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HomeMy WebLinkAbout020-1190-80-000 � ° $ C) � 7 � ° - k e . \ 0 2 � « � ] � § � § � ƒ � J � � 2 � ) z 2 f k � J � Cl) \ E U) •• o \ \ } m e z q � to k \ j k 7 F § z ± 7 7 N ? : o D 2 co } k k 6 0 � \ z o ) ƒ c k k E G CNI \ CL ) AD _ \o a ) k 8 cu (0 0 / / k § § z 7 2 m m m CL _ _ _ \ � / / 2 2 » § ƒ ® 6 § -e \ § ƒ M f ) in § C k f \ E c a a E $ E / k ƒ \ ik — ) \ \ , � $ k \ r - f E f k CD ¢ \ & I 2 / o z £ / 2 2 k C _ « a .. � » - 2 0 , c J k I k k C T r � Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 5a hi n7. ���r TOWNSHIP SEC. T a `l N-R� ADDRESS e � � Off-X�2g Z ST. CROIX COUNTY, WISCONSIN I` n ! H u t"5 O /,cJZ s�U ,� SUBDIVISION Q".*6 t� LOT LOT SIZE `� a✓ S PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i V j_- i a / Df 'per : / I 1 110 fi M�� N SO A 7711 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Li/t Liquid Capacity: sQ /. Number of rings used: / Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,Q Side, Rear, O J ro0 feet From nearest property line Front,OSide,QRear,� S feet Number of feet from: well 97 , building: .6 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE ,1 PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: k Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM . Bed: /41 Trench: �— Width: Lenith: Number of Lines: Area BuiltvC'fr-, Fill depth to top of pipe: 41m� Number of feet from nearest property line: Front, O Side, O Rear,QIft Number of feet from well: / �" Number of feet from building: to (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one) . HOLDING TANK Manufacturer: /,r Capacity: Elevation of bottom of tank: Number of rings used: i Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: _ �' -, 2-- 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. is6N,WI BUREAU OF PLUMBING MADISON,WI 53707 NW,' -,S21,T29N-R19G1 CONVENTIONAL ❑ALTERNATIVE IState Plan l.D.Number: Town a{ Hud/san ❑Holding Tank E] In-Ground Pressure El Mound (If assigned) Lot 16 Jacab4 Land%n NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE Sam MiUeeA Rowe 1, Sax 282, Hudson, W1 54016 [;)-Cr) 1-615 C)b BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: JMPIMPRSW No Cnunty. Sanitary Permit Number: Haug StAohbeen 5432 St. cAoix 112781 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER 0 /�-y PROVIDED: PROVIDED. BEDDING: rV/V`EN/TJ�D+IAG.:•^♦•D IVE AT1 / HI<3NWAT / C 6� 6-S6 RYES ONO ❑YES NO NUMBER OF ROAD PROPERTY ELL BUILDING: T FRESH ,[7� ALARM FEET FROM // _ LINE. 9� �. IVENT AIR INLET ❑YES NO ❑ [:]No YES NEAREST W DOSING CHAMBER: MANUFACTURER. BEDDING. j1_iOUtDCAPACITY PUMPMODEL 1111"P LI:SIPHON MANF AC TUREH WARNING LABEL LOCKING COVER ROVIDED PROVIDED: OYES ❑NO ❑YES ONO 10YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER HOPaFT WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FR LINE AIR INLET PUMP ON AND OFF) DYES ❑NO MARES' SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I(N(VTT+ �IANIITIIIH J IMATEHIAL ANO MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH IND OF IDISTH PIPE SPA(:IN(, COV i JINSID1 DIA 'PITS LIQUID BED/TRENCH THE S r M II L: PIT DEPTH. DIMENSIONS,(Jl_p GRAVEL-DEPTH �nFIL E H UISTH.PIP UISTH PIPE DISTR.PIPE MATERIAL NO DISTH NUMBER QF +`PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIES AHD C VEH E(EV.INLET ELEV END c PIPES LI - ) AIR INLET : 1 Z 7 Z NEARESTO� 011ie MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE JPI IIMANI NI MAHKEHS OHSFHVATION WELLS OYES 1:1 NO YES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEO 11E PTH OF TOPSOIL SODDED S1MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO 1:1 YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: QED/TRENCH WIOTH LENGTH TRENOCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD DMATERIA O UISTH UISTR.PIPE UISTHIBUTION PIPE MATERIAL 8�MARKING E LE V.. ELEV. DIA ELEV. PES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT L Y RIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ❑NO ❑YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF 'Pq OPERTY WELL: BUILDING: 0 FEET FROM LINE: DYES ED NO DYES ❑NO NEAREST L Sketch System on oLYhty R t .