HomeMy WebLinkAbout022-1048-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 561085 0
GENERAL INFORMATION 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:
Johnson, Anthony Kinnickinnic, Town of 022-1048-10-000
CST BM Elev: Insp. BM Elev: BM Description: SectioNTown/Range/Map No:
/tSZ~ w C29-1 17.28.18.P257A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /D6 Bench`m+ark~ z-7.5 115Z--75 Q
Dosing t ~O Alt. B~~
Aeration / Bldg. Sewer 1 Y`~
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' / Dt Bottom $ C
Dosing I 1 Header/Man.
y $jf /
Aeration Dist. Pipe ►
Holding Bot.System
rO ^ .
Final Gr e
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
l G 3 5, Co 8, S /is~ 3 1.9 `19.8
Model Num
cGP6d:;
TDH Lift
7 riction Loss System Hgad ~ JT IH Ft j
Hg
• i C1 i ly, 311
Forcemain Length Dia..z Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of jrenc PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS .6
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of ystem: CHAMBER OR
UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
1
Pipe(s) f 1
Length Dia Len as, p ing Z I
SOIL COVER I Pressure Systems Onl xx Mound Or At-Grade Systems Only
Depth Over Depth Over jxx Depth of xx Seeded/Sodded xx Mulc ed
Bed/Trench Center Bed/Trench Edges Topsoil ' P_ ~ No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 389 N. Liberty Ro iver Falls, W1 54022 (NE 1/4 NE 1/4 17 T28N R18W) NA Lot 1 Parcel No: 17.28.18.P257A
14h- G8 J e.`.
1.) Alt BM Description ~-r2.) Bldg sewer length
amount of cover
=
3.)Contour
Plan revision Required? ❑ Yes to 1 1 f ~J
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's Sig ture Cert. No.
re,?s
A,Ajv%.-
Portage, WI (800) 362-7220
Innovation, Quality Spooner, WI (800) 336-3416
And Service Fond du Lac, WI (800) 641-5937
Since 1965 Maiden Rock, WI (800) 325-8456
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Project Name: Computations B Date: !
Location: Checked By: Date:
Title/Item: ki "rG Sheet: Of:
County Ia& ti Safety and Buildings Division . Vl O
07
t, 201 W. Washington . - ox 7162 Sanitary Permit Number (to be filled in by Co.)
P ttl Madison, W7
State Transactign Number
Sanitary Permit Application NA-
is In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
required prior to obtaining a sanitary pen-nit. Note: Application forms for state-owned POWTS are submitted to Project Address (if differe tha~m piling `address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ~k
purposes in accordance with the Priva Law, s. 15.0 1 m , Slats. ~L2 Zj~
1. Application Information - Please Print All Info ion Puy
* #
Property ner's N me Parcel
Property Owner's ailing Ad ress n Property Location (~2G7a
r .J
r~ itd^ ST C Govt. Lot
City, State _ Zip Code I~b8ne Number'/.'/., Section
h ~L ~ cucle oneL i
T N' R E o
1 c:. ,~vv)
II. Type of Building (check all that apply) Lot#
Subdivision Name
1 or 2 Family Dwelling - Number of Bedrooms .Jt•
04 Q Block #
❑ Public/Commercial - Describe Use ` r ❑ City of
P ' CSM Number ❑ Village of
❑ State Owned - Describe Use `
~
icable
U
III. Type of Permit: (Check only one box online A. C plete line B ipl
❑ New System reatment/Holding Tank Replacement Only PS Other Modification to Existing System (explain)
joe f << )
List Pre onus Permit Number and to issued
B. El Permit Renewal C1 Permit Revision El Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner A-,
IV. Type of POWTS System/Component/Device: Check all that apply)
❑ Non-Pressurized Iri-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat ent Area Information:
Design Flowgpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
S Capacity in Total # o
VI. Tank Info of Manufacturer
O U
Gallons Gallons Units U u N N
New Tanks Existing Tanks
J,tu~,~, t"; a U in ti w i7 iL
Septic or Holding Tank < , W
Dosing Chamber
t3
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW TS shown on ;ached plans.
Plum s Name (Print) Plu Signature MP N r Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
1
7)
VIII. un /Department Use Only
Permit Fee Date I sued Issuin ent Signatur
PProved ❑ s z 5 a g~3o / 3
❑ iven Reason for enial
IX. Condit 71tiasons for Disapproval 3) ota r
1: Septic nk, effluent filter and `
dispersal cell must all be serAces f rnalntained 1 1_ G~
CA.
as per management plan provided by plum. Pty b~ Moa i- &A-0
L AN self 4& req%*@hle t roust. be
CIS per ~pp11t code / off~118t1C>fi. 'st`o n 1,J /riaC'r►-/ rzo,.4-i~
Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inch size
SBD-6398 (R. 11/11) Z Z5
COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS
PER COMM 84.25 CODE CHANGES 2/1/2004
Access Opening, not top of cover, Access Opening, not top of coyer,
must emdend to a point no greater must e3dend at least
than 6.. Below Finished Grade 4" Above Finished G ade /
.
