HomeMy WebLinkAbout026-1115-70-000
STC - 104
Cg" AS BUILT SANITARY SYSTEM REPORT
OWNER W%tICKZ Rlue~.~a,.w~ v~M`~V„re
ADDRESS 1 5 c S
A~w
SUBDIVISION / CSM# I~CJ~Ll~/C i%/1°i1~ ~~2~3O~c~•S LOT # 7
~T 30 N-RW, Town of_( )'Y) 0
Y1
SECTION
ST. CROIX COUNTY, WISCONSIN
dik, AL h) n 'e
PLAN W
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
/.Sd
O
p
A ~.J 'tit
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t
a
BENCHMARK : ~e r /JS I /as /
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: Ze;) Jr~
Setback from: Well +/dD House Other
Pump: Manufacturer Model# Size
Float seperation WIA Gallons/cycle:
Alarm Location )u F
SOIL ABSORPTION SYSTEM
Width: Length 7a Number of trenches dAj_
Distance & Direction to nearest prop. line: 546 ►U604,
Setback from: well: +/J 5 , House 67 Other
ELEVATIONS
Building Sewer ST Inlet ; 97, 4 ST outlet 9 7,#?
PC inlet PC bottom /4 Pump Off
Header/Manifold 9'•(05 Bottom of system ~S- 7S
Existing Grade Final grade 01 9,3
DATE OF INSTALLATION: PLUMBER ON JOB: ~~~Qc,w••'I Q7n►-~-.~
LICENSE NUMBER:
INSPECTOR:
3/93:jt
IAA i ~ art 01.30.18 p~yJA1'fSNFAGE 5Y5~PMC0. RD. unty:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit
Permit Hol'der's Name: ❑ City ❑ Village EjTown of: State Plan D o.:
lev.: Insp. BM Elev.: BM escnption: A/~ Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300058 -
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark -SDosin - 4 Zjj OS, as
Aeration Bldg. Sewer
Holding St/ Ht Inlet S ~lp.a
TANK SETBACK INFORMATION St/ Ht Outlet 97-38
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic j~ NA Dt Bottom Q
Dosin NA Header-A~ 3 -00, 2
i
Aeration NA Dist. Pipe $ 6 1
Holding Bot. System r 6-75
PUMP / SIPHON INFORMATION Final Grade 5!d3~ D 37
P d s.t, 9~ 9s"
Ma urer Demand
G f'~
Model Number GPM
TDH Lift Friction System DH Ft
oss Forcemain Length HDUi FFii Dist-ToWell~ F-
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIME I N
LEACHIN Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type O vii OR UN T R Model Number:
System:
DISTRIBUTION SYSTEM
Header A44a"4&I4 Distribution Pipe(s) x Hole size x Hole Spacing Vent To Air Intake
r / ri r-
Length ~ Dia- Length ~ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over „ Depth Over n xx Depth Of xx Se ed
Bed / Trench Center Bed /Trench Edges Topsoil ❑ Yes 0 No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 01.30.18.672,SE,NW, LOTS 17, COO. RD. GG
_ sr
>rFe f
f d~ G 1[J//f
Plan revision required? ❑ Yes to p
Use other side for additional information. 6 15^-' d 2C-Z SBD-6710 (R 05/91) ~C~ (1 f to Inspector's Signatur Cert . No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
E DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
ZE7
57` G x
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ cht if" revisio to pr lous 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
W c,J 00-Y-- t w~ klA~ 5E %4 NW t/4, S T N, R /8' or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/-50-S AIIA111 S /7 1
CITY, STATE ZIP C0 6E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
-0 -Afte-1
u.11 w 5 0[ 7 7/S' aSK-~-;i+d l1o w R~~a.~
II. TYPE OF BUILDI G: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLAGE :
❑ Public L 1 or 2 Fam. Dwelling4 of bedrooms ARCEL TAX (
111. BUILDING USE: (If building type is public, check all that apply) oZ L , 1 / 6 .
1 ❑ Apt/Condo
20 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. X New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 5Seepage 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
IP 00 S S S % !v • 7 N 95, S Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank SOD
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 Sig e: (No Stamps) /MPRSW No.: Business Phone Number:
C-40#1-r, po ",c. /5, 7/S oZy~ S'/3S
Plumber's Address (Street, City, State, Zip Code):
/ 9L / ifj~,kr%nol w ya
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss ing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determin 'on 6
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
r
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 aut`iority.
