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HomeMy WebLinkAbout020-1140-10-000 tom. ° 3 o I ~v O 603, a a 0 I ~ I 0 o I N N I I ~ I C I I I O o I O C Z I ti c I ~ ¢ I o c) N I ~ y E O V rn Z ti m I C o o Z r :3 d z a ° o N H r I rn y Z E I hh~~ r+~J N M c0 N N N •IrV y o U _ 0 (D O Z co z N z I v m > N I v R c co m - d o O1 0 o y .c3 d O C ~n u~i C D CL M 0 N I co U) U) wo r o v o0 0 o Zo I IL M IL I IL a = N N 7 N V cc rn rn } ~i J ° o o C O r _ 0 O O a I CD ;5 O N O N O O O :3 O ~ p) pp 7 co y o a o co 0 V~ _ ~ y y I Sri o ° -2 O C~ O m O E (O r- co U T N O N C C fy1 a~ O O (vl ^ f2 Y Y C~ N N wl C C N N C d' 0) O C: r pj O N y ~ ad+ n O N N > C a+ C t r r l O 2 ! CO r O Z W (n O~ w = I ~ I fat a €a `Iv ea a m d rr~~ e ~1 A uIL !OmC> i •.4Parcel 020-1140-10-000 08/25/2006 08:57 AM r PAGE 1 OF 1 Alt. Parcel 19.29.19.712 020 - TOWN OF HUDSON Current k ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner RICHARD E & MARY ANNE BENNETT O - BENNETT, RICHARD E & MARY ANNE 346 AUDUBON LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 346 AUDUBON LA SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.261 Plat: 2167-MALLACOVE SEC 19 T29N R19W MALLACOVE LOT 7 Block/Condo Bldg: LOT 7 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 720/31 07/23/1997 690/460 07/23/1997 577/371 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.261 59,200 280,600 339,800 NO Totals for 2006: General Property 1.261 59,200 280,600 339,800 Woodland 0.000 0 0 Totals for 2005: General Property 1.261 59,200 280,600 339,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 117 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 cPARTM~NT OF REPORT ON SOIL BORINGS AND SAFETY & BU INDlJS{TRI~ , r - - D LABOR AND PERCOLATION TESTS (115) , P.O. BO HUMAN RELATIONS MADISON, WI 5, (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIPlR ITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: NE 1/4 m1 1/4 19 /T29 N/R19A (or) W Hudson n/a n/a n/a COUNTY: OWNER'S NAME: MAILIN ADDRESS: St. Croix Richard E. Bennett 1346 Audubon Ln., Hudson, 111. 54016 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence 3 n/a ❑ New Replace 3_11_92 n/a RATING: S= Site suitable for system U= Site unsuitable for yste r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TTAnA,NK: RECOMMENDED SYSTEM: (optional) ®S ❑ U ®S ❑ U DS ❑ U ❑ S ®U ❑ S L~ conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: class 1 Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 57 ME BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 84 none >84 0-10, 10yr3/2, L.; 10-33, 10yr4/4, ls.; 33-84- 99.52 1 r5 4 co. S. 2 84 A8.62 none >84 0-3, 10yr3/2, sl.; 8-29, 10yr4/4, ls.,;- B- 29-84, 1 5/4, Co. S. B-3 82 98.92 none >82 -7, 10yr3/2, sl.: 7-27, 10yr4/4, ls.; 27-82,- 1 4 4 co. S. & r. B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P- P- P-see esi rate 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. SYSTEM ELEVATION 95.62 15 f J3 P l?IL E z_ F ~Gp 3 ~c 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): TESTS WERE COMPLETED ON: Gary L. Steel 3-11-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. AVe.,NeW Richnond, [Ti. 54017 2293 715-246,%200 CST SIGNAT DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - F. 'HE : i TO THE J AS BUILT SANITARY SYSTEM REPORT OWNER f1 l c # A LQ 13 7 T TOWNSHIP IVC1 n/ SECTION / 9 T_,L2_N-R_Lf W ADDRESS_ 3y4 L A ST. CROIX COUNTY, WISCONSIN 1&0 - ro /V SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~ C /~rT/cA c Sco/~C' r ~ A~vE 15 T, 1--t 1~ ~ 1 I I ~ CLL 1' ~J I I I ~ I I &,4,e At C S -CA C-' « _'yd i INDICATE NORTH ARROW BENCHMARK:Elevation and description: STec=L- Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grad ev: Tank inlet elev.: Tank outle ev.: No. of feet from neares d:Front , Side , Rear Ft. From neares op. line:Front , Side , Rear. Ft. . of feet from: Well , Building: (include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact. : Pum i.ze Elevation of inlet: Bottom of tank el ion Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: witch Type: Location _Ft. Distance from rest prop. line: Front_, Side, Rear D' ce from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: --LI_Length ! O Number of Lines:-,,~--Area Built Exist. Grade Elev. 179 Proposed Final Grade Elev. 9Z Fill depth to top of pipe: 301 /t No. feet from nearest prop. line:Front , Side, Rear Ft._,L No. feet from well: d2 No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bott n Elevation of inlet: No. feet from n st prop. line:Front , Side , Rear Ft. :1-arm . fe rom: Well building , nearest road Manufacturer: INSPECTOR: DATE : PLUMBER ON JOB : LICENSE NUMBER: 3~0 6/90:cj I C!ATI9P: HUDg0y 19.29.19.712 NE NW AUDUBON LANE isconsin partmento In ustry, PR(WE SWAGE SYSTEM County: fety and Human Relations Safety end 64ildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 175644 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: ENNETT, RICHARD E & MARY ANNE HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: t`J 1'12e..1 /ri ,a,. 