HomeMy WebLinkAbout020-1282-20-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~ /M0 SSGUE/'~
ADDRESS 13019 '7d~- 5f 4 vy-y1vu IL- PO-55
SUBDIVISION / CSM# &M IM) f iDlr~ ~ sT LOT # 10.3
SECTION 17 T Z N-R 11 W, Town of ~7 UOf o.J
ST. CROIX COUNTY, WISCON~Ie
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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Provide setback and elevation information on verse`s VV -,k~ Pe •
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Provide 2 dimensions to center of septic tal. magole,-Cov
BENCHMARK: --lop O'f TRA --lS IORM E R BOX i 7- SGv • Z070-' C'10AAJ t4_
ALTERNATE BM: /t/Ovuel Box 4, !5y-b
SEPTIC TANK / R / N
Manufacturer: 4> Z5f 5 45ZIA.)6.0(( Liquid Capacity:
Setback from: Well /V/~_ House ~Z Other
h Pump: Manufacturer 4114- Model# Size
Float seperation IV'0~_ Gallons/cycle:
Alarm Location
'{I SOIL ABSORPTION SYSTEM
Width: 7 Length Number of trenches 2-
Distance & Direction to nearest prop. line: !v-S7 /of L
Setback from: well: N House Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet
PC inlet PC bottom Pump Off
Header/Manifolds Bottom of system S~z,¢
Existing Grade '4nal grade
Z8-~3
DATE OF INSTALLATION:
PLUMBER ON JOB: HOMESITE SEPTIC PLUMBING CO.
NEIL RD., HUDSON, WIS. 54016
A
~ MASTER ULBRIGHT
LICENSE NUMBER: PLUMBER LIC. N0.3307 M.P.R.S.
~G~l ""IN. INSTALLER & DESIGNER LIC. NO. 00663
INSPECTOR-
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3 HOMESITE SEPTIC PLUMBING CO.
ONUNEIL RD., HUDSON, WIS. 54016 P
ROBEKr ULBRIGHT
WIS. MASH PLUMBER LIC. NO. 3307 M.P.R.S.
~
MINN, Rr?STALLER & DESIGNER LIC. NO. 00663
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L(,~,QAWJ,Q,1@Tp~rt 65Q,~jr,,st}y7.29.19 ' VAQ3 TS SkU S~TEVS) County:
Labor`and,4u'pan Relations INSPECTION REPORT
Safety and BuiIX6gs6ivision ST_ CROTX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
1 9346-1i
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
ER~ff~N ev.. Insp. BM Elev.: BM Description: Parcel Tax No.:
020-1282-20-000
TANK INFORMATION ELEVATION DATA A9300127
TYPE MANUFACTURER CAPA TY STATION BS HI FS ELEV.
Septic 6 Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
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 System TDH Ft
Forcemain Length Dia. Fi 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 Type O 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/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.17.29.19 LOT 103 (OVERLOOK PASS)
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 ,
r ,
SANITARY PERMIT NUMBER:
i
[:7EDILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code C UN~
STATE SANITARY PERMIT #
r
-Attach complete plans (to the county copy only) for the system, on paper not less than 3 V &S
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 n PROPERTY LOCATION ,G
f/(~W . T IPI;f 1e5 fW~AJ Cc) % 5f '/4, S 17 T 2i , N, R ~y E (or)
PR ~ €RO~ NE ~ /AI 01,LING ADDRESS LOT # /O ~ BLOCK #
33 E
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBE
II. TYPE OF BUILDING: Check one CITY : #0V NEAREST ROAD
( ) ❑ State Owned o VILLAGE : D~
❑ Public F] 1 or 2 Fam. Dwelling of bedrooms PARCEL Ax NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) e i1r
1 ❑ Apt/Condo 7c7
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
120 Service Station/Car Wash
Mobile Home Park
4 ❑ Church/School 8 ❑
Office/Facto Specify
5 ❑ Hotel/Motel 9 1:1 Office/Factory 13 ❑ Other: IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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 r 43 ❑ Vault Privy
14 ❑ System-In-Fill ~T ,Z - ~~()4~its
VI. ABSORPTION SYSTEM INFORMATION: S~ • t~r_ '_7f- G
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE r6~. SYSTEM EL✓. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./ich) G~ ELEVATIO
s/v r& s70 , Feet /00, eet
VII. TANK CAPACITY Site
In gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PI mber's Name (Print): Plumber's Sign ure: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's dress (Street, Q'e, Zip Co
&ss Z d •
IX.. COUNTY/DEPARTMENT USE ONLY v(/ T
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature )
KApproved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination d
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6388 (formerly Pib-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 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 and controls dose volume elevation differences; friction pumps ces, fiction 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)
Q M = 1 Op or- I-Lt 1 4- uv t is u I- ;,t of
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• F.l C c? p. Cc 1` Pt! Ns-F'o►Ph-t c.12. I~ o X 5.x03
aT sW DoT C4R a F2 1 = 30,
f u~tT oN r s c -r~ p = ~o o . '94cffw4 4- P, rs
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qC HOMESITE SEPTIC PLUMBING CO.
