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HomeMy WebLinkAbout040-1210-20-000 -0 0 Qr O ~ o o p (!A C O tl I I fO O N L t~ iII N 11 y Q i e s 0 0 'p Z I c LL m LL C 0 Q ' I co I Z V! N U) O Z a> d 00 w a m N H Z o I o Z d c U o _ 0 d z ( z E II, .a ~ M I 0 N O = co N 'n N O N O • O IL (n L U co O o c Q w Z co z o N N z _c Co N L N M E N N m N N L d x CL 2 L G a C Q ~i a LL 0 0 0 J z • bra 6 m m m FL B 4j L. O M co N 7 O N I 0) 0) N N J U 2 rn rn U o n r o co o l C N O T O N 0) N N U MO •N- E N a) (o d m M O N N N O 7 n 6 m Q Um 7 7 C C) co N C " O CZ 9 O O O C O C C U 0 0 0 0 O T O O O O y ~r N C , O O O Y N N N V C O O OII ~ O N N O (O N r-- 4.r N N E N M Z +2; O 00 N W N L: N I~ 04 0 E a) yy O N F- '7 O - F- to 4 ~ E m y 10 d m xt a a w • ca c a .2 m s ~1 A 0 ~ (L o '4 00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_ -FO VV'-`Q S _el ADDRESS SUBDIVISION / CSM# s-4 G ro ` ` 4` L g*t,- c~ LOT SECTION . S^ T9 ~?N-R°1'o~~ t~ Town o f v ST. CROIXC COUNTY, WISCONSIN 3 T3 a PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYST j ti T, UJ INDICATE NORTH ARROW V Provide setback and elevaIGAeWfoY'fiItriS on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: _ t r g ~j~`l~ V11.♦ 6 7- ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.-TANK INFORMATION Manufacturer: Lk)wQ S 40 y- Liquid Capacity: 1000 Setback from: Well -ed House 3 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: l oZ Length Number of trenches 0 ~ Distance & Direction to nearest prop. line: - 15, 40 - K) Setback from: well: cZV U House L ; Q Other ELEVATIONS Building Sewer ST Inlet: C/~ ST outlet S^. C~ all PC inlet PC bottom Pump Off b Header/Manifold Bottom of system S U ~ Existing Grade Final grad-e-_.-„_.... DATE OF INSTALLATION: PLUMBER ON JOB: 14-1 ,ati•= LICENSE NUMBER: INSPECTOR: 3/93:jt LtdMZQ*4irtWd1AQN in2&&y~Z8.20.997 0 FtIFv WWA@E 1 E MIRCLE County: - Laboran;A Auman Relations INSPECTION REPORT ,Safety and Buildings Division (ATTACH TO PERMIT) sanitar ~,it GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI X"= 3 X ev.: Insp. BM Elev.: BM Descriptio Parcel Tax No.: /00, .,r" ? 210-20-000 TANK INFORMATION ELEVATION DATA A9300215 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /r Benchmark /D t $4, 160? Dosing /01,54 /001 Aeration Bldg. Sewer qtl g/ Holding St/ Ht Inlet 2 Oq y 4-v TANK SETBACK INFORMATION St/ Ht Outlet i 11 Vent irito ntake ROAD Dt Inlet TANK TO P / L WELL BLDG. A Air Septic >d~ 1 U 3v 7-3a, NA Dt Bottom Dosing NA Header/ Man. ?