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HomeMy WebLinkAbout014-1017-70-100 Z-0 ° c h O 64 Cb o 0 0. M 0 ~ I 0 o ~ I, I N N O y I I ~ I o z c 6 1L c o C ~ Z} ~ Q I ~ I ~ M ~ a I • O Z ~ y y FM- Z m co c z v o z m z ~ z V Y O ((V~ u 1~ C • c L O O O © = Z Z w N z ~ _c° I L; E N N {6 i CD O d d C In 0 m e c a` CO N z ai U) w I- dl co N 14 3: ~r 3: 0 It I J d d d Z° N .2 1 co O U 7 N w to J U ~ rn rn y I ° 0%44 O o0 O O N O d n O 'O m Q C7) O Z U) Q ~ N N N Y! c f O p N O C E -q 0) O^ 3 .y. O p. y O O C O O 12 r- c O N ~ N d M 2 in E ca L LL z O U cet I v 0 M a m EL u a w • a m .R m y c rr`i~~l E c c 3 `~1 A u a j' 0 N v + DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND~ P.O. BOX 76 PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP(: LOT NO.:BLK. NO.: SUBDIVISION NAME: PTE 1/1 NW 1/1 8 /T31 N/R15)&(or) W Forest n/a n/a n/a COUNTY: OWNER'S NAME: MAILING ADDRESS: St. Croix Maynard Paulson 2761 Co. Rd. #Q, Clear Lake, Wi. 54005 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence 3 n/a ❑New ®Replace I 5-3-91 n/a RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONALMOUND: IN_ -GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S gU S rEJS HU : CCU ❑ S E3U ®S ❑ U holding tank 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: n/a Floodplain, indicate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 7 FnB BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHXK ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 2.58 n/a none .33 .33bl.1. 1.25bn.mot. sil. 1.00b .mot. 1. B 3 3.92 n/a none .25 .25bl.1. .50bn.mot. sil. .58bn.mot. 1. 1.42bn.mot 4 3.08 n/a 3.00 .25 .25bl.1. .83bn.mot.s.l.fill 2.00bn.mot. sil. B-9 1 1-90_ nja none ___50 1. 1.00bn.mot.s.l.fill 2.00bn.mot. sil. 6 3.91 n/a none .58 .58bl.1. 1.58bn.mot. s.l.fill 1.75bn.mot.l. B-7 3.34 n/a none .42 2 1 1.50bn.mot. s.l. fill 1.42 bn.mot. sil. B_8 3.42 n/a 3.00 .58 .58bl.1. 1.42bn.not. sil. 1.42bn.mot s.l. 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 PERIOD 3 PER INCH P- P- P_ n a 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 n/a 3 lot . E , E I r i d ~ 1 3 . m_. r > E'er. /c4z- TN E E E 3 E 3 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 5-3-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Ave., New Richmond, wi. 54017 2298 I715-Z46-6200 CST SIGNAT DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 1 Parcel 014-1017-70-100 o4io2i2oo7 03:08 • PAGE 031:08 Alt. Parcel 8.31.15.117D 014 - TOWN OF FOREST Current X 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 O - MEASNER, CURTIS E & JUDY P CURTIS E & JUDY P MEASNER 2731 CTY RD Q CLEAR LAKE WI 54005 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 2731 CTY RD Q SC 1127 CLEAR LAKE SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE PARCEL LOCATED IN NE 1/4 OF NW 1/4 SEC 8 Block/Condo Bldg: T31 N R1 5W CSM VOL 6/1541 DESC. ON CSM QUESTIONABLE RESURVEY CSM 6/1647 STILL Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) QUESTIONABLE 08-31N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1172/334 QC 07/23/1997 1145/402 WD 07/23/1997 716/163 07/23/1997 123/477 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/17/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 15,000 117,300 132,300 NO Totals for 2007: General Property 2.000 15,000 117,300 132,300 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 15,000 117,300 132,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 125 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER fG,, u /5®1, TOWNSHIP ~E~Y`c S SECTION ADDRESS ST. CROIX COUNTY, WISCONSIN X f A o- /I of ^ ✓ ~f O o s~ SUBDIVISION LOT --SOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 63 ~ L V$ C i D INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front Side , Rear Ft. No. 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.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: I Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from well: No. feet from building HOLDING TANK Manufacturer: ZAle- Capacity: ~a i No. of rings used:,2 Elevation o b ttom tank: Elevation of inlet: yL-3 No. feet from nearest prop. line:Front , Side , Rear'kjt. 1931 ,0~ No. feet from: Well building nearest road lG Alarm Manufacturer: f'PZ V, INSPECTOR: DATE:_ PLUMBER ON JOB: , LICENSE NUMBER: 6 90:c / J Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division NE'NW,8,31,15W (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Co Q 149139 Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.: Steve Paulson Forest S91-20617 CST BM Elev.: Insp. BM Elev.: 715M Description: Parcel Tax No.: 1170-014-1017-701000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing n?.