Cover with `~C~a e .GUF. V NITS/ I~ -row
Locking Device C br 89x APPtdy~P CAP
Finished Grade a yy~
(typical) l2 ./i'I /Nv
~ Min. 23"
30 Fr. ~QZ ~r Access Opening
U~
jM5ULATE Min. 23" Access Opening
P) P67 2
c S[,~'
Ouh:t Effluent Filter
,f
A f Union AgPP_0yE.A 70/P6- 3 iFT.
Inlet Baffle
i
Pump
or ve-~ ca~ty under w~ , c'chfer 2., /over ~d Ps
3 SQ.nol Ira Two bad
ComparFment Septic/Pump Tanh ale~ o n oxide
SPECIFICATIONS
TANK MFR: W DOSES PER DAY:
TANK SIZE: SEPTIC GAL. DOSE VOLUME: GAL.
DOSE &60 GAL. (INCLUDES FLOWBACK & <20% OF DWF)
ALARM MFR: CAPACITIES: A = INCHES = GAL.
MODEL #
Switch type: B = -2-INCHES = GAL.
PUMP MFR: C = INCHES = GAL.
MODEL
SWITCH TYPE: D = INCHES = GAL.
REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e)
VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) = FT.
MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) _ + FT.
FT. OF FORCEMAIN x FT./100 FT. FRICTION FACTOR FT.
TOTAL DYNAMIC HEAD (TDH) = FT.
INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH
MP/MPRS SIGNATURE: LICENSE NUMBER:
Portage, WI (800) 362-7220
Innovation, Quality Spooner, WI (800) 336-3416
And Service Fond du Lac, WI (800) 641-5937
Since 1965 Maiden Rock, WI (800) 325-8456
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Project Name: U~~' alb Computations By: Date:
Location: Checked By: Date:
Title/item: D ~ • Sheet: Of:
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: )G d'~1
Owner's Address: l 1f ber k" L(
Legal Description: ko )FZi
Township:
e
County:
Subdivision Name:
Lot Number:
Parcel ID Number:
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: License Number:
Date: Phone Number
Signature n ~ 1+
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner AGl l fl Septic Tank Capacity Gli gal ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturers C c ❑ NA
Number of Bedrooms j ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity L L gal ❑ NA
Estimated flow (average) gal/day Pump Tank Manufacturer y ❑ NA
Design flow (peak), (Estimated x 1.5) gal/day Pump. Manufacturer ❑ NA
Soil Application Rate gal/day/fts Pump Model 47 h ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) :_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODO 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 (BODS) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ;3-Mound
Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Y8 in dia. ❑ JNA Other: ❑ NA
Other: ❑ Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 7 ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Pump out contents of tank(s) P , "c When combined sludge and scum equals one-third (Y) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 ears) ❑ NA
year(s) y
Clean effluent filter At least once every: ❑ month(s) ❑ NA
• Q-year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
year(s)
❑ month(s)
Flush laterals and pressure test At least once every: E] year(s) wiJ1 Pill ❑ NA
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 failing 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 (Y3) 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.
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 Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
af
System start up shall not occur when soil conditions are frozen at the Infiltrative surface. Page
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess
wastewater will be discharged to the dispersal oeli(s) in one large dose, overloading the oell(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 fife
of the POWTS: ardg)btics; 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 Bowing steps shall be taken to Insure that the
system is properly and safely abandoned In compliance with ch. Comm a.33, Wisconsin"Administrative Code:
• AN 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-property 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'
It the POWTS fads and cannot be repaired the following -measures have been, or must be taken, to provide a code
compliant replacement system:
O 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 regt*W setbacks from Wig; and proposed stinxture, lot Ones and wells. Failure to
protect the replacement am will malt In the need for a new soli and site evaluation to establish a suitable
replacement arse. Replacement systems must comply with the rules In effect at that time.
0 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.
0 The site has not been evaluated to-Identify a suitable. replacement area. Upon failure of the POWTS a soil and
site evaluation must be perfomled_ 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 faded POWTS.
13 Mound and at-grade sod absorption systems maybe 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 ANDIOR 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 Name
a Wad 1b)14 Phone _ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Z Agency a YL;';? -S ,
Phone Phone 19.0n% _y .60
MIS damawnt was dnftd by the staffs of the Green farce. i4ta"q a and WausNara County zoning WW- Sat b*M agenda. This document meets
the minimum requirements of dL Comm 83,?3MX1Xd)&M sad 83.54(l),(2) & (3), Vl axisin Adm(rttsftgm Coda Use of this document does not
guarantee the performance of the POWTS.
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Portage, WI (800) 362-7220
Innovation, Quality Spooner, WI (800) 336-3416
And Service Fond du Lac, WI (800) 641-5937
Since 1965 Maiden Rock, WI (800) 325-8456
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Project Name: Computations By: Date:
s
Location: - Checked By: Date: m\al Title/Item: ~~.y~ Sheet: Of:
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
wBuyer ?l~Gr1 '~2 yt
,r /4/1
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
J r
City/State Parcel Identification Number '~Gl
LEGAL DESCRIPTION
Property Location A6 , 4ZL , Sec. , T -9Sf N R_,6~_W, Town of AhIl /C// Me
Subdivision , Lot
Certified Survey Map # , Volume Page _
Warranty Deed # Volume , Page #
Spec house yes no Lot lines identifiable yes 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.