4. Changes in ownership or plumber requires a Sanitary Permit Transf~-/Renewal Forrn (SllID 6399) to be
submitted to tht , ;ounty prior to installat+pn. ~
5. Onsite sewaue ~ystems must be proper iy maintain-ed. The 'tank(s) mist be''- i s P90 by' ~ licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your dnsite sewage system, contact your local,6ode edministr0or 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 bo installgd:
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. 9 u 9 tYP ~ Type of ;permit. Check only one in line A. Complete line B it permit is for tank replacement, reconnection, or
repair
V. Type of system. Check appropriate box depending on system ;yp= .
VI. Absorption system information. Provide all information reques 'd in 1-7.
VII . ar-A information. Fill in the capacity of every new and/or exisiir,; !a<<k 'ist the total gallon.; E;umber of
tanks and manufacturer's name. Indicate prefab or site constrt2~ -d and, tank material. Gcn p et::: for all
sep +c, pump/siphon and holding tanks for this system. Check • ,,F-ime,ital approval only it tanks received
exporin -~-,<al product approval from Dil_HR.
Vlll. Responsibility statement. installing piurPher is to fill in name, 1,_Hnse number with appropriate pre.fix (e.g.
MP, etc.). address and phone number. Plumber must sign :~,pp'i,_ tion furor
IX. County. Department Use Only.
X. County/Department Use Only.
Complete tJians and specificatior* not smaller than 8'/z x 11 inches m !=.t r t; submitted to the county. The
plans rnt;~,t include the following: ra) plot plan, draw^. to scale or with :~rrrrYle e dimen6k ns,. I,)c3tion of
holding Tank(s), septic tank(s) or ;the., treatment tanks, buiidirg serrer- weil,,3: water n ai ;s; eater service;
streams and lakes; pump or siphon tanks; distributi,?n boxes; soil abso, Al,W systems rer~i ~reCr er t system
areas; and the iocation of 'he b,u '.';'g served, B) hc!r zorta' Lino' vett!r:1' 3levaticn ref'?rer cinti;
C) complete specifications for pumps and controls; dose vclunte, :~n, differences,; frici cn loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by th@ cZounty; E) sqi1jest data on a 1 form; and F) all pizing information. _
- - - - - - - - - - - - - -
GROUN15WATER SURCHAAGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) ?or a number of
regulated practices which can effect groundwat-r.
The monies wilected through these-surcharges are ~Jse.r++~) =it ~r~, woater, q;c,und.- t•
water' contamination investigations and establishnoF ,t c
t
SBD-6398 (R.11/88)
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.w I ~16w Cow :T61 nt 0 444f%k,~~. `7
S -N w S,!41 T3 O--f,vIN Fr01I1 Air Inlel► And ODearrolion Pipe
~~'---Approrid Vent Cop
• e 411nlmum 12• AOOre Will, I1Qlil'.1 ~LYK-r 6u)LS Final Grad.
20AA
Plpf _ 4* Cut Iron
To Venl Pipe
Mer en NeT Or Sring
Lgele
O0 0 Tee 6
e
De ° PerlOraJea PIPS baler
o ~C#%AIAg Terminaling At
Bottom 01 System
Prop 1,tID PI~a•I
SOIL FILL
DISTRIBLITIOI.1 PIPE
~r APPRovED SI)i1p Tic cov[
OR 9" OF STRA4
2" OF hGGR EGA ~ OR MARS►+ HAy
E: LEV• OF (~1r7 EET_~'wY~. G~0FlL-212 AGGREGATE ~P•V~
DIS'1-RIDUTIrOU PIPE TO 6E AT LEAST c?_ IUCHES BELOW ORIGIMAL GRADE
AAIV AT LCAST40 IAICHES BUT 1.10 MORE THA1J 42 IAICI{ES BELOW FINAL GRADE
MAXIMUM DaPtH OF EXCAVAT100 FXOM OKIGWAL 6~AK WILL BE IUCHES
tAJKIMVM 0Ee71i OF EACAVATImN rAOM C'~16'I IAL• GRADk- WILL BC Z_ INCHES
S I G 1,1 C 0: 8•tg.9-CMS
LIGCIJSC 1.)UMBEIt:
DATE: y-/ - 93
I10 .
