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HomeMy WebLinkAbout018-1038-60-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Permit Holder's Name: ^ City ^ Village ^ own of: Hammond Townshi CST B Elev.:- Insp. BM Elev.: BM Description: C?t~ • or l7U . O~ o .~ rwwly Iwle~rfwwwTli\u I/'11~1\ IIYI VI\IYIAIIVIY TYPE MANUFACTURER CAPACITY Septic ~ ~ ~ p Dosing Aeration Holding TAN~IE'S~TBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Airlntake ROAD Septic ~ tW~ l ~ ----- NA Dosing ? /~ ' c' -,, 2 ~ 1 NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufacturer Demand Model Number ,~v 'T ~ GPM TDH Lift Lriction Syetem.,_ TDH Ft Forcemain Length ~Sr Dia, FZ `~ Dist. To Well ~VIL~VI(I'lIV1V ~T~ItM ELEVATION DATA county: St. Croix Sanitary Permit No.: 363892 State Plan ID No ax STATION BS HI FS ELEV. Benchmark ~ . Z ~ IoG.21 ~ aU .~ YI/I 6 • ~ Z 14, c(Q r M BI~~tS~ v~'8r ~~ ~ ~,.~ ~ St/Ht Inlet ~j,o3 Q}.18~ St/ Ht Outlet ---- Dt Inlet -- `~ Dt Bottom ~Z.lo cj3, ~ ` Header /Man. . ~ L oZ, ~{ 9' Dist. Pipe 2 ~ 3.8 [~ tf.. }Z .. z [ O I, ~ oZ• `l9 ` Bot. System L S' ~~ . to loo, S~ , o . ~ 2- Final Grade ...~ o'~1~.01~ St cover ~ l o , Ov . I 1 TRENCH Width ~ Len th I No. f renches PIT - No f Pits Inside Dia. i Depth DIME s 8 DIMEN I N SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING cturer: INFORMATION Type O 1 CHp` Model Number: System: "`"~ ~--~ UNIT DISTRIBUTION SYSTEM 7 ~ ~ `.~ Header ~ ~ t~ Distribution Pipe(s)f ~ x Hole Size x Hole cing Vent T o Air Intake , Length Q.Qi Dia Length ~ Dia. ~ Sparing f ~ d'a l SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: o$/~/Inspection #2: / / Location: 926 170th Ave, Hammond, WI 54015 (NE 1/4 SE 1/4 17 T29N R17W) - 1.) Alt BM Description = -{ro ~j tsar-S ; U lyer~k, ~'. 2.) Bldg sewer length = ~. 3~` -arr>ptxnt of cover = > 2 N ~~~ Cdr 3~ Sa~~ ~'~~ S tlreteyv 1. o e w ~`~ ~ . n n ~~ ~w`.,~ C.evtl wvi ll ~u,d'' ~'- 1$ a ~!~' ~`~.~ -- ~. rte`" g . ~ Plan revision required? ^ Yes ~ No Us other sid or additi nal i fprmation. pg Z.S" tTp ( ~ 5~6T10 (R 397) ~" Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ___ ~- qZ 6 ~ ~ - ~"~` - `~SCO-1S%I1 SANITARY PERMIT APPLICATION Department of Commerce In accord with Comm 83.0 .A m, C,9 • Attach complete plans (to the county copy only) for than 81n x 11 inches in size. • See reverse side for instructions for completing this Personal information you provide may be used for secondary Safety and Buildings Division 201 W. Washington Avenue POBox7162 Madison, WI 53707-7162 on per not l~ county R ~! (I ~~ Y ' x On t ~~~~~ v~~+ State Sanitary, PerJ~p~q~,~~`yt'~Number .. i. F: w~ ~] Check if revision to previous application ~r nvaa.y maw, a. , .a.v. ~ i ~ ins/r. .. ,~;; i~ :S X fate Plan Review ransa on um r I. APPLI ATION INF RMATI N -PLEASE PRIN ~ '•9~ IN ~ N Property Owner Name ~ [ ~ roperty Lpca n tia ia R lI E (or)~ S l 7 T N r .v s~Q , ~ ~ Property Owner's Mailing Address ' : tot umb~ Block Number ~~ City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F B IL 1 G: (check one) ^ State Ovvned ^ !ty Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms ~ Towan OF o.v d III. BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) ,'~ a,, 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility! Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 _ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an ______System ________System _ __ Tank Only______________ Existing System ________ Existing System B) ^ A Sanitary Permit was previously issued. Permit Number 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~J Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 7. 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. ftJ (Gals/day/sq. ft.) (Min./inch) 1s ~, ~ Elevation '4~Sd 9DO QdD . S ~ Feet /oY• y Feet VII.. TANK INFORMATION Ca aut in allo s Total l # of Manufacturer s Name Prefab. Site l St ,Fiber- Plastic Exper. N E i i Ga lons Tanks concrete ee glass App ew x st n struded Tanks Tank Septic Tank or Holding Tank Vo /OQl~ ,' t ~ y~c,/ ~ ^ ^ ^ ^ ^ Lift Pump Tank/Siphon Chamber L SD ~ .` ,t Y~ ~~yy r L!g ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber 's Name: (Print) Plumber's Signature: o Stamps) MP RS W No . : : Business Phone Number f y / ~ p n / Plumber's Address (Street, City, State, Zip C e): , ,~/~ o lr6c ~ /' G IX. COUNTY /DEPARTMENT USE ONLY ' ^ Disapproved ' . anitary Permit Fee (Includes Groundwater ate slue Issuing Agent Signature (No Stamps) {Approved ^ Owner Given Initial Surcharge fee) t-- ~~J ~ 3~~ Z'~ ~ ~fJ _~ ,~ Adverse Determination ~ J I~~-- X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: ` ~ ~~e/~ ~ ~ ... ~,:U. ~ ~ _ over SYs~" ,~~~~~%~-~t, ~.~/u„~.S ~°~'^~ ~ ",~.~~ ~ I~ . r_ w,. ~ ~ u i ~ 12199 , . y, ne copy T :Safety & Buil ings Division, Owner, Dlumber ~ p~ ~ ~ ~~~ ;. _ , INSTRUCTIONS t. 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. Changesin 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 parce- 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 online 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. V11. 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 (eg. 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 1/2 x 1 1 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. GROUNDWATER SURCHARGE 1983 Wisconsin Act 4i0 included the creation of surcharges (fees) for a number of regulalE~d practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~. - - .~ ~~~ ~`..:1 ~ w ti' ~. ~. ~ G ~~ ~ ~ ~ ~i y ~~.~,~~ pfd - S°f~c /~ 3//C/~'~ PUMP CHAMBER CROSS SECTIOt.1 ANG SPECIFICA~T'IO~JS VEA1T CAP `1~~C.I. VENT PIPE WEATHERPROOF ~ 25~ FROM DOOR, JUA1CT10AJ 80X WINDOW OR FRESH 12"MIU. AIR INTAKE I GRADE i CONDUIT ~-- 16"MIN. IAILET T *~ A 6 C ELEV. FT. D V PROVIDE AIRTIGHT SEAL *APPROVED JOINTS WITN APPROVED PIPE 3' ONTO SOLID SOIL PUMP -~ COAICRETE BLOCK rnr.,t cF APPROVED LOCKIAIG MAIJHOLE COVER 4" MIIJ. IS"/hI1J. I I~~ I ~ ~ I ~~~ ~ ~I~ ~ ~ ~ ALARM ~ II ~ I ~ OIJ ~ I 1 --~ _-l OFF \,/ ~- RISER EXIT PERMITTED OIJLy IF TA1JK MAAIUFAGTUR6.R HAS SUCH APPROVAL SEPTIC E SPEGIFIGATIOAJS DOSE ~ ~WeS~ ~ ~ TAIJKS MA-~IUFACTURER:- - ~ '~ ' NUMBER OF DOSES: PER DAy TAAJK SIZE: ~- ~`~ GALL01J5 DOSE VOLUME ALARM MAIJUFAGTURER: .L e U~hl~~+^ IAICLUDIIJG 6ACKFLOW: ~~`3 GA~EONS MODEL LIUMBER: ~~ ~ CAPACITIES: A=~IWCHES OR -~- CALLOUS SWITCH TyP[: ~ ~ CMG g c 2 IIJCHES OR .2L- GALLOIJ: PUMP MAIJUFACTURER: ~tt k ~o~S C=~IWLHES OR ~-~Y GALLOIJ°. MODEL NUMBER: ~.d B elf D = ~ INLCHES OR 1= GALLOAI! SWITCH TYPE: Y!?CN~ WOTE: PUMP AUO ALARM ARE TO DE MIIJIMUM DISCHARGE RATE ~~ GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFEREIICE DETWEEAI PUMP OFF ARID DISTRIBUTIOAI PIPE.. ~~ l FEET -}- M IA IIMUM IJETWORK SUPPLY PRESSUR . .. ~F FEET E / ~ TT, / • ~ FEET OF FORCE MAIiJ X 3'°~? F/pp Ir~FRICTlo1,1 FACTOR. FEET _ TOTAL Dy1JAMIC HEAD = ~ FEET \ ~~6~ ~~ ~~~ ao „ IAITERRJAL DIMEIJSIOAIZ OF ~~ TAIJK: LEIJGTH ,WIDTH LIQUID DEPTH '3~~ SIGNED: LICENSE IJUMBER: DATE: -_ ti APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes •Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS Pump: EP04 • Solids handling capability: 3/4" maximum. -- • Capacities: up to 55 GPM. .~"' • Total heads: up to 24 feet. • Discharge size: l'/z"NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BONA-N elastomers. • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Pump: EP05 • Solids handling capability: 3/a"maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size:lYz" NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. ~, J~ iirl~ ~~~~13~~1~ ~~3~37~ ~ ~ r~ LJ 7 EP04 EP05 • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 Hz,1550 RPM, built in overload with automatic reset. • Power cord: l0 foot standard length,16/3 SJTO with three prong grounding plug. Optional 20 foot length,16/3 SJTW with three prong grounding plug (standard on EP05). METERS FEET 10 s s o ~ a ~ s g } 5 D a 4 O ~ 3 2F ©1995 Goulds Pumps. Inc. • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Automatic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermo- plastic Semi-open design with pump out vanes for mechanical seal protection. ^ EP05 Impeller: Thermo- plastic enclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplas- tic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING SP' Canadian Standards Association (CSA listed model numbers end in "F" or "AC".) i ~ ~~ ~i 30 ~ -~~5 GPM I ~~~ 25 ~ i = ~ - - i i j 20 ~ i i ~ I 15 ~ ~ ~ EP05 f0 ~ i ~ ~ EP_0_4 5 i ~ ~ S 1 ~ ! ~ 1 O i i 00 10 20 30 40 50 GPM 0 2 4 6 9 10 CAPACITY 12 m~/h E'fecti•: a ~Aav. 1995 i~iwu~i~u~ vYp~tr~nidnt or ~omrnerca SOIL AN.B-SI-'~ EVALUATION Divislort of Safery end Buildings Sur~af integrated Services i Ord311Ce~ith~~5. II,h~R 8 9, WiS, Adm. Code p ~~/TTLCCC/" ~ ~~L77~ / I ounty Attach complete site plan on paper not I 8 than i/2 x 11 inches in si must include, but not limited Lo: vertical and h M), direction and j percent elope, aoale or dimenei~ss, north arrow, and location and distance to nearest road. Parcel I.O. N APPLICANT INI:ORMATION • Phase print al! lntormafloh. A view Personal informstlon you provide may bs ussd for sscondary Pusaoses (Privacy t.aw, B. 16.04 (t} (m)}. ~, ` ~~ r a~- i Govt. dot ~F' t/a$~ t/a,s ___ ~ M ~4 gineklk sutra. Name or C C}ty a State Zip Code Phone Number ^ Cit~r ^ Vihage j$) Town Page ~. o' ~- '-22-2a~ T~ g' ,N,R `7 E (or~ Nearest Road ~ 7~ 7 New Consuuetion Use: (~Residentisrl 1 Number of bedrooms ~ Addition to axle@ng building ^ Replacement ^ Public or commercfai • Dsscrfbe: Code derived ddty tbw yso qpd Recommended deaipn loading rate - y bed, gpd/fi~~trench, gpd/fi~ Abeorptbn area required //~ S bed, fta SOD trench, ft 2 Max4mum design loading rate _~~bed, qP~~trench, gpolft2 Recommended inflitration eurtace elevation(s) e ~~ ~ y R (as refeaed to sits plan benchmark} Addhlonal deaign/eite conaideradane % ~ ~ ti'vz ° r ~~~ `t' /3 ,13G vr~ C ~tl DS. 30 Paront materiel ~~~~c u I o~ti7'i/ws'~ Food plain elsvation, H app-icabie ft 8 ~ Suitable for system ""` 1Y°~ ~ °"` "" u ~ unsuitable for ayatem ®s ^ u ji~l s ^ U ®s ^ u .