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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOTr
SECTION__Z._?_T_N-R,,,~?~W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERY HING~WITH N 100 FEET OF SYSTEM
s
.~.y
~o
NDICATE NORTH ARROW
L_2
AP
Provide setback and elevation information on reverse of this -form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 5 ,fir - J / D
ALTERNATE BM: SEPTIC TANK PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well-,/, House y other
Pump: Manufacturer Model#Size /o
/
Float seperation Gallons/cycle:
Alarm Location Lz
:SOIL ABSORPTION SYSTEM
Width:_ Length Number of trenFhes
Distance & Direction to nearest prop. line: Setback from: well: House~_ Other
ELEVATIONS
Building Sewer &0, 8G ST Inlet : ,,PS y ST outlet 9R.s'
PC inlet 97,5$ PC bottom Pump Off g
Header/ManifolBottom of system
Existing Grade Final grade"
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
t
IZtQ43A I icr~rt>~@f"4s@l $$Y.13.30.20 +"1JATjJM4A(j VEM County:
Labor and Human Relations
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) sanitar rmi
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
X
I-Mwp. BM Elev.: BM Descriptio r E Parcel Tax No.: 27 1166, c 6
TANK INFORMATION ELEVATION DATA A9300204 1/42
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark L Co
i
Dosing rr r/ 1 i e~{4 a 71'* 105,13
Aeratio Bldg. Sewer S U2~ v, R's
Holding - St/ k Inlet 8 7~
TA SETBACK INFORMATION St/ Outlet 7 , W, c!~
TANK TO P/ L WELL BLDG. VAe Intake ROAD Dt Inlet 9jJ 7 97/
Septic NA Dt Bottom 3g~ r
Dosing NA Headers / &
Aeration NA Dist. Pipe
Holding Bot. System S r
PUMP INFORMATION Final Grade
_~"`.5"Y '
Manufacturer
Demand
Gcjds
Model Number GPM' / 93/
TDH Lift f Friction a System TDH ~3Ft
oss ea
Forcemain Length ~I Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt/ No. Of Trenches PIT No. Of Pits Inside Dia.
DIMENSIONS ~ --'55K DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING " urer:
SETBACK
INFORMATION Type Of n" _-c CHAMBER de Number:
OR UNIT
System:v >
no-
DISTRIBUTION SYSTEM
Header / WPW -7 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length /a 1 Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems O
Depth Over Depth Over n xx Depth Of ed / Sodded xx u
Bed/ tenter ~Ow Bed / lwvdd-Edges X, Topsoil El Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOnCDATTI-ON: OMERSET .13.30.29.777A LOT 1 (23RD) L
Plan revision required? ❑ Yes to "
Use other side for additional informatio . aS;Z~2~~_ - --t-
SBD-6710 (R 05/91)~ Date Inspector's Signature Cert. No.
s
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
~ DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
IT #
STATE S IT Ri
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /
revious application
8fz x 11 inches in size. C eck if p
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP RTY OWNER PROPERTY LOCATION
'/a '/4, S T , N, E (or)e
4m.4 Ac PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned VILLAGE :
IMN OF:
❑ Public 9 1 or 2 Fam. Dwelling of bedrooms ~ PARCEI TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) C xxswao
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.E] 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 ® 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 12. 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
s- . _~17 Feet 99 Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber - - 5
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for install tion of the onsite sewage system shown on the attached plans.
Plumbs 's Na a (Print): Plumber's Vign ure: (Np S ) MP/MPRSW No.: Business Phone Number:
m s Address (Street, City, tats, ip Code)-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing A re rstatops)
❑ Approved F-1 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
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 El'f 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; elevatior differences; friction loss; pump
performance curve; pump model and pump manufac*lurer; 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)
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PAGE OF
PUMP CHAMBER CROSS SECTION AMD SPECIFICATIONS r
VENT CAP
4*C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVER
25' FRCM DOOR, r . .1
WINDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE I 4' M(N.
18" MIIJ.
COIJDUIT--
INLETPROVIDE I
AIRTIGHT SEAL I I i ( V
I I ~ I APPROVED ,]OIAITS
APPROVED JOINT A
W1C.I. PIPE I III W/C.I. PIPE
EXTENDIM(, 3' I II ALARM EXTENDIAIG 3'
ONTO SOLID SOIL I i ( ONTO SOLID SOIL
B
~ I GU
C I
PUMP --j
OFF
D
CONCRETE BLOOK
I
RISER EXIT PERMITTED ONLY IF TANK MAULWACTURE.R HAS SUCH APPROVAL
3PEC.IFICAT IOKJS
LPTIC AND
)OSE TANKS MANUFACTURER: C IJUMBER OF DOSES: PER DA!