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 3
Labor ° nd Human Relations _ Of
.Divisifflk af Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix
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
Derrick Construction, Inc. GOVT. LOT SE 1/4 NW 1/4,S 1 T 30 N,R 18 fc(or) W
MEF Iy' OW,NV~ 3 MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
~j``~c 17 n/a 14illow River Meadows
CITY, STATE CODE PHONE NUMBER ❑CITY ❑VILLAGE 'OWN NEAREST ROAD
New Richmond, WI. 5406 1715) 246-2320 Richmond Co. Rd. #GG
JcA New Construction Use [x* 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 bed, gpd/ft2 •8 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) 95.75 ft (as referred to site plan benchmark)
Additional design / site considerations none
Parent material outwash 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 S❑ U S❑ U QS ❑ U )Q % ❑ U O S 1 U ❑ S t3U
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 Trench
1 -16 1 r3/3 none L. 2/m/sbk mfr c/s 2/f .5 .6
2 16-29 7.5yr4/4 none sl. 2/m/sbk mfr g/w 1/f .5 .6
Ground 3 29-84 7.5yr4/6 none Is. 0jSg ml n/a n/a .7 .8
elev.
99.25 ft.
Depth to
limiting
factor
>84
Remarks:
Boring # 1 0-7 10yr3/3 none L. 2/m/sbk mfr c/s 2/f .5 .6
2 2 7-20 10yr4/4 none sil. 1/f-/sbk mfr g/w 1/f .2 .3
3 20-84 10yr4/6 none ls. 0/sg ml n/a n/a .7 .8
Ground
elev.
99.25 ft. Z
0
Depth to
limiting
factor
>84
Remarks::
CST ,ary L PI Steelt Phone: 715-246-6200
A~ 200th ve. New Ric and WI.54107
Number:
Signature: 12-1 -95!'t': 2298 CST
PROPERTYOWNER Derrick Const. / SOIL DESCRIPTION REPORT Page 2 of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0-13 10 r3 3 none 2 m 1: mf
v' ?{2 13-24 7.5yr4/4 none sil. 1/m/sbk mfr /w 1/f .2 .3
Ground 3 24-86 7.5 4/6 none S. 0/s ml n/a n/a .7 .8
elev.
99.55ft.
Depth to
limiting
factor
>86
Remarks:
Boring #
::.::•w~4 1 0-17 1 r3/3 none L. 2/m/sbk mfr s 21f .5 .6
.4 2 17-32 7.5yr4/4 none sl. 2/m/sbk mfr /w 1/f .5 .6
3 32-82 7.5yr4/6 none Is. 0/sg M-1
n/a n/a .7 '.8
Ground
elev.
99.28.
Depth to
limiting
factor
>82
Remarks:
Boring #
1 0-8 10yr3/3 none L. 2/m/sbk mfr c/s 2/.f .5 .6
i
5 2 8-20 10yr4/4 none si_~. 1/f/sbk mfr g/w 1/f .2 .3
3 20-86 10yr4/6 none S. 0./sg ml n/a n/a .7 .8
Ground
elev.
100.1t5
Depth to
limiting
factor
>86
Remarks:
