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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1y 1A&IPJ 4 aRTOWNSHIP I~1UQ'S0K
Douce !U
SECTION o~ T TN-R~ W
ADDRESS ST. CROIX COUNTY, WISCONSIN
me 11ARMI)D Dp',Vc-
SUBDIVISION -LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
OPQD
lu 11)00
0
38/
ie
06.
00
Bmzoom
HOME
r
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: L U
Alternate benchmark
SEPTIC TANK:Manufacturer: Lj e Liquid Cap. UU
used:~,Manhole cover elev: Final grade elev:
Rings
_
Tank inlet elev.: U~_Tank outlet elev.: 9 a'85
i
No. of feet from nearest road:Front X , Side , Rear Ft.~
From nearest prop. line:Front , Side,),"_, Rear Ft.
C ~ 7 f
No. of feet from: Well -17 ) 1 -1 Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
a
s7
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:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side_, Rear_Ft.
Distance from: Well Building
Sh ic►o.oo NepDeR 90.56 ENn `)O.yb
SOIL ABSORPTION SYSTEM ~ O0' ° 10-56 70-YU
/ ►v 9 o 613
Bed: V Trench: Seepage Pit:
Width: [01 Length Number of Lines:_a_Area Built LQV
Exist. Grade Elev. Q Proposed Final Grade Elev. g d g
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side , Rear X Ft.-
No. feet from well: II8 No. feet from building h
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE : PLUMBER ON JOB : ~L C 11'11 QQ,Q^~
LICENSE NUMBER: 3 1 y 1
6/90:cj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON WI 53707 State Plan I.D NW 4 , SE 4 ,Sec . 24 , T 29 - R19 (If assigned) .
Town of Hudson Lot X CONVENTIONAL El ALTERATIVE
M Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Ma -r Hafner~ 1 Green S Hudson WI
BENCH MARK (Permanent re erence point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: ( ST REF2.T. ELEV.:
C,, 17 -7
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
St. Croix 128816
SEPTIC TANK/ K:-Eo
MANUFACTURER: LIQUID CITY: TANK INLET ELEV.: "TANK O ELEV.: WARNING LABEL LOCKING COVER
I ~ , RO IDED: PROVIDED:
N
(~/I ~ 20 yr+- YES NO ❑YES ls~
BEDDING: ~d~1i T DIA.: i~r#T MATL.: HIGH WATER NUMBER OF ROAD: PROPERT WEL BUILDING: VENT T RESH
C .O. •i C O, ALARM: yL4. LINE: ~T< < AIR INLET
❑ YES NO 7 ❑ YES NO NEAREST-1111i" .S °Z
ER:
MANUFACTURER: BEDD CITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: MP AND CONTROLS OPERATI NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF PU ED YES El NO ReftREST -11110-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTE . 1
WIDTH: NO.OF STR. PIPE ACING: CO R INSIDE DIA.: # PITS: LIQUID
BED/TRENCH
TRENCHES: MA~FRIAL: PIT DEPTH:
DIMENSIONS h
GRAVEL DEPTH FILL DEPTH DISTR. PIPE pISTR. PIPE DISTR. PIPE TERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLETS EL V. END r y~, yL7 ✓wl✓ PIPES: FEET FROM LINE: 1 AIR INLET:
S-
NEAREST
MOUND SYSTEM: y
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS,
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOP IL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRA L DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: R"QISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPE DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION D PLANS
❑ YES ❑ NO MMES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST~~
UJIC.
D
Sketch System on tain in county file for audit.
