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HomeMy WebLinkAbout002-1056-90-000 0 3 00 O 64 I ti C 0.+ 0 `c ~ N N I C" N L C ~ t4 a I o~i ~ o I .o a v p Con v > N w a °c Q c 0 c c c a~ LL m LL c (D O U > a~ o ' 3 CL n€ a =EQ 0 ~ y W z a m 04 rn N H W O Z a V ~ ~ N u~ Z ~ c to ~ ~ N I N 3 1~ H O 0 0 • L N m N v tr- O N iz z Zzpo r N N co C d C) E O LO e lE (D C - a m N ) d D o ~;ooa 0000 a •N aaa a I O j N co J U O m Z LO 0) "0 C) w c m aa) °o C) Q N N U r _ 7 N d co coo 'a m p 61 N LO (D N '6 QI Z w t6 L d ~ 7 U) ~i o 7 H E o O O m C N U O N co co N U ° LO o f = o N c a rn o o l Ci co 75 M c d C LO c li j o C ° 3 v U) - ` L v of o L a) y a~ H d C N ICI N 'O p 7 C No cn ca o u1 E O t4 U • O o N m (A C) Z N Z r2 fA (o d 7 e a • c~ a d .2 v r`~i E ` c c J Lv9R T.IgN: AAQIW > y23.29.16. W ATE SEWAGE SYSTEM isconsin a art e n r County: Labor and Human Relations INSPECTION REPORT Safety a yd Buildings Division (ATTACH TO PERMIT) sanitary mit ,GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village I_LTown of: State PI TROBUSH HE X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: W2 Ie56 90-000 TANK INFORMATION ELEVATION DATA A9300348 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent irIto ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Ar 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 TDH Lift Friction Syesatem TDH Ft oss Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Model 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: BALDWIN 23.29.16.350B Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No SANITARY PERMIT APPLICATION 7DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY r p./ X STATES IT R ERM -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ if I/ 8% x 11 inches in size. if vi Ion us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. .5 C?,3 7_ J PROPERTY OWNER ~c PROPERTY LOCATION /mar -~7~ o GAS SGa'/a SZE 4, S 2,3 T29, N, R (or) W / PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ) ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Z,e II. TYPE OF BUILDING: (Check one) CITY / NEAREST ROAD ❑ State Owned ❑ VILLAGE ~/a ~C~7 L tJ c f ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) U 6D ~b S Qb O()C) 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 40 Church/School 80 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.E1 New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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) ELEVATION _~~510 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank Tanks 14;:t- _r1151: Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: _1 ~ oa_ f. - Plumber's Address (Street, City, State, Zip Code): / IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issuing,% nature ( tamp Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by 1:he 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'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) 0 ~ R Od ~ • ° g `8 ~ 01 f ~ i ' 9 0 N Q T q` N o G ~ . Vy'.d4.Ad N Ako ao "'age Of • HOLDING TANK CROSS SECTION " }----WEATHERPROOF JUNCTION' BOX ON'8POL E OR IN/ON DEVICE AND 77t BUILDING SERVED . WARNING LABELAT: COVER.: 2 HIGH WATER WARNING DS/lCE k'-MANHOLE 12" MINIMUM 4 MINIMUM. MIN. 2" CAST IRON VENT WITH MIN.24" ID GRADE RETURN BEND OR 4" Cl WITH APPROVED VENT CAP. 25' MIN. FROM DOOR, WINDOW OR FRESH 18" MINIMUM AIR INLET LEAD JOINT AIRTIGHT SEAL .HIGH :WATER 1 ALARM SWITCH - BLIND PVC OR CI PLUG DEPARTMENT APPROVED 'JOINT, WATERTIGHT JOINTS ARE INDICATED ..BY UNLABELED ARROWS *PROVIDE APPROVED PIPE FROM INLET TO 3' BEYOND EDGE OF-UNDISTURBED.SOIL SPECIFICATIONS SYSTO TANK MANUFACf". TANK CAPACITY: ` 'GDS cl i'l G.Al LONS . 0 C~ 2 b ~~y3 L rRo LIBOR i NUAAN kTiOFS DEPT. I1F iNOUSTRY, OI ON OF S ETY AND BUi n PLUMBER SEE CORRE'~ 'E SIGNATURE: LICENSE NUMBER DATE :10 -/8 - 93 yeary, in accordanrilh"lLHR 93:fl; Wis. Adm Code x . ♦ (t/MM1.f/lq 4~ `}/{r I~+i1++.....