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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1_ of 3
Lahr and Human Relations
Div' ion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Ed.ian REalty GOVT. LOT T1F 1/4 SE 1/4,S14 T20, N,R j or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
700 Second. St. 6 n./a Fudosn Fills
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE xWWN NEAREST ROAD
1Tudosn WI. 54016 ( ) fiudson lFolden Rd.
",New Construction Use [ XJK Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 ed, gpd/ft2 ? trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate _ 7 bed, gpd/ft2__8__trench, gpd/ft2
Recommended infiltration surface elevation(s) 97 25 ft (as referred to site plan benchmark)
Additional design / site considerations n/a
Parent material stream terrace Flood plain elevation, if applicable n/a ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 93 S ❑ U t2S ❑ U fRS ❑ U EIS ❑ U ❑ S E ❑ S -k1U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
U 1 0-12 1 r3/3 none L. 2/m/ r mfr /w 2/f .5 .6
2 12-20 10 r4 4 none sil, i f k mfr g/w 1/f .2 .3
Ground 3 20-33 7.5 r4/4 none LS. 0 s mvfr w 1/f .7 .8
elev.
100.69. 4 33-82 7.5yr4/6 none S. 0/s ml na/ n/a .7 .8
Depth to
limiting
factor
>82"
Remarks:
Boring #
1 0-19 10yr3/2 none L. 2/m/sb1r, mvfr g/w 2/f .5 .6
2 2 19-27 10yr4/4 none sil. 2/m/sbk mfr /w 1/f .5 .6
3 27-36 7.5 r4/4 none SL. 2/m/sbk mvfr w !If .5 .6
Ground
elev. 4 36-82 ~Qyr-5/4 none Co. S. 0/sg ml_ n .7 .8
100.50 ft.
r;
Depth to
limiting kc 5
factor
82" m 17
L
Remarks: sr l= r,
CST Name:-Please Print Phone: =Crfi
r~,'•
C~ary L. Steel -
Address:
jr
t- V An - NA
I T 5403 7
Signature: 5-2541te: 22Q~ er:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 0-14 1 r4/4 none SL. 2m r mvfr w 2,1f .5 .6
3
2 14-48 10yr4/6 none S. O/sg ml g/w na/ .7 .8
Ground 3 148-90 10yr5/4 none CO.S. O/sg ml n/a na/ .7 .8
elev.
100.6 ft.
Depth to
limiting
factor
>9011
Remarks:
Boring # 1 10-10 10yr3/3 none L. 2/m/gr mfr g/w 2/f .5 .6
g/w 1/f_ .2 .3
4 »II 2 10-2.4 10yr4/4 none sil. 1/f/sblt mfkr
3 124-49 7.5yr4/4 none SL. 2/m/sbk mfr g/w 1/f .5 .6
Ground
elev. 4 149-80 7.5yr5/4 noen Co. S. 0/sg ril n/a /a .7 .8
103.20.
Depth to
limiting
factor
(~1,
l./ Remarks:
Boring #
.5 .6
1 0-9 1Oyr2/3 none L. 2/m/gr mfr g/w 2/f.
y 5 2 9-15 10yr4/4 none sil. 1/f/sbk, mfr g/w 1/f .2 .3
3 15-2.9 7.5yr4/4 none LS. O/sg ml g/w n/a .7 `.8
Ground
elev. 4 129-84 10yr5/4 none CO.S. 0/s ml n/a na/ .7 .8
102.2.3 ft.
Depth to
limiting
factor
>841,
Remarks:
Boring #
i
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel
C.S.T. 2298 New Richmond, WI 54017
MPRSW-3254 NF%SE'SSltt-T29N-It19[>> (71 ) 246-6200
town of Hudson
lot #6, L v'son =Tills
eo' wl
rm r - ~1 O-C
1
1
I
V qo
1
~ool~
t
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -ee IcLrT,; ,4,1
ADDRESS 4 a--.e-
AF
SdA le/r L; yl~/
SUBDIVISION / CSMI LOT
SECTION. A4 T '17 N-R 11 W, Town of
Y~ o
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
hvrl
hl ~ ~
1
A'i
K
1-1a 4-3
r;
~5 eve ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t ~
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
ce
Manufacturer: miG~we57 Liquid Capacity:J26164, A/e T,t ~(a~{ ejL
Other
Setback from: Well House
Model# Size
Pump: Manufacturer
Float seperation Gallons/cycle:
Alarm Location
-;SOIL ABSORPTION SYSTEM
Width: Length 7S Number of trenches
Distance & Direction to nearest prop. line:
.u0 rl -Rr- (k 4 .
