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HomeMy WebLinkAbout020-1369-05-000. /* , Wisconsin 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, sv 5.04 (1)(m)). Permit Holder's Name: McCabe, Thomas ^ City ^ V T wn of: `~>~dson ~'1`ownship CST BM Elev.: Insp. BM Elev.: BM Description: tr ry,,, TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ ~ ~2$D Dosing Aeration Holdin TANK SETBACK INFORMATION TANK TO P(L WELL BLDG. vent to Air Intake ROAD Septic > ZS! 6 ' NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION an Demand Model Number GPM TDH Li Lriction Syst TDH Ft F cemain Length Dia. H Dist. To we-I SOIL ABSORPTION SYSTEMrt c-1,- Q „__ n~ .c _ ~~ . ELEVATION DATA countySt. Croix Sanitarx 2,e~plitNo.: State Plan ID No.: Parcel T(S~U °1369-OS-000 ID~ay~1q, ~~qS' STATION BS HI FS ELEV. Benchmark ~ ~.y,D 1t3,~{o ~_ p ` ~` 9 ° 05 ~~ Bldg. Sewer ~ / 8 .22r St/Ht Inlet `l•S8 o'S•SZ~ St / Ht Outlet ~. 9 $ 2~ o Dt Inlet --"~ - --- Dt Bottom "'~ Headerl Man. 13. So ~, gvi Dist. Pipe (3 ' } ~,0.3~ Bot. System ~ ~ 9Q , (, 2,' final Grade 10 -~S ~n 2.6Sr t cover ~~ u o r ~s t 1 Jew[. TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM `f 3 •~'S DI N I SYSTEM TO P / L BLDG WELL LAKE 1 STREAM LEACHING Ma of au er: _~~~ SETBACK INFORMATION Type O r CHAMBER o e Num er: System: ~ ~ (~ s---> OR UNIT DISTRIBUTION SYSTEM Header /Manifold It Distribution Pipe(s) x Hole Size x Nofe Spacing Vent To Air Intake length Dia. ~ Le acing 1 ~0'p~ 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 JTrench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.l Inspection #1:D8/a9 /o© Inspection #2: "t"'1"- Location: 691 Old Hopkins Place, Hudson, ti'VI 54016 (NE 1(4 SE 114 10 T29N R19W) - 1029192195 Hopkin's Prairie -Lot 5 1.) Alt BM Description = ~~ r 2.) Bldg sewer length = Ib .a -amount of cover = > (a rrS~ ~ C~'"'~ Pla revlslon required? ^ Yes '~Vo Use other side for additional information. SBD-6710 (R.3/97) atE C!D-~~- S Inspector's Signature Cert. No. C` lp_ ?R. l~i.~21~5 Sanitary Permit Application Safety & Buildings Division ]n accord with Comm 83.21. V1'is. Adm. Code 201 W. Washington Ave. PO Box 7302 `~SCOf1Sin See reverse side for instructions for completing this application Madison WI 53707-730^ Department of Commerce personal information you provide may be used for seco ttgloses ,,, ,• , I 1t (Privacy Lav,•. s. 15.04(I)(m ~ ,.,, .~ . (Submit completed form to county if r~ ; {-••~ ~' ~::~_ state owner Attach com lete tans (to the county co ~ only) for the svst 'b er not ss t -1 x 1 I inches in size. Coun State Sanitary Permit Number ^ Check if r 'si to pre 'on tat Plan I. D. Number ~ OS 1!.~ I. A lication Information -Please Print all Information Ilbc ion: Property Owner Name ~?, .' ,,.• ~ ^n C VI~ ~ S7 C 1 P ,gpe y location ) ' s ~~~ gOfX E or f4~ I/q. S a T ,N, R Property Owner's Mailing Address ~ ..~)` ZONtNGOFFICE .;Lot, umber Block Number , State City Zip Code S ~i ~ Phone Numb ; ~~ "Subdivision Name or CSM Numbcr ll /~ i II Type of Building: (check one) ~ ^ City ^ Village ^ 1 or 2 Family Dwelling - No. of Bedrooms: Town of ^ Public/Commercial {describe use): ^ State-owned t-t. `3 III Type of Permit: (Check only one box on line A. Check box on line B if appl'scable) Nearest Road A) I. (New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Tax Number(s) o2v - 13Co9 - oS-~c S stem Tank Only Existin S stem B) Permit Number Date Issued ^ A Sanit Permit was reviousl issued IV. Type of POWT System: (Check all that apply) ~Nlon-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground O Holding Tank ^ Single Pass ^ Drip Line ^ At-grade ~] Aerobic Treatment Unit ^ Recirculating ^ Other: _ ~`~ ~t ~ f l~~ `~ ~ V Dis ersal/TreatmentRrea Information: D