(og /F~a_,+a~ /~tS , a Aeration Bldg. Sewer Holding 5 a _loo o 3* ~1(/ Ht Inlet 4 3~' ~3 q TANK SETBACK INFORMATION SA/Ht Outlet Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding j 861 Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand w; trirv't / I , y V ~ r , ~ Model Number GPM TDH Lift Friction System TDH Ft mead 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 DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Mode 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 6 Plan revision required? ❑ Yes ❑ No S l J Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. =Z701LLnH~R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY , STATE SANITARY PER IT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / 8tf x 11 inches in size. c eck re Iston to previous application -See reverse side for instructions for completing this application. STAT LAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 1 - ` R PROPERTY LOCATION PROPERTY O71e,e Y. /a, S T N, R /,3-E (o4V l PROPERTY OWNER'S MAILING A DRE LOT # BLOCK # le~4 I/ CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o !S II. TYPE OF BUILDING: Check one CITY NEAREST ) State Owned VILLAGE : Cw v/,GrJ ,W OF: ❑ Public 91 or 2 Fam. Dwelling- # of bedrooms JE- A RGEL . AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 7 O bl c~ Ol 7 - 7p~~c 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.E1 New 2. Replacement 3.E1 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 414®:Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 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 Feet Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank Q't'y ~ FpFpr-l - Ll Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's ame (Print): Plumbe ' Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: r Plumb s Address4tre I , City, State, Zip Code): s%~ ' D ~ sn ~ LfJ O© IX. CO NTY/DEPA TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Ag At Signatur (No Stam Approved ❑ Owner Given Initial Surcharge Fee) c Adve a Determination ~~v / ~ S1 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber FLU I i- LAN PVO E 4T SffU ac.(~ o jADDRESS !r? - C~/C~,c r e ~t ,y~if) 1Sg/T3/ N/R / j-W TOWN r~ COUNTY s rS MByron Bird Jr. 3318 DATE :2 42~ - BEDROOM~ CLASS PERC CONVENTIONAL- IN-GROUND SSURE CONVENTIONAL LIFT MOUND! HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE L Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. JZi L Borehole Q Well Scale Feet 0 Pere Hole System Elevation cfefPY~rr /.r, Cc~a7csf/~1io, ONSITE SEWAGE SYSTEM TD, C +'b 5 a 1 1 EPARTMENT OF INDUSTRY, LABOR A."M HUMAN RELATIONS DIVISION OF SAFETY AND BUILDINGS EE CORRESPONDENCE I¢ GC. go -j'41 1 IO D 1 J~Pr v nid 00.e r _ o. li e - c;., S91-2061'7 FLU li i-LAN PROJECT 5tle L ~a ;ovADDAESS Q Cc.,i 1 114 1/4/S/TN/R TOWN r~ COUNTY S ~t+ c, MP S Byron Bird Jr. 3318 DATE - BEDROOM~ CLASS PERC CONVENTIONAL— IN-GROUND FWESSURE CONVENTIONAL LIFT MOUND- HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE ► Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. ni C1 Borehole Q Well Scale Feet 0 Pere Hole System Elevation „Jo 4e c%fPr~ ~n <</a /sf~~>Lc., G~ A ONSITE SEWAGE SYSTEM 9 +KCV I;3aij'•s~~ p~j'i~ 4T ~x 1 kY. D' ARTMEI',4T OF,U19USTRY, LA O R A70 FSAAid RELATI NS UIVISIM OF SAFETY AND Bdllws SEE CORRESPONDENCE r' ~d 30 ~o o ~ c~ 2 Uvsr S91'20617 ' It V •t It. c au Q • . A r M • we o x t,r uov I. Y a 1i1Y W 0%N _ NZ o • Y tyt y c c C- h 0 1 _ C i- b1 ` r J Vf Y r » ► 0• ,y M Y • • • Y • \ N • M O tr i. O N w S 1 ~ A 6 i G• , AM it i N U , W ~ a ! 17- d"b Q + Y r • ♦ S~ , x . ' p < • i w W.. 86 A • • r • • ~t O N JO • 0. 