Boring #
i:}\
\
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 988 N. Shore Drive
C.S.T. 2298 Derrick Const. New Richmond, WI 54017
MPRSW-3254 lot. #17 (715) 246-6200
Willow River Meadows
SE-';,n1'. S1-T30N-Rl8W
Richmond, township
to
gym= ~
4+ &k
a
boast 60 425•10outlot 1
17
203 Aar J11.0704 M a Wi I I ow
N 16 River
2.01 ACM 2 012 A"a..
20 Meadows
2.63 AOM
15
141951
2.15 Aaft
305 L= AAamft
s
13 I~
206 '
Z 1 e
1S 2-16 ACMG ' rro 2.0 ACM
N
X22 1y8J 361.13 v e^^9
N 1 0 161.1' 206 + 263.16
2.01 A=- u~ 2.00 Acru O1 0
N N O
266Aa.. „ 12 22
2.01 AGM ~y 2.00 AIM
206 214 135.26
Public 'I
20 .►a ~s a~
4s6.7s
n
10
23
N N
2.00
N 7-00 ACM N 2.22 AC1N T AfJM 6
s N
266 206.30 24
504.30 v9
' ,a 2.00 Aa11s
28
a 2.62 Aan h 2.27 Aa1N
425.25
,
N 5 a 31633
25 "
N 2-01 Au9s a 2.04 ACM
440.49 y N 27 r
29 Z CM
N 2.32 Aa66
4
wYbw
zo Aa.. a ' River
476.33 260.57 ~P 166.SR 77.60 cry of New RIChnimd
N ~
3 26
zao ACM o a 4a, se 2.11 Ao a
H
N `2°
507.06 30
226 zoo
=
211.03 S 2.06 ACM
County Rd. GG
323.20
v
N 32 33
A 2 a « . ^ 2.20 ACM N 164 Atri6 °
31 N °
1 61. A06{ w 2033 AGM a _
200.50 326.37 226
Highway GG
D R ICK (715) 246-2320
Route 1
New Richmond
CONSTRUCTION=~ Wisconsin
SC°""'C "tl:iK SAL:iTr:1AKC= A(:ZZ :!E:IT
' 5 c . Cro i~ CuuR c'~
~vr ~~o w ~cn =Jai " V'E_f4Iv'9C
oWrrc:t~ ~u•f~z /ur c*,~Ef... ~ S;-~y~~us
MOUTZ190M YU:KBEM /SOS /]WF I &..S Fire Humber
t l
CZT•t/STali~ ~~t-J ~Ic.NMOMJD~ ZI° ~~4/J
I >
P^IPZi~''L LOGI2IDN : G t✓ t4'. Section 2=Y f~ g V,
Town of &IM a fjD St. Croix CounC 7,
Subdi•ris ion lytt u-'s► Lac cumber 7
Zmarooer use xnd maintenance Of your seaci c syscam could result is
ice premac:srs Failure cc dandle ,sascas. Proper maintenance can-
sizes at pumatag out Cho seocic tank aver, three years or sooner,
i! needed. by a L icenssd see a_ cicc tank ouavet. 9hac you puc iato
tae syscam can ar_acc Cho runec- n e the septic tank as a c=eac-
nene stage :a _hes sasca disposal svscam.
Sc. Croi= Csunc-r residents may be al i gi5la cc receive a grant For
a Ma:c__a j e 60Z U d Cho case Q f reolacemenc of a Eailiag syscam,
which was za oneracion prior cc July L. L978. St. Croix Caunc?
accepted this program Ln August of L980, wtch the requiramonc chac
owners od all nova svss agree co kae3o Chft_I ' 372csms properly
maiacaiaed.
T`ze 3rooer:7 owner agrees to submit ca Sc. Croi: CJunc7 Zoning a
cart:.=action loin, sighed by alts owner and by a =as-car plumber,
journeyman plumber. rest=iccad plumber or a Licensed pumper vert-
Ey_:tg than (L) she on-sica wascawatar disposal syscam is in grace
ooeraciag condition and (Z) ac':ar inspection. and pumpiag.. (iR aec-
essarq) , chw seacic tank is Lass Chan L/3 ILiil. of sludge and scum
Car:if:~ae:on fora will be sent aporoximaealy 30 days prior Co
carat year etpiracion.
Zd'7Z. _he tinder s4-4mad, have read Cho above reauicamencs and agree
cc mai :caia cho pr:•raca sewage disposal systam in accordance 'jica
the scandards sac for_h; harass, as sac by cgs 1413consin Depart-
cnenc uc Vacsral lesources. Carts=-cation lova must be completed
and rec•a.Zed cc the St. Croi» CounC7 Zaniag OE:ice within la, days
of the Cares fear Wt?ir:sc_on data.
S
.C.. II
z M
0AT= -2-q, -4
Sc. Cro___ Counc,r on_4n-4 UE__c_
t'.U. lox
4ammo"a. '..Z 540L
ti i.~1 ..ntl ~.~i~,`•'7 .l .tfl.lVr~ 1udC? ,
y~
APPLICATION FOR SANITARY PERMIT
STC - 100 •
~I
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
is..suance. 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Q- - - - - - -
jec/ I JIFF -L 14.S
Owner of Property aj/L-i'O &j pwca O/ N ~El~!
Location of Property S 6r_~4 Nul xr., Section T ~fl N - R 9' W
Township co ~A4,014
Mailing Address Sa S f-f-1/VV ~5..-
CW )e!4-lMO!JD~ ,SYOl7
Subdivision Name IV/l-LO(-1 AV107- Me-A0oW5.