+• : ~..v VW({(( . ~w 4-1 J C s-~.oy H r a e srle an on papor rat Isaathan 8 t/2 x 91 ir~che . Plan nwst3rlClude; but ` i- 71 point r8tut); dpi scale or . PARCELLD 8 . Ts -fir= .s~tsotfiarietilo~erficat andTionzo,telere L d~mens+onedr horih arrow, and locafari and d~starce to nearea~ ~:.Y..~' t,~, y.~ _ - g w _ _ REYIEWEO BY ~DA7F ~ ; , ~'~1pP11CANTi<NFONMA7tON-PLEASE PRINT All INFO`RPR~ERTYQNNEFt i PROPERTYLOCATION ~`"t ro c is 6(~1f OT ~L(J 114:4114,5 T Z q N.H /lo [ (or) W Ala FROPERIYONNER'S LWUNG AODR S LOT R BLOCK 1 SU80. NAME OPWSM X CITY. STATE/ ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD l c~ooow ' % S-%0Z (7151 (1 New Construction UseA Residential./ Number of bedrooms Replacement (j Public or commercial describe Code derived daily flow J`~© gpd RecDmmended design bailing rate bed, 9Pd ? /✓X trench. gpoW Absorption area required _AIA bed, (t21,14 trench,,, (t22 Ma*ntn design loading rate bed. gpd/g&,4 trench, WW Recommended infiltration surface elevation(s) / V 7 (t (as referred to site plan benchmark) Additional design / site considerations Parent matedai Flood pWn elevation. N applicable Sri ft S = Sellable fOr System CONVENTIONAL MOUND PRESSURE AT~IADE SYSTEM N FILL HUM TAW v =!U sn=e to tem ❑ S jau ❑ s 0U_1 s u ❑ s'0u. ❑ s nu s❑ u SOIL DESCRIPTION REPOT;T Depth Dominant Color Mottles Structure GPO/ft Boring # fHondzon Texture Consistence Baxxiary Roots in. Munseil Qu. Sz Corti, Color Gr. Sz. Sh. Bed Tierxt / L t^ z 2.5 S. "c 2., A -0 2,-F Z =z3' /oY'R 5 L 2 "J R~ C Z / Z Ground elev. i~-ZZIL Depth to limiting factor t Remark`s: ' 6orfng -/a yf A111 sic ,Z mSt~1~ InVir. a ; Z- A0 5,44 In 7- Ground elev. I /40•51tL Oep(h lo - latl *v factor - I Remarks: CST Name:-Please Print Phone: 1War.ss. f~Zd signature, Date: CST Number: Boring Horizo Depth Dominant Color „Mot>jes ; Structure t PD/ft - in: Munseh " . y Zhr:Sz.Cont.Color Texture- :'Gr. Sz. Consistence Roots 77 YR SA G"naiad t -tj 4? 1► , fay 1. i3 ,e+t .-r` _ ~.i•,. i _ etev. - Depth to uniting facto - Remark=s: Boring 13 Ground _ elev. Depth to finifing factor _ Remarks: Boring Ground elev. It Depth to 6ni6ng factor Remarks: Boring 9 A"~)?Yx j{MR Ground elev. K Depth to irrNting (actor Remarks: ~L 3 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations November 8, 1993 2226 Rose Street La Crosse WI 54603 I BOLDTS PLUMBING 820 MAIN ST BALDWIN WI 54002 I RE: PLAN S93-41238 FEE RECEIVED: 60.00 STROBUSH, HELMUTH SW,SE,23,29,16W TOWN OF BALDWIN COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not: been reviewed for the code requirements set forth in chapter I1,HR 82 or in chapters ILHR 50-64, G~`isconsin Administrative Code. This plan submittal approval. will expire two years from the approval date, or, if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can he made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, Gerard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 Slit) -oa23(N. 111/91) HOLDING TANK SERVICING CONTRACT Coniract Date 93 -,)f This contract is made between the - Holding Tank Owner( Name(s) and Pumper's Name /V ~0'5 ~ L,IG~~s$ 5~~ ~fehGre.~ i We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) 07 rim T~ / ~l6 CIcf06 G s~ C c OLD! go t o~ jS r C. j, o~ s bo se 7 -5 ! ?o ~t i~ ~7.5- PU S 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement reqtlhired in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of rov 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner( ) Name( ) (Print) Own is Siclnat r (s) Subscribed and sworn to before me on this date. . ~D dS -'7 uhf Pumpe cs Name (Print) ~ Pumper 's S' nature, Y^~~ Notary Public y commission expir s: NAIVE 8, f.ERT G/ 'e S -e~ J5 V ~~_c~ Noary ~'0~ Pub1z Pumper's Registration Number n RA 7 3-3 SBD-7574 N. 11/85 ( ) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. ( r 5 08988 DocumenjVo.. This space reserved for recording data YA, HOLDING TANK AGREEMENT A reeme e I t This agreement is made between the i2ec'd for Reoc~Ri j ounty or Local Governmental Unit Hol in auk(s) wnsr(s) 7 o~ a ~cQ w i 11Iy1ui uS NOV 15 1993 _ro wh s ~ 1~ a Called Munlci all below r 4:30 P • We acknowledge that application is being made for the installation of (a) holding ~'-n--~l` tank(s) on the following property, (Provide legal land description:) 6 ~~•3rd 9/ 66 C~c.hQs l PG L X 31, 1? 