� in file for audit. Reverse Side. SIGNATURE. � TITLE: DILHR SBD 6710 (R.01/82) ZDming Admtini.6t axan DILHR SANITARY PERMIT APPLICATION COUNTY Cam/ �.,...,�...o� In accord with ILHR 83.05,Wis.Adm.Code STAT SA T Y E IT# �/ —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION �y 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LINO PROPERTY OWNER PROPERTY LOCATION Ile W &W'/as(�,�'/a, S N, R E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME /C y� ep , Z r� ` S Lo I-N CITY,STA/T� ZIP CODE PHONE NUMBER CITY EAREST ROAD,LAKE OR LANDMARK 4ASD ,% Wi- O/1 37 ❑ VILLAGE: O 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. [A New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d.❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Seepage Bed b. ❑seepage Trench c. ❑seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C -3 (Of/s, , Z Feet ❑Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of N Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank ©� / Ge/Q i S 01,- ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ Ej Ej ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: ,Slce,k 6 Plumber's Address(Street,City,State,Zip Code): N"a�me�of Designer; 1nrtitaa mil . $' O� 7a S /Ol► (0�N VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# C A0, /s/rc/ CST's ADDRESS(Street,City,State,Zip ode) Phone Number: vg.- A/ 3 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) 'Approved ❑ Owner Given Initial ( �y� S'jcchaarrg(e�Fe/e� I,, }�j� Adverse Determination 1 l.LJ "*'C ��w 9-' "� �Wt X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION t TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 81A 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; dosing or pumping chambers; 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. ---------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground included the creation of surcharges (fees) for a number of regulated practices which Wisco ifl`S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried T9 tSllIr is used in your building is returned to the groundwater through your soil absorption 0 system or the disposal site used by your holding tank pumper. 0 The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) 4 ,Cpl`GlQ- S IFC h 4"At �d'1` ,+pra.er a 'r a "` / p/,o c :;v� s 2 S r` 04 0 ?•r"x a v' t i I LA LA o rn � S W • J H �- h ' P p s P E " �` w : G U tr I p P P P s fl F I o r s I P p s ps o T 40 yA': DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, c DIVISION BOX 76 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 H HUMAN (H63.09(1) &Chapter 145.045) LOCATION: SECTION: OWNSHIP/ 1/6 OT NO.:BLK.NO.: SUBDIVISION NAME: u� /W/a . I /T.29 N/R/70(or) so — "`°� .S fr- COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: \ SY c o r S,9 /e,- O Ga �SO S , si Ol fi USE DATES OBSERVATIONS MADE NO.BED MS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER ATION TESTS: Residence / 'lew ❑Replace 7—/4 -/6 - q '7 ^L 0 / y RATING:S=Site suitable for system U=Site unsuitable for system (r S' G' B C d t /CAM RKS NNVENTIONAL: MOUND: IN-G(RO�UND-PRESSURE: SYSTEM-IN-FILLHOL ING TANK: RECOMMENDED SYSTEM:(opptional) F_j❑U ZIS I .L�J S ❑U DS � S ®U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: I Floodplain,indicate Floodplain elevation: /"' PROF j!f DESCRIPTIONS BORING TOTALP DEPTH TO GROUNDWATER44 PWG►S CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B 7 J u•�' � 7 7 S' 7 91 S/ r �� C S S 2 SA k C S m 7 7r S ' t Z A^ . ar /CS YZAA CS B- 3 J.d` ///. / ' ` d'. d` g S csjo 6. 