0 gross o-~-Pfaff 7 II
y: I I
Lot Number c
Previous Owner of Property 5CIiW i 0 7
Total Size of.. Parcel
Date Parcel was Created ho -!R `C~ 0
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume b and Page Number '7 g,G as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
In additton, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTy OWNER CERTIFICATION
I (We) ce4ti4y that at statements on this Bohm ane tAu.e to the best o4 my (ouA)
know.fedge; that I (we) am (one) the owneA(b) o{ ,the p) opeAty descAi.bed in this
,i.nAu4m0:ton 4ohm, by vittue o6 a wa Aan.ty deed te_coAded in the 064ice oA the
Coupty Rcpih.teh 13oodA. 71, T)no~,m~nt No, q9-9-2--o(,:3 : and that I (coo.)
pn.eise.ntty own .tie, phopoAed site. Aoh. the sewage izpo.scl -sya.tem Ion I (we) have
ob.taine.d an e"eme.nt, to h.un with the above desehibe.d pnopwy, 4on the
cons•thucficon o6 .5a,i.d system, and the same, has been uty ne.conded in the 064ice
04 .the. County Re.giAteA oA Veeda, as Document No. 520 fo ) .
'J/ 4
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
3 - Z~ 93
DATE SIGNED DATE SIGNED
455206
I '.GiPAGEQ~V 1
REGISTER'S OFFICU
ST. CROIX CO.r WI
~t
• Michael. R. Stevens, . William ll.. Derrick,
Wi111am.14.. Derrick, Thomas. E.. Derrick. a.nd... Recd for Record
Ronald L.. Derrick as. tenants-in-common IJAN 11 IJ90
at 8:30 M
ttJ11Yt1tt :tl:,l ,,:tlf:ttt~+ to Willow. River.. tl.oint •i , a ee~X.
....Venture _
Rep>s1f1r of Uht1d~
I
.
. . . ................•i...... I
I.111 (nllnlvinn! tlcs+•111,111 rend ertnte in ..................county,
Stnte or i irconsin:
II Test 1•ereel Not
Southeast Quarter of Northwest Qiar~vWnsand hipN30tNorthr QRanger
of Southwest Quarter of Section
18 West.
n EA
it II
rim
fI 7
II
~I'hhf , ~f~..t1_bti. ~1nftlbildild IJrnpcl•E}+ . 11{~r~i;i,l~'•I,:1.,. ~
II (isti (Is nofl? +
rltrepttol, tq+ wnrrontfeo! Muntelpal and toning ordinances t easements And
tobtrictiond of reeord,,
Janu ry.............. ► 1 ..90.
I~ ItJ+th11 (Isle . Jlny of
• (S1:AL) L•... JSPAL)
Michael R. Stev. ne t William M. Derrick
(9 r
be 1fck
t~ ..William. !I. Detrick mh9mas
L' i • 1 41--Y"'
-KSYisg1 d w ~y M ®N
AUT11PINT1oAT.1014 'r
Michael ...P; .Stevens;.......... - STATi, OF WISCONS1M
.
I;i-iint1ic(aj
Wi 11 a 11. Derr.ii ck r W~:1 am f4 . R
Deli:r• dk Thvma Derrick.. and Cnunty.
It:nl ) s nr d.antiaty..........................
no at3 pe ak ~
qq ; 111..0 _l.ersonnlly cNtne beford - me !hie .:.....:.....,.-tln~ of
nnthPnted
t~ ~ t.N ~~n•.-!......... .,..18.........the shove nnnlc+l
Juditia A. Remington .
T1111,131 Alt-011)rtt STAT19 uAlt or wtgvx)Nslr4
(l1 not.
nuthorixcd by 4 700.0 0, VGIs. Stnfn.) . to me known to be the person Jvho executed the
forepolnir Instrument hnd nchnowledtte the acme.
t►t19 INSTRUMENt V/AS MnAFtto f!Y
XNGTON...LAW OFFICES
R 1..............
~tgg
l~~~i~cthv i mi ton
r.................. ~ O.l ~ Note+•y 1'uhlic ............Counts, Nts.
(SIrlinturra ntny be n0hrittirnfed or nrltnm~lcdtr,l, [loth M. ('nntn111 Im1 In permnnent. ((f not, stnte explrntion
are not neccsznry.)
dntet 19.........
' '.n+rt ul p~rsone .Ir,nlnr. In asp ~nrn.ily nh•rot.) iv 1~p••1 nr prh+l.•,I le•Irr+e Ih+•Ir ~It:nnlan~.
t•!AnnANTT h1'1"n STA•TIS !1111 OF W19C.ONS14 q'Ir,tnn+ln L11Te1 hinnk 1'... (+.r
r.... •r .