Reverse Side. SIGMA RE: TITLE: /
SBD-6710 (R. 06/88)
II
SANITARY PERMIT APPLICATION
C~7DLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITeviY fPRMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. pr application
-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
AP- 0 f C' e r,, j 1/4 '/4, S T , N, R E (or W
PROPERTY OWNE 'S MAILING ADD SS LOT # BLOCK #
o reetJ
CITY, TAT ZIP CODE PHONJEE UMBER SUBDIVISION NAME OR CS UMBER
II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLLLAGE NEAREST ROAD ,
mnsn
S)
❑ Public or 2 Fam. Dwelling-# of bedrooms A RCE LAX N UMB ER(
III. BUILDING USE: (If building type is public, check all that apply) s-9,55 A ' Q
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. D~New 2.E] Replacement 3. ❑ Replacement of 4.0 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
RE vl~ IRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) LEVATION
Y ~ 0) Q.,)OFeet 113, eet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncre a Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ooo
Lift Pump Tank/Si hon Chamber. M~= M Fj
VIII. RESPONSIBILITY STATEMENT
1, 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/MPRSW No.: Business Phone Number:
I', rn i 3 1(71 g00) C>
ddress (Street, CAI, State, Zip Code):
rVZ6 ,A s. s
TY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin gent Signature No St ps
ed ❑ Owner Given Initial Surcharge Fee)
.VA
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS 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 ybd 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 sanitarypermit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served.'Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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; 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 11,5,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 sfandards.
SBD-6398 (R.11/88)
67 PLOTA 14 1) 1-,' 0 S S 5 E C t I
N A M E'r _ A T ) w Y Q e M E i m BoLirywulck
k; 0 C A T 1 0 L I C E N S E =q-_
hiFe N~JnL2N~ 5 ,
' l0o~fi fic~~rh Se~ G ~ Sys~elr ,
IVo~e W44 s
y
tI~AN 7.~ ~C ROM Qr~l O
• Se~ I t S~s~el~ ~jV
Kmc- it) k. f6
~y
ys ~ -goo - •
a 30'
to
vo"
Roc o~~ I~fi 1i►+t '',ni
S' tj C.t~ ~r.►tir N"~~' 1i G
_
X14 ~A
, FRESH AI1; INLETS-AND OBSERVATION PIKE
CROSS SECTION
r f~~ ~pprovec] Vent Cap
Minimum 12" Above 13-i o
Final TINA) Giv) A
Ya" 1
9" Cast Iron
Above Pipe Vent Pipe
To Final Grade!
Marsh Hay Or Synthetic Covering
Min. 2" Aggr.eg';.il
Over Pipe
Distribution> Tee
pipe 1~-
11
QQp ~0 Aggregate Perforated Pipe Below
G I 13encath Pipe c -Coupling Terminat:ing r
Bottom of System
DEPARTMENT OF REPORT ON SOIL ! BORINGS AND SAFETY St BUILDING:
;tN
LABOR DUS~'ijiY, OIVISIOr`
HUMA RE PERCOLATI. TESTS 115 P .O. BOX 7981
HUMAN RELATIONS
ter 145.0451 MADISON, WI 6370;
9(1~ a1: ap
SECTION; M Nl(!i f LITY: OrL
T O. NO.: VISION NA-
N
QA
T / 4 /T ZgN/R rg ~t ~ o s'd; z - PP-0 PvSe~ C•.s M.,
COUNTY: NE S/BUYEM-4 NAME: Mx Volless:
8 -C62 6f9r." 4ZrC?'''': !o`~=\ 5r. uDS.AJ t'j
USE
i'DATES OBSERVATIONS MADE
14f4sldence ❑Replace ZZ L
rV.>'•t _ IMP 4/ /8~ ¢ L /~9
11ATITIJNU
um OLO : S-• Site suitable for system U- Site unsuliable for system ~Q~`T E ; -I`-ST Do1J E Ifp r- Wvp fz_MVIG\Aj IN-FUL S MV: ~ a~ ~r--a„ Q~ STEM
~ ' ~ D COMMENDED SYSTEM:IoDllonal)
LLxx.1J --1 XI\
1, Pvicclation Tesu are NOT requlred OESI N RATE:
i under r,H63.0FX61(b), Indice : N It any portion of the tested area Is in the
V l=Girnh t_ Floodpiain, Indicate Floodpleln elevation: /V .4.