/ 7. 3 655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT UtBRIGHT
G~- WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
I NfNN. 114STALLER & DESIGNER LIC. NO. 00663
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BM
pvE,P/ooK PASS
1
Fresh Air Inlets And Observation Pipe
/fi(rff Ti~'E'v~ ` Approved Vent Cap
'
Minimum 12" Above
Final Grade
r~ .
30 4" Cast Iron
Above Pipe
~ Vent ffpo'
~ 'tt Final Grade
i
Marsh Hay Or Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution 5,,4 .z-7 zy Teo
Pipe 0 0 0 0 0 .
CP Aggregate 0 Perforated Pipe Below
• Bone oth P":pe 0 Coupling Terminating At
Bottom Of System
s srE~,
Y
,GOZU T~'E'v c h~-
Fresh Air Inlets And Observation Pipe
lf:~)•------ Approved Vent Cap
Minimum 12 Above
. ~ivis y~Q .G~drhDE
Final Grade
4" Cast Iron
3 "Above Pipe Vent Pipe'
-to Final Grade
• Marsh Hay Or Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution-.. s~ • Z~Zq Tee
Pipe 0 0 0 0 0
S STS ~ Aggregate
Beneath Pipe o Perforated Pipe Below
` Y 'y •
Coupling Terminating At
Bottom of system
Wisconsin Department Industry, SOIL AND SITE EVALUATION REPORT Page / of 3
Labor and Human Relations _
Division of5afety & Buildings in accord with ILHR 83.05, Wis. Adm. Code V
~i,Pt > j-G COUNTY 5?14'
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. # s
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
~C/ifst D/~j v~ ~ssCU GOVT. LOT -51Zl 1/4 SF 1/4,S/7T 1 j N,R /7 E (or) W
PROPERTY O9WNEIT:S LING ADDRESS BLOCK # ~D. NAME QR CSM #
130 -71 S r~/ow ,PiDbE Lc'ST
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE TOWN NEAREST ROAD
/fv~sv.~ Lvj, Syo, G (11S) 4717 vrJSo.✓ OvE~f'/oa,~
New Construction Use [ ] Residential / Number of bedrooms -3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow god Recommended design loading rate • 7 bed, gpd/ft2 - d' trench, gpd/ft2
Absorption area required (O 3 bed, ft2 S43 trench, ft2 Maximum design loading rate bed, gpd/ft2 ' 0 trench, gpd/ft2
Recommended infiltration surface elevation(s) -S-e-- P . 3 ft (as referred to site plan benchmark)
Additional design / site con ' ations Zf S c Z -F 'X 5 7 ` EA
Parent material SC S. SP 801WA44P7_ - G/,yeie/ -qe, fT Flood plain elevation, if applicable NCI-- ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE 7AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 21 S 11 U ❑ S ®U C].S 11 U ❑ S E1U ,®S ❑ U ❑ S o u
7-y- 10116^c7-eV
Td Soy t SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncbry Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tench
/ p A-yo
1
t /G-9f ~a y4 /f~ S O, C ,
Ground C S S ter,,, , 7
elev.
ft.
