HomeMy WebLinkAbout032-2053-10-000
ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY G~
- :Awm
STAT SA _ RY QE~i IT #
-Attach complete plans (to the county copy only) for the system, on paper not less tha~np,~ L ?J~~`
8% x 11 inches in size. Y" ❑ CIS if revision t previous application
-See reverse side for instructions for completing this application. ' ° v STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINTALL INFORMATION.
PROPERTY O NER PR ERTY LOCATION
G k 4 /a, S T , N, Rl,~;p E(
PROPERTY OWNER'S ILINGc,A.DDR LOT # BLOCK #
d / f7 G ^ c
CI , STAT ZIP CO PHONE NUM ER SUBDIVISIM NAME OR CSM NUMBER
o Gc ~ d O ~ .SG
. TYPE OF BUILDING: Check one CITY EAREST ROAD
11 ( ) ❑ State Owned VILLAGE
❑ Public 1 or 2 Fam. Dwelling-# of bedroom "PARCEL AX N eog
III. BUILDING USE: (If building type is public, check all that apply) 3 ;7, - Q - O
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
Imo'
A) 1New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 r7l Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El Holding Tank
12"'N Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
43 El Vault Pri
13 ❑ Seepage Pit Pressure
vY
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
e d Feet Feet
CAPACITY
VII. TANK Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks ranks structed
Septic Tank or Holdin Tank .Q
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.
Plumbe ' Name (Print), / Plumber's ' nat e: (No Sta ) MP/MPRSW No.: Business Phone Number:
Plum 's Address Street, City, State, ip Code
lt~l L°~ d
IX. COUNTY/DEPARTMENT USE ONLY`
❑ Disapproved Sanitary Permit as (Includes Groundwater Date ssue Issuing Agent Signature (NoStamps)
Ju Approved I Owner Given Initial Surcharge Fee)
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
p l
1. `'A sanitary permit is valid for two (2) years.
2. "S our'•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 tc, this permit must be approved by the peri,it issuing authority
4. Changes in ownership or plumber requires a Sanitary P e ft E ransfer/R nr,wal Form (8130 6399) to be
,submitted to ~-ounty prior to installation.
5. Orisite sewage _~yutems must be-pr operiy rn.eintainec. tank(s) rc~. ire y r ~d ~ry -a i~,-er ed -
pumper whenever rnecessa.ry, 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 numberls) 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. Absorpton system information. Provide 0 information requested in g1-7.
VII. Tank ,rr.,l matiun. Fill in the capacity of e ~r„ ,yew and/or existin( la st thee ` j-.I ~lul~: number of
tanks and manufacturers name. Indlcati. or site consUrUt,tU! i ;an'r: =ndIE;C cti. ( i:ri- ^ to i r all
septic, pump!siphon and hooding tanks fo! ti. s :system. Check ex;nrr %,pprovai o ny : ':_tn-,s received
experime-r-tai p,oduO approAjal from Dit_s .
VIII. Responsibility statement. Installing Plumber is to fill in name, license r1F~rnlie- with apnrof.,rir e prefix (e.g.
MP, etc.), address anc phone number. Plumber rnuM sign application
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plan` and specif cations not smaller than 6,~ x 11 itlc i 4 - must be submitted rl'., coUrty. The
pans must incl-,de the fC O- ing: A) plot plan, irawil w 5 aye or . -,Of7 ple,:-- ,te iO`~- Y atnon Of
hoid'ng tank, tank:` c, r,ther t ,carnE11 tarks', ~i)Il Sr t-"r 'h/dil`3: °1vU .4'..ef service
strrreams anti frr~rnp or if?r i kY!~ G3iSt'itlUtif)ri t?Grr S, r Qtit~fl Sy$tF,fT~.. rPri,.+,.'47?e t System
. Of the tiU, ? ) hcrizOlitcl ra ,F )in`.s:
at£: h+.if V-1 r> t: Si
C) complete speciil -ations for pumps and o;s, dose r,,:evat:or diffe(ences; fr icti-.n 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 Wiscon--r.,, Act 410 included the creation of surcharges `t-; ) for a number c
regulated pnac,ces which can c. fa;;t greundwater.