Setback from: well: 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:
PLUMBER ON JOB:
LICENSE NUMBER: Q yob
INSPECTOR:
3/93:jt
~c
L~ par eT Q lu, i• 29.19.100A% fiA%% SYSI' S,HOLDE n,yUff
Labor and Human Relations
Safety and Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village k Town of: State P an I o.:
/-I v.: Insp. BM Elev.: BM Description: Parcel Tax No.:
~C ?J TJ c5 f
TANK INFORMATION E E ATION DATA A9300265
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic d~ Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet io-I g
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.; D,S fig, 1
Aeration NA Dist. Pipe
Holding Bot. System '10 617
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand SiU 16 1
Model Number GPM
TDH Lift Friction System TDH Ft
mead
Forcemain Length HDi Dist. To well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION _7, .9-- DIMENSIONS
LEACHING Manu acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION -TW-e-OTIVL~D , CHAMBER Model Number:
System: Coxv-1 J Z~/ N/+ 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 E] Yes ❑ No C] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATIOK: HUDSON 14.29.19.103D,NE,SE,HUD N HILLS,HQLDEN LOT 16
Plan revision required? ❑ Yes ❑ No / , / t r
Use other side for additional information. sW%Uv
SBD-6710 (R 05/91) Date Inspector's signature Cert No. .
r
~a ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
a
i
i.
f A
SANITARY PERMIT APPLICATION
'75ILHR In accord with ILHR 83.05, Wis. Adm. Code COU TY
ATr&Zy
STATE SAfd~JR ERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than j
88% X 11 inches in 312@. ❑ Check if reo PERM to pr ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
RTY OWNER PROPERTY LOCATION
PR LOCATION
Y4S'L='/4,S ,.T N,R If' E or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
w ` /415e-6 5'g, /4-1.'//T
11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE NEAREST ROAD
❑ Public
L-N 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NU R(S)
III. BUILDING USE: (If building type is public, check all that apply) eta _ le ;?;z - Jed
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 420 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 ELEVATION
~D 97t~S Feet 00, 7,5"Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total #of Manufacturer's Prefab. Fiber- Exper.
New lExisting Gallons Tanks Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank A+__ ;W: /
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number:
,4 li.e .5-r-.4 ac GY' I e. ~
Plumber's Address (Street, City, State, Zip Code)-
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sa *tary Permit Fee (Includes Groundwater a e ssue Issuing ent lure (N Stamps
Approved El Owner Given initial & 40 Surcharge Fee) Q~
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
a T
INSTRUCTIONS T -
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:
I. 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'/z 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 ifv
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)
M
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S o ~ 7'~L
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_S~ a A re I
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SOIL AND SITE EVALUATION REPORT Page 1 01, 3.
- 1 ~txtt rnxt I hmrrnr rielntirnis
Uivisi(m of Salr+ty P. Rttilditx)s in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St- Cr~ix
rent limited to vertical and horizontal reference point (BM), direction and %of slope, scale or PARCEL I.D.N
dimrn^•ioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
I
PROPE I I Y OWNER: PROPERTY LOCATION
r'al iilfl RPxIl ty GOVT. LOT NF 1/4 SE 1/014 T29 N,R 19 a) W,
f no_rEnt Y owNFn':s MAILING ADDRESS LOT r BLOCK # SUBD. NAME OR CSM h t
7(N) Second St. _ 6 n/a Hudgen Hills i
CI I Y, S I Al E ZIP CODE PHONE NUMBER QCITY OVILLAGE WMN NEAREST ROAD
Iltictdisn 14.1. 54016 ( ) Hudson Holden Rd. '
(x l: New Construction Use ( x)x Residential / Number of bedrooms 3 Addition to existing !wilding
( ) fleplacrntenl ( ) Public or commercial describe
Code derived daily Dow 450 gpd Recommended design loading rate _ 7 bed, gpolft2J,jL _trench, gpo1R2 i .
