Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
012-1023-40-100
v Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: 499241 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Mammen, Lesley & Shannon Erin Prairie, Town of 012 - 1023 -40 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 09.30.17.125A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic IF. . s,` Benchmark (', r"• t c. ZED ( A F' B 9"54 17.Y Aeration J Bldg. Sewer ` Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet $, l`t 9S , Zy TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet et, � �;'� 1,.- qy, 77 Septic 6;ei bpi ��• I 6, 9 5 2 i Header /Man. 77 7 q.7ZC�3.51 Aeration Dist. Pipe 9 .9 z, q's . sl /o.a1 2 Z.9 Holding Bot. System // • it .0L //. 7 9 q PUMP /SIPHON INFORMATION Final Grade 7.5 1 15 .93 Manufacturer Demand St Cover GPM t 15- 97.93 Model Number EZ C.0 TDH Liftr Friction Loss System Head TDH Ft Forcemain Length Dia. to well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 gs -� V 3 rf e,l. SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: J� 3 1 �(� / /ba UNIT Model Number: y p 4 r, 3 DISTRIBUTION SYSTEM S ( + 1 .rt_ S Header /Manifold � Distribution x Hole Size x Hole Spacing Vent to Air tak� Length , Dia Length \ Dia \ Spacing \ \ 3 r 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 1 '3 Bed/Trench Edges Topsoil ---" ] Yes No �ygs lid I No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1797 170th Avenue Unknown (NE 1/4 NE 1/4 9 T30N R17W) NA Lot 2 Parcel No: 09.30.17.125A10 1.) Alt BM Description 2.) Bldg sewer length = / ; c pp Go c �-►�v-✓` c-� 1 J loa�'t A� - amount of cover = � ✓�' v / l C GdJ Plan revision Required? Yes o y[ (,, !� 544 71 Use other side for additional informati n. 1 ` SBD -6710 (R.3/97) Date Insepctor's gnatur Cent. No. Safety and Buildings Division County Ivisconsin 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 Sanitary ermrt Num� (to be filled in by Co.) Department of Commerce (608) 266 -3151 ` 4 A7 4 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informatio ou provide N may be used for secondary purposes Privacy La 04((tn) Pro" Address (if different than mailing address) I. Application Information - Please Print All Informan 7`1 7 7� era Property Owner's Name V Parcel # Block # Property Owner's ailing AdcVrcss �O Property Location of City to Zip Code Phone Nurp� %., %., Section � rrcle T N E X) �i l Z-5 II. Type of Building (check all that apply) : R 111 or 2 Family Dwelling - Number of Bedrooms tt Subdivision Name SM umber ❑ Public/Commercial - Describe Use _- /� 4jb5 ( ❑ State Owned - Describe Use �- -j' ity ❑Villag wn ' _ op of _ III. Type of Permit: (Check only one box on line A. Complete tine B if applicable) A. [I New S ys t em lacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing tem List Previous Permit Number kL ed V. B. El Permit Renewal ❑Permit Revision El Change of ❑Permit Transfer to New �� Before Expiration Plumber Owner IV. T S e of POWTS stem: Check all that apply) 1 r f o - Pressurized In Gro und 11 Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground . ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter thing Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis ersal/Treatment Area Information: ` Design Flow (gpd) Design Soil Applicatio Rate(gpdsf) Dispersal Area Required (so Dispersal Area Pro osed (sf) System Elevation �l` U 112-:5 1�2 1 7z' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass Tanks Existing Tanks eptic r Holding Tank ,y f erobic Treatment Unit lo U / Dosing Chamber VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber ame (Print) Plumb ignatuue MP/MPRS Number Business Phone Number Pl r' Address (Street, City, State, Zip VIII. Court /De artment Use Onl pproved 11 r v Sanitary Permit Fee (includes Groundwater Da Issu Issuin cut Signa Stamps) Surcharge Fee) ^ ❑ Given R or Deniai 7UO l 7 D(0 IX. Conditions of Approval/Reasons for Disapproval �t SYSTEM OWNED: 3) od 1. Septic tank, effluent filter and dispersal cell must all be services / maintained 0 Ga as per management plan provided by plumber. 