1' tL°'T PROFILE 4ESCRIPTIONS
►tORING CJTA TEll H A R SO H HICKN S , C L R, TEXTURE, AND DEPTH
riltlRllER El*TH'1el ELEVATION V
V__ btil.11IGH 'r T.Q QED HOCK IF OBSERVED EE ABORV. ON BACK.)
94-7(- )\10"e 9.0 • I.m' 3L ~L S% 2•T3 20LiNS:~~ .oo• o Bar w 9 i0
.7
ROB,J L3 /GR~ I.oO'Dt: B..rC 5 -^V600- 3.00' L~ p t B
' starer e+~• Mao
1113- F. SU oyZ•,G G .l~' fa r_ Sa. TS; /.67'rzo S.r 5 : t_; so' Rc B.., nns~ Ls
orJE 7' c~• O 4. 17' ~r 8,.► C S v. G2
I. WS 'S-L T ; ZL•t:s 3•r L w ~.,crS /.$a-B.+Mta S cs c
13• 9.Sa 4.~,~" f`~ r0 •.l>: > :ng' I> c B,i Gl5 w/G►,.~ o.7S' Bev k E S• /.83'G,e g,., Mo
e 1
B- `j.7s ./x'•31 IN Onl2. ~ g ea.s:c TSB 1•47' L.r S:L; Lob' B.r L j 4.-5.3'8N Mat
' h C S V /62 a S A-l-r ft0.__YCLY F..rG BAL`S ./,6.
G~, tLY 4 M e o tv $ J
B. /0•.7 G• / of iG • I O r~' 8 L S L T t
/C. 7.5 /,7S 13•r S. t.; f.ls7. 8w 1A &a ro,3•i.
DSc 8.1 to MertD 5 w~6~ t! S ' 3,r7' JD t:. a4 Mtn To
M. ,s tATTCI~th G2. J
I~~4arnML. PERCOLATION TESTS hbT E: N UMBER- C0R-~-ESPo.vos wr rH
ter
AWAr DEPTH W TER OHOE TEST TIGEN t3uG8 AFTE SIN ERVAL•MIN. RAPE INU S
_tUQN
J, 3 1 NON ER INCH
; < Z
P• 14 N N E •C 3
2,31 r.r E " 9( 1
` 2
P S
3
P. < 2
P. R LZVA o
r'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable toll areas. Indicate scale or distances. Describe whet are the ho
,'ontal and vertical elevation reference points and show their location on the plot plan. Show the Surface elevation at ■ll borings and the direction and perce
ofland slope. NOTE: ELLV, (°f'1.S-0 REQVIR_I;S Sonny LAfr_Aee- AL.r[-77wrion/
eVS tELI ELEVATION 69,oa
50
T
BENCH A1~ IIiiS \
Mh21L IS q
I' Iltor.J PI Pt's
APPte.oXrMArra:1..Y
ON LOT LINE.
= L.e V. / oo.oo ` I ~~d~ ~c•~/
MOR
LE • ~t- r tie~~ o i'''I tr O / fi J O PeficcwL/
- 4-O o. .ha t qtr T~-,T µ
G
k ~nr, ~.f
SW CoRrv6R t,` G
the undersl~rsed, hereby artily that -0 loll tests re+r I I;: ,,portedn this form were, made by me In accord with the procedures end methods specilied In the Wisconsi
ldrninistrot Iwo Code, and that the date recorded and the location of the testis 51 correct to~thi best of my knowledge and belief.
II ? I
{ rent TESTS WERE COMPLEI ED ON:
_ ~.u c~{ 1 4~Z lS9
iiUi~ cfi , CiRTIFICATION NUMBER: PHUNE NUMISER(oplronell
_ 5•t. 4ALj 4 San) Gvf. Sow/G 'S `8. ~/s 3tj6,-367q
;I CST SI ATUIIE:
)ISTI\IBUTION: 1)rrpnt;d urmi urea ctMsy In (tsrasl Authranly, Prnp.nsy l)wrva nnrl'Snrl Inslnr.