Absorption area required 643 bed, N2 563 hench, 1112 Maximum design loading rate-Lbed, gpdM2__a_trench, MW ~
} necommonded infiltration surface elevation(s) 97-75 It (as referred to site plan benchmark)
Additional design / site considerations n/a I
patent material stream terrace Flood plain elevation, D aocable n /a R
S = Suitable for SySlem CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HDLONO TANK
U= Unsuitable fors stem us ❑ u us ❑ U f! S❑ U ]as ❑ U ❑ S IaU ❑ S Bu l
SOIL DESCRIPTION REPORT
(loliny # I Iorizort Depth Dominant Color (Mottles Texture Structure consistence GPD/ft
Boundary Roots
in. Munsell t]u. Sz. Cortt. Color Gr. Sz. Sh. Bed Trench
-1._ 0-12 10 r3/3 none L. 2/m/gr mfr w 2/f .5 .6'
2 12-20 10 r4 4 none ail. I!/f/sbk -mfr P/W 1/f -7.
Ground 3 20-33 7.5 r4/4 none LS. 0/se mvfr
elev. -
I(x).69. 4 33-82 7.5yr4/6 none S. 0/s Ml na n /a .7
Oeplh to
limiting
factor
fientarlcs:
13otitig p
f - (1-110yr3/2 none L. 2/m/sbk mvfr R/w 2/f .5 .61'
2 - 10-27 10yr4/4 none ail. 2/m/sbk mfr /w 1/f .5 1.6
3
(:untrxt 27-36 7.5yr/i/4 none SL. 2 rm sbk mvfr w 1/f 1 .5 1 '.6 1
elev. 4 36-112 10yr5/4 none Co. S. 0/sg 111111 n/a n/a .7 .8
1(N).5Oft. =
Depth to - - - -
limiting
helot
flemarks:
I Namo -f'hice Piint Phone:
Cary-L._-.Stec - -
~rlrhr•!s:
1554 '7(X)th. Ai?,.v1 Tloca Richmond, vi-51401T_
i BCST Number
5-2541"! :
t 27.9
YVNER .
SOIL DESCRIPTION REPORT page 2 of 3
i. i
(t it lorizon Depth Dominant Color Mottles Texture Structure Consistence GPD/ft
In. Munsell Qu. Sz. Cont. Color Bm nci3y ROOtq
Gr. Sz. Sh. Bed
1 0-14 10 r4 /4 none SL. _Z Lm
r mvfr w 2 f .5 ' .6
2 14-48 1()yr4/6 none S; 0/s ml
f, g/w na/ .7 ~
Ground 3 413-90 10yr5/4 none M.S. 0/s ml
elev. t n/a na/ .7
100. 6 It
I
I)v11111 to ;
limiting
fido►
I ~
Remarks: l r ,
i
Boring q
1 0-10 10yr3/3 none L. 2/m/gr Z;/w 2/f .5.i .6;
4 2. 1.0-24 10yr4/4 none
sil. 1/f/sbk mfkr g/w 1/f .2 63
3 24-49 7.5yr4//+ none SL. 2/m/shk mfr g/w 1/f .5
Ground .6
I I I
elev. /r 49-S0 7.5yr5/4 noen Co.. S. 0/sg ml n/a /a .7 .8
itt.t.:~1t.
Depth to -
inciting
ficlor
- XI I-0
Remarks:
Boring #
1 0-9 10yr2/3 none L. 2/m/gr mfr
g/w 7./f .5 .6
2 0-15 10yr4/4 none
sit. 1/f/sbl: mfr g/w 1/f
Ground .7 ;3
3 15-29 7.5yr4/4 none LS. 0/s mi
/w n/a .7 8
elev. /r 29-84 1()r5/4 none •
102.73 - It. CO. S. 0 s and n /a na .7 .8
Ikplh to -
imitiog
liclor
>1?4,.