TANK SIZE: " .S!`k'> GALLONS DOSE VOLUME: GALLONS
ALARM MANUFACTURER: a ~i✓_ CAPACITIES: n= INCHES OR S CALLOUS
MODEL NUM6ER: S= -INCHE5 OR -?S GALLONS
..SWITCH TSPE: CINCHES OR JSL,2_ GALLONS
HUMP MANUFACTURER' D= :Z IAICHES OR Xl/ GALLOMS
MODEL NUMBER: ~nn 11a~~~E- 5 NOTE. PUMP AND ALARM ARE TO BE
bWI1CH TYPE:. IAJSTALLED ON SEPARATE CIRCUITS
.PUMP DISCHARGE. RATE GPM
VERTICAL.DIfFERENCE BETWEED PUMP OFF AND DISTRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE, . . ~ FEET
Z~ FEET OF FORCE MAIN X F/ooFT.FRICTIOU FACTOR.. FEET
TOTAL DYNAMIC. HEAD = FEET
IIJTERNAL DIM S101J5 OF TANK: LENGTH ;WIDTH -;LIQUID DEPTH DATE:9
SIGIJED: LICEAISE NUMBER'
Performance
P .
mps
Curves
METERS FEET
90
MODEL 3885
25 so SIZE 3/4" Solids
WE15H
70
X 20 WE10H
60
-WE07H
15 50
WE05H
40
10 WE03M
WE03L
20
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
1 1 1 1
0 10 20 30 m'/h
CAPACITY
MGOULDS PUMPS, INC.
SEPECA FALLS NEW YOPK 13148
METERS FEET
120 MODEL 3885
35 SIZE 3/4" Solids
110 WE15HH
100
30
90
25 80
OQ 70
= 20-
.j
F ~
0
~
15 50 WE05HH
40
10 30
20
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L 1 1
0 10 20 30 m'/h
CAPACITY
01985 Goulds Pumps, Inc. Effective July, 1985
C3885
INDUSTRY
DIEPANTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
~ •INDUSTRY DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION` SECTION: TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION NAME:
NE 1/ 1/ 13 /Tjo N/R 2oE sp m FRse-T-- 1 s~ v2 • l • 2~?S
CO NTY: OWNER'S NAME: MAILING ADDRESS:
S 40t x SAND A1o v'opoF Sf • M.O. HL)PrOa
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: P OFILE DESCRIPTIONS: P R OLATION TESTS:
New ❑Replace
Wesidence ? N.
v
RATING: S= Site suitable for system U= Site unsuitable for syste 3 'SJyt~Ti~I G'D ✓ 11~ 7-1 Cam
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S ST N-F ILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
KIS ❑U ®s ❑u s ❑u ❑ S Du ❑ s au '`eo-,vuaes -for To sot t,
• s.
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: C `A SS Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS IPJ I)ECIF" i Pf .
BORING TOTAI DEPTH TO GROUNDWATER-IN _ CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i
B- 9.0 Sp 9 d ;t Aii - s to. Is -i o . s/
RJ64- 2A3. S1.
J/,. Gy. 41F. AA3. 37 7.0w
B-3 st 2d > f- S bA s/ • R~a~- as
0 / IYZ r4AI V1, . Rj 7- 6
B- > .p -75 •W ' 3 S W H l'X 3.04• W- a.3. S 1.
S o ' S o 7 ' y s"/ (7 • BJ. V 33 • 4.1.13AJ - C17. . P.L '
~ Q.(S%o- 7 3' S. _ Q a
B- 9.
B-
5UAkCXCX_ REV,1VO135 G•S . PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN AFTERSWELLIN INTERVAL-MIN. PERIOD1 PERIOD2 PERI D PEERRINCH
P- B a-- 1 04411(
I ..7
P-
P-
Ito, o
P-_
F_P-3___1 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. f 1,6V.4r1bjj of LbwER 771 ai c s 96. Q ff .
