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HomeMy WebLinkAbout020-1293-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S-t o-7 /y7 l ~ log ~ f 1 ADDRESS D X" r a, SUBDIVISION / CSM# LOT # Z S SECTION. -7 T~N-R Town of i St ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM F A 1~.Kt,=eP ActfRr.'~'~ SIB a o + ~Q E ^ Vo, 1~go Ga y~ b lv aryr$i W ~ `Dwa, y INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: T,p a ro/NG4// /yd pp ALTERNATE BM:- 7 y SEP IC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W~~s~✓ Liquid Capacity: ~o©O Setback from: Well 62- House Z Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: " Alarm Location .SOIL ABSORPTION SYSTEM I i Width: Length S' S Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House yt- Other ELEVATIONS Building Sewer ST Inlet; ,S• Z C) ST outlet e.; PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~LC~cyJ LICENSE NUMBER:',~'e~ INSPECTOR: 3/93:jt L~~'~'s~~part~~dr`f~ustry27.29.19 r -PR1V~4~~~EW/4~iE SYSTEM HILLS, CIT-L ounty: HRD- Labor and Human Relations INSPECTION REPORT Safety and Buildings Division tENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 19 952 Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: 1HUDSON v.: Insp. BM Elev.: BM Description: r arcel Tax No.: 160, 66 , ~ c nQ I" Cd TANK INFORMATION ELEVATION DATA A9300358 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic -Pc4F! ~ 44d Benchmark Id, 7S' Dosi l ( /Y(, M d -R, V ~ Aeration Bldg. Sewer Holding St/)(t Inlet T TBACK INFORMATION St/ W Outlet S6 ds,/1 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic '>6_bi NA Dt Bottom Dosing NA HeaderT $ Rd L~, ~ II Aeration Dist. Pipe Holdi Bot. System 9 a(o' U/ i PUMP/ SIPHON INFORMATION Final Grade 66 p' Manufa Demand 7b~ SST Model Number GPM TDH Lift Friction m DH F`? - L Forcemain engt Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length No. Of Trenches PIT 0. Of Pits Inside Dia. Liquid Depth DIMENSION Z`~ ~S DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI Manufactur SETBACK INFORMATION Type O tia C. r/ i Model u System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing irTnT e Length Dia. Length 5 Z Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S ms Only Depth Over Depth Over „ xx Depth Of xx Seeded / Sodded g xx Mulched Bed /~erRtfCenter - qO Bed /zcekEdes - qQ Topsoil ❑ Yes E] No E] Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON. 27.29.19,SW,NE,LOT 25,HUMBIRD HILLS, HILL FARM RD. Plan revision required? ❑ Yes [~Pd~ 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 DILHR SANITARY PERMIT APPLICATION 'f _DI In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~ "rut STATE SANITARY PER IT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ 8% x 11 inches in size. cheacff revisi evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION 5WY4 E %,S L7 TZ N,R 19 E(or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBDIVISION NAME O M NUMBER CITUS~TE Z O~ PH30~NUMBER II. TYPE OF BUILDING: (Check one) CITY A NEAREST ROAD ❑ State Owned ❑ VILLAGE : d~Sfl N Wi// FQ✓ ❑ Public ~Z1 or 2 Fam. Dwelling-# of bedroomss PAR LT N/U"M ER III. BUILDING USE: (If building type is public, check all that apply) Z _ ! _ L 0 1 El 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. 1u1 New 2. ❑ Replacement 3-E] Replacement of 4. ❑ Reconnection of 5111 Repair of an yN 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 7s0 / Z $fo 13 z O o--7 Feet DSoo Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank S(~S t,Ja.~ 3 ✓ F] F] F-1 El F1 F] 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. Plumber's Name (Print): Plumber's Signature: (No Ptpmps) MP/MPRSW No.- Business Phone Number: + DOCK ea 1,I deh G.s ~J 3'L L'!'7 3Z Plumb 's Address (Street, City, State, Zip Code): IX. C TY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A nt S Mature ( Stam Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination *Ilk 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. Asaq;itgry permit is valid for two (2) years. 