The rtionies co;lected through es ' `charges ~-t •
water contarrnhiation investigations and establishn,.,:?i
SBD-6398 (R.11188)
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER r La R-1-
ADDRESS /D--/ ZQ at ,
XZ12 D Gt. 5530 3
SUBDIVISION / CSM# CC LOT #
SECTION_Z,5 T~N-R Iq W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
j ~ ► t
-4 "M r
.n 9
`Yl Z
10
v
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: p P
ALTERNATE BM• U r ('j
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION 1
Manufacturer: CA-) Liquid Capacity: zovL1 / IDA
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
;SOIL ABSORPTION SYSTEM
Width: J Length 6:o Number of trenches h IL Q~
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet, . / ST outlet
PC inlet PC bottom Pump QOff r
Header/Manifold 4/6/,-3 Bottom of system ~9,
Existing Grade Final grade
DATE OF INSTALLATION:
- Z `6 J V
PLUMBER ON JOB:
l~atu
LICENSE NUMBER: -3-3 INSPECTOR:
3/93:jt
'LQq, 'i, qi• SOt ~tasrT 15.30.19 PR VAfE SE`WA~GE SYSTE'M155TH County:
p a rt men o n us
Labor and Human Relations ry, INSPECTION REPORT
Safety ano`Buildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 193416
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
UGE HENRY SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-2053-10-000
TANK INFORMATION ELEVATION DATA A9300074
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Lam,,,) 100 0 Benchmark 7 G Z /D7-6Z.
Dosing
Aeration Bldg. Sewer 2 -30 / 0y L
Holding St/ Ht Inlet 3- rZ. /Ov /v
TANK SETBACK INFORMATION St/ Ht Outlet 3 -v L 103. $
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 0 2-7- Z S NA Dt Bottom
Dosing NA Header / Man. y 3 /d 3. 3
Aeration NA Dist. Pipe 03. S
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand Z./$ `~7
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. HH Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width/ 2 Ler~tl~ No. Of Trgnches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS C DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O pQ /O f 3 OR UNIT Model Number:
System:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length _ Dia. Spacing C
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: SOMERSET 15.30.19.698E,SW,NW, LOT 3, 155TH
00-
Plan revision required? ❑ Yes ❑ No 3
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
PLOT PLAN
PROJECT ADDRESS
1/4 1/4/ ~ /T /R W TOWN COUNTY >-G~~
MPRS Byron Bird Jr. 3318 D TE
.BE0900M__-F CLASS PER CON NTIONAI_XIN-GROUND URE
CONVENTfIONNAL LIFT_ MOUND HOLD G TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE -ABED SIZE ~~yc6
1116 Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
*
M Borehole Q Well Scale Feet
O Perc Hole System Elevation v,
Uent
12"
TYPAR COVERING
2"
12" 3' 4 6' 4O 3'
I 6 " Sewer Rock
~r 12
'
1
l~
l h1
3 64
ILQ,.1-
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/rte ' LjtA /i /
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y, s ~
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6~2.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION P.O. BOX 7969
LABOR
REANDLATIONS PERCOLATION TESTS (115) MADISON W1 3707
HUMA
HR 83.0911) & Chapter 145)
LOCATION: SECTION: WNSHI UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
54, )114 /T3o N/R/ E
COUNTY: MAILING ADDRESS:
f~.~«~,c /jam ii~ ~✓`~30~
51`~Lrvj~ e/~r~ 4f0
USE DATES OBSERVATIONS MADE &~/.;t 4-10 7 O-?
Ji~Resiclence NO. BEDRMS: COMMERCIAL DESCRIPTION: New ❑Replace PROFILE CR PTIONS: 1PERCOLATION TES S:
3 -
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U [XS ❑U $ ❑U ❑ S ❑ S ou 7~0
14J La
If Percolation Tests are NOT required DESIGN RATE: i If an portion of the tested area is in the
under s. ILHR 83.09(5)(b), indcate: Floodplain, indicate Floodplain elevation: /a/
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES HIGH-EST TO BEDROCK IF OBSERVED (SEE ABBRV. N BACK.)
d - ~ 4/1 r ~ v-6 c y5s- ~ Ste'
B- j 9
B- ~ fAl
Alll~
B-
B-
B- Z
1/V/1 r !J / ERCOLATION TESTS /
P
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH
P 2
P_ G
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SY TEM ELEVATION'
_ - --i
p- IC
E
b ` f { PO f ~
71
€
I
I I j } 3 C.la~. bso~ j I
i € I ~ I i
.dd.E
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y
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1 1 ~ 3
t
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein accor jhi he pT6~edureand me ecified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of m o ge i 3 d ie f
NAME ( 'nt): TESTS W •COAillz ED ON:
AD S: CERT (CATION NUMBER : PHONE NUMBER (optional):
g o~v . m e a o 311 7
CST SIGN RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
,~2
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use suction must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
6. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
at - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
's - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well
Is - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand < - Less Than
'1 - Loam Bn - Brown
'sil - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic - Silty Clay III - few, fine, faint
'c - Clay cc - common, coarse
pt - Peat mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
' Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
• SEPTIC TANK MAINTENANCE AGREEt1ENT w
St. Croix County
m
OWNER/BUYER ~i~✓i2~ ~iyy'
r c if r o
ROUTE/13 X NUMBER r' ' ' :plp ~•r~ A 'y Fire Number
CITY/STATE,~pijlieSr ' 4--"I ZIP C7
PROPERTY LOCATION:'.S°4-j'Section /1'377,. T ,30 N, R W,
Town of Sa-«~c~sT St. Croix County,
u~ Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to-handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'ed' 's'e t'ip, .tank pumper. What you put into
the system can a ect the- unct on o• the septic tank as a treat
ment'stage in the waste disposal system.
