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HomeMy WebLinkAbout032-2076-60-010 (2) f t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER r Z'nZeEUI-K/ ADDRESS [ J c5C0a7 SUBDIVISION / CSM#LOT SECTION ~T0 N-RW, Town of fSQJ'7ElE'S~ j ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -scour CA11FI-) A? 0, r t. 30' ~ ! lf~X`53 s~ EpA~-~ ~ L ~ ' 390 AN EL, f(X~,O 2 ~ /doe C-L FO kC'c G /NN - Lie C' -L S1, p 'C /Z f, ;10 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r BENCHMARR :Q ,D / $ %eEL 1-1 o4 p_ fErC~CL G/.c~L ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: (,L9A,16F/C5 Liquid Capacity: /am Setback from: Well House Other Pump: Manufacturer L?Fi/~ Model# Size Float seperation Gallons/cycle:[ Alarm Location 7 3 SOIL ABSORPTION SYSTEM Width: Length 6-3 Number of trenches 3 UW Oe,0 Distance & Direction to nearest prop. line: ef}S% Setback from: well: House 30' Other ELEVATIONS Building Sewer ST Inlet; , 5, ST outlet _ p PC inlet; PC bottom 77, 3_ Pump Off _ Header/Manifold__~Z,Z.Z Bottom of system__91-0,-Y-,,'Z, Existing Grade Final grade DATE OF INSTAL LATIO PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt I s I r.:~-r -y,~- I 7 .3(-, r~QG ~ RD. County: fL7 U gip s ~~`~artri ist ~ • 20 - YRfV gfWSTsfK f Labor and Human Relations INSPECTION REPORT Safety and Buildings Division o.: (ATTACH TO PERMIT) sanitary it GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan D o.: rrzm T BM E ev.: Insp. BM Elev.: BDescription: Parcel Tax No.: ' "R..e. X" TANK INFORMATION ELEVATION DATA A9300016 ShROM :M TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark Dosing ks Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet /7.3V Air Intake Septic NA Dt Bottom a,033 Dosi ng NA Header / Man. q, S~ 9 j• a a-- Aeration NA Dist. Pipe q, 1,o•7 Holding Bot. System PUMP/ SIPHON INFORMATION Final GradeF 9~{,0 Manufacturer Demand ; I bale ( a Model Number GPM C TDH Lift Friction System TDH Ft oss mead Forcemai n Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM 0 U BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold 0 Distribution Pipe S), ` P t a z x Hole Size x Hole Spacing Vent To Air Intake Length T Dia. + Length `V Dia. Spacing ~o 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 Edg l ? Topsoil E] Yes ❑ No El Yes El No COMMENTS: (Include code discrepan s, persons present, etc.) /14/ i t f . LOCATION: HUDSON ~2-.-~.20 0OG,SE,NE, SCOUT C" i ~tr~ , I ~°is as (fl~iL.(w Plan revision required? ❑ Yes ❑ No Use other side for additional information. J3' j 1 3 l/ rya (:_A_ f< ' SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. F ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~°-SANITARY PERMIT APPLICATION 701L RIn accord with ILHR 83.05, Wis. Adm. Code Co~1N • STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 f T'C*]/A 8% x 11 inches in size. C ec i rev on``t'o' rewous 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 F Y4 '/4, S T p, N, R D E (or rvo PROPERTY WNER'S MAILING ADDRESS LOT # BLOCK # Z9 7 6FJ0 CUo CITY, STATE ZIP CODE / PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER O/ G 11. TYPE OF BUILDING: `(Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE * S G ❑ Public 1 or 2 Fam. Dwellin9# of bedrooms PARCEL TNUMBER(S) a a_~ll-~~`dd III. BUILDING USE: (If building type is public, check all that apply) a 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. ❑ 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 N 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 4/ Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed 5 S tic Tank or Holdin Tank 3001 1 U/ AL /f Lift Pump Tank/Si hon Chamber r . + Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): I u 's Signature: (No Stamps) W No.: Business Phone Number: Pf-umbbr's Address (Street, City, State, Zip Code : IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatur o Stamps) Approved El Owner Given Initial Surcharge Feel Adverse Determination X. CONDITIONS OF APPROVALIREASONS 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: r. 