i P l R I. Design Flow (gpd) 2. DispersalArea 3. Dispersal Arca 4. Soil Application at on ate erco S. Required Proposed Rate (Gals.tday/sq. R.) (Min.linch) Elevation VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks O ^ ^ ^ ^ o ^ ^ ^ o VII Responsibility Statement I the undersi .ed, assume res onsibili fer installation of the POWTS shown on the attached Tans. Plumber's Name (print) Plumb Signal a (no stamps): MP/MPRS No. Number Business Phone `` " ~(o Plumber's Address (SVicet, City, Statc, Zip Codc) VIII County/Department Use Only O Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) ,Approved ^ Owner Given Initial Adverse Surcharge Fee) ^ g'r'tS=2~b ~~ ~ Determination 2. o ~ IX. Conditions of Approval/Reasons for Disapproval: ~.~ SBD-6398 (R. 07100) J~ N G~ v~` /~ a. -~s~ No" ~~ ~~ ti~ ~ ~~ r,,...~ yU yo' , ~a~ r~w~~ ~~ ~aoa~''~ i/ a~` 1` ~ ~~ ~ `g°° ~~ lg~ ~. ~,~~ ~ ~~ n;ti'~ 3a .~ ,~,) so 1 ~- ~'~~ _~ ys 39~ /w~. aao3s7 ~~~~~Z~ ~' 1 r---_ ~~ J ~'8. G • Wisc~~r;~ih Department of Industry, v Lalxl'r and Human Relations Division 4f Safety & Buildings SOIL AND SITE EVALUATION REPORT Page 1 of 3 ~_ ___-_J __.'aL II I IPl nn nr \.I:~ -A Jr.. l.~J~ ~'-. 111 QVVVIV ••INI ILI 11 ~ VV•V V, • vVV i~ ,,, r ~' ~» COUN •• but '~° ' Play must include er not less than 8 1/2 x 11 inches in size Attach com lan on a lete site St. Croix , p p . p p not limited to vertical and horizontal reference point (BM), direction and % of slope,; scaf9 or ~ PARCEL LD, # ~` dimensioned, north arrow, and location and distance to nearest road. X020-1x10-70-000 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION ~ ''' ~ R VIEWED,iBY DATE , ~ PROPERTY OWNER: PROPERTY LOCATION Kerrion .Bast GOVT. LOT NE 1/4 SS~ irgg~ 10 T 29 ,N,R 19 !~{or) W PROPERTY OWNER':S MAILING ADDRESS 848 LaBArge Rd. LOT # 5 BL na AME OR CSM # Hopkins Prarie CITY, STATE ZIP CODE PHONE NUMBER ^CITY (]VILLAGE [~COWN NEAREST ROAD Hudson, WI. 54016 (71~ 386-7775 Hudson Old Ho kins Plc. [~ New Construction Use [X) Residential / Number of bedrooms 4 [ ]Addition to existing building [ J Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpolft2 •8 trench, gpolft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 98.60 ft (as referred to site plan benchmark) Additional design !site considerations na Parent material outwash Flood plain elevation, if applicable na ft S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT•GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitablefors stem ®S ^U ®S ^U ®S ^U ®S ^U ®S ^U ^S [~U SOIL DESCRIPTION REPORT Boring # 1 Ground elev. 102.6 ft. Depth to limiting fact 0" Boring # 2 `?_ Ground elev. 101.8 ft. Depth to limiting factor +Qrl n Depth Dominant Color Mottles Texture Structure Consistence Boundar Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. y Bed Trend 1 -11 10yr3/3 none 1 2msbk mfr gw 2f .5 (.6 2 1-20 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 0-36 10yr5/4 none sil M na gw na np .2 4 6-90 __-- 7.5yr4/6 none o s Osg ml na na .7 .8 ~, ~ ~ /~ - r- ~g/~ « Remarks: 1 -15 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 5-90 7.5yr4/6 none cos Osy ml na na .7 .8 ~~ D Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Ave. ew Richmond W 4017 Signature: ~~ _ Date: 11-16-99 CST Number: m02298 PROPERTY OWNER Kernon Bast PARCEL I.D. # 020-1010-70-000 Boring # 3 Ground elev. 102 . St. Depth to limiting factor +g ~~ Boring # 4 `> Ground elev. 103.1 ft. Depth to limiting factor96 ~~ Boring # 5 ................. Ground elev, 102.5ft, Depth to lim~ji~ting f+7~ ~r Boring # .... II ................. .Ground.'