Loading...
HomeMy WebLinkAbout040-1032-95-100 -O1 O c o o• s1 o O1 U~, r;. rc y I 0. O C t~ o I O N O ~ C M N X C N L() 'O Q) co L 'ZS ~ C O M O N o n ~ I Y o z Uw C o ~ U LL C 0 O _O O O O O Q y Cl) z " w E o Z 00~ a ~ai am H U) I oz,+l! c V N m Z O d c N F- O C c N ~y 0 0) w co CL 0 w 0 N N O. N rn U) C U.) Z ~ N O O •y\~ a V U O C O O N O O c Z F- Z Zo ~ o y E I Y O to - tY = }y o a CL 'R co V a n y d o U C ooa con > N F F FN- a = O O O •~a a a a ~►j N N Fib 7 p N U) 0) 0) LL M O 5 N p O O 'a m o ~ N~ co a d m ~l o ^iO O O N N C 'T r7 Q) LO co © i O O a U m v) O rn O ~ O C c O O T N V co O 0 'n C c N p F- N v V v r N T 3 M O n N yT,~' O O F- = 0 O N tD U 2 UJ v Ea r/] S ` G L: a w *Ali • C~ G d Y ' d y a A U a 0 v) V ~C o II m °o I M ti O o Q a C 0 o ~ I y I o _ I N a I N N f6 ~ I O _O V C i m fy I ~ ~ I `o P~ w I N U M N N ~ a O Z c C n LL Cl) I ; .2 ~ 0 I o o Q v c I Cl) ~ I N w E 0) = O zs z 00 a m 0 E z :t y Z v o (A H r CD Z o co c J c c O 0 o E Q 0 Z F- Z N z r-- cc E N °D Wit c % mi aEi - _ m to 4 m m d V 00- °o O G G a E N hw Q o otr~tr~rm :3 ~o t~v4J Z 0333 EL Zo 000 IL IL a ~i N U O U) J Z 0 g! g! LO LL i-o ~a C:, w O N =O C Q O E r m c d 'd N Z m a? M m Q v) d w y ° O w M C O N D OD 4) CD G o (L C U d (m p p r \ C " € O "O N N V O M O ,FO O N C j T 3 v C L a OD Co O y N N Co • 2 ! m O N O R U O ice. O O H 2 O Z U Z (n V .r m Cc € a 7 I It • C~ C. d G7 Gi C t~ C) IL U) 0 0 b ~ r C"7 z f Cpl rn s T o rn• v m y m o 'tn -I Cn -3 TJ T O z ►r to v < c~ ~ z t--4 It ~ N 0) N CD O O et IV N O CD rn ••G c .0 tD p to a 0) a+ n d 9 N N o p c rr -3 m m rl- to n a s ~ N ~ O n O o n tD O -1 C tt n a o. r C1 1 to oT • C) w -n z o = fr rn • 'r o c--I 0) z z o Cl) o CD CO r=-1 to m S Cl n O o 2 . V z S O p ~i tT o m -1 1--1 m rn tl ID £ m C) 7 Z a o) o rr tD n „ a o rt, ° ~rr 3 .•r 'D T N o tD tD p rn N '7 2 O D CL D) T rn to m m< `G ~ O N (,J1 N ~ 2 s - o a ~ m c = to o m Cl) m 171.47 003 0 d V L1 r- S N N O to W. M -n O 2 N N 7 C• N y V p m m S O V < C) CD 3C ~ 7 1 n O v z 1 c 1 C V O O + tT N r C O I O 31C N3 I~ O m co ~ z I ~ ~ fl) CJ7 w I + - nD c-, c N - \ o c r T a to N j d Ir N ` 11 II II It 11 11 II :0 C1 0) a) 7 o w r j y w o N z 4- r N tr r m N 'T A 00 N h-• O) C) OD ? CD I O 9, I d \ n O to W C Fo V O N NO I to _ i ) N Cl1 t0 W V O DE m I O O O) Ln W w Cn - O 1 7 CO W \ 1rA O tJ1 O V --1 N I tD to , G v o) F= a N N I d W • - - I S CT O S 8 N 4 CD C) O I rt W , r1 ICD , I CD y O 1' O 1 1 tiJ Ito C p , ft - 255.77' m N0100414 "W 661 d ~ N rn r z •3 T I IV Co. fD I i O O < O N 1 1'D " O N m 1 O C11 sy~ ( 1 to = O I CD tr ~ Of j c w r • ~ O 1 o~ + O t ~ 1rt 1 1 N O 1 V O N co r N •O N r -1 ° ° w --i ~ n a + G7 I a m o m• rn 0 m o x m x C7 N . rn r. C7 N 1 T tD O A 1 71 c r• y, 0 7 o r m c < a 3 o p_ N 7 ~~ry@tFg~e `o' o tt o r•• o• t~D ® n m 0 -3 to 7 A CAI w ~ n c.• Ci .a Rr1 u In .