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. FIII 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) plat plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainslwater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas, ,-d the location of the building werved; B) horizontal and vertical elevation Deference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance cuive; pump model and purnp manufacturer; D) _ross 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 1933 Wsconsin fact 410 included the creation of surcharges (fees) or -I 47umber of regulated practices which can effect groundwater. The rricnies r•ollected throrigh these surchargos are used for rnoniioring grourdwater, ground- wate=r contamination investigations and esta blitit;ment iaf standardts. SBD-6398 (R.11/88) REPT131 SOMERSET ST. CROIX COUNTY ZONING PAGE 1 105/19/93 15:53 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/20/93 AREA: MJ Activity: A9300016 5/20/93 Type: CONV93 Status: PENDING Constr: Address : TSE,NE, SCOUT CAMP RD. Parcel: 020-1111-06-100 Occ: Use: Description: 193356 Applicant: MAJEWSKI, STEPHEN,& NANCY R HEDI Phone: Owner: MAJEWSKI, STEPHEN,& NANCY R HEDI Phone: -Contractor: SCHMITT, DONIVAN - - ------Phone:-568_4948------------------ - - Inspection Request Information..... Requestor: DON SCHMITT 0 Phone: Req Time: 1 Comments : 03 pr` Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION . I I i T- 1 I r I , I i i I RAO' r ,4 IA i PA V G 12 I I ' f_ j { , I I i , e eL ID - i I ~ I I t ~ - - 12 -e 1 Yii t E , ~ I , i i i I I I F f ~ f , i POOP , ' I ' E ~ t{~u I i I I ~ ► ; ESL, Pd7 I ! I ~A 1 1 s I i _ I i I 1 , .1- L - gi'l woo p 60 ~ - 1 ~ ~ j ~ ~ i i ~ ~ ~ ~ ~ 1 i i . I j .j ~ t ~ ~ ► 1 _ - , i j ! , i ~ ~ ~ ~ i i. i ~ ~ I ~ ~ j _ ~ i ! ~ ~ ~ i I ► i ~ i _ ~ ~ i I - l ( ~ _ ~ ~ _ ~ , Tf I i ~ ~ ~ ~ . ` I, _ ~ i - + i - , ~ _ ~ i I _ . i _y_ t 'r t. I _ ~ _ _ ~ i ~ t _i.. ~ _ _ i I ~ - ~ i i ~ i a - i f ~ i _ I ~ i PAGE CF •,^,1'~ PUMP CHAMBER CROSS SECTIOU AIJD SPECIFICAriokis VENT CAP 4"C.I. VENT PIPE WEATHERPROOF APPROVED LOCKING 25' FROM DOOR, JUUCTIOIJ BOX MANHOLE COVER WINDOW OR FRESH 12"MIU. AIR INTAKE I GRADE 1 I `1" MIAI. ~ CokJDUIT-/ V= 113"MIAI. \ 111 INLET PROVIDE I AIRTIGHT SEAL i I ! I s f \ A I II I I I II ALARM d I II_ I I C *APPROVED i ON , JOINTS WITH I ELEV. FT. APPROVED PIPE 3 1 ONTO PUMP ` j OFF 0 SOLID SOIL COMCRETE BLOCK RISER EXIT PERMITTED OWLH IF TANK MAMUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFI-CATIOAIS DOSE TANKS MANUFACTURER: LIUMBER OF DOSES: PER DAy TANK SIZE: - 6900 GALLONS DOSE VOLUME ALARM MAMUFACTURER: LE/1 F 4 f APM IWCLUDIMG BACKFLOW: GALLONS MODEL IJUMbEit: - JVA CAPACITIES: A= A &L IMCNES OR S CALLOUS SWITCH TYPE: 17~F/I GUiP L/ g = 2 INCHES OR GALLOLIS PUMP MAIJUFACTURER: _ ~D't~/ / '6 C= -Li_ INCHES OR 113 GALLOMS MODEL MUMBEM 13? D=INCHES OR 210' GALLONS 5WIfCH TYPE: A NOTE: PUMP AMD ALARM ARE TO BE MINIMUM DISCHARGE RATE ~O GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEREAICE BETWEEN PUMP OFF ARID DISTRIBUTION PIPE_ ~ FEET + MIIAJIIMUM NETWORK SUPPLY PRESSURE . , , " . " . 