00 .0 H r • O, M Y M iN V iJ ' W g=ZT4 gn 4.. i 1 r : C N v ► , t ~ t O • t u1i t• 60 '~v i 1~ • •t r r v s •s \R\ Ima we 04 : SW -MA f" go I «►RR A . / i ~1•nri 0 Z e sil n i ~w 0 16 ~ X M Ir O y 1 • u •r r N u M 46 rl i a H /11 1 be ~i• y ty ~i tn be to #A 41. m t4 bd mg ♦ W CA in vu tM LS CD W O t y ► r A ' 0 .4 VA 0 • it T. 472454 yn, 911 PAU 616 HOLDING TANK AGREEMENT This Agreement is made and entere in this .2 day of ? lam, T 19D, by and between the hereinafter called the "municipality" and hereinafter called the "owner." I We hereby acknowledge that application is being made for the installation of (a) holding tank(s) on the following described property: i ax Iahce /y f' ~5' <6 T3/ A /'5-- /J? 10 ~f or that continued use of the existing premises requires that a holding tank be installed on Q T ^ 7 the property for the purpose of proper containment of sewage. We also acknowledge that said i -769 /490 property cannot now be served by a municipal sewer, any other type of private sewage system as permitted under ch. ILHR 83, Wis. Adn. Code, or ch. 145, Stats., and that the property does not contain an area of soil suitable for any other type of private sewage system as permitted by ch. ILHR 83, Wis. Adm. Code. Therefore, as an inducement to the County of ~a i_ to issue a sanitary permit for the above described premises, we hereby agree and bind ourselves as follows. 1. Owner agrees to conform to all applicable requirements of ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. and the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. Amer agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the -wner within thirty (30) days from the date of notice. In the event the owner does not pay tie costs within thirty (30) days, the owner hereby specifically agrees that all of the co is and charges may be placed on the tax roll as a special assessment for the abatement of a nuisance, and the tax shall be collected as provided by Wisconsin Statute. 3. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under ch. NR113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or their registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business i days from the date of change to the service contract. - EXAMPLE 7 - ` ' . VOL `~11 PAGE f 17 4. Me owner agrees to contract wi a person licensed under ch. NR113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall file the agreement with the register of deeds which shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the proper where the holding tank is installed. SIGNATURE OF OWNER(S):) i SIGNATURE OF MUNICIPAL OFFICIAL (Include Title): Zl-~Y1.. ` State of Wisconsin )came before me this L day of A.O., 19 QL, )to me known to be the person who xec ted the foregoing County of )instrument and acknowledged the same. Subscribed and sworn to before Me this day of 19 ,k) 0 q ~ Notary My commission expires 19 ql~ . G wIS~ RECEIVED FOR RECORD 12thday of August A.D., 19 91 , at 2:50 o'clock P. M. and recorded in Volume 911 of Deeds page 616 James O'Connell ister of Deed • W A -4/ County This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. - EXAMPLE 8 - HOLDING TANK SERVICING CONTRACT This Agreement is made an! entered into this22T1dday of July 19 91, and between hereinafter called the "owner„ by and~Ohm 1.1 ~1o9✓G~/~~l hereinafter called the "pumper." We hereby acknowledge the installation of (a) holding tank(s) on the following described property: ,max ~ •~ee ~I~O l~~ ~ ~rv~ j ~ 1`s~`t/ f / ] Q 1. The owner agrees to file a copy of this contract with the local governmental unit i-/e9/ ;Xereinafter called the "municipality", which has signed the pumping agreement required in ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of St Cro1X 7 e loo 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code and to the county a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to submit a report which shall include: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County of \ r°`',e!