~9(0 (0o, 9 Aeration NA Dist. Pipe 106• -7 V Holding Bot. System L/'o qq, gd PUMP/ SIPHON INFORMATION Final Grade c Manufacturer Demand 5,014-0 Model Number GPM I Loss Friction System TDH Ft TDH Lift Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS !11 DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O 3~ 1"50t / /1" OR UNIT CHAMBER Model Number: System: / J-O t7 DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 ` s i J -T Topsoil [I Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) t (o LOCATION: TROY 25.28.20.997,NE,SW,LOT 12,G EN CIRCLE z ~ N (~rz6 r 1 Lp= Plan revision required? ❑ Yes IVo f Use other side for additional information. J "7 Ja11.6 T /o SBD-6710 (R 05/91) Date 1 pe r' gnature Cert. No. ADDITIONAL COMMENTS AND SKETCH R * T SANITARY PERMIT NUMBER: ' T DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code - ~.a.~., STATE ITR RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ((//JJ Q.j ion to.~evious application 8% x 11 inches in size. ❑ chec if revis -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 L , . Q.. !'/4 S U) t/4, S T N, R .2 © (or) PROPE TY O ER'S MAILING ADDRESS LOT #L r BLOCK # CIT~TAZE ZIP CODE PHONE NUMBER SUBDIVI N NAME, OR C~Slyl NUMBE II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE la =N O~: ❑ Public [Z1 or 2 Fam. Dwelling4 of bedrooms- PAR L N M R v` III. BUILDING USE: (If building type is public, check all that apply) a 1 ❑ Apt/Condo T 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. F2 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 54~ 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 RE ED (s PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Q, ELEVATION /47 A, 7, 1 ~ rOA XS ~ / Feet LO Feet L-1 Sr~ VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete glass App. Tanks Tanks structed Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber, El I L1 I F1 F-1 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 SS MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): z; #1 C4,/ ef IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing Agent o Stamps) QC)Surcharge Fee) ® Approved ❑ Owner Given Initial 41J U Adverse Determination X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: S1313-6398 (formerly Pib-67) (R. 11/98) 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 parmi" 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 (d:13D 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%i 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, €ocation of holdirg tank(s), septic tank(s) or other treatment tanks; bui?ding sewers; vwelis; water m~iin -/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systerns; replacement system areas; and the location of the building served, 6) 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. Tha rraoi G c-'11octed through these surcharges are used for monitoring groundwater, grotind- water c:ontarnir ation investigations and establishment of standards. SBD-6398 (R.11/88) 6ttA U ~ - RQ ~d 1 0" 4 ~ ~ m 1 i ~ 'eC .Ji I C o .J V4 1 ~a PAGE OF , crUSS ~CC~I0(1 Q~ i~ LJC17 J~SIc'n'~ fresh Air Inlets And Obcervallon Pipe _ ^ -Approved _ Vent Cap Minimum 12" Above Final Grade 20- 42" Above Pipe -4" Cod Iron To Final Grade Vent Plpe LT Marsh Hay Or Synlhetk Coverings Min:; 2" Aggregale ; I