2. All setback requirements must be maintained• �. as per applicable code / ordinances. c{ J � cLa,� O e � lam' ez ` Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches n size SBD -6398 (R. 01/03) PLOT PLAN 'PROJECT Les Mammen ADDRESS 1797 17 0th St. Newrichmond Wi. 54017 NE 1/4 NE 1 /48 9 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 10 -31 -06 BEDROOM 3 — Il Le , 2, DATE CONVENTIONAL XXX At Trade ONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE o .4 ABSORPTION AREA 1 125 # of chambers 45 BENCHMARK V.R.Y ase of siding ASSUME ELEVATION 100' ❑ BOREHOLE (E) WELL *H. R. P. Same as BM y12" Vent SYSTEM ELEVATION T -1 =92.1 T -2 =92.0 T -3 =91.9 Of Bio Diffuser with ZC ae t per chamber 170 th Ave Long 34" Elevation Well driveway 45' 40' Co 30' Rd T Garage 3 Bed Hou e 44' 15' BM 40' 60' E ST Failed S ste st BZ 40 15' B O ob pipe B1 � ' 7' C op y 15' B3 95' 30' 9(i' PT PLOT PLAN 'PROJECT Les Mammen ADDRESS 1797 170th St. Newrichmond Wi. 54017 NE 1/4 NE 1/4S 9 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 10-31-06 3 DATE BEDROOM CONVENTIONAL XXX +Atra4e ONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1 000 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .4 ABSORPTION AREA 1 125 # of ehasnUers 45 k k BENCHMARK V.R.P. Base of siding ASSUME ELEVATION 100' D BOREHOLE 0 WELL *H.R.P. Same as BM >12„ Vent SYSTEM ELEVATION T -1 =92.1 T -2 =92.0 T -3 =91.9 Of Bio Diffuser with Cove t per 6 „ chamber 170 th Ave 6' 1- --de at Systern Long 34" Elevation I Well driveway I 45' 40' Co 3GlHou Rd T Garage 3 Bed e 4 4 1 15' BM `1Y I - T 40' 1 60' E ST Failed S ste st B2 44 15' B O ob pipe BI 80' s 7 ' 95, / B3 15' Pi y6' Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Ws. Adm. Code G Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. fa� /O c�—�ifCJ�— CGc9 Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 716 Property Owner I Property Location ,sus 3ovt. Lot &,e_ 1/4 4 /4 S T 3cj N R 1,7 E ( OW Property Owner's 10alling Address Lot If Block # Subd. Nance or CSM# City S to . p Code Phone Number ❑ City ❑ Village. W Town Nearest Road T All Eon ❑ New Construction Use: (Residential / Number of bedrooms Code derived design flow rate GPD (,Replacement ❑ Public or com rcial - Parent material /; i �w / ;0� �t �_ Flood Plain elevation if applicable General comments �� and recommendations: (i" �G- �k� S l V — — yp�_ / 1.,;7- 6' f� REC IVED © Boring # Boring _ p�° to'+ E] Pit Ground surface elev.; CR01X CC7UNTYmitin facto in. Sal Application Rate Horizon Depth Dominant Color Redox Desaip Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 4 41 C- Z �2 Boring # EyBoring ❑ Pit Ground surface elev. ft. Depth to limiting factor '7 f4ly in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Ef1#1 •Ef1#2 1� Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg& ' Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L CST Name (PI ase Print) Signature _ CST Number Address ate Evaluation Conducted Telephone Number s Property Owner ,C 7 :�2 06' fy!& ell Parcel ID # Page of R Boring _ ® ❑ pit Ground surface elev. y5 ft. Depth to limiting factor in. Soil Application Mate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. C 'Eff#1 'Eff#2 �1 I I �I Boring # Boring ❑ Pit Ground surface elev. ' ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. / *Eft#1 'Eff#2 c Q Boring # ❑ Pit Boring Ground ❑ Gd surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = SOD, > 30 1220 mg/L and TSS >30 1150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mgfL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. san4330(RAM) Sail Test Plot Flan Project Name Les Mammen Jr. Byron ird Jr. Address 1797 170th St. NewRichmond Wi. 54017 CsAi #220527 Lot 2 Subdivision Date 1 0/31/1906 Gounty CROIX N E 1 /4 NE 1/4S T 30 N /R W Township E Pr E] Boring G) Well PL Property Line# Alt. BM 6BM or VRP Assume Elevation 100 ft of siding System Ely T-1 =92.1 T -2 =92.1 T -3 =91.9 H.R.P Same as BM SCALE 1" = 40' Unless otherwise Noted 170 th Ave drive Well way 4.5' 40' Co 30' Rd T { Garage 3 Bed Hou ie 44 