SEPTIC TANK MAINTENANCE AGREEMENT
w
St. Cro i'x County
rt
• e~ w
OWNER/BUYER
0
--hi Fire Number
ROUTE/BOX NUMBER " d
o
CITY/STATE ZIP rt
PROPERTY LOCATION:-/'?- k, _A;, Section, R
Town of St. Croix County,
Subdivision ~-~-t►~ Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen'sed 'se t'ic tank pumper. What you put into
the system can a ect t e unct on o. the-septic tank as a treat-
ment-stage in the waste disposal system.
idents-ma be eligible to recieve a grant for
St. Croix County res
a maximum of 60% of the cost.of replacement of a failing system,
whi.c 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 .s s_y t.ems agree to keep their system properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary),
sent s apthan 1/3 proximately 1 30 of days sludge
to
dc~
Certification septic-.tank
Certification form will be sent approximately 30 days prior to
form c will k be is
three year-expiration. y
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 Depart-
menC Natural the oStCeCroixeCountyaZoningoOfficetwithinm30edays
and returned to
of the three year expiration.date.
J .Q t
SIGNED VAf
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
I
APPLICATION FOR SANITARY PERMIT
STC-100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property -L q
Location of property - (,J 1/4 1/4, Section, T N-R 1l W
Township
Mailing address
Address of site
c
Subdivision name Lot number
Previous owner of property -~-2/
Total size of parcel
Date parcel was created ~S
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes No
Volume ( ? and Page Number 12 3 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. L/.S /(o O ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County R gist of Deeds, as Document No.
J~
Signature Of Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
DOCUMENT No. STATE BAR OF WISCONSIN FORM 1- 1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
1156tc0 b61ME183 _
- - , REGISTER'S OFFICE
reenwood Enter rig CROIX CO., WI
I This Deed, made between G
-----------------•--••---•_----P-___ses,,_.IA
Rec'd for Record
FEB 2 6 ~,~3U
- -
Grantor, 10:45 A nn
.
ild..-Martill- -F~---fiafiler_-and__Joy_ce_ f...,. hW;-b41-11d__and-
_wife,.as _survivorship__martal__prQp~ry_..............
Req~tK of peMlr
Grantee
Witnesseth, That the said Grantor, for a valuable consideration------
conveys to Grantee the following described real estate in RETURN TO
County, State of Wisconsin:
I~
Tax Parcel No: -
fj
Lot 2 of the,Certified Su~vey Map filed in the Office of the Register of
Deeds for St. Croix County on-May 1, 1989, in Volume 7, Page 2092 as
Document No. 447453.
I
T JkNS o£R
This i$_.jaQt homestead property.
(jok (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And. ---------G.reen~aood_.nxexpxe,..znc..----------
%arrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and protective covenants or restrictions of record, if any
and will warrant and defend the same.
Dated this 21 day of Febr_uar_y.-=----------------------------- 19__90...
I~ (SEAL) (SEAL)
JAMES E. RUSCH, sident
-----(SEAL) \ - -------(SEAL)
- - MA 7itional USCH,..Secretary/ reaagrer
See ad Notary on back
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St. Croix. ss.
authtzAiem4,,d this ________day of__________________________1 19______ .........Personally came before me .this 44. 4.. a, . of I
kebr_VAry---------------
-
Ma;`y -Ba_.Busch
• r------------------ . .
TITLE: MEbIBER STATE BAR OF WISCONSIN
(If not, 4'v i
authorized by § 706.06, Wis. Stats.) s
to me known to be the person .___.._._....1{exectlted the
foregoing instrument and acknowledge tt Isame.
:HIS INSTRUMENT WAS DRAFTED BY f
Heywood & Cari, by Walter Hodynsky
P.O. Box 229, Hudson, WI 54016 ` do =
Notary Public .••---_,St_.__CSOX County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration
are not necessary.)
date: 194;
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc,
FORM No. 1 - 1982 Milwaukee, Wis.