Depth to
limiting
eta ~i
Remarks: /fo/Pi Za✓ Gri.~S LO-y~~TEfJ~ ~lEGG7vi~~<1!~ / E ~Qdi~ph.
Boring #
/o pe 31( S/ 1,,,,,, 5 Zf , S-
L G1.1-)0 7,S yR 'J S
ti ~ S
C p-1G 7d R S 01 C, S - 7
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
7/f7- 3
Address: YP
6560'NEIL Rd., HUDSON, WIS. 54016 6-/0- 3 CSTM I
Si nature: Date: CST Number:
WE. MASTER PLUMBER LK;. NO. 3307 M.P.R.S.
mmitc NSTALLER & DESIGNER LIC. NO. 00663
ORIGINAL
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PROPERTY OWNER ~I SSG(>t~~ SOIL DESCRIPTION REPORT Page,Z of
PARCELI.DA I C! f 10 4114dw
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo rb3y Roots GPD/ft
in. Munsell Qu. Sz. Cont Cola Gr. Sz. Sh. Bed Trench
O-/O /d Z C S 2'f= A r 3
Ground 13 - /0 r/X y~ S, f 5~,E' /11" fi C s U 71' z .3
elev
ft. /D y/P Jr~ s o, C, s 71,
Depth to
limiting
factor
>/o d
Remarks: ft /yt~ip'ZO-y i S ~E ✓i'~~f//y ~a-~~A e" T~ .
Boring h# z, f, 4 . S i
13, -/S /0 ye 314 51 Ae r S 3f S • e.-
/S - 2 4 ,o ye s/ 1,-F, sb,~ f, ~s of s
Ground ~►j~ C, $ n,, ,
elev. G' 216 -y&/Ot/,e 7 5 - S
ft.
Depth to
limiting
factor
Remarks:
Boring # D-/D ~S ,3uf ~l/j0 NP
` ,e5- 0-4 00 3160 f 44 nMf, s of . 2-,3
I3 -36 /0yl 111f • Z 1,3
Ground
elev. /O y e S1 7
ft
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft
Depth to
f limiting
I factor
Remarks:
COf1 00•!/110 AC M01
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'Q 97. r!o 3 655 O'NEIILRD., HUDSON,, WIS. 54016
ROBERT UtBRIGHT
WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
MINN. INSTALLER & DESIGNER LIC. N0.00663
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/ 7• 3 655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT UtBRIGHT
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HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT
1S. MASTER PLUMBER LIC. NO. 3307 M.P.R.&
INSTALLER & DESIGNER LIC. NO. 00683
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER- W I'LLt44 at R+U.D /A~/E EssGJEe4J
ADDRESS 456 oUE2 Look P ASS FIRE NUMBER ! S
CITY/STATE NU 3>so xi W r
ZI`r Sao
PROPERTY LOCATION: S w 1/4,S E 1/4, SECTION r4 , T=N-R /Q W
TOWN OF_ H u D so &.i , St. Croix County,
SUBDIVISION ' l Il Lolu RIAREC 'SL Egs T , LOT NUMBER X03
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 a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system. .
St. Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement what owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certificatio, form, signed by the owner and by naterr .lumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping. (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning Officer within
~30 days of the three year expiration date.
SIGNED:
DATE: 17St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
HOMESITE SEP i
655 O'NEIL RD., HUDSON, WIS. 54016
ROBERT ULBRIGHT
'I S. MASTER PLUMBER LIC, NO. 3307 M.P.R.S.