2. ;VouI r ~`sahitary 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 pumpedby a"licen§ed 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- watey contamination investigations and establishment of standards. SBD-6398 (R.11/88) 'o ~;t -0 Tri t A P A -71 1. c •6 10 o ll~ O ~F co Jmx L6 -b y ~ol % a o P ~ ~ G m ~ ~ I p I ~ i I,o N log O I ' Z I _ < i rri I ! I L m I U 0 I y :7 I ,'o d , O I ~Q z ' A z V► I N C d , -tl m Tl I - i.J I m Z 'j'y j~ Q° X 0 ,jay (`Ah\v\ -C1 cO D O Ct) t6al --I 7C~~ F V ^ m v A z m -v ja cn m i . I ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than f FFf,5- Z 8% x 11 inches in size. ❑ Check if revision to previous applicaticin -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION S L 54/'/a 41 E%,S Z TLS/,N,R E(o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, SZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER O -We- z ~ LGs 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE OF: ❑ Public P 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL AX NUMBER( b) III. BUILDING USE: (If building type is public, check all that apply) Q Z 4 - l L 9 3 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. ~0 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 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 7 SD (L(S 7Z0 0,7 /Ol. 910 Feet 1041. Oo"Feet VII. TANK CAPACITY Site in al Ions Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 149 040 `,i rM El 1-1 1 Lift Pump Tank/Si hon Chamber F] El D I OR T [E =11 F 1 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.:77 Business Phone Number: ~ /L- ZY7 3233 Plumber' Address (Street, City, State, Zip Code): 0I 7- -L- N 11,W R.i k MNk IX. OUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ' ry Permit Fee (Includes Groundwater Date Issued issuing gent big N Sta Approved ❑ Owner Given Initial ~Surcharge Fee) A vers Det rmin tion v .w 6~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (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 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 through4hese surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards.- SBD-6398 (8.11/88) AD ZsspO 1 FARM ~A l07 /'H.~ a o s o Til I _ 3 rya s J ~ e W Q ~ s kA 4 N ~ ce\ `.a ~1 eft _ ° z nsv.W \ J 4 4 J 6 11 O v i- ~6 I v L N r $ 1-- at 1) Z 1 cc ~ N Z, w QO J ~ ! . ryr o~ Vl v & 4 ~N ~ N s y l Q i Q LU lot ~(L 110 W LU N ,4r- a J Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page j of 3 Labor apd Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 'Attach complete site plan on paper not less than 81/2 x 11 inches in size,. Plan must include, but f CrQO h PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and /o of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWI~J~R: PROPERTY LOCATION Q SAM f (V~ GOVT. LOT SW 114/V&: 1/4,S-2 -71 T 2 N,R I i E (or) W PROPERTY OWN ':S MAILING ADDRESS Oft BLOCK # SUBD.,NP~ QR,CS r jILLS T STgTEE w ( I E PHONE NUMBER []CITY ❑V-IPGE OWN NBREST ROAD New Construction Use Residential / Number of bedrooms [ j Addition to existing building j Replacement [ ] Public or commercial describe Code derived daily flow (S gpd Recommended design loading rate C? bed, gpolft2 trench, gpolft2 Absorption area required L~q< bed, 11:2 trench, 11:2 Maximum design loading rate L •7 bed, gpd/ft2 O , trench, gpo1ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system C NVENTIONAL MOUND I -GROUND PRESSURE AT-GRADE SYSTEM IN ALL HOLDING T U= Unsuitable fors stem ( S❑ U ID'S ❑ U INS OU OS ❑ U MS ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rends - .S 166 1? 3 L I c, m 'r C 0-4(3:5 4,c. I, SDK mfr 0:2- 3 Ground 4 5 Ih r Al I a-7 0% elev. Depth to limiting ? tort Remarks: Boring # ' A lla°t~ 2 / cry C Z& 16ye, Ground elev. /-117 f- - S r ISki It. Depth to limiting factor Remarks: CST Name:-Please Print Q -vd y JQ;O.(Nso N Phone: O a Address: U W t Signature: Date: / ( r T,7 CST Number: ~4 PROPERTYOWNjjER JAM MILL(L2 SOIL DESCRIPTION REPORT Page 2- of PARCELIM4 LO', 2S uw ~►R~ U-S Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rer& 8° P"3/1 4 i A s6 K r r- Z 0777 Ground 9'7 i S r~ r / A Jev /-/rS -8'14/4 s , r 1 7 Depth to limiting Remarks: Boring # 3S . 3 5t... Sbk r,~y G 2 Ground 4b 1(1 M, 9 r r ©•7 D elev. S-12 0 /61- 4 i 5 d r r7~ ) 7 `d (j l~tt. Depth to limiting factor Remarks: Boring # Ground 4 L* ©Op 1 > - 6 ? elev 100 7~ ft. Depth to limiting factor > 9Z Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) C PAC, 3 I, I M I, I I II III I y ~.I m II A /(300 II ~ c ~~I I II N ~ 'i ~IIC ' ' 4 d ~ Q 11h 1 7 4 I' \ J 40 4 41 44 3 ,z id do (A UA y3 w n1 m .I---- r-------- O I C% I S~ I I I ~iV G7 ~p D I 0 h I I I C O I I ~ rri co z I I I N r ~U I I I -o I T rbn t I I m I O w I I I w I I I I ~ j ~ I I I N j r I I I D I I I j O I 1 I I I I ' n I ~ I I I m I I cn I rrl I I ~ I z° I i i -gym i ~ ~o o I -n I I I m I I I Z W N I m I 0 I O Z _ T m R° >t O -P. i °c q 90 O 'i to O F o =i x < v 0 0 m -o z b -o m m X O= 'D c m P A. z ~ m .p O ~h LA S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER~2/ ADDRESS FIRE NUMBER 7 kFl CITY/STATE A Zf "0'- PROPERTY ~/L/LOCATION : -J ~1/4 ,~1/4 , SECTION, T_ s~ N- 1 TOWN OFD _1d/":A 11 St. Croix County, SUBDIVISIONllriv,01 LOT NUMBER-2-f-- . 