6 9512 \3 TJ9 N R4 6V PT J10 5L ..Cop, '3410-h- ~J S 1-: cob _ Return To or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. As an inducement to the County of s CO+`- o y - to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner falls to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered, The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within, thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83,18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. - 5. This agreement will remain In effect only until the local governmental unit responsible for the regulation of private sewage systems-certifies that .the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. + 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. .4%(s) Na (s) i Own s) Sig re p r0 Subscribed and sworn to before me on this date: jo as _C7 Gc~ ca-cl Municipal Official Name (Print) Municipal Official Signature Notary Public &4n f- 7'h K14 n c*°rr,•~a~, ~ My commission expires: Neg. Wg.LERT plft Municipal Official Title (Print) &ab 0 Wft0ns ~ le,-,k, To wx n 144;)1 SBD-6123 (R. 10/85) This Instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. 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 /e1i2~2 Z~/ Location of property /V 1/4 1/4, Section T L N-R Z V • r Township Mailing address Address of site Subdivision name A Lot number /t/X Previous owner 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 resale (spec house)? Yes No Volume = 1 and Page Number zlZ~ Z-`as recorded with the Register of Deeds. i--------------------------------------------------------------------- i 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 am (we) (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) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorlded in the Office of the Count R ter of Dee , as Do ument No. Signature of Owner Signature of Co-Owner (If Applicable) - X73 'Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN-FORM 3 e QUIT CLAIM DEED 326698 BOOK 522 PA;E 4441 THIS SPACE RESERVED FOR RECORDING DATA BY THIS DEED, Gerald Strobush, a single man, REGISTERS OFFICE ST. CROIX CO., WIS. Grantor Recd for Record thls_3Ah quit-claims to Helmuth Strobush 4 ri1 day af--=ai--------A.D.1975 at__ 1:00 - M. Grantee-, for a valuable consideration Regis/ei o} Deed' the following described real estate in St. CCO1X County, State of Wisconsin: RE URN TO Commencing 440 feet West of the Southeast corner of Harold D. Olson the West Half of Southeast Quarter (W' of SEu) of Section Twenty-three (23), Township Twenty-nine (29) North, of Range Sixteen (16) West, St. (YIoix County, Tax Key • Wisconsin; thence North 170 feet; thence East 100 feet; This isnOt homestead property. thence South 170 feet; thence West 100 feet to place of begnning. F 1P EXEMPT Baldwin Wisconsin this 18th day of April Executed at SIGNED AND SEALED IN PRESENCE OF (SEAL) Gerald Strobush (SEAL)' (SEAL) (SEAL) signatures of authenticated this day of 19-. Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 ♦is. STATE OF WISCONSIN St. Croix County. as. 18th April ~ 19 75~ Personally came before me, this day of the above names Gerald Strobush, a single man to me known to be the person- who executed the foregoing instrument and acknowledged the same. t T-' A-( 1l. F EC ~ t r 1~ LC / i This instrument was drafted by Harold D. Olson Harold D. Olson, Atty. _ oho Notary Public St. Croix County. Wis. ^ My Commission (Expires) (Is) Rer an nt The use of witnesses is optional. ames of persons signing in any capacity shoo bet A r5nt,3d'belp~r their signatures. ` g.Ap-C p*jmTI" Co., SAY CLAIMS. Wia QUIT CLADA DEED-STATE BAR OF WISCONSIN, FORM NO. 3 yw pli