7 An S B- 7.S' /0!.7' MKc-- 7 , s' S/, r c c s B_ PERCOLATION TESTS TEST DEPTH/ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER ING"E9 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD P R D PER INCH P_ r ,3 z G 6 < 3 P_ 2- a .2 6 6 L 3 P- -3 0 P-. P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION ° 6s�, 1ti /Af _ _�..�..d._m__.. � t . RAP `d6^ 6"� INE r � 33#1 *( e4f- 83 7'b /1 NA4 7;04v Ifcr frta/ i /(eft u :re /-7iW* I, 'e undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: 11 s i I��S a 40-d p 4-00Y ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 17/J CST TU E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — ' l | INSTRUCTIONS FOR COMPLETING FORM 175' SB[} 6395 Tohea complete and accurate soil test,your report must include. � 1. Complete legal description; , 2� The use section muStdear|y indicate whether this is residence or commercial project; 3� MAXIMUM number of bedrooms or commercial use planned; 4, Is this a nmm o, replacement system; 5. Complete the suitability rating boxes. AS|TE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; / 8^ PLEASE use theahbro/ia/ionoshown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram e*cu,me|v locating your test locations. Drawing to mo|n is pref*rmd. A separate shect may be used ifdesired; 8. Make oum your henohma,k and vertical elevation wf nwnov point are clearly shown,and are permanent; S, Complete all appropriate homz as tu dates, nnmes'addresses, flood plain data, percolation test*xomp' tion' ifuppropriate; ` 10, If the information (such ao flood plain,elevation)dn'snn/app|y' place N.A^ in the appropriate box; 11� Sign'he form and place yov,current address and Your certification number; 12. Make |ngiNc copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL 7-ESTERS Soil Separates and Textures Other Symbols . ot Sxnne (ovpr1O^) BR — Bedrock � cc)1) — Cobble (3 10'') SS — Sandstone � g, — Gravel (under 3") LS — Limestone � s — Sand .HGVV — HiVhGmundWut0r co,,-- Coarse Sand Porr — Percolation Rate medo — Medium San(] VV — NveU ' fs — Fine Sand B!dy — Building Is — LoamySand ' — Greater Than d — Sandy kem / — Lou Than 7 — Loam Bn — Brown °sii — Silt Loam B! — 8|aoh si — 8||t Gy — Gmy °o| — Clay Loam Y — Yellow oc( — Sandy Clay Loam R — Red »id — Silty Clay Loam mot — Mottles sc — SandyC|ay m// — vvith sic — Silty Clay fff — few, fine, faint °o — Clay rz — common. coarse ` p1 — Peat ` mm — Many' medium m — Muck � d — distinct » — prominent HVVL — High water leva|' ° Six general soil textures m,i ace water ` fo' Uquid waste,disposal BM — Bench Mark ` VRP — Vertical Reference Point ^ ' ` . , . . ` ^ ` ` - ` TO THE OWNER: , Thix ,oil test report is the fiox mop in securing sanitary permit. The county o,tha Department maynmuest ve,|fimm/ion of this SoU test in fhe field prior to permit issuance, A comp|nte set o| p|ans br the private ��aoe sySlern and a peiniii application musi be submitted to the anump,imx !uoo| outho,bv in order ^, ottoin a v parmir musi be obtained and posted p,iorto zhemar/ cif any oonxt,ucdon, —~ STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER fla-e- ROUTE/BOX NUMBER r - FIRE NO. CITY/STATE_ u ` Saovt L0 ZIP PROPERTY LOCATION: A/ 1/4 � /� 1/4, Section A- TAN, R /s O Town of rru 4 S O N , St. Croix County, Subdivision _ecovb_t Ia^ SJ , Lot No. �. 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 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNEDyL, DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address 1 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 -Q--dl7 A//,AL Location of property j("Ul 1/4 S uJ 1/9, Section T_1-1� N-R Township �l"SDYt Mailing address Address of site I-el._` - -T c Subdivision name �To-eon x L� Nq Lot number Previous owner of property Y/'l4 i rli��t z`1r'T'0 Al - Total size of parcel _Z- SO W«✓S Date parcel was created 2 - 2-Z - = Are all corners and lot lines identifiable? _ K Yes No Is this property being developed for resale (spec house)?