~ s ^ u ^ s ®u ^ s [~ u Bot~ng # s r Ground elev. /O~fG IlmiLng :actor G. D in. goring # ~' ~~ Ground elev. ~l~2~• Depth to limitlng faS~r min. Remartcs: CST Nams (Please Print) Sig~~natura p Teisphone No. SOIL CEBCRI PTION R1II iPOAT M t l Structure R t Horizon Depth in. Dominant CGor Munseii o t es Du. Si, Cont. Color Texture Dr. Sz. Sh~ Consisbnce Boundary oo s Bed ,Trench ~ ~ ~ .~ ...- a 7 , , g' a~f' /o%• y~ ~ , ~ I q . L/ss~.u~ -- ~..~ ~C ( ~-- Que.r s . Qnm~rk'c• ci y S' ~ / rrl5' b ~J1 ~ ~ J ~ ~ `~ ... S ~ ~ 2, s ~, S ~ ~~ a ~ ' 9 - ~ '~ 0 ~~ 1~7U Scc ?`~`_~~ 1~~-vlS'~.,rJ GJ ~°~G/~ `~~/d~'cG ~~ ?SID' ~r~`~~ ~' d~y~ SOIL DESCRIPTION REPORT wage a of ~ ~ROPfcRTY OWNER - PARCEL 1.t7.N ,2 1-lorizon Dapttt Dominant Color Boring # Monies Color Cont Sz Qu Texture Structure Consistence Gr. Sz. Sh. Boundary R~~ Bed .Trench {n, Munselt `~~ ~ . . . ~ j `l .~1~ ~~~ ~ C s ~ ~ ~ .~ ~ ~ 3'~: J o-f , ~ ~ S y C /d6 S':`C f ~ .it~5~~i ~ ~ ~ ~~~`' Ground 7~.. ~6 elev. 7° ~ ft~ ' Depth to pmiZinp 3S -~ O bg tactor ,~In L .._.Y__~._. " 1~ Boring # ~r , y~. t3round elev. IQ..~tt- Dspth td limitin g factor H~in' Remarks: Horizon Depth Dotttknant Color Mottles Texture 8truoture t3h Gr Sz Coneietonce Bounda ry Roots Sad , Trenc in. #11une6Y Ou. 5z. Cont. Color . . . Baring # ; o a~ ~~ 3 ~- a ~, s y ~y ~ ~ f Sf ~ ~ ~ 2 3 5 Sc / a In D . 4round elev. / .~.L~ Depth to lirrdting taotor . ,;~in. Rnrn~rita~ Bot'ing # xn 4~. s , F / urQU1 ~ Akev. ~D'!. 7 ft. Depth to 11m1tlng - factor ?~~j 3-'~~~• Rsrrtarks: - S6D-8330 (R. 07198) ~/ /~ f1- ~% yu ~~ ~'c.~l~ ! '' = yD -~l/ %~~,~'~~' /zP~.r~eoyc?y ADO, c~ f I ~i ~ ~ i~ I II O ~v - - _ • 1 1 ~~ . ,'' , ~_~ 1 pas. „,P~ ~ ~~ ~ ~~ ~ ~ ~~ ,,. _,~ m °~ ,'~ . , S'h ~ ~ oIJ ~ do. ~ -a 3dF3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMBNT AND OWNERSHIP CERTIFICATION FORM OWACf/BUyCf ~Yr.~.,v K /I.'/J~Y~ Mailing Address T l fl'.~ ,2.~~. S '~ ~~ mfr, ~,~ d ~ ~ ~ ~` ~/~l~ Property Address ~a ~ (~6 `T6Y ,~.~~ (Verification rrquirrd from Pianaiag Depargneat far aew construetioa)_ _ ' ~ `e City/5tate t~~ ~..~,. ~~ Parcel Identification Number _ _~'~ ~` - ld 3 ~ -s~ -~'~~ LEGAL DESCRIPTION Property Location ~!~ /,.fit' %, Sec. „jam, T~ R 17 W, Town of _~/~. ~s ~ a,~~ , snba~~ Lot # ____._. Certified Stuvey Map # .Volume _ .Page # Warrstaty Deed # C'.y2 ~ t ~ f Volume ~~ ~ Page # ~ ..~ 6. Spey ~+ou9c D yrs ~ no Lot tines itiaitiflabie ~ yes ^. no ~~~1^~~=~dtesakmitspre.mattrc~.fu~lure~obaadle~rastes.Propam~aa~oe eaosists of pampiag oat rise septic tank e~ay timx yeas ar if aeededby a Iioeosod pampeG What you pnt into ~ :ysbem ma affect.tire ~EmctiOa of the ~ tsdc-ss, a 4ratmcad ~ in Qre ~a~bei.zysoeat. T~ P~P~9' o~ ~ ~ ~bimit to sc. C`iois Zooiag a oatificman form, a~o~ed by the ~avmec ~ ~by a P~3~ymsap odglambcror'a iioeasod~ Gist (1) t>se oaMite aastc~vaterdrspossi:y:~m is is ProPu' ~~8 e~oadi8an andloe (~ after boa and pampiog.