Remarks:
Boring R
Ground -
dev.
Depth to -
limiting
ficlor ,
• l t:.m•tr~: C.
;I
STEEL'S SOIL SERVICE
L SIMV>
.T. 2298
'RSW-3254
xA1a~
M SE ,-Slh-T29N-R19W New Richmond, wit 54017.
town of MI(ison (71 ) 248-62pp'
lot #69 f`~tc'eon .fills I
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d f
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09/22/93 06!50 $612 828 5218 METZ BAKERY RSV C 001
SEP- 2-2~-9W WEV d, 39 KH I SI._EY CONSTRUk: 1 t Ury
fw
SEVTIC TANK MAINTENANCE AGREEMENT °
St, CrOfX County
r
n
rat ~ o
OWNER/BUYER
Fire Uumbor_~~ v
gp / BOX ""r"R •
ZIP
GlIMSTATS R W.
FROPERTY LOCATXON:'.' k." k, Section / To No
Town Of lttal~pl~ St. Croix County*
subdivision 1.0t number •
iMproper use and maintenance of your septic system could result it
-
ict pzeu~ature failure to handle wastes. ' prover
lists of every ~aintenante tan
pumping outn~the sept C tank ed' -a' tic tank un er. What youaPu*. into r-
if needed, by a lice
the system can a ecz a unct ono t e-septin tar,c as a t.xeaz
Mont stage in the waste disposal systeM.
Sd, Croix Countyy residents•WX be /eligible to recieve a grant for
a ; maximum of b07. of the cost.of Jul 1, of St~aCroix Co~+nty•
wh c was in operation pLiar to
secepted this program in August of 1990.witx system properly that
owners of all off, 's sy t!m agree to keep thei intintained.
The ro erty owner agrees to, submit to St. Croix County Zoning a
Cert~tication fQSm, °gnethlumberrox~a ~iconsedep~p~bveri•
journeyman plumber, restricted P
k7ins that (1) the on-site wastewater disposal system is i~fproper
operating condition and lesrrthat$tp}.%3ifulLnofAbudge Bred sow.
salary), the septic tank
Certification form will be sent approximately 30 days prior to
three year,expiratibn. }
IIWE the undersigned have read the above requirements and agree
to m ►
' to aS~ntsin the private sem&ge disposal system in accordance Wisc ee standards act ources. Cer4fication fothe rm mustobeicompleted ~
mnt of of Natural Ress
end returned to the St. CrxdateCounty Zoning Office within 0 days
of the three year expiration
SIGNSD '
DATE
It. Croix County Zoning Office
911 4th St.
.Hudson, WI $4016
386-4680
Sign, date and return to the above address.
APPLICATION FOR EASITARY PERMIT
99'C-100
This appliaatien form is to be completed in full and signed by the ownes(s)~ of
the property being developed. Any inadequacies vial only rpsulh in delays of
the permit issuance. Should this development be intended for regale by
owner/cont;actor,(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, I
r r• ~ r r~ r .r
IMrrrrrr o--■■^.,■,rrrr ra-r~rrrr rrf~r
•~~r~r~~rrri
Owner of property ~ar~ld~d. _rl J1
Location of property r l/~ 1/4, Section Z,429ul-R-/-q-w
Township d6on
IIr~~■I /1~1.~.■lrilr,~1~ I ilk`■~Y.~il■~. i1~lYl~l~r~ 1I~r-
'Mailing address _ A6 JO,e 'y ~n .
~ud so n, Ltl) J Sa/d / ~h
II~iYrhY~ I~rHr.~llrr.+~~. r ■ ■ ■1 ■ IA~Y■~~rra/rll ..y
Address of site 4v 14 1&n
Subdivision name 1~ud or1 14i llg
I llr~gl~ll r I I r
,Lot number
Previous owner of property _ . Srud& j'1;/~.S~r~
1 ~Iril IC
Total six* of parcel s , d OCre.
.L■.rl
,Data parcel was created lg7a
Are All Corners and lot lines identifiable?