SYSTEM ELEVATION E lritl4 Boa of- R 1'949-d TeFAjcG,, s 7 D f
sx s T t - " "gyp f N .t~ L rv s,) *76 LI *&A- I
e
i ?f $C- A:IRo 4o*ES , . =B, CC0640-
E ,
T
1
Sys
ear'
9je
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print : TEST WERE COMPLETED O
HOMESITE SEPTIC PLUMBING 00. 2, o S
ADDRESS: CE T FIC TION NUMBER: PHONpE NUMB Ea(optional):
ROBERT ULBRICHT sy' O 2 yP2._
03, Mi PEUMBER HIS. NO. 3307 • • CST S NATURE:
MINN. INSTALLER & DESIGNER LIC. NO. 00663
L DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) - OVER -
1
. a
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
x
To be a complete, and accurate soil test, your report must inclutle,
1. °Complete legal description;
2- The use section must cle< ' indicate 'this is a'residence or commercial project;
3. MAXIMUM n aer of I ooms Or cart n rcial use planned;
4. Is this a n-, 3lacern system;
'5. Cornpiete the s:; ability -ig boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE LED OUT BASED ON SOIL CONDITIONS;
6PL ~aSE use the abbr showin here for writing profile descriptions and completing the plot plan;
7. M" A LEGIBLE accurately locating your test ations. Drawing to scaly= is preferred. A
I-- may I_ df,,ired;
Your bend n, vertical elevation reference are clearly shown, and e permanent;
l 'ropriate r as to dates, names, address food plain data, pere st exemp-
10. in, el . } does ri-t : place N.A. in the appropriate box;
11. add °d your number;
12. ALL SC TESTS MUST FEE FILED WITH THE
L.C ~.UTI; Y kNITHI:: OMPLETIC
A;-, -VIATIONS FOR CERTIFIED SOIL TESTERS
it mbols
C~ ` "M ,rye
r - 7e
`s - G aundvvatei
s _ )I on Rate
rrte f 5
m t
ci to 't'
scl R
sicl - Sil- _,y I snot c11
f Clay,
ay ffi _ T,
t,€; - r r
rrim - N' m,
nr d d
p hrornin: .
HWL High wat
six en --)il text surface vv:.
for ligl dispe BM + Bench M
VRP Vertical ice Point
j
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit, The county or the Department may re=quest
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.
r
W 1/4 GUNNtli
-SECTION 13 OWNER
COtiNTY MONUMENT RANDY LIKES
iOl NCNROE ST.
All I.
1!
o co NORM mOSON, c .
3 - hands - oungd by_other5 5401:
F
f t0 CO
4 "J
fn
NORTH LINE - SW 1/4 CENTER
v S8804814811W SECTION 13
455.89' 11/4" IRON ROO
LEGEND N
LOT I
249,008 sq.ft. I c REBAR FOUND
5.72 ac. EX. R/W
° 1" x 24" IRON PIPE WEIGHING
252,M sq.ft. 1.68 LOS/LIN. FT. SET.
5.79 ac. IN. R/W o
21 go
SOn"h81
IN f•'7 N
410 $1' 4
Irt N O F
x N LOT 2 -BEARINGS REFERENCED TO THE NORTH
LINE Of THE SW 1/4 ASSUMED TO BE
'K4 x m N 221,112 sq.ft.- 5.08 ac. c - U88°4314811E.
N 228,772 sq.ft.- 5.25 ac. IN.R/ %A1 SCALE IN FEET
Ile MY 1 V F° C91 ti
I SS880531474 200 100 0 200
b ~7 J ec+o ~o _Y o' .31V Y.
16P-26T 71
r 201.315,,,
1A V N LOT w I v
W O
66' a Ln 135,122 sq.ft. n N
0 3.10 ac. EX. R/W v C!
%
Ln O tV7
uf O~ O N
L" 156,309 sq.ft. ty
/ ti.