(lf nay}. $~ :~.taak is kas fan 1/3 ~fa1l of sIodgc. >~ the uade~,Od have rind ~e abome ~ ~ ~ iq m~a t6e private sewage disposal system aridt the standards oet ~, beneiq'as set by the Dept of Qoam~eroe sad the of Natnrat R,esoarcea; Sloe of Wis~n.. boa ~ ~ ~C Las boon mast be eotapkted and reduced to tba St. t~+oix.Co<mty Zoning O&ce ~vitlain 3Q day:• of the. 9u+iee Yar dace. P~:-- SlGffiAT<7RE OF APPLICANT DATE S CER'I'~CA1~ON ' I {we) oatifjr that all stag oa ffiis form arr ttae to the beat of mY (om} imowledge. I (rue} am (arc) the owner(s) of ~ iY d / by vi~c of a a:r¢aty deed tocor+ded is Register of Deeds Office. SICINA OF APPLICANT DATE «««««« ~y iafosmatioa that is mis-tr~prescatedmay result to the:aaitaty permit being revoked by the Zoning Depa:bmeat, ~«.««• «« Iaciadc with this appiicatioa: a stamped rrractaaty decd from the Register of Deeds officx a copy of the certified suxrrcy map if reference is made is the warranty deed STATE BAR OF WISCONSIN FORM 1 - 1998 WARRANTY DEED r . j' a e,^F t ~ Document Number ~ t%!_ .~.. v ~ i.J Pn ~ _ ~ ri This Deed, made between JOHN H. HlVAIti, a sir>~le man _ Grantor, and FKAN(:15 J. H1VARll and JA1V1Wti hl 1t1YAft1) Husband and Wife as rlAttl`1'AL SUtiVlVritSHl:k~ FR~P~N`1'Y Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate In St. I:TUlX County, State of Wisconsin (the °Property"): A parcel of land located in the tYOrtheast Quarter of the Southeast Quarter (ivE of S;rw), Section Seventeen (17) , 't'ownship 't'wenty-nine (29) =North, iTange Seventeen (17) West, St. Croix County, Wisconsin described as follows: Eo,nmencing at the Southeast corner of the Nox'tl~east Quarter of the Southeast Quarter (1vEp of S~;y) of said Section Seventeen (1'j) thence west along the South line of said Quarter Section 23? feet to the point of begin- ning: thence west along the South line of said quarter section 1515 feet= thence 1~orth 4UU feet: thence East 1511 feet: thence South 400 feet to the point of begin- ning. Recording Area 6221$1 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR REC~tD OS-O1-2~0 4:00 PM YARRANTY DEED CERTPCOPY FEE: 8 COPY FEE: TRANSFER FEE: REGORDIN6 FEE: 10.00 PAf~S: 1 Name and Return Address ~~Q ~z~.s ~o~pp .2 0 ~ J ~ O'~ 2 ,r ~ Q /-- o~ y'~ ~~ ~a- m wt- D n ~J ~~, ~ ~o/ Fart of U18-10 j$-SU-UUU -~~ Parcel Identification Number (PIN) This 1S ~D7 homestead property (is) (is not) The parcel shown on this document is being added to the parcel shown on the document recorded in Vol. 61 j, Yage '147, Locument ivo. '3t,4t~03. described as a parcel of land in the Northeast Quarter of the Southeast Quarter of Section 17, `t'ownship L9 North, Range 17 West: Commencing at the Southeast corner of the h ortheast Quarter of the Southea~•t Quarter of eats= Section 17 as the point of beginning: thence west slang the South line of said quarter section 237 fra~t: thence North 400 feet: thence East 23? feet: thence South 400 feet to the point of beginning. 't'o create one parcel, and this transaction is thereby exemptfrom C,~apter 18 of the St. (:roix l:ounty Lana Use ttegulations pursuant to Section 1ti.05 (A j (j) . "Together with aii appurtenant rights, title and interests. Grantor warrants that ttie title to the Property is good, indefeasible In fee simple and free and clear of encumbrances except Dated this ~ day of /~7f'~/w~U~ , (SEAL) __ (SEAL) * J UHt~ ~ttl YAiih '" _. • (SEAL) (SEAL) AUTHENTICATION Signature(s) ACKNOWLEDGMENT State of Wisconsin, authenticated this day of ss. Personally came before me this ~~ TITLE: MEMBER STATE BAR OF WISCONSIN