1.5' BM 40' S0' ST Failed S stem B2 40 15' B B 1 1.5' B3 30' 95' 96' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity & 41fl ga l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) g al/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) ae 6 gal/day Pump Manufacturer ❑ NA NA Soil Application Rate al /da /ft2 Pump Model ❑ Standard Influent /Effluent Quality Mont ly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODJ 530 mg/L YHn Ground (gravity) ❑ In Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Events Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third ('Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ me th(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) ❑ NA year(s) Inspect pump, pump controls & alarm At least once every: D ❑ year(s) m p NA s} Flush laterals and pressure test At least once every: ❑ month ❑ ye ar(s) ye ar( ❑ NA s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fairing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal celi(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: • A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and /or soil limitations. Baring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. . The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name f'd ' • Name Phone /,7�.2 6I-76 G Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name y, ' Name Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. . The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name f^� r r, Name Ce,O�7.02 Phone 7 1,7 — . 2 �� 76 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name y , l Name _ STATE BAR OF WISCONSIN FORM 2 - 1999 �' 4IC=b Z WARRANTY DEED KATHLEEN H. WALSH Document Number RESISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Todd R. Mishler and Jod M. Mishle RECEIVED FOR RECORD husb and wife, - -- - - - - -- - - -- 04 -17-2001 3:15 P* - - - - -- __ —.- — -. __. WARRANTY DEED Grantor, and Lesl F. M a_ mme n, J r., and S hannon J. Mam EXENP.T 4 husb and wife - - - — CERT COPY FEE: — - -- COPY FEE: TRANSFER FEE: 398.70 RECMDING FEE: 10.00 Grantee. "" Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Part of the NE 1 /4 of the NE 1 /4 of Section 9, Townsh ip 30 North, Range 17 Name and Return Address West, St. Croix County, Wisconsin, described as follows: Lot 2 of the N UNION Certified Survey Map filed March 28, 2001, in Volume 15 of Certified V1/ES pOSt Off BOX CREDIT IT Survey Maps, Page 4056, as Document No. 641438. Menomonie, Wisconsin 54751 01 1023 -40 -000 Parcel ]dentitication Number (PIN) This is _ homestead property. Exceptions to warranties: Easements, restrictions and rights -ofway of record, if any. Dated this �� day of M arch 2 001 T od d r - - __.. M Mish ler AUTHENTICATION ACKNOWLEDGMENT Signature(s) T odd R. Mi shler a nd Jodi M . Mi shler, h STATE OF WISCONSIN ) and wife, - - ) ss. —� — — County ) authenticated t day of Mar ch 2001 Personally came before me this day of - - - .. - - - -- - - -- - -- - - -._ the above named r K ristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN _ (If not, to me known to be the persons) who executed the foregoing — - authorized by ti 706.06, Wis. Stars.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY r Attor Krist Ogland Notary Public, State of Wisconsin -- Huds W I 54016 M Commission is ( - - -- -- - -- - -- -- y permanent. 1 not, state ex piration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) * Names of persons signing in any capacity must be typed or printed below their signature. intonation Profewionats company. Fond du Lao. WI STATE BAR OF WISCONSIN 800 WARRANTY DEED FORM No. 2 - 1999 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �y Mailing Address , ll Property Address � (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION �� Property Location 1 /4 , y 1 /a ,Sec., TN R� , Town of Subdivision , Lot # Certified Survey Map # `� , Volume l 5 � , Page # Warranty Deed # / ,Volume O Z 4 Page # 3 l� Spec house yes Lot lines identifiable 4.6 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIG URE OF APPLICANT DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) c am`` "�` T ,' R. • .k ° N U. se,>�v e� :. n 1 nt1 ,,,,, � • CERTIFIE EY MAP Located in port of the Northeast Quarter of the Northeast Quarter of Section 9, Township 30 North, Range 17 West, Town of Erin Prairie, being that property described in a Warranty Deed recorded in Volume 1382 Page 555 in the Register of Deeds Office for St. Croix County, Wisconsin. I I Prepared for and at the request of: OWNER_ Todd R. and Jodi M. Mishler NORTHEAST CORNER 1797 170th Avenue SEC77ON 9 -30 -17 New Richmond, WI 54017 (FOUND NA7L-F7TS 77ES) Drafted by- Ty R. Dodge UNPLATTED LANDS 6R7H U7VE A� THE NE 7/F — -- - - - - -- -- I I I t I� - ---- N " - -- 2 - -- — ' N89'03'50'E 237.22' ib N89 "E 2407.83' �7VtESPtTAtE O ��� S89'03'S0 "W - - - -- —' - - -- — �__0_ - - -- / C I w/r�r�p� wAr NZ w � 196.61' NORTH 1 4 CORNER I I S C I j O SECAON 9 -30-17 Z I y tm (FOUND 1 ' IRON PIPE I N I � I {rn �i� cn loo / w�� 25 =I j CAM 1 4 LW 1 v GE O O R� X v O I 1 I --- + f (n CN N r*i O �� in i D t < �l cn v! vv= in A ° I ID N �r'l �. u. Ifnr7s � 0 "m L� `'� I N89.03'50'E .1 I -� N8 2 B 84� E , / :LOT 2 �� oy� I r■ C,! j 50.01 , 4 131 I 2 o° s r2. T - Z m o _ / a 1 1 t CL __ � o o j -1 N88 "E 244.641 a o S tT � t ct CL .°« f Z 1 ■ N 1 I � •� '-� 1 t 1 � N I I N 1Z i-U 1� Z NO2'f0'10'W/ 1 01 N 1-1 o ' ° tp 11.17 B1 I I r�1 it --ITI v o >E m NO TH I �c�j - - -- es L7 0 1 4, X01 { 1 11❑ o C: it i °'J� S 1 IZ w t I r - I m �aii iD Qom, � I I i D ''' I LOT 3 Sall !`0 1 '`31 ��� 3 o+ TOTAL AREA: = i O rn1 I co UZI 0 3 424,524 SO. FT. ; i u CA p 9.75 ACRES SOILTEST,`_ f fol O _ 3 m 2 , - AREA EXC. R -O -W: TYPICAL ° 0 o n I k 392,825 SO. FT. 1 a g 1 9.02 ACRES ° I q n w� CL 0 1 -1 O s O I { s CIO n a + 1 l ' m APPROVED NOTE: AREA SOl1TH OF SHOWN FENCE MAY ` I ST, CROIX COUNTY + BE POSSESSED BY OTHERS. CONTACT ADJOINING l Planning Zoning and Parks Conlirnittf LAND OMER OR AN ATTORNEY BEFORE REMOVIN 1 SHOWN FENCE. t 1 3B' MAR 2 8 2007 4. i If not recorded w;ttnn 30 days of S88'44 644.56' approval date approval shall be 1 Fr:FA1n- nw, and void 'S' U_N_PL_A_T_TED__LA_NDS 4.5' -65= Q} Section Corner Monument of Record • Set 1" x 24' Iron Pipe weighing LOT 2 I 1.13 pounds per linear foot TOTAL AREA: O Found 1" Iron Pipe 90,263 So- FT. { rn ❑ Found Axle Shaft 2.07 ACRES Building Setback Line (100' from Right of Way) AREA EXC. R -O -W: g y) 66,814 SO. FT. 1 1,53 ACRES / JOB # A00123 � I / Prepared by. � 150 0 150 JEO Consultin Grou LAND SURVEYING & LIVIL ENGfNEERING EAST 1/4 CCRN£R� GRAPHIC SCALE .SEC77OW 9 - 30 - 17 Phone No. (715) 246 -4319 SCALE IN F 109 East Third Street, P.O. Box 325 FEET: 1 inch = 150 feet (FOadI1D Sr/Rb£Y A/AR11C NA 7LJ New Richmond, WI 54017 BEARINGS ARE REFERENCED TO THE EAST LINE OF THE NF 1 1A nr CFr`T1nN a Tr1WNCH10 in N PAN!- 17 W V01.15 Page 4056 •4 Wisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM y Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353163 Permit Holder's Name: ❑ City ❑ Village rg Town of: State Plan ID No.: ishler, Todd Town of Erin Prairie CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: 012 - 1023 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer [ Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of 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 E] No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: / Location: 1797 170th Avenue, New Richmond, WI (NE1/4, NE1 /4, Section 9 T30N -R17W) - 9.30.17.125A Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division Vi scons i n SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue I n accord with ILHR 83.05, Wis. Ad P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper n ?t less " Co ty r than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application - State, nitary Permit Number Personal information you provide may be used for secondary purposes ❑ Ciec if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. , i CRO StatePl n I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL 11= - R Prop�trty Owner Name ry' 0 Yy,1 \ i /4 / , T . N, R E (or)( Property