOLD MATERIAL. NO. DISTR. JDISTR. PIPE DIS FRIBUTION PIPE MATERIAL & MARKING ELEV.: ELEV.. DIA.. ELEV.. PIPES. DIA.: ELEVATION AND . DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: _ ❑YES ❑NO ❑YES ❑NO CUM ENDS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: Jr' ~ \1 FEET FROM LINE: 4~ ( I/ 3 ❑YES ❑NO ❑YES ❑NO NEAREST I a g I qS V ov2E`` c~9Q,,► x,05 C7 3 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: 4 TITLE: DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT -DILHR COUNTY oE,aRRTmEr1T OF (PLB 67) UNIFORM SANITARY PERMIT # InOUSTRV, LRBOR 6 HUMRn RELRTIOnS /v 950~ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING A RESS ~i~l r-~ E .tf G r _S 1.4 4 [PROP RTY LOCATION CIT : 1/4 /4, S TeY1, R c') E (o W V QWNIL OG E : /Z-/2 SS Nf& ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER LOT NU BER BLOCK,N MBER ISM DIVI I N NA TYPIE O BUILDIN OR USE SERVE - /a ;or 2 Family Number of Bedrooms: ❑Public (Specify): THIS PERMIT IS FOR A: ><New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification u IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. XSeepage Bed ❑ Seepage Trench Cl Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy a ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity i Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total *of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity i Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROP SED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of PI 'nber (Print): Signature: MP/MPRSW No.: Phone Number: Plum er's Address: Name of Designer: 4Z%1j, - il-Is _2 COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 7 L~ ❑ Owner Given Initial lJ /v C Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: D I LH R -SB D-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. a ~ ~i X11 v 1 -15 fl iA c ~o Z-lev PAGE OF Cr~SS Szc}IUr1 p~ ~ Urt~ ~ S~en~ Y ~ Frech Air Ineetc And Obliervatlon Pipe Approved Vent Cap Minimum 12" Above Fly naade !7 20- 42" Above Pipe _ 4" Cast Iron To Final Grade Vent Pipe Marsh Hay Or Synthetic Covering Min. 2" Aggregale Over Plpe Distribution PIP& 0 0 o v -Tee 6" Aggrs Pdle a Pertorared Pipe Below Beneelh Pipe _ o Covpting Terminating At Ballum Of Syclem prop 1D FIf1wI ~~r.c~{ = i ~IeJ•.~ I on tip lI SOIL FILL DISTRIBUT1014.1 PIPE APPROVED ETIC COVE o ~`-tMAT~~I^~ OR 9 OF STRAW 2"OFAGGREWE OR MARSH HAy 4o' OF AGGREGATE 'ELEV. of FEET, DISTRIF5UT10A1 PIPE TU BE AT LEAST INCHES BELOW ORIGIUAL GRADE AIJU AT LEAST20 INCHES BUT AIO MORE THAt.I HZ IAICNES BELOW FINAL GRADE MAXIMUM DEPTH OF EXCAVATIOP ROM 0AIGINAI. 6RADE WILL BE ~ INCHES NNNIMUM VEPT"tl OF EXCAVATION ROM OiIKI(AWAL C3RAVE WILL. BE -361, INCHES r SIGIJED: i I LIGEtJSE IJUMBER: DATE : calll /V,:~t D RARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDGSRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (H63.0911) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 189j/ IS /TA<jN/R/8 E (o VA At A UNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIA/VE IPTION: ~y~ IPR~ 7,c';? SCRIPTjI S: EI Ol/ATION PESTS: n esidence Phew ❑ Replace arm 1 / y y RATING: S= Site suitable for system U= Site unsuitable for system CONVEAITIOoNAL: MOUIj)p: IN-GROUS Pau RE: SYSTEM-IN-FI~LHODLDING TA .RECOMMENDED SYST~EM:(opt io ) FS 191 If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: /Vq Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-Q B-S g3 10"kAns, h 11 , 1e n 5 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN H S AFTER SWELLING INTERVAL-MIN. P )'IOD 1 P 00 2 RI D PER INCH P- Q / 4-1 / P- aLaL P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. f SYSTEM ELEVATION ° 3~ = r E 6 ct IAi 3 ° I ie. 13 cv), ~I lj _ - E I, the undersigned, hereby 'certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WRE COM ETED ON: 49 1'C_k yel ADDRESS: A ^ TgICA ION NUMBER: PI LONE NUMBER (optional): 13 ( - Q, 31 -Q151q CST ATURE: s DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - I1' ~TRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a comp and accurate soil test, your report must include: 1. Complete 1, rscription; 2. The use Mast clearly indicate whether this is aresidence or commercial project; 3. MAXIMU )er of bedrooms or commercial use planned; 4. Is this a new of - ent system; 5. Complete the su I-/ rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTE -RE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abl eviations shown here for writing profile descriptions and completing the plot plan; MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A 1 separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, place N.A. in the . to box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILi D WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. y ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures. Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Grorr --ivroi* , cs- Coarse Sand Perc - Percolation Rate rued s Medium Sand W - Well 's Fine Sa Bldg - Burldina_ Is - Loamy > - Great?r Titan `sl Sandy Lf , n < - Less Th-i *I - foam Bn - Brown *sil Silt Loam BI _ Black si Silt Gy ' 3ray "cl - Clay Loam Y Yellovv scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc Sanely Clay wl - with sic - Silty Clay fff - i,f=vv, fine, faint c ay cc - common, coarse pt nIT) - Many, medium n1 - d - distinct p - prominent HWL High vvat level, Six general soil x -,:,res surfar for liquid wa_ - 'osal BM Bench M v VRP - Vertical =rence Point: iE OVVNrP: a 1fy r;:--he L , . the D na: d :quest -rmit A , „f fo, -vat( mlit to ell tar r ` ally H En H ST C- 105 r y H SEPTIC TANK MAINTENANCE AGREEMENT r+ 0 St. Croix County z 0 9 H OWNER/BUYER JR~ve s t [J~, ROUTE/BOX NUMBER Fire Number CITY/STATE WI',~ ZIP -3 PROPERTY LOCATION: IV W k, 57W k, See tionL~ T;L9 N, R_/S!__W, Town of Q r r erg St. Croix County, Subdivision Lot number Improper use And maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. Ho I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 'v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED"- DATE St. Croix County Zoning Office P.O. Box 94, Hammond, WI 54015 715-796-2219 or 715-425-8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property iJ '4 _k) ~4, Section , T 27 N - R - W Township ! r Cc r,\ Mailing Address Je leo h ter- ~-s , Cc/.jr- s"y v a 3 Subdivision Name Lot Number mt Previous Owner of Property Z~ ; i.j rig 5 Total Size of Parcel /a a c re s Date Parcel was Created ~u" LT 7, q 03 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number / 3-0R- as recorded with the Register of Deeds INCLUDE. WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified. Survey Map shall also be required. PROPFRTy OWNER CERTIFICATION I (We) eeAti, y that a.U statements on this 4onm a,,Le t,,Lue to the beat o4 my (out) knowledge; that I (we) am (are) the owner (b) o4 the pnopenty de cAibed in thin injonmation 4onm, by viAtue o{ a wa~ftanty deed neconded in the O{6ice ob the and that I (we) County Reg isten o Deeds as Document No. jtl, pne6entty own the prroposed site {ion the sewage di.6posa2 bybtem (on I (we) have obtained an easement, to nun with the above de5cAibed pnopehty, 4on the con t,tucti.on of .said system, and the same has been duty neconded in the 06{ice a4 the County Reg-csten o4 Deeds, as Document No. 3 r l S NATURE OF OWNER SIG ATURE OF CO-OWN R (IF AP I(7BLE) DATE SIGNED DATE S GNED DOCUMENT NO. STATE BAR 07'W CONSIN FORM 1-1982 T.I. SPACE RESERVED FOR RECORDING DATA WARRANTY DEED ' `a i6 2"I ► p ' 668 PA"GE264 R6eGJSTiRS OFFICE ! Thi D e made w en g y ST: CROM CO., h. Colette 1~I. I~a~aT~ir►s , ~''ca Colette M Rasmussen liiasband _ 11th Kin sle E. Hawkins an. and wife--as -in comroi%------- do Rec d. of for Jul Re"d Oft 83 i Grantor, y _ y A.D. 19 and ---Jame- ------Quilling--and--Debra._L. uailjing_,--husband--_--._. at 4 :00 P Me and -wife--as--3 ants i ~NMar M ON/9 ~ Grantee, Witnesseth, That the said Grantor, for a valuable consideration of- -one.: dollar - and _ other _ valuable- . consideration _ RETURN TO ! conveys to Grantee the following described real estate in $t,__Cmix---.____. County, State of Wisconsin: Part of the NW 1/4 of the SW 1/4 of. Section 15-29-18, Town of Warren, St. Croix County, Tax Parcel No: Wisconsin being Lot 1 of Certified Survey Man filed on July 7, 1983 3:15PN in Volume 11 5 , page 1308 of Certified Survey Maps, as document ~k 385952 . THIS WARRANTY DEED IS GIVEN IN PARTIAL SATISFACTION OF A LAND C(NTRACT DATED DREDIBFR 1, 1982 AND RECORDED DECEMBER 15, 1982 IN voiLw "656", PAGE 447-448, AS DOn_P0W_. #381646 AT THE REGISTER OF DEEDS OFFICE FOR ST. CROIX COUN'T'Y, WISCONSIN. I ~ rj'Rp,I~Slr~3 $ 9 0 This 1$._W.t homestead property. (is) (is, not) Togethd? with all and singular the hereditaments and appurtenances thereunto belonging; And- _K+7.I*10Y..L,--F1s~Sn1 irA._s~ (I_CS),~ejt~__M•__HaW)sj S_,-.f/k/a,_cose t-_M.__Rr7.SP.11aSsen...--.-•--- ! warrants that the title is good, indefeasible in fee sirAple and free and clear of encumbrances except recorded protective covenants, easements and restrictions of record, if anv and will warrant and defend the same. ~I Dated this Q~ ..Q_.k)v~ day of `Tay. 19..a.a__. ------(SEAL) - . r....4-J'4_1---------------- (SEAL) lap ley E. Hawkins * ~ ~ ---------•---------------------------•---•----------------•-----•---(SEAL) 4~W - .---•-----(SEAL) Colette--M...Hawkins--f/k/a_-Colette M. Rasms, AUTHENTICATION ACKNOWLEDGMENT __a't'ure (e) _.e._.-. 0V_WI9CONSIN- t 1 Signat St. Croix so. ----County. authenticated this day of ..........................119 Personally came before me this -----774 day of Jy---------.-------_•, 19---83. the above named Kin lev F Hawkins and. Cosette__M. Hawkins f a Colette M. Rasitnass TITLE: MEMBER STATE BAR OF WISCONSIN 41.,_ (If not, ? authorized by § 706.06. Wis. Stats.) }o me known to be the person . cu the foregoing instrument and ackn~avbedg@~,'he#saml. N Z F++ ~O THIS INSTRUMENT WAS DRAFTED BY ~ i P4)beXt- -k'_• WA 1i~' - c4-- _____.Kathlean_ S._ Maaanl 522 Second Street P.O. Box 151 Notary Public _________St. _ Crol__ l J~onty Wis. H , V 'e authenticated or acknowledged. Both My Commission is permanent. (If note. state ..expiration (Signatures may b be aut are not necessary.) date: •Names of persons signing in any capacity should be typed or printed below their sisnawree. - Wisconsin Legal Blank Co. Inc. WARRANTY DBED STATE BAR OF WISCONSIN F1982 Milwaukee. Wis. FOAM No. 1