St. Croix Count residents'' may_ 'be eligible to recieve 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 'sys't•ems agree to keep their system properly
maintained.
The property owner agrees to. submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or. a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and .(2).after inspection and pumping (if nec-
essary), the septic.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
a
I/WE, the undersigned have read the above requirements and agree o
to maintain the private sewage disposal system in accordance with J
the standards set forth, herein, as set by the Wisconsin Depart- r
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration.date. y~ ~J
SIGNED /
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
• APPLICATION' FOR SANITARY PERMIT
STC-100
This application form is to be Completed in full and signed by the owntr(s) of
the property being developed. Any inadoquacles will only result in delays of
the p2rmlt issuance. -Should this development be intended for resale by
owner/contractor,(spac house), then a second form should be retained and
completed when tha property is sold and submitted to this office with the
appropriate deed recording.
Own e r of property f~1"'I_
Location of property 5G(1 ~ 1/4, Section C S T 3~ x-R ~S V
Township ✓~o0-7'c<SeI` -
Na 111 n g address G
Address of alto 5a.~ mot!'
lubdlvlslon news
Lot number L e T age ~
Previous owner of property GtiJ~I~-~C <:TC9X:'1.SQ /
Total 5130 of parcel - J, It A
Dats parcel was created `r~'~Sr ly
Ate all cornets and lot lines ldentlflable? X Yes No
Is this property being developed for resale ('spec house)? Yes X xo
Volnma f00 and Page Number 42- as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWINCr
A WARRANTY DZID which includes a DOCUMENT NUMBUR, VOLUM! AND PAOZ NUMBaR, and
the ORAL OF THE R80ISTER 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 Ceitifled Survey map, the Certified Survey
Hap shall also be required.
PROPERTY OWNER CERTIFICATION
I(Ve) certify that all statements on this form are true to the best of my (our)
knovledge) that I (wet 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. ¢9Z S_41 i 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 dul recorded in the office
of the Cvynty Reglstec of Deeds, as Document No. 91, 1
X &I. & f =-EJ
lignatu Ow a Signature of co-owner (it Applicable)
Date of signature Date of Signature
` THIS SPACE RESERVED FOR RECORDING DATA
,~000UMENT NO. STATE BAR OF WISCONSIN FORM 1-1982
WARRANTY DEED
498541
Vol PAGE 6 REGISMR'S MICE
This Deed, made between Wi 11ard A. Johnson and ST. CROD(Ca•M
Donna M. Johnson, Husband and wife, as joiner Roec'dfor Rne ord
tenants MAY 51993
Grantor,
Q.
andHenry J. Auge III an Barbara uge, 10:4
Ht,-,hand and wife, as joint tenants
P-4sw of Deeft `
Grantee,
Witnesseth, That the said Grantor, for a valu ble coqsider Ion -
(1.00) Dollar and other good anQ va~ua e con RETURN TO
conveys to Grantee the following described real estate in St. Croix W, tlwd _r14,Vs d.4
County, State of Wisconsin: 2q-.),40 S NEP?
WkW A i c,~MWO wL SY~ c
Lot 3 of the Certified Survey Map Dated AUgdsst 21 , '1:9,79
and recorded in the office of the Register of Tax Parcel No:
Deeds in and for St. Croix County, in Volume 4,
Page 963, of Certified Survey Maps.
SAN SF~
This is nnt- homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Willarej A- Jahnar)n and Donna M. Johnson Husband and wife as joint
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except tenant
Reservations, restrictions and encumberances of record
and will warrant and defend the same.
Dated this 27th day of April 19 93
(SEAL) N." "31 )tI, % 0S. ~:4.~ (SEAL)
Wi lard A. Johnson
(SEAL) GtQ (SEAL)
• Donna Johnson
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)__tAd L I-1/ tY A,+^~`~ STATE OF WISCONSIN Ss.
County.
authenticated this_)-r~--day of 199-? Personally came before me this day of
'19 the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who excuted the
authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Z- Yt td J . L. 't 1 Ie 14.
1\ ~Jl 10" ~ V 01 ,r t Notary Public 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. NF 3573
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms, P.O. Box 10208, Green Bay, WI 54307-0208
FORM No. 1-1982
HARTMAN CONSTRUCTION
103 Main Street • P.O. Box 326
Somerset, WI 54025 (715) 247-5337
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