Over Piper 01Uribullon -Tee ' Pipe ; o 0 0 0 0` rnr 6" Aggregate o Perforated Pipe Below W Beneath Plpe o -Coupling Terminating AI Bottom Of . SyUem } v' z.. }~r4 T- I SOIL FILL DISTRIBUTIOFJ PIPE APPROVED S414PETIC COVCR ° " -MATRIA~ OR 9"' OF STRAW 211 OF'AGGREGAlI oR MARSU HAy 9 4, (e~0 F1y-Zt~2 AGGRE AT -34 DISTR 'aUT.IOU- PTE TO. E QT LE?,ST liU,cHES x, Cvl.. $,E,l Ow ORIG,i.tJ,AL RAOE ; _rM ~,!Jev A~ A s Y z o a ,c a k~ W dap T u o Q; Ire A 2 ll~ke,yt,E s try •L o w ,i,w1 ,L ,G,~ wo,E w r G7t!~X , 94P ni OF F-XcAVMTiop F'RQm oKiMNA- , Rai WILD BE 11JCr,+ $ /r1,1; d; U REP T -1i OF XC !/A TI ON oM ,G.g 4,9,~ WILL $ E i N C H ,r- S " ti r C . a` ,fit ,f z LIGEUSE AJUMBER: DATE zo~© A3 i t n E PARfMF_Nr OF REPORT ON SOIL.-BORINGS AND SAFETY & BUILDINGS dUt.)ti1 fi1•• DIVISION MADISON, wi 53707 IWC is PERCOLATION TESTS (115) i' 0. BOX 7969 UINIAN Iil::lr^~EiU1~5 M63.09(1) tic Chapter 145.045) _INPd$lil f!1•t!~'ff'r~rR'F'f1' Lill Jt~~~LIC.N(l'"UF'I7IJISIOI~)i`IArv1~:...-..__._.._. E ,~~W4 Z ~~2~/ T~TZ..c I Z (i~(1CyFIW1.hNL1 OUN i Y t~ i0"i"rii. _jA:lil~°:'' . Tvf~ ~ ~iSFfCfifi"' -r YAtL..._LE5$~e.D 7zS PINE A1066 T'aFr_A.C1 . R-( y~~JcA k.~/• ;l DATES OBSERVATIONS MADE E QF~tiffi QTIOV TM-71 DES nln."It~(~r:nr> 1j: t iTvTM~f> rF /i:~~TS sct~lrt rroni: l,•- i3FfC1 ~fftts,.)_ .I 1. N . Yt _ New ~..1Raplarcca I Z P ~ ~~~Z% /t tO S,,nIL 11__1.5., 011..5; .BXC2 $UR.IC.14 P.RL~T 4iTING: 56 S,t,i suitable forsystarrt Un Site unsuitable for system SK pL 7N~ 9NTI'5TIAt: P Ui\iD.-' i(V-c1AdU_ LJRE; ,Iu 1~I-T li IiL OLDINC1 T NK RECOMMENDED SYSTEM: (optional)~ c s. a s.LAI._ s~c~u 4 r sou u .__,Z, XsZ' most) 1't'!t: „ ' NCt1 rt rpnt, A ~GC:9TGN FinTC If any portion cif the tester) area is In th,; nL+, a.t16 !,,i')E(tit rilir;!It N A C,,L ASSZ- Mltil Floodplalo, indicate Floodplain elavetion: 1V A. PEtcTMRo- PROFILE DESCRIPTIONS 1 t+~FtA I t i i INS ' tPAWA?TTM_0 IL Wl1 H TtI~CICf~I SS, ~filt~#i, l''EX1TlFtE, AND DEPTH )fJtl i Ii 1'It',,y, f I It t,d U'i, it It L11 1 (U HFiJ K IF ASEL Vc.D (SEE A_88FtV. UN BACK.) A-50' 8r_ Vi_ IrS l.za' 8,4 S; L j G•oo' Bw C~5 6L S:L ..1'S% 1^vW8r4/.oo R0 A../4: ro I 2 ? 8 •ZO I Sao, 3 i Oi~(cr' y 8• Zt3 Mt4 7 r3~/ C' 2 4.~v ,V /,o ' SL 5 •L . rS 0.80 i3.,/ S C. o.4o' 3..i L w G~ I' 3 .17• .~5 ioz, 38 4~v+✓ > 7-35 o.40' 8 •j CS W/ c= r?-. ~.~s ' r✓ CS ' spa ' D' ~ D l.4- 7.90 /03.8Si A10 ME: > 7•`)v ~ ~ _4,oo'B~/GSL~ 5+ m•so~ MvS__; I_ ,_.._..i _,.1 e- tr ' gL 5;L 7'S; 1.70' II~ S: L; I•0 0 M0 Q G 7.Zo loo,03 ° , J - y ? 