I/we, 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 Naturil 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 /re true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty ed recorded in Register of Deeds Office.
5
Number of bedrooms
SIGN URE OF APPLICANT(S) 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)
i
IIIIIIIIIIII IIIIIIIIIIIIII
I II
State Bar of Wisconsin Fonn 3-2003 8 0 5 1 7 5 6
QUIT CLAIM DEED Tx :4038567
Document Number Document Name 952585
BETH PABST
REGISTER OF DEEDS
THIS DEED, made between Tara M. Johnson, flea Tara M. Finch ST. CROIX CO., WI
03/15/2012 12:59 PM
EXEMPT#: 8M
("Grantor," whether one or more), and Anthony L. Johnson REC FEE: 30.00
PAGES: 1
("Grantee," whether one or more).
Grantor quit claims to Grantee the following described real estate, together with the
rents, profits, fixtures and other appurtenant interests, in St. Croix Recording Area
County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Nan1c an'D Wrli?f"I"Estreen
Parcel 1: 304 Locust Street
Lot 1 of Certified Survey Map recorded in Volume 8 of C.S.M., pg. 2138, being a7 `t Street
located in the NE'/4 of the NE'/4 of Section 17, Township 28 North, Range 18 West, Hudson, WI 54016
Town of Kinnickinnic, St. Croix County, Wisconsin. This lot is subdivision of Lot
1 of the Certified Survey Map recorded in Volume 7 of C.S.M., pg. 1981. Subject
to private roadway easement as shown on said C.S.M.
022-1048-10-000
Parcel 2: Parcel Identification Number (PIN)
Road easement as shown on the Certified Survey Map in Volume 7 of C.S.M., pg. This is not homestead property.
1834. (is) (is not)
Together with and subject to a 66 foot Private Road Easement as shown on said
Certified Survey Map and as shown on Certified Survey Map recorded in Volume
7 of C.S.M., pg. 1834.
Subject to a Mutual Easement and Maintenance Agreement recorded in Volume 888 of Rec., pg.280
Dated 3 ' 13 -12-
~j PAZOUMONG
(SEAL) fit Ca"'miuto" 4 " ft L W :3MI. 110-99999wWwwV
* *Tara M. JohnMn, fka Tara M. J nc
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF VA t.. )
) ss.
authenticated on 4AAP(V' 1 COUNTY)
Personally came before me on utVY(,& (9, 1'-
* the above-named Tara M. Johnson, flea Tara M. Finch
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
Attorney David J. Estreen No Pu li , State of MALNWM
304 Locust St., Hudson WI 54016 My commission (is permanent) (expires: -
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANYa90DIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QIi1T CLAINI DEED 02003 STATE BAR OF WISCONSIN FORM NO. 3-2003
* Twi name below signatures. INFO-PROT" Legal Forms • (800)655-2021 . infoproforms com
r~
450658
CERTIFIED SURVEY MAP
LOCATED IN THE NE I/4. OF THE NE 1/4 OF SECTION 17, T 28 N, R I8 W,
TOWN OF KI'NNICKIN'NIC,-_ST.- CROIX. CO., WISCONSIN.
OWNER: ELDON WAGNER
RT. 2 BOX 272 B ~C N 1/4 CORNER SEC-
RIVER PALLS, WI 54022 17,
•'J WEST LINE NE-NE • 2
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Ex1Sr1NO 66' ROAD N. PLATTE,D L.AN•DS
EASEMENT p
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JANES O•r.'nvNFLL
Register "I Dews
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St. Croix Co., IN) /
9114 CORNER SECr10N.17 '^C; /
(COUNTY MONUMCNr FOUNDt. i
N C CORNER }ON I r
N1°23'42"~ 1!99,23' • (COUNTY MONUMENT
S l 0 25 4 2 W 6 3 5. f 7 FOUND ap/~ga►
CAST LINO OF THE NC114 ~►ovsS.,
!JW_PLATTED .LANDS
• JAMES M.
= WEBER
• . I•' IRON Pore FOUND. S-1804
o. x 9 r I ;,a. z IRON PIPE WC10HINO VEF° D SPRING VALLEY
1. l3 LOS. PER Lf-Ng--A-4 FOOr. AP ! CIS.
SCALE 1":200' AUG 17 1989 ',~~ti0 SURV~~~~w`•
O' !00' C CROIXIRAMM nP1/V~/'M1(v N,#Ifts*tMM,
200' 400' ANDK*04000M1hAlITME - r w .o
JAMas M, WadaR d-I604
SHEET I OF 2 O A T a o r..a r. s. w,a$
REV~S~ FARM 1y~1481•i.
89. s9 VOLUME 8 PAGE 2138
THIS 1NSTRUMCNT DRAFT[O dY~~~~~•