-2f—Yes No Volume OS and Page Number 414 Z- 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. ,�� T/Jr' ; 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 Register of Deeds, as Document No. Y Sf</7 ) . Signature of Owner Signature of Co-Owner (If Applicable) q - 12.- g Date of Signature Date of Signature 00CUMEN11 NO. WARRANTY DEED *"to SPACE Wiig&n IED FOR RECORDING DAM •a'I ',. STATE BAR OF WISCONSIN FORM 2-1>19! REG'FEWS OFFICE '• • 435417 '4? 51. CWX co., wi Ind for ke6W Virginia M,. Hanson, a single woman. . . .. . _. __....._.. _....._.. . _.. NAR tt .. . .. ....... .. .... is 8:00 AM .................. conveys and warrants to . S.am..E. Miller...a..single man... ......._.. 0 . ............. ........ `/MN s10Ni . . ......... ... ... . . .... ........... .... ....... ........ _ _ .... ................ ... . ........................ �. .... ..- .... ...... ... .... . ... .... .. .. .. ......... . . ............. .. .. ..... ........ .. .. .... RETURN TO ' ... ... .. ... ... ... ...... ..... .... . ... .... .... ..... .I..... ... ..... .. ... ........ . the following described real estate in ......St. Croix County, State of Wisconsin: Tax Parcel No: .............................. West Half (WI31) of the Southwest Quarter (SW'S&) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the public highway and except Lots S, 6, 7, and 8 of Certified Survey Map in Vol. 6, Page 1747, Doc, No. 419479. That part of the West Half (W11) of the Northwest Quarter (NWIX) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. 7 O EEF This . ..is not. ..... . homestead property. tkk (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. Tr }� Dated this ' day of . .01 A r C L' 19.88 _. .... . . .. . .(SEAL) �.l�fC� �///r7flilLs+LA�_'r'/1SEAL) • . ........ ....._. ...... .._ ..... ......... ......... _ . _ . • .Virginia.M...Hans.on . . (SEAL) .(SEAL► AVTH3NTICATION ACHNOWLZDOMSNT Signature(a) ............................................................ STATE OF WISCONSIN ................................................................................ r r as .....%+k..... yc... ........County. authenticated this ....... day of........................... 19...... Personall• came before me this ..` ..,.......day of ........ ................. 19.88... the above named ................................................................................ Virginia-M. Hanson a........................!..................................................... ................................................................................ TITLE: MEMBER STATE BAR OF WISCONSIN ......... ............................................................... ...... (If not............................................................. authorized by 4 706.116, Wis. State.) to me known to be the perpon ...... who executed the foregoin• ' trument and aeknowledge the same. THIS INSTRUMENT WAS DRAFTED BY UI {,4is.A,..Murray,,..Heywood,..�eri..b..MurraY.... ...... .... .. . ...... '•., . ..... . .... P..O....Bax..229a..HudgQn=..wI....54016. '-... ... (.. :.. . . . . .. ...... .. \otne�- 01te �y. County, Wis. (Signatures may be authenticated or acknowledged. Both my Co mikel gtt�1hent.(If not, state expiration are not necessary.) t Z • . date: .. �{ _. _ 19P9..) •Names of persons shining in any capacity should be typed or printfA M•.ow• th.it xixnnl.:rt• WAE1tANTT DEED STATE BAR OF WISCONSIN Wwonsin L.-mat PIRO. t-.•. Ne NORM No a— 11.412 ylawb••kr , l�'1•.