2. U I paol►~'yl. PERCOLATION TESTS F'e s'r . II"' ) t~CP1ft f ilAEEF?Ir1Plftl h 1['>T TIMF. DHOP IN W IE i 1 EV •L-I CH b RAT MINUT s t,~u tt T"* "S ar 1 bJi Sy1t t LINt3 IN7ERV L•MIN. °j 1U~5 1--' _..,_f t"i4T i- Fi~jf'Z'`T":•-._ PER INCH 3 ±4 tl N_..Qn~ 2 >.G_...._ ~ _}.E•~-~/,~Tl stn/ _ ~ i,'t' i'i AN. $:how lovatlovs .0 porcalatkm trrts, ;.oil hotings and the dimonsions of suitablo coil drwis. Indirata stau! 4r tUstunres. I t-w:rtbu what are tile liari tat wO o•!ttcnl o0vattnn rt htrcnco 1 iAtit- an(t shuav their location on the plot plan. Show the surface elevation at alt hnrintis awl the ditrction ands perturnt kw:! iota,: YSTEM ELEVATION 19a SEQ..' Mk'_'sW 1= of K-ft N TN u•+:I ;r,ad, hwtari>y ::ert(fy that ov! ;;oII testy telmrtt,d on this Form were made by me in vecotd with tho procodurtt, wid roethods s►>n0fied in tit(! Wisconsin r~'„~ist: rn,..e C:oatu, :trxi iha#th,a data rc an-,:fetl lnrl ti,,Q lowtiot, of tho tests are correct to the host of my knowledito awl twllnt. iF ,i j :Fti (,OMPI FTk D tJPJ _ ~ LFtt I It-In'n' I,. y fu1,iV1N1:1'Ft(,P.11: NI.,t\A13E'It a lionatl. :!t:t:.~.',.: }nf. :.i~.y, n,.. .rl , !..:n: a!,Y.rtl;<H ltl' I''th Y•)w;,al t,:,:i :>V;, I ',.titrt 6 ti w LocATi,o►J 5 c. 14 u - /Nr~sn' /eo > . Nb Via. r IBS//viir • i _ e"Q, ta% b / sia~.. r /io • ore T~ h C f/e /e~ f~fb/ro~ /6 AO s Kr+abue 6b Gene yp~. t "33 tSMn B. 'a L%OUean ~ ~ ~ r ~ w°COO~ ~ P 1B M.6 ~ • ~ / V .t9.1 • ~b /yam. ` G J. r .li0 ~ r (j 4 A/ 8 E N G H IVI AAK. S TOP / j; of G U L..VBw-T 6'l... .r COQ. oo ,5,)V-f i Cae~V/'a ~ ~ i / vfl,~ o 14 S o Z 1Q ~ N $~5 / ¢~P~~~P EN7 0 ' 6 ilC ~ - O o + 3 ~ Sao ~ ~M C4 a C P-4 P-t ~ Z1 II sc~ E : ! ° = Zo' 3-3 4 e \ (4 4S s ; 5 I J. 4 P''• p 10 0 to. 0 m \ r + NOO•DO'DO'N e4" N ~ \ r' Al 6 / 1`01• \\•~o--'~~~ AO ANT 6 Q w 90.00-0011E 3 + f ` '6o•`~C/ACS /fq• ♦~a• f~+~ , \ ,sO?,v . 0 10 lO• UT14i rY ' ~ ~ 1. ~ N \ N~ T Z 9 W 13 &A f- _ 12 . \ \ \LO Q \ + -1..T~ X55.29__ ' 1 ♦ \~s g 10 \ ElEE NOTE) \ \ \ Sp, i IO'VTILITY LrAtL7' f \ i 1M. S•S7 •S 1?6'7. ~Ati¢M WT b. 1 Q J ~~i ' X65 •S b 776,1 r!0 NO ACCESS - :r•t1•r. !f~ 7.52^E V f ESS 190' • I eb. 1-. 377.65• NOO.13138'U 462.431 NOO•49'5Z"u x -'-.NOO•49'5?- _--GLENM0NT.- 0A0- " r - J V A h F .IL,•..•T ni w~~ Fr,•fM • M1M N88"13'38^N 1330.$3' DISTANCES SWOWN ARE. AT RIGHT 4N4LE TO NU RTH ' RIC.HT OFWAY OF L•LE.NMONT 0.040 ' UNPLATTED LANDS OWNED BY OTHERS 1 NOTE; OUTLOT 1 TO OE RETAINED OY OWNER! -LISTED HEREON AS A NON CONPORYINO - - I LOT AS PER WISCONSIN ADMINISTRATIVE - CODE CHAPTER "I "I ANDST.CROIx - LOCATIONMAP ,u a COUNTY IONINY ORDINANCE CHAPTER I3.' r: SEC. 23,TZi 4,420w 0 O ° r .v~b I N W NE 1 -r ° / • N C N ' Z 10 x,OV O:ENrr .+NT rN RIlAO z SW SE N V 0 10(1 ^Oi P7 SCALE 1^ • :000' ll ] P I:N c 'I03r'T m~ JA SHEET I OF 2 Jy -to S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER. !MM ftPkL--- (AdVt ADDRESS ' . FIRE NUMBER CNor.Q,&,4-30) CITY/STATE \l(~.1' ra,t\s ZIP~'~Y c~ PROPERTY LO~C,A~TION:1/4,y!1) 1/4, SECTION TocO N-R~W TOWN OF Ivy~ , St. Croix County, SUBDIVISION GJ 016L ~.Jhl , LOT NUMBER la . 