2.5 FEET + S FEET OF FORCE MAIM X 3,`r,L FyortFRICTION FACTOR._ LI- 2 FEET TOTAL O JAMIC. HEAD = 12, FEET IMTERAIAL DIMEMSIOMS; OF TA1JK' LENGTH ;WIDTH -;LIQUID DEPTH Ila SIGUED: LICEMSE NUMBER: 3~pS DATE:.a_-,I / -J3 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS 115 P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: Sc % / /T10 N/R l,OE (o - '5 S ,0 yEaS & - .26 ,/c,t COUNTY:. &AWEftWBUYER'S NAME: MAILING ADDRESS: tjo IX X_-11M -_4 /30/3 o 19S4/;vski /o yo S. FRo ) r 5~. e USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER ATION TESTIS: ]Residence N4 WNew ❑Replace 71 -3 1 TING: S= Site suitable for system U= Site unsuitable for system e 33 JNC2i ;6911-57#/64645 RA CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑ U ©S ❑ U ® S ❑ U ❑ S U ❑ S ®U oaq. 13,D aw 7-",vaEs If x 3 If Percolation Tests are NOT required DESIG/~N RATE: p st If any portion of the tested area is in the under s.H63.09(5)(b), indicate: l3evAr9 DR Floodplain, indicate Floodplain elevation: Im 'DCCiMAL Ft, J, PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH' I ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) - S ~I3• 7 33' /3,u• S// 33 1-y" '0 S:/, •-03' RA(,-~3N • 33 B ' 60 y 5_ emmit -13 A) . /S :1 . - aj gtdASe S/. B- 2- 15j/, . ?5 ' 44. -&Y. F/4, TA.v 7 p • S'8 ' of as . II . J 9 `l~ 8'S PRJ sf W 5440 ockxts 3 • ' '^jj. RPS s1 1 &U. SA J) . 33 ' D~• 2" . 5i/, -93 'Gy si'/, 6 7'Z/- • S"", 133' A-) B- 3 sl . 3 '1-M( /3N. 5 ,j. Is > 33'Qa•s!/, /.,f "1 (3N s;! 1./7 'L1/ y . si/, 7 f ' N. S r / B- CDC l~ /a s W jot, 4.ecsr . SA O Gk~¢-'7fS r .112,' P : 6N . s; / ~ .o ' ~ . GA) . 5" I's S M /)C, 3 B- 9 5 9 J` ~aw► S aR.~ f, G .2 33 " PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN. AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PERIOD 3 PER INCH P-l .0 O P- P_ 2- . Z O P-_ PH7 & 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. /J° 77 QM 7AC4)GG, 67;("114-PP9,v = P 7 FT . SYSTEM ELEVATION / ~ m I 4 3 - p U ....t`1... mm_ E I C41 M , r I .I _ , 7,' - - i S ►e X31 ~1 ! r Q i a a ip ,407'1 -l W? _ I F - - I V 00 9 I .......a_... 'lip,i f_j -3d'nls~ 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 ldministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. ME (print : ITOMESITE TESTING CO. TESTS WERE COMPLETED N: STAT$APPROVED SITE EVALUATIONS PERC'TEST I - / ql ey DRESS: MINNESOTA LICENSE NO. 00063 CE IFICATION NUMBER: PHONE NUMBER (optional): t WISCONSIN LICENSE 140.55-02482 3 .Q 3- JLTO 2 D=LrtaaHulSwisW154016 CST SIGNATURE: , RIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -SBD-6395 (R. 02/82) - OVER - 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 section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commerciaj use planned; 4. Is this a new or rn --rant system; a Complete the SU ,r rating boxes. A SIT ;SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEM- ARE RULED OUT BAS LSOIL CONDITIONS; 6. PLEASE use the abbreviations shown here fc citing profile descriptions and completing the plot plan; 7. "AKE A LEGIBL' diagram accurately locating your test locations. Drawing to scale is preferred. A --te sheet -Y dy k ° r£etld if desired; sure your mark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10, If the information is flood plain -'on) does not apply, place N.A. In the C `e bo.x; 11. Sign the form and , your current adc_ and your certification number; 12. Make legible copies and distribute as re, Ared. ALL SOIL TESTS MUST BE FIL, WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Ti Other Symbols st - Stone {ove=r. 10") B - Bedrock col) - Cobble {3 - 10"} SS Sandstone gr Gravel (under 3") LS - Limestone Xs - Sand HCdV Nigh Grout cs - Coar,-n Sand P, - Percolatiu,a rroed s - Medii!t Sand Well fs Fi Building Is - Loa ! S . id zater Than sl t Than Bra - In *sil I BI - Silt Gy r. Loam Y - Clay Loam R - 1- ay Loam ntot _ es 1y Cay . vj/ a y Clay fff, fine - ~ - ornmon, Many, mi o rr).rck - distinct p _ l ninent HWL wa ;~osa! RM - • VRP - ~.I R Point I TC OWNER= ng Erie county or , f A corn(„,~, appropriate Ir~ A, r A snit by obtait: :d prior to the start of z 011 O/Z ti 3TC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ,P '/~E/~Q~_TL~L~~~ OWNER/BUYER S ~E ROUTE/BOX NUMBER FIRE NO. CITY/STATE ~IDUc 7Q & W/" ZIP PROPERTY LOCATION: ~S~F 1/4 /4, Section T_ao