-1 o C. z z z c rn :3 ~ ail c l L c STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER PriT~V ~ru s ra rat ADDRESS d. o l Lit SUBDIVISION / CSM# LOT SECTION T N-R W, Town of r© ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 d (4 o Y S e G, r, .e _ 1U 5q i r 'v 1b0 L~-C c v%,'t Y INDICATE NORTH ARROW Provide setback and elevation information on reverse of this, form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: 751 lion 42!r}- 5E,/7 Coined ALTERNATE BM: SEPTIC TANK / R / HOLDING TANK INFORMATION Manufacturer: 1.Jc c~ s Liquid Capacity: i000 Setback from: Well vv V House Other Pump: Manufacturer N A Model# w14 Size tg loat_.seperation . w A-. Gallons/cycle: r, Y} Alarm Location'k ='r, d1 7 _ . E; SOIL ABSORPTION SYSTEM Width: S I Length 6o' Number of trenches "Z- Distance & Direction to nearest prop. line: 78` ,j '}i ~ Q„b /L 04~ lh.. W hw. $Y S~'ar. W J J ! 5~- I~,# Setback from: well: House Other p k ELEVATIONS Building Sewer I o 3.3 ST Inlet; / oa l~s ST outlet . I c' ,P, '3 y PC. . inlet N P PC bottom A/?- Pump Off r 1 r~ ' ° ' ~i>rf I 101 41, 71 lUo Pi l Header/Manifold r„ A- Bottom of system z Ior. ,~,.3G o 5 3 to 4, Existing Grade Final grade_ is g. 3( DATE OF INSTALLATION: C` . J , r PLUMBER ON JOB: 4 = LOCATION: TROY 7.28.19.109C,7,SW,SE, CO. RD. F WisconsirPDepartment ofIndustry, PRIVATE SEWAGE SYSTEM County: Labot and Human Relations INSPECTION REPORT ` Safety and Buildings Division ST. _CRQTX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149306 Permit older's a ❑ City ❑ Village l] Town of: State Plan ID No.: =Elev-.:Insp. ETROY CS v.: BM Descript Parcel Tax No.: 040103295100 TANK INFORMATION ELEVATION DATA A9200152 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Q. 3 Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet 7 TANK SETBACK INFORMATION St/ Ht Outlet -73q w a, 3.1 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom 8.35 Dosing NA Header/Man. ,7 y d, S-q /0 7/ Aeration NA Dist. Pipe 9 107,36 Holding Bot. System 9,7a 200153 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. li Dist. To Well SOIL ABSORPTION SYSTEM PIT No. Of Pits Inside Dia. Liquid Depth BED/TRENCH width Length No. Of Trenches DIMENSIONS DIMENSIONS tO~ LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O 160 I CHAMBER Model Number: System: -41- ~E. OR UNIT DISTRIBUTION SYSTEM -1 Header / Man(fold « Distribution Pipe(s) t t x Hole Size x Hole Spacing Vent To Air Intake Length Dia- 4~ Length ~Dia. Spacing ~ / `.I ~ L SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of Jxx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes El No ❑ Yes C] No COMMENTS: (Include code discrepancies, persons present, etc.) t ?._fta i~.<,G'kC~{~.~ ~ZyW1 464 ~~x/`~vc./ , 1..~'~.~.'✓"f fin/ 7-.'f..A1~a . Plan revision required? ❑ Yes ❑ No Use other side for additional information. ~f r { z ` y 6 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION ILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code ,..o.,..,..,,.,..e. STATE SANI Y PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than El I f ©Are 8'h'X 11 inches in size. Check if r islonto ousapplication -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 Pt,-T L or 5W'14 5e Y4,S TQ8,N,R (or)k? PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # u CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 14 k Is a iv W ' 15,q 7 /S 346 - 7131 V Vd~ 17 R'? 