7 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/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 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 011 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 by the owner(s) of the property being developed. Any inadequacies will only result ~n delays of the permit issuance. , Should this development be intended for resale by owner/contractor,(spec house), thenia 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,Alt,.1/4 SO 1/4, Sectiond~ , Ta~ N_R~?Q W Township Mailing address Address of site Subdivision name-_2 ftbi~ hlb-MS Lot no. loD Other homes on property? yes No Previous owner of property Le_~;saed Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ---L_,Yes No Is this property being developed for (spec house)? Yes No Volume and. Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICA'T'ION 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 (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded i the office of the County Register:of Deeds as Document No. / 7~s and that I (we) presently own the proposed site for the sewage disposal system obt ' ' or I (we) ained an easement, to run the above described property, for the construction of said system, and the same has been duly recorde in a office of County Register of deeds as Document N Zakl- Si natur of applicant Co-applican Date of Si nature Date of Signature r • ~ ~ T..If fIACL R[S[RVLD IOR RECORDING DATA DOCUMENT NO- WARRANTY DEED i STATE BAR OF WISCONSIN FORM 2-1988 4'71'753 von 9R)FAu 567 REGISTER'S OFFICE ST. CROIX CO., WI Recd for Record Valmore M. Lessard, a single person JUL 2 3 1991 at 8: 30 A. M . n C. James ana Lora $akke James, convey s and warrants to .......-...-.y....--.........--- pro RepisterofDeeds husband and wife, as suvivorship marital perty - . RETURN TO ' the following described real estate in Pierce State of Wisconsin: Tax Parcel No Lot Twelve (12), St. Croix Highlands in the Town of Troy, APke"e County, Wisconsin. St. Croix . ~`3`ii Q~►~ is not This homestead property. Xk* (is not) Exception to warranties: . Dated this day of (SEAL) SEA ) - - -1 E-f'` k y l Valmore M. Lessard • - - ----(SEAL) . ----(SEAL) . - y AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN Signature (a) .............County. Perso Ily came before me this of authenticated this .-----..day of.._--•--••-•-.-.. 19 / 19.11. the above named Valmore Lessard TITLE: MEMBER STATE BAR OF WISCONSIN - (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed t e reg~ g instrument and acknowledge -the same. fo r THIS INSTRUMENT WAS DRAFTED BY ~ f Russell E. Berg -Attorney at Law-_----_----_ a /-c _ //l~ - - . River Falls, Wisconsin 54022 No y Public . - . .County, Wis. tlon my, C'ortlmissi is permanent. (If nnf,~ .tate expira (Signatures may be authenticated or acknowledged. Both Y. 19-...._..) are not necessary.) date: ..................jEFFF?tY 6r1 !TC%•zl: _ Notary Puhhc S,a'a ~t -Names of venous signing in any capacity should be typed or printed ~1°w their eiEt'.atures. ~y CpP11711SSIGf1 [:X~IIdS 1~, ~ ' STATE BAR OF WISCONSIN Stock No. 13002 p FORE[ No. 2 - 1982 9MIff ~r