Owner's Mailing A dress NUCtfb�er ;� ` Block Number '1 - 7l 7 �' Cit , tate f7 t Zip Code Phone Number Subdivision Name or CSM Number 11. BUILDING: (check one) ❑ State Owned Itr Nearest Road p Vil age r f I ) Public 1 or 2 Family Dwelling No. of bedrooms Town OF 1^ s , I III. BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) / 5 0. ' 1 - - 1 ❑ Apartment/ Condo Q 0,7 -- /0 -000 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 box online A. Check box on line B, if applicable) Rl, &G, Li,fr- A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ Q6 Repair of an ______System ________System Tank Only System _ ExistingSyfstem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 [Seepage Bed J V6 0 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill �! I r ,� ►� 'S 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 2 o Feet 8 , � eet Cap acit y VII. TA NK a ORMATION i n gallons Total # of Manufacturer's Name P refab. Con- steel Fiber- Plastic Exper. New Existin Gallons Tanks Concrete struded glass App. Tanks Tank Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1 ❑ E11111 ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsi ility for installation of the onsite sewage system shown on the attached plans. !P rint) amps) Business Phone Number: s 7 Plum is ddr ss (S r et, City, State, Zip C IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved jpitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) ` ❑ Surcharge Fee) Owner Given Initial �' ay - [[ ``►► Adverse Determination � ro X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (R.1 1/97) 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 a 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 and Buildings Division, 608 - 266 -3151. 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 on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /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 81/2 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; 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. ---------------------------------------------------------------------------------------------------- "ROUNDWATER SURCHARGE 1983 Wisconsin Act 41.0 included the - creation of sur- charges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. " Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09 Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size; Plan must County �}. include, but not limited to: vertical and horizontal reference point (BM), direction and 6t C r O , y( percent slope, scale or dimensions, north arrow, and location and distance to neareslid' ij parcel Lf . # _ �f 1 4 0.0 C) APPLICANT INFORMATION - Please print all informitton. evio Date Personal information you provide may be used for secondary purposes (Privacy 0p is,15.04 (1) � T ''-'SIX INTY PrODertv Owner c.. pr��l(�tBaGi1QtE ` u (� M' l h ��. \ �vt, E 1 /4,S T Q ,N,R I E (or)c> Property Owner's Mailing Address bd. Name or CSM# 1 4? 17ort pt ' ) eL , City State Zip Code Phone Number ❑ City [:1 Village (�] Town Nearest Road 4�N moo,. ❑ New Construction Use: Residential / Number of bedrooms ' Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow Q gpd Recommended design loading rate bed, gpd/ft2 _ trench, gpd/ft Absorption area required — bed, ft — trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft pp 4 t- Q • ii8eannenderl infiltration surface elevation(s) -! 7. 0 f7 ft (as referred to site plan benchmark) Additional design /site considerations Parent material LL ► I Flood plain elevation, if applicable ft L= U = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank Unsuitable for system ® S ❑ U ® S ❑ U [A s EJ U I R s ❑ U EIS Lau ❑ s 9 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD/ft g Texture Consistence Boundary Roots 3vx in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench OR- C) 41 p,3 Ground ��, a t! 0 y 1� 5 Depth to ��.. .. limiting ; factor Win. Remarks: a 1 1 ef � Boring # D ass in t: .. e_ NJ IQ 14 Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address U Date CST Number .1 17 Y la a SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench Ground elev. ft ' Depth to limiting factor in. ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ri Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) : ro � � YY1;s►�le r N NIF- 1, N �� 5 .9 T R. 7 w Da r �►�' -ter k 3`�� tY �Q j h S o- w; ♦ i 59 �� f ( So o . t k lot I,►•e.) to _: STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St Croix County OWNER/BUYER MAILING ADDRESS / 2 2 /70 16 421L'2 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE / PROPERTY LOCATION I V & 1/4, IV e-, 1/4, Section l , T a,2 N -R TOWN OF i % i*✓ /aii ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 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 County Zoning Officer within 30 days of the three year ex ' tion date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving G the O�4 r residence located at: ! 1�, � V., Sec. T -2& N, R ' 1 W, Town of ,c' e!� p f. - U, St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced C Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: J000 Construction: Prefab Concrete — Steel Other Manufacturer (if known): Age of Tank (if known): (2 (Si to (Name) Please int �. • s � e •. sic �:....�, _ � � � S `� (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (exce r inspection opening over outlet baffle). Name Signature �'° MP /MPRS S T 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 /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 Z ,:tj� I f Location of property C_ 1 /4 _ 1/4, Section ,T , - j,_ N - R _Z__) W Township �6'',�,:� Ag lip , {� Mailing address Address of site Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property jj o , go Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes ' No Volume ,,!!�;9Z -and Page Number � � as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. ��Z-T 7 3 , 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 recorded in the office of the County Register of Deeds as Document No. Signature of Applicant Co- Applicant Date of Signature Date of Signature ,r fV STATE BAR OF WISCONSIN FORM 2 - 1982 'S9 ?373 1 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. L i359-PA4 5 ST CROIX CO., WI _ RECFIVED FOR RECORD Marvin L. Rogers , a sing, a man 12 43-1991 1:30 AN ma"" IEE1 _ EOPT N CERT COPY FEE: conveys an d waTTarts to Toud R. Mishler and Jodi„ M. Mishler _ _: W5 .� husband and wi, , . as survivorship marital property RECORDIN6 FEE: 10.00 PAGES: 1 - _ THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN SS SQ,, the following described real estate in St. Cr Coutttx f �•s�+�o'�"" State of Wisconsin ' P" NE 1/4 of NE 1/4 of Section 9 -30 -17 EXCEPT North 338J I W €eet of W *at 212 feet cf E 1/2 of RE 1/4 of NE 1/4 and EXCEPT South 33E feet of NE 114 of NE 1/4 and EXCEPT West 686 feet of North 1016 feet of NE 1/4 of NE 1/4 012- 1023 -40 and EXCEPT Certified Survey Map filed August 19 PARCEL IDENTIFICATION W'MSER ' 1977 in Vol. "2 ", page 444. This is not homestead property. fat (is not' Exception towarranties: Subject to er cements, restrictions and covenants of record. Dated this day of A.lj., 199R._. (SEAL) — _ _. _._ __ (SEAL) —_ (SEAL) _. __ --(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix Count authentirat:d this — _ day of 19_ PersouaRy came before - this 30th. day of November 19_ 9$ , the above named Marv ogers TITLE: MEMBER STATE BAR OF WISCONSIN _ (if not, - - — — authorized by §706.06, Wis. Stars.) to me known to be the person: _ -_ who executed the foregoing instrument and acknowledge the same. THIS INSTR'.itNENT WAS DRAFTED BY Ronald L. Siler - - -- VAN DYK. O'BOYLE �SILER, S.C. ulie C. Dodge Post Office Box -- Nev Richmond, W1 _ W-tary Public, _ _ Pi_e 0 _ County, Wis. (Signatures may be aL: u:a;cated or acknowledged. Both are not bey coma issk r. is permanent. (if not, state c;;v y:ion date: necessary) JULIE -_V_� -= A pril i jq(200Z Notary Pubtit;/State rA Waconalct • Nanw; of persons signing in ar, rapacity shoo''' be t j aed or primed below their signaiurts. iTATE BAR OF WISCONSIN Wisconsin regal Etw* C WARRANTY DEED Form No. 2 1962