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 that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix zoning a certification 'form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1). the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/tqe, 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: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 STC-100 This application form is to be completed in full and signed b ~the owner(s) of the property being developed. Any inadequacies will only result ~n delays of the parmit 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 Location of property=l/4 N C1/4, Section Township ~vra~-SDVi Mailing address _ ,6 t A'm't L.... Lf i rr W~ Q • Address of site 7~-F( 1.,11LL r-X e A 1 R42.41- Subdivision name b~~~ Lot no. _ other homes on property? yes~_No Previous owner of property Total size of parcel Date parcel .was created !'Are all corners and lot lines identifiable? X Yes No is this property being developed for (spec house)? X Yes No Volume-/OZ/ and. Page Number Z Vz- 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. so z Z oS , 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 Sozzo' 9 signature of applicant co-applicant ff ~ CD Date of Signature Date of Signature. j DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19821 THIS •►ACI RESERVED FOR RECOROINO D^TA I WARRANTY DEED ` 502209 YOL -021.etz REGISTER`S C ST. cl ;1o;x co. 4%,i ~ This Deed, made between Humbird Land Corporation, F2 c'J foI Record ' A Minnesota Cororation authorized to do business in-.wisc - JUL 12 1993 , Grantor, 8t 4:2U P. N1 j and.... a>4_.~..Miller 7 n•~ V i RRe Ister of Deeds B Grantee, • • Witnesseth, That the said Grantor, for a valuable consideration...... - F~ . conveys to Grantee the following described real estate in ...S.a.e..- ro lx ReT~Rrr /y- County, State of Wisconsin: i y ~o-~-~ d.GetQJ~ ~ L~ Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 in the Plat of Humbird Hills, Town of Hudson as filed Tax Parcel No: and recorded in the office of the Register of Deeds for St. Croix County on April 7, 1993 in Vol. 5 of Plats, Page 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25 in the Plat of Humbird Hills 1st Addition as filed and recorded in the Office of the register of Deeds for St. Croix County on ~tl April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. R~~j5~C0" This Jln_-not......... homestead property. (IaJ (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...Huv UrdAot.xd..Co1pQration warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. Dated this 12th day of .--July.-----------•--.......--------•--------.....•-••-•-•....., 19..93... " Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin ........................................................(SEAL) BY........................... (SEAL) Austin J. Baillon President • / ...-•--•---•-•--------------------------------•••-•••--••--•--------.(SEAL) (SEAL) • AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSI14 / County. authenticated this day of 19 Personally came before me thia . / ..I ay of . Ad July 19-.49.. the abblvi mWied r ' '..1-It • q Baill n President of o TITLE: MEMBER STATE BAR OF WISCONSIN ' ...HuIIlbi,rd--1<and..~orporatiog_;!.:'--~.)1.~.~_ 'i.~ (If not, -n P authorized by § 706.06, Wis. Stats.) I . M f to me known to be the person O %V Uted t ' foregoing ' strument and acknowledg-A4e -1eCQ r; O t THIS INSTRUMENT WAS DRAFTED By IL J 14 N 0. ~ I t V X D•Q k • •'•,I Kueppersr..Hackel..&_.Kueppera . - 1350..Capital.-Centr-er._St.__-PauI .MR.5.5102- Notary rDro Sic ....5_T.....C .~-/.~.._.....County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date- 19--------•) { { •Names of persons signing in any capacity should be typed or printed below their Signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leaal Blank Co. Inc. .1 FORM No. 1-1582 Milwaukee, Wis. M