Is this property being developed for resale (spec house)?....,11_Xes - o
volume / and page Number 3g as recorded with the Registeg of needs.
~~rr~~r•■■~rrri..rr.~~l..■■rr.~rrr..Ir...■~r~rr.---1■r.-ir~lrww~.....wr~r rel.. •y~~~~r~
INCLUDB WITH THIS APKICATION THS FOLLOWING:
A WARRANTY DEED which Includes a DGCW=? NUMgF.A, VOLtM AND PAQS itMZR, 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 descrlption references to a Certified Survey Map, the Certified Survey
'Map shall also be required.
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PROPERTY OWNER CRATIRICATIOK
IiWe) Certify that all statements on this farm ato true to the best of my (ogr)
knowledge; that I (we) as (are) the owner(s) of the property described in
this infoxmatian fozm, by vittae of a warranty abed recorded in the Office of
the County Register of Deeds as Document No.
Presently own the psoposed site for the sewage disposal systen►■(otdlt well have
ebtained an easement, to gun with the above described pxopesty, for the
construction of said system, and the same has been duly ueaorded in the office
oft County Register of Deeds, as Document No, oa
1•
AWY(n) Win
8 gnaCure +i! Owner ~
Signature of Co-pMist It 401 01
i Q
;pate of Signature Date of Slgtlatdre
Z►Z.r.~3!
ci hi ~ Z _L ~ C"1 c! ~ M CI ~ r') S I 1~+ ?I 9 t+l a CL 3 M
DOCUMENT NO. WARRANTY DEED THIS S►ACL RCsCRVtD open "CCCIPOING "T"'
STATE BAR OF WISCONSIN FORM 2-1982
502495 VIL 1022PAGE 384 REGISTER'S 0
FHCE
BRUCE C. NILSSEN 1 ST CROIX CO., Wls_
Rae'd WReaord
5. _
- JUL IS 1993
a A
conveys and warrants to . LENDA K..MARTIN, at 8:30
M
- -
RCTl1RN TO
the following described real rotate in ....._.8t..._.Cr.Qi~e ...................County,
State of Wisconsin:
Tax Parcel No:
Part of NE1/4 of SF1/4 of Section 14-29-19 described as follows:
Commencing at E1/4 corner of said Section 14; thence S(r 441E on
E line of said SE1/4 1162.88 feet; thence S68'3914011W 455.51 feet
to Point of Beginning; thence S88049118"W on S line of N1/2 of
said SE1/4 414.35 feet, thence N1.06120"W 630.28 feet; thence
N88.55140"E on Sly line of proposed Town Road 171.84 feet; thence
S700331E on Sally line of said proposed Town Road 132.95 feet; thence
S12.331E 594.8 feet to Point of Beginning.
f
'MS b
5 f
is not
Thuk" homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way
of record, if any.
Dated this . G day of ................July 19-..93
P
t4A F._'.. (SEAL)
(SEAL)
Bruce C. Nilssen
.
i
- (SEAL) .................................................(SEAL) '
•
• ` s
i
AUTHENTICATION ACKNOWLEDGMENT
gi~iatase(s) STATE OF WISCONSIN
- - - - -
St. Croix ss.
- .................•-°---.County.
3 authenticated this day of 19 Jul ;ersonally came before met f...... day of
19........ the above named
Bruce--C-:
33
Y TITLE: MEMBER STATE BAR OF WISCONSIN c~
eJQy--
(If not- i6a--- .
authorized by 1 700.06, Wis. Stats.) to me known to be the pe' 4I. ee uteri the
e the same.
g
ng inst ent and ac %wl
THIS INSTRUMENT WAS DRAFTED BV
+
Fristina Ogland
'f Attorney at--raw ,ill yce Joy rs r
W
_ Notary Public Pt. ...Croix
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: -----July 12
;S tNams of persons signing in any capacity should be typed or printed below their signatures _ i •i
!I i
WARAAN'r7 DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. 2- ly32 Milwaukee, Wisconsin •~+t'y J "
A, .',e ,k x° .:6 y •y in.-'lyl• Y i , . a!i .4:t.t. r y. .,r. «,i..r, , t ,3' c +
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