0 I:y II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ILLAGE : -T O C 0 ❑ State owned E1!2 l VTOWN OF: ❑ Public M 1 or 2 Fam. Dwelling-# of bedrooms A EL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 0 Q - 0 2 5-5 ( 00* 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ 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) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 0 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) d i ; V TLON 15o 7 Y Ifz p eet 1,0ejp_5_3Feet • VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted H Septic Tank or Holding Tank 1000 14)00 L wcck.~ F1 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. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/ o.: Business Phone Number: 15 a?S o? 17S Z, 322 cLr Nit Plumber's Address (Street, City, State, Zip Code): 1617- : w IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Is in gent ig ature (No Stamps) pproved ❑ 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 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 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; (lose 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. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) Fresh Air Weis And Observation Pipe - - `Approved Vent Cap y for Minimum 12" Above Final Grade ~_.14A l tJKSFORD 20- 42" Above Pipe _ 4" Cost Iron= 7 73~ To Final Grade Vent Pipe P Synthetic Covering win. 2" Aggregate Over Pipe Distribution Pipe 0 0 0 0 0 - Tee $M Top 9"P4 Foal " ~Of~ "t Gdva~✓ 6 Aggregate ~ N6 1--t Beneath Plpe ° f},SC~umc EL)00,00 _c-L. 2 l a1. .SGR~G 1 Ni q0~ _~c too°~" LET i a 2,a /1C rto Gn - r' AITI:Rru19rE A Ri` lq CBS v Z 9 6u o 2 W ALL Qv t~ • ~r4d~ S wY 3 wcfc loca~e~ xiss T ° &Z # 2 FL Ial.0 LTC;.:- 0 "k7k Rr~rti'ty ~`~-c 479-35 I ~r = 4 0l P.O. BOX 76N PERCOLATION TESTS (115) HUMAN,RELATIONS Ca_t MADISON;W 3~~1 t (H63.090) & Chapter 145.046) llL, . FORKS s'v^3 I'-°.'' TOWNSHIP/ p IMyCNTCTP7ILTTY: T N0. 5 Adl 7 ! s - p ° N/R ~ E (or) W R d/ c M' su9o I COUNTY. WN S AME: N IMAILIN St.c2olx rNA If? f- ~f-Ft~so0 sos &*(AkA ~ • 0. UDioa WIS. S41 E G : OM DATES OBSERVATIONS AAADE ~ pResidence 3+o+ I N ❑Re I r /V (~lew p ace A J 6, • 1.~ I ft RATING: S- Site suitable for system U- Site unsuitable for system 7 C / ~3 L«O t ~'H £ R y~ rj V R y i~ ,s CONVENTI NAL: MOUND: IN GROUN S EM•IN-FILL OLDING TANK: f C~ MMENDEO $YSTEM:loptional) ES ❑A QS QU ©S ❑U ❑S ❑S LivE~T'~oivhC,_ I "If Percolation Tests are NOT required DESIGN RATE: "under s.H63.09(5) 1b), indicate: C LA S S S- If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: /V PROFILE DESCRIPTIONS 30RING TOTAL P H T R UNO -ATER•INCHES CHARACTER OF SOIL WITH THI KN SS, CO U VUMBER DEPTH IN, ELEVATION L M. E TUBE, AND H gS RVED H TO BEDROCK IF OBSERVED SEE ABBESS ON BACK.) t Ila- $.Z ~D /oz./Q '149 > 9 0 '•S' ) a sl. , ss'T~N VzIlx cs G/~. E;~3 /Q, S /DI`• yG ,Zo' '/D. Jv 75 'A~-,~v.1~ , ~0~ Zm- f~. TAN cS;P "3',J hD~D y/Did 9a. S" 3a.Si ,7. CS 6:je 3- PERCOLATION TESTS W VEOy C s Af TEST ItAVIBER INCHES AFTERSWELUNG INTERVALAMIN. D RATE MINL 1..