C' 3.59 ac. IN. R/W ✓ ryo%,~
%
D579.25'
0
I Ile, 9 L,
LOT 4 203,986 sq.ft. 4.60 ac. EX. R/W m
4 188.390
1 1183"E 9 237,705 sq.Ft. 5.46 ac. IN. R/W
13957~11
1 ~U r 238.97' .1
1268.79'
C 5 1 T 11F 1304.24' rec. as N88'S2"E 1304.62 ' i
! u-_7 Tatted lands nuned_b others
EXISTING R-' - -
66' TOWN ROAD/ r
CURVE DATA TABLE
1,0CURS" LOT RADIUS CENTRAL CHORD CURVE CHORD
} ~ ~•~~G ~ A~ ~ ~ ~ NO. 110. LE11G71 h~ CLE. LENGTH LENGTEl BEARING
s V y`' 1-2 149.69 50°13'11', 127.04' 131.`.'0' 1162050147.5"E
y` ALIEN C. 1 31025,13211 81.00' 82. ; w' N53026 1 58"E
NYHAQEN 2 18047'39" 48.88' 41.1C' N78033153.5"E
S.1407 1 111~4~ 3 116.59' 79n0g1;4'j 140.10' 161.22' N4 0022'31"C
HUDS„iv, 1 60°.'2105" 117.34' 122.95' 1138050'41.5"E
1dfi( 2 1604713971 319:10' 38.21' If 711033'3 J. 5:'f
le, 5-6 82.69, 75005' 3111 107.00' 109. a;1 ' 1150024' 37"E
F
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DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SO-ACE RESERVItU FOR RECORDING DATA
_ WARRANTY DEED
502536 v 1022nGE 519 REGISTER'S OFFICE
This eed, mad be weep • Randy Likes, a/k/a ST. CROIX CO., M
t
Randy W. I.kes, a single person Rac'd for Record
JUL 2 0 1993
, Grantor,
Q.~A
and.............................................................. me~~lm ren--------••--•-.._.......... at 8:3~ ~ A. 'M
Ite03ter of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
St. Croix RETURN TO
conveys to Grantee the following described real estate in
State of Wisconsin:
Part of the NE 1/4 of the SW 1/4 of Section 13,
Townbhip 30 North, Range 20 West, Town of Somerset, Tax Parcel No:
described as Lot 1 of Certified Survey Map filed
in the office of the St. Croix County Register of
Deeds in Volume 6 of CSM, pave 1559, Document 404156.
fRA SFEI3
P~
is not
This homestead property.
6W (is not)
Together with all and singular he hereditaments and appurtenances thereunto belonging;
And ndy Likes, a/k/a Randy W. Likes, a single person
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants and restrictions of record, if any,
and will warrant and defend the /same.
Dated this L.Q................ day of July 19...93..
(SEAL) . ------•---..._..-•--.---......(SEAL)
' Randy Likes...
(SEAL) .•---------------------•-----------•----------....-.....-•----------(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Randy _Likes1__a/k/a STATE OF WISCONSIN
Randy W. Likes, a single person
---------County.
authenticate is. of July_____ „ 1_ PersonaLy came before me this . -__-_•_---day of
19 the above named
Samuel R. Car
LE: MEMBER ATE BAR OF WISCONSIN
-7--06.-08---------•
authorized b
y , Wis°. StataJ to me known to be the person who executed the
foregoing instrument and acknowledge the same.
S THIS INSTRUMENT WAS DRAFTED BY
Heywood S Cari, S.C. by Samuel R. Cari t---•----------••-•---
a
P.D~_-BDx .224_,._liud;30 54016.---_.•---- Notary Public ..........................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is peralanert. (If not, state expiration
are not necessary.)
date: 19---•----•)
.Names of persons signing in any capacity should be typed or printed below their signatures
i
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Inc.
FORM No. I - 1982 Milwaukee, Wis.
~s• - e s ,r.. ,,r~. p : r«r. -..K,. s' ,1+. - ,y^ r..y_ a
C .
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), 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 TA M C S W M A L. MG RE N
Location of propertyNG 1/4 SW 1/4, Section j3L, T 30 N-R 20 W w t_5T-
Township 50rv,MRSIET"
Mailing address ~J b X Y 5 o m l R is 1- W IL/ 0
Address of site
Subdivision name Lot no.
Other homes on property? --yes No
Previous owner of property _ R A N Dy 1 C..s
Total size of parcel 7 9 AC.
Date parcel-was created
'Are all corners and lot lines identifiable? =Yes No
Is this property losing developed
for
(spec house) ? 4ft No
Volume- in_and. Page*
Number 1as recorded with the Register
of Deeds.
I
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED 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 (OPL-) am Vxmn) 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. 40x-11 5(0 , and that I Ow) 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. .
• I
S ature of applicant Co-applicant
Date of Signature Date of Signature
SEPTIC TANK MAINTENANCE AGREEMM
St. Croix County
OWNER/BUYER_ V +1 MES W. M AL MG-R M N
ADDRESS: FIRE NO:
LOCATION: I~ C 1/4t _ 5 W 1/4 , SEC. T_4 N-R_ 20 W, 1 ST
TOWN OF:- SO M E R 5 Er ST. • CROIX COUNTY
SUBDIVISION: LOT NO._
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 to
help with the cost of the 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 the St. Croix County
Zoning a certification form, signed by the owner and by a master
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. Certification from will be sent approximately
30 days prior to three year expiration.
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 form must be completed and returned to the St.
Croix County Zoning Officer within 30 days of the three year
expiration date.
SIGNED:
6 1
' DATE:
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016