~ within ten (10) business days from the date of change to this service contract. - EXAMPLE 9 - t I SIGNATURE OF OWNER(S): SIGNATURE OF PUMPER (Include License Number): State of Wisconsin )came before me this 22ndiay of July A.D., 19 91, )to me known to be the person who executed the foregoing County of Barron )instrument and acknowledged the same. Subscribed and sworn to before Me this 22nday of July 19 91 - Notary Patricia Egg eston my commission expires 1-26 1992 This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. - EXAMPLE 10 - APPLICATION FOR SANITARY PERMIT • ST C- 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/contractgr,("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 /.S a Location of Property uJ, Section , T :3~ N - R /SW Township F6 r-es 4- Mailing Address /2 Subdivision Name Lot Number ' Previous Owner of Property n e 5~~ h 5~~ Total Size of Parcel 4 c'-e- Date Parcel was Created K l Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume / _ and Page Number 16.3 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION 1 (We) eenfii.6y that aU statements on fih.is 6onm ane tAu.e to the but o6 my (oun) knowledge; that I (we) am (ahe ) the owneA (s ) o6 the pno pent y da c i.bed in thi b in6o4mafii.on 6onm, by vi,%tue o6 a wahAanty deed neeonded in the 066ice o6 the County RegiA teA o6 Deeds a6 Document No. Qh w ; and that I (we) plies en<tty own the pnopos ed 6 to bon the sewage pod s ys.tem (on. I (we) have obtained an easement, to nun with the above ded eh ibed pnopenty, bon the consfihucti.on o6 said system, and the same hu been duty neeonded in the 066ice o6 the County Reg"' t o6 Deeds, ab Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED • K ~ ,r se lwwrt ai1~N -avow WNW& 91Mla11filr «..w..- . `.......B..CXQ,~I(...__.. . ...adf~ Ali Map recorded A parcel described in Certified Survey - in Volume b, Page 1541 as Document #402924, being 0 ~s rt of the Northeast 4uarter of Northwest Thirty K (NEis of NNiW of Section Eight (1 , Township irty one (31) North, Range Fifteen (15) West. a: ' I1~11Y n - FEE ~i l~seraal tatles by this deed der eoaPp to G:•stee dl of ftiw winimer aid es Is 1611l Angwili to sieat's deafly mind aB Of the 40-Aft a" b6wl* lrneoal Mm will aim" a°o°iead' J_IUY DOW ~.ath-------- w y ....w.. ,i ! Lcl~YrL.a..l~::=`~'S==d!~l•'~..(SEAL) .William Hennessy------_-•-•-•--•_-•------ • r.....i Passed amm AUTIMUNTICATION Q ~ r; *P !t~i1 .HgnO s STATE OF WISCONSIN 7& '1 O 19 ...$5 Puy . _ • Hendrik W, Van D k Y TM Z: MEMEtB STATE EAR OF WISCONSIN r.M rtM~' (If not . aothorised by 1706.06. is. State-) to me known to be the Pw@MS foregoing instrument end &*Wwbbw tip now* x THIS ImSTRUMtNT WAS ORAFT[O aT. - - •~~+4 `'"~r Reinstra,-Van Dyk & Needham S.C. 201 So. KNowles Avenue New--R-iVhtnond-jW1 .54017....__.- Both my Commw n 0 PeT+...eat (1t AMR. ~IN~ res W be antbsatieattd or acknawl f . date: olew~tw+o. s` *wMM a 1eMr Sigel" i. W GGPi olo dd be tTwd or priote~ beloo "r ITATt iAR Yf wISCON 1t r`: DOCUMENT No. STATE BAR OF WISCONSIN FORM 6-1982 THIS SPACE RESERVED FOR RECORDING DATA PERSONAL REPRESENTATIVE'S DEED i William.. Henne.. s... Ernest Frank as Personal Representative of the estate of ("Decedent") for a valuable consideration conveys, without warranty, to Steven B. Paulson and Diane L. Paulson - Grantee, RETURN TO J the following described real estate in $t.e...Qlrnix ...................County State of Wisconsin (hereinafter called the "Property") Tax Parcel No: A parcel described in Certified Survey Map recorded in Volume 6, page 1541 as Document #402924, being a part of the Northeast Quarter of Northwest Quarter (NE'k of NWk) of Section Eight (8), Township Thirty- one (31) North, Range Fifteen (15) West. i i ~I j . i~ i i Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this 25.th................... day of June 19.....85 ~ lr...l...C.:?~!:M-ti.l:...- ~a~ . (SEAL) (SEAL) ~lliam Henness Personal Representative Personal Representative AUTHENTICATION ACKNOWLEDGMENT ii Signature (a) STATE OF WISCONSIN liendrik.-J1.._. Y,m_.JZyk........_........._.. a8. County. authenticated this ....25day of............. Tune 19....85 Personally came before me this ................day of l 19-•...... the above named TITLE: MEMBER STATE BAR OF WISCONSIN II j (If not, authorized by § 706.06, Wis. Stata.) to me known to be the person who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY ...Reinstra, Van Dyk &,.Needham S.C. _ 2 So wl .....01 . KNoes Avenue 1 N'eW •-R-i-ehmorrd-jW1...5$•()1•x• 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 sisniari in any capacity should be typed or printed below their sicnatures. ItrflrWller STATI0 R/!R OF W18CONSIN a,...... two FO Ne. a-,++a Stock No. 13005