~ s Z PER CH •7 . .iii r'LMU: :ailUW locations 01 Percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what an thf hl tsl and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and pfs Mq and slope. , . s 31i9Ct'.f c Jew&- rx YSTEM ELEVATION _ X02' .r = ~E,ec s~'rES SCALES Mo.vu- -Y fu E - N: -r- a 0-0 44! :TCIP So i t_ _ I i 1 I ' - i-- i I F- 7 _ ...`~l,i~ ~~st ' s st m•I ~ t ~ i ~ 11 ;r,. - ~ fir a cbn en j i t 3 4 D 1 ~N V. Z- T e 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 inistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. IE (print : TESTS WERE COMPLETED O ltuaftSlIf SEPTIC PLUMW00. 806.- C g 7 R ESS: ROBERT ULBRICHT CER~FIC~ION NUMBER: PH;-NE NUMBE lop onal 1j,:l 11111141. .7 •11AU ER & DESIGNER LIC. NO 00W CST SI NATURE:~ / 31BUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. NOTE H oVSE M V ST Li f: > 2~~ fRO j,.). R-SBO.6395 (R. 02/82) - OVER - TEST AREAS . GTE// Mfc S'o ~ieoM resr .t Ss G7 A 2 , ~ ~ N d VI m - G ° rt N N O N O O C~ 3 c -1 S A y~ D O 0- ai cx -.10 .m CD m F (A • N Z m O N Fn :3 N N O rD d I• A y c O' N O O m rn n. v A It tv O N '7 ?C N "'C 7 rt m n = rt .o s + rD = T N ro ro ° c CL CD co C) to of re C') -r TI 0 1- C o° ° C.T.H. 'IF If cn -11 o m LL~ m C) m 171 , 4 7 0 _ v n. z I^ N '"r ~ N N O N O A 7 S v O O C y N V m m c:) -c n rD I D O ' A 2 C... I G V O o I c co N = 0 O i'O O ~ 3 N _ m 00 ° u ? co 1 rr W v I ry- ~ n N i o rn m m r m z n x A cS') c c rt A n (O N I m I'"' II II II II II If II m d 0) C) r Ln x N w 0 N z r r Vf v, r rn rn m 0 o r m N = w o ITl a, o m n w rn O o (o w ul Fo v O 0 0 O ' - N cn (o w V O O rn u, w w L, - O O I-- y> w w , Y1 O V+ - - O v -1 rn C' (.n (O 1'( 'q f F_ V1 r 0 a - s ° o N F- CT o I rr C w ` c, r r- O y rt - Q co S - - - - - - Cb P11SD0 j . 255.77' ° N01~04'40nW N I P1UU ee 11987 rv ° I 66' 9D ~R as. sooMA COUNTY N Do* T I v a COh',YRC'ti:M(VVc ?A.fCS .°1.i:1 :WV (V ru I 0 b N I I~ m 1 O N O I r, rs -h 4 d O w O I O O I rt rt I I w . I I N O F-. v O N co f" N b to w~ T V - rt O (D r O C_ rt m v CD O F..I D rn O N.. fTl C) O Z A N A m 0 ~ 'O x ~ x d I N (-f~ I-.• '7 c _ o f* (v c •e o, -f o o A 9r c = rD m m ' . o ai n Cr r' C) I O A L ^ S3 C~' ,f r'r '.'OLUME 7 PAGE 1870 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER d L N L KS,Ca 1_ ADDRESS: FIRE NO: LOCATION:_s JA/ 1/4, 1/4,, SEC.-- 7 q+ 2_8 N-R_L_L_W j TOWN OF: Ro tr ST.•CROIX COUNTY SUBDIVISION:---So c..,,?'H ra g, k 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: G~ i. • ' DATE: St. Croix County Zoning office 911 4th St. _ Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by the oc;mer (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. -------------------j-----------------,-/---------------- Owner of property AND G..yNAN& Location of property55W1/4 SE 1/4, Section- T29 N-R_Z c W Township / RIO Y Mailing address Address of site Subdivision