" .ht.JALLER & DESIGNER LIC. NO. 00663
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 in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), thenia 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 Wi«1!jM aiuD _D IR+tJC E5SUJe1AJ
Location of, property 5w 1/4 SE 1/4, Section _ 7 T _:!E9 N-R_j?_W
II
Township Hui>s'on)
Mailing address 130e fA S f,
14UDsON w.r sgol6
Address of site 1456 muER LooK P.4s*-y
subdivision name wic.cmGO RIDG-E .IL ERsT Lot no. 103
other homes on property? yes_ X No
Previous owner of property __B ak if ~DCUCLOPM e7fU T-_
Total size of parcel _ 1.3 017" E S
Date parcel was created L11I1g1
Are all corners and lot lines identifiable? __X -Yes No
Is this property being developed for (spec house)? Yes _A-No
Volume 00 and. Page Number g7cl as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & T11E 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. 14H'7001 , 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 County Register of deeds as Document
No. 49 9C)n /
Signature of applicant Co-applicant
3 ~ i~~ 193
Date f Signature Date o Signature
DOCUMEN r NO. WARRANTY DEED THIS SPACE RESERYED FOR RECORDING DATA
498001 iSTATE BAR OF WISCONSIN FORTE 2-1982
~
YOt 1004PAGf 4 /9
F~GISTER'S ONCE
B & H Development, Inc. ST,CROVCQ.4VA
APR 2 7 1993
s:2o AM
.
and warrants to ..w_a.nsj--_Ri_ane._..._
L ._.Ess-vei.n,_:.hushand..and...wi-fe
FtFI:LLe of Oat
a., N TO
the following described real estate in St..._.Cr-O.i.x ..............County,
State of Wisconsin:.
Tax Parcel No:
I
Lot 103, Plat Of Willow Ridge East II in the Town of Hudson,
St. Croix County, Wisconsin. ~I
II
i
j
~I
This i s-- PAt homestead property.
i (is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of
record, if any.
Dated this Apr iI
.:ay of 19__9o
II
B & Deve op nt,. Inc
by.
---...(SEAL) -------------(SEAL)
-Donald---&...Hjo____-st -ad
- - •
by 1W C,
- ------------(SEAL)
- (SEAL)
William C. Harwell
' •
AUTHENTICATION ACKNOWLEDGMENT
Sigma, as(;P.9j 14 __G•__-$jQ n)stddl-..... STATE OF WISCONSIN
Harwell as.
auntie ca _ County.
j.
® I is
i, day of.---- Apr i 1-----..., 19.91 _ Personally came before me this ................day of
'E -
----•------f 19 the above named
- -
Rr~i t
'01F . - a
tM21. ~C and
$TATE BAR OF WISCONSIN
ME
`~~a'' awtbRAisett`y ?06.06. Wia. 3tata)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED 3Y
Kristina Ogland 'I
11
Notary Public
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration i~
date: 19...-----•) it
•Namen of persons sicnins in any capacity should be typed or printed below their si ---i!
matures.
WARRANTY DERD STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
FORM No. 3 - 1982 'vlilwaukee. Wisconsin
I
Fresh Air Inlets And Observation Pipe
~f i (fff 'v Approved Vent Cap
Minimum 12" Above i:v~sLc- '
9
Final Grade
4" Cast iron
30 . Above Pipe Vent Wipe'
I
{ -it Final Grade
Marsh Hay Or t,idhetic Covering
Min. 2" Agor egate
Over Pipc
Distribution s~ 27~~ Tea
Pipe 0 0 0 0 0 .
Aggregate o Pertbrated Pipe Below
Beneath Pape
0 Coupling Terminating At ,
.
Bottom Of System
S 5TE'~y ~ .
y
how Teti ~
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
7 -c
Minimum 12" Above '
Final Grade ~i!ViS y .G-~Q,tQE
Now
99x0
4" Cast Iron
3 "Above Pipe ` Vent Pipe`
'to final Grade .
• Marsh Hay Or Synthetic Covering
Mint. 2" Aggregate
Over Pipe
Distribution 7 Tee
Pipe o 0 0 0 0
10 Aggregate p Perforated Pipe Below
S yST~i~J Beneath Pipe 0 Coupling Terminating At
Bottom Of System
Z4
~~Q