020-1140-10-000 TANK INFORMATION ELEVATION DATA A9200303 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark I bS, I/ Dosing Aeration Bldg. Sewer Holding c+ TANK SETBACK INFORMATION sty r-a Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt-[PAP_t Septic NA Qt--g©ttom - Dosing NA Header / Man. 3 q 5 / Aeration NA Dist. Pipe ' G6 c} y Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. Towed SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS car 0 DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM INFORMATION TypeO f CHAMBER Model Number: System: OR UNIT 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 Topsoil E] Yes No ❑ ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons pr5tesent, etc.) 5 + 1U' e r. i ❑ ~►;5 Plan revision required? ❑ Yes No - Use other side for additional information. (J~~ l t~~' / o~y ll C~ 1 f .~'"'~tx-t,d' SBD-6710 (R 05/91) Date L Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 17DILHR SANITARY PERMIT APPLICATION ` In accord with ILHR 83.05, Wis. Adm. Code CoUN STATE SANIT RY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than / L/ 8% x 11 inches in size. ❑ cn k i resion previous pplication -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 91C k ,EF% 4V%, S/ T 9, N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # a I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 14 UP 5QA1 IVA 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE : NEAREST ROAD P9 S ullalV ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms AR CEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 0 1 ❑ Apt/Condo 2 El Assembly Hall 6 E1 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 El Hotel/Motel 9 El Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.E1 New 2. ® Replacement 3. ❑ Replacement of 4.E1 Reconnection of 5.E1 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 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 O 0 , krL 9~6 Feet , 0 Feet .12 VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank 02 Q - Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show2=9 ached plans. Plumber's Name (Print): Piu is Signature: (No ps M /MPRSW No Business Phone Number: T - l _ Plumber's Address (Street, City, State, Zip Code): L F r p IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved San!!fy Permit Fee (includes Groundwater Date sue Issuing Agent Signature (No Stamps) *Approve d Surcharge Fee) ❑ Owner Given Initial Adv rs Determination E a GJ 4; '9 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 r 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 mainta.ihed. The septic tank(s) must be pumped by a licensed purnper 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, (308-266-3815. 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% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimension`, 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 tit==ved; B) iorizontai and vertical elevation rMerenc:e points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manu'`acturer; D) cross section of t° e i-oil absorption system if required by the county; F) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 11983 Wisconsin Act 410 included the creation of surcharges (€ees) ;ur a number of regulated practices which can effect groundwater. The monies coil+. Jed through thcose surcharges are w;eo fioi nvionJoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (8.11/88) i i 34 I - 7 - - - - - - - N I T !S - ! - S E Qlc~ lot; tj, X 6 O - - 14 Ir ~ I I I ~ I I ~ j I ~ I ' I I i ~ l lj I I j I I I i I ~I G' l i I I I I I I ~ I ' I I I I i I, I ' i I I i I I I I I I I I I I I I ~ I i I I I I' I I li ~ I i i it I I i I I ~ i, ~ I I, II i I I i I I I ~ I _ ' I i I I ~ I I i - I , i I I li ~ li I I I I I I I I I I f I i I ~ i I I I i I I I i I i ~ I I I ~I ~ I I ~ I l i l t I I i I I I f l ~ ~ i l l l ~ j_ ~ I I , I 1 1 I I I~I ~ ~ DEPAPITMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W3909 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/fTY: LOT NO.: BLK. No.: SUBDIVISION NAME: j~k I NE 1/4 Nw 1/ 19 /T29 NlIk9A (or) w Hudson n/a n/a n/a COUNTY: OWNER'S NAME: MAILING ADDRESS: St. Croix Richard E. Bennett 1346 Audubon Ln., Hudson, 11I. 54016 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER AL DESCRIPTION: E T S: ERCOLATIONTEW,,tS: Residence 3 n/a ❑New Replace 1PROFILE 8-11-92 n/ai FE RATING: S= Site suitable for system U= Site unsuitable for system „ «t ONVENTI AL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S EJU ®S ❑ U J DS ❑ U ❑ S ®U ❑ S r conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: class 1 I Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 57 aE BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND D PTH NUMBER DEPTH IN. ELEVATION OBSERVED E HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 84 99.52 none >84 0-10, 10yr3/2, L.; 10-33, 10yr4/4, Is.; 33-84,41. 1 r5 4 co. S. 0-8, 10yr3/2, sl.; 8-29, 10yr4/4, Is.,;- B.2 84 98.62 none >84 29-84 1 r5/4, Co. S. B_3 82 98.92 none >82 -7, 10yr3/2, sl.: 7-27, 10yr4/4, Is.; 27-82, 10 r4 4 co. S. & r. B- B- S B- PERCOLATION TESTS TF EPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUT NUMBER NCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH a< P- P- P-see EE gn rate 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. SYSTEM ELEVATION 95.62 . , r it, ? All , I 4-1 S~ E , l A , I 'Cb j i I I I ~ 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 W 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 : TESTS WERE COMPLETED ON: Gary L. Steel 8-11-92; ADDRESS: CERTIFICATION NUMBER: PHONE NUMBERIop 1);y 1554 200th. Ave.,New Richmond, Wi. 54017 2293 1715-246/~i20 CST SIGNAT . _ f r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DII IR-SBD &395 (R. 10/83) - OVER - i STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER lei (2- ~ d ROUTE/BOX NUMBER ,t30 FIRE NO. CITY/STATE /4.f o / ZIP a' PROPERTY LOCATION: _AL,~114 x_1/4, Section 12 , T_,V N, R__4,9 W, Town of I-I'C4 p s 0'_'- , St. Croix County, Subdivision Q o v'F_ , Lot No. -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 $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 " 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 A~N i) Location of property &CAJ 1/4 &z!!^ 1/4, Section / 9 , T_-:~y N-R7W Township - AllaA Mailing address : L1 801"1 Jq ,yam Address of site r.! go.~/ k Z C Q,y~ k' I/. s-l~Q /6 Subdivision name /77i9/1,,q(2o tJ , Lot number Z Previous owner of property C Total size of parcel ,x Date parcel was created y--a- 7~ Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house)? Yes N0 Volume ~~and Page NumberL 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. t,/Q ; 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. Signature of Owner Signatu of Co-Owner (If Applicable) Date of Signature at Date of Signature t Irmo nne. Bennt • .._{t#~,`p-1.~~i.~ir-- tss...itei?a!?~ts witA + T~ac Grantor. a IMUFA Croix........ _ . - ~priMd sat .sate is the t•11•wins ty Sto G"Is"s tate of WiNonsin, Cnn Tax Paved No: Addition to the Town of Hudson Lot 7, 1+lallacove s covenan" f TOGETHER WITH and SUBJECT TO any other easements, this smell enetimbr reservations or restrictions of record, if any, such other recorded but not be deemed 'to law therefor. not be established by - beyond the term m i homestead proPmry : 15 This - (a) (is not) urtenances thereunto belonging: `I Together with sit and singular the hered"ments and aPP ...ilcox...... And indete+tsible in fee simple and free and clear of encumbrances excep Rose M.W warrants that the title a good, none C September 14.:,.,.... and will warrant and defend the same. k 3rdday of v;. Dated this 777 ....(SEAL) (SEAL) . Rose M. Wilcox (SEAL) k - i ACRNOWLlIDOIts N ADTSENTICATION STATE OF WISCONSIN of Rose M. Wilcox ss. Signature(s) County. of - 85 Yersunally came before me this , r_ . ptember Is... .19 authenticated this ta►. above nsm.d a _ f y o Ze, . Hug . TITLE: MEM BER STATE BAR OF W (S( ONS ' who executed the to me knoll to be the person (if not, the ssmt• suthoristd by - - - Stats foregoing instrument and ,knowledge THIS INSTRUMENT WAS DRAFTED By - _ Gonnty~~ Gwin Gavin ...4........... 54 ..0. 1.6 >Et not, state exp Streg t - Sec1W isconsin . rota-~ Pnbltt p - IKt• ('nmmission is permanent. ~1}~$Qn.r.. W.. _ (Signature= may he authenticated or acknowledged. Both date' are not necessary) •huuld is vr'• ur I'rintrd he16•+ their .!tortures. • of prnon• •i~nlni in •^Y r&PI-Ay br N.~• ' aTATE tA* Of 1-If w_%ONnia1N lORra 110.