name. ~~~t~'TN ~orzK Lot no. other homes on property? _veS__ No Previous owner of property Total size of parcel A Li,~ F S Date parcel was created ALA(" (7 j - j j Are all corners and lot lines identifiable? ! Z_Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number L~. as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUUITY DEED which includes a DOCUMENT NUItBER, VOLUME AND PAGE. IIUIIUI R & THE SEAL Or THE R1;GISTL I 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(wc) certify that all statements on this form are true to the best of ny (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 n the office of the county Register of Deeds as Document 1Io. 'q J 9 o , and that I (we) 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 record d in the office of Count Re ister o y 9 of deeds as Document No . g L 1 /~1. Y, (1 X1 A~ A TLL FT l ignature of k lic Cd~appl cant D-at e y o of ignatur Date of s gnature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 481968 L,PI REGISTER'S OFFICE Charles R. Ellefsen II AKA Charles R. Ellefsen ST.CROIXCo.,W1 -and Michele a sen Reed for Record APR 141992 convey andwarr In Fe ter A. aw s or an nann °f 11:55 A. M H w sfor Pus an an wife as survivors p L. marital property y ' Re9tster of Deeds RETURN TO the following described real estate In St. Croix County, 1_ State of Wisconsin: 040-1032-95 100 Tax Parcel No: Part of SW 1/4 of SE 1/4 of Section 7-28-19 described as follows: Lot 1 of Certified Survey Map filed August 17, 1987 in Volume "7", Page 1870. TOGETHER WITH a 66 foot `r J O private road as shown in said Certified Survey Map. FEE This is not homestead property. (is) (is not) EkceptiontoWarranties: Easements, restrictions and rights-of-way of record,if an/. Dated this 14th day of Aril 19 92 `O/L (SEAL) (SEAL) • Charles R. Ellefsen II Michelle E. Ellefsen (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. p~ County. authenticated this_4_/day of 19~ Personally came before me this day of 19 the above named TITLE: MM ATE BAR OF WISCONSIN F (If not, to me known to be the person who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Charles R. Ellefsen II 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. SB2 NTF 0121 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No.2 - 1982 T28N, R19W, LUME 3, PAGE 760. 0 r C;t OWNER LEGEND Charles Ellefsen Q Set, 1" X 24" iron pipe weighing 1.68 Rt. 3 o pounds per linear foot. - Hudson, Wi. 54016 e 8 O St. Croix County Section Corner Monument found. • 1" Iron pipe found. LOT AREA, Z 87,136 S0. FT. 2.00 ACRES L: J rJ w t•1 > 7 00 CURVE QA DATA m v) Z U R = 487.00 = 5001715711 CB = S65°35' 05.5"W C = 413.93' east line of Lot 1 of ~L`•iLE.I L = 427.53' C.S.M. vol. 3, pg. 760 ivY~in `11 w TB = N8901515611W I N89°15'56"W, 30.371 3 S-1 407 TB = S40°26'07"W HU).t?i ' o V A v I 3 1 r ° proposed lot 2 cn a I :n o 66' ' 540°26!07"W N o 39.40' 1 103.63' 439.95' - 1 - - - - 8901515611E 479.35' south line of the SE,'-♦ Affidavit 802-121 SE CORNER unplatted lands owned by others SECTION 7 - no. 87-22