N, R_Q~W, Town of s~/~s 4E7"rt~ , St. Croix County, Subdivision /IA , Lot No. /y/4 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 $3000 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 systems properly maintained. The property owner agrees to submit to 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 form 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 Department 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. SIGNED DATE ' St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address I APPLICATION FOR SANITARY PERMIT 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), then a 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 _5C-_ 1/4 A(6-1/4, Section y , T_20N-R,,gO W Township ; Ilma4 'e 7 Mailing address 6eou Dy all 12.azZ Address of site ~ GDu7 L'_A ft!?G!~ %DN /Zf _ r Subdivision name Q Lot number A(A I° Previous owner of property Total size of parcelL f Date parcel was created Are all corners and lot lines Identifiable? es No Is this property being developed for resale (spec house)? Yes _N0 Volume 9 2 .2. -and Page Number 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, and 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. ~199ZI6•11 ; 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 duly recorded in the Office of the County Register of Deeds, as Document No. y~ S~yO y Signature of' owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature J DOCUMENT NO. WANRANTY DEED T/115 51 ACE nESEnV EO FOfI nCCOnDINC DATA 1 11 STATE BAR OF WISCONSIN FORM 2 - 1082 48.9404 REGIST .R'5 Q rig Robert J. Kol-ash i nski and Kim M. Kol ashi ns.k.i , ST. CROIX tp.' W1~ husband and .wife 4; Reed fof RglpF~ OCT 0 21992 at conveys and warrants to Nancy..R . RedzLn-,-.a_sing1e•.woulan.-and 9:50 A. M SePe??..A.e..1KJewk..i3..S?Itg~_.10.~n V ~M'tiM Re terofDeedsT= nETVRN TO the following described real estate in St_..CroiX .......................County, State of Wisconsin: Tax Parcel No: E Part of the NE1/4 of SE1/4 and Part of the SE1/4 of NE1/4 of Section 14, Township 30 North, Range 20 West, St. Croix County, Wisconsin descsribqA as follows: Commencing at the East Quarter corner of Section 14, said East Quarter corner is also the point of beginning of this description; thence S00°06125"E along the East line of the SE1/4, 1319.70 feet; thence S8963i'31"W (recorded as N8904910011E) along the North line of the SE1/4 of SE1/4, 360.30 feet; thence NO1°01'48"E, 2204.96 feet; thence NO06081 15"W, 416.95 feet; thence N89032155"E along the North line of the SEl/4 of NE1/4, 313.45 feet; thence S00°15'11'tE, along the East line of the NE1/4, 1301.34 feet to the East Quarter corner df said section 14 and the point of beginning. This 1 S not homestead property. R AN E. O (is) (is not) . Exception to warranties: I)ated this lst day of .C.tober'.................. 19..92... (SEAL) ............(SEAL) Robert J. Kolashinski (SEAL) .....f .!..A.... 1•:-•' ~!w!!~-'.~.(SEAL) Kim M. Kolashinski AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF MIS' 1MM MN Bg' ° Washington .County. authenticated this day of ..........................1 19...... Personallv came before me this ~t....day of . obQr I9 92... the above named Kol J. (r.) *6 inski.,...husband.and-. t zZ =r- TITLE: MEMBER STATE BAR OF WISCONSIN w z.Q...m - 5 (If not . I- -z Ai. 1 authorized by § 706.06, Wis. Stats.) co nown to be the p on .......S... who executed the to -"°pg instrument d cknowledge a same. ~ E > Aid('J fV'~'~'~fY'1 E~FTST~YLWATER - {i > Q 9 °i t83 1V~rt~wesern Aveni.,e ~ AM.. a Public -Washington..................... County , ' . MN t f v a ~'r ff j,8~knowledged I ommission is permanent. (If not, state expiration ( Sign atu res m Bo are not necessary.) y / .Names of persons signing in any capacity should be typed or Printed below their signntures.