. el v. e I ~ ft. Depth to ~ limiting i factor SOIL DESCRIPTION REPORT 1 Page 2 ~ of ~3 i Ho Depth Dominant Color Mottles Texture Structure Consistence Ba rnda-y Roots GPD/ft r zon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. . Bed Trench 1 -14 10yr4/3 none sl 2mgr mvfr gw 2f .5 .6 2 4-34 7.5yr4/4 none sil 2msbk mfr gw if .5 .6 3 4-96 7.5yr4/6 none cos sg ml na na .7 ~ .8 1 .S~ Remarks: 1 -12 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 2-36 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 6-96 7.5yr4/6 none cos Osg ml na na .7 .8 Remarks: 1 -13 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 3-34 10yr4/4 none sil 2msbk mfr yw if .5 .6 3 4-96 7.5yr4/6 none cos Osg ml na na .7 .8 Remarks: Remarks: . sn ~ I STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM229$ NE4SE4 s10-T29N-R19w New Richmond, WI 54017 MPRSW-3254 town of Hudson (715) 246-6200 lot #5-Hopkins Prarie This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not. be as shown as permanent lot lines were not established at the time the test was conducted. N 1"=40' BM.= top Alt. BM.= •~~ °~ ' i~ ~~ Gary L. Steel 11-16-99 ~~ ~~ 6-15-1995 5:55PM FROM P.1 ~ ~>v~ w15wh9f1USpa~4~rnorinuuavl. 'AIL ANA +'711C CVALYNIIV~r 11CrVR1 1°b°.~-~~ Libor snd4dumin I~eletians Di~pr et~SsMty 8 euit!dn~, in accord with ILHR BB.05, Wis. Adm. Cabe St:. Croix Attach complete Site plan on paper not lees then A 4/2 x t t inches in size. Plan must include, but pARCEL,t.D. ~ not Nmited to vertical arrd horizontal rs}6rerice point (BI1~, erection and 90 of ydpe,.acale or, 020-1010-70-000 dimensioned, north snow, and location and dis~anCa to nearest road. Rif p 9Y OATE APPLICANT INFDApaTtpN~PLEA8E PRINT AlL INFdANATtON ~, ~ . Rd. WI, 54016 -.. ---- (71~ 386-7775 PROPk~iTY LpCAT10N . coMT. LOT t+~ tla 5E t/a,s 10 T 29 ,N,R 19 p(oi) w LOT A SLACK 11F SUED. NAME tJR C3M tr 5 na ii~opkins Prarle _ --- Plc. ] ~ Near Cor~tuc4ot- Use [X ] itesidentiN / 11G,tnlber of bedrooms _~_ (. I ~ ~ ~ ezititing building [ 1. Ri~laoement (] Pudic or cgmnrerraal desczibe . . Code derived dBNy flow ~o0 9Pd, ~ Recornnren0ed design teadirg -ate ~ .~.... _bed, 90d~ • e Absorption area required 858 bed K2 y50 trench. R2 ruleximum design boding rate . 7 tied gpolt'f2 -8 trerrCh, 9P~ ReGOmmended in4ltratiorl Surface elevation(s) 98 Fz0 K (as referred to site pler+ benchmark) Additionet design / site cortsiderd Parent malterial out Flood plain elevation if appNcable ~ na it S = $Ull~l@ tOr gyg}~ CONVENTIONAL MOUND Ir~CAOUND PRESSURE AT•GRADE 3YSTt]VI tN FILL FlOLDIN6 TANK ~ =unsuitable for ,~, ~ s ~ o u ~ s CJ u ®s r~ u [~ s a u ®s i7 u >~ s f~:u e..u r~rC/~d~DTIA\I REt!(SRT Boring # 1 ~. , Gtourr4 ~~. 102,Tb ft. Depth rc lirniflgg . factor +90" Boring ~ 2 Ground elev. 1018 n t~pth to limi8ng ~~ Horizon Oepttr Dominant Color T Mottles Texture Structure $h Gr Sz ~~~, g~~ Raptg GPD/ft s~ rerldr in Munsell ~l]U. Sz. Cont. Cobr . . . ' 1 . -Y1 10yr3/3 ncne Y Ztnsbk ~ttfr~ ga' 2f . .5 :6 2 1-20 l0yt•414 none ail ~ t+Dfr ~ yW lf~~ .5 I .6 3 0-36 10yr5/4 none ail M na gtr na nP -2 4 6-90 , 7.5yr'4/6 none cos Osg tttl na t1a . 7 . ; . 8 i Hama, ~. 1 ,. -15 10yr3/3 none -- 1 Z~osvk mfr ga 2f .5 '•' .6 2 ~ ~ 5-90 ~ ? . 5yr4/6 nc~e cos ~ Osy ml na na . 7 ~ . 8 Remarks: cs't Name:--PlcBSe~_ GSrY. L. Steel Addiess: 155~- 201?th. Ave. w Ricl"a„Motu Signao~tt: /~ ~• Prune: 71 Dace. 11-1t-99 c-sT Nu;tnAer: mo229s -15-1995 5:56PM FROM PROPEA'tlrowNEq Ke~~r- Hast_ SOIL DESCRIPTION REPORT P~IRCEI i,D. ~! 020--1010-70-000 _ P. 3 Pape Z ofd r~ . ~r,.~ Depth Dom~Rant Color Hori2oR in. NluRSaN 1 14 10yr4/3 2 9-34 7.5yr4/4 Mottles , aU. SL. Corn, Cofo- vane none Texture si ~ sil. Structure Gr. S~- $h. 2mgr ZmsbiK avfz m~z ~~ gar g~ ppp~q 2f if GPglit ~{ t~¢, .5. .6 :5 -b 3 9.-96 ? . 5,yr4/6, zione cos Ossg ml na ria . 7 . e Ramarks 1 : - -12 10yr3/3 tame 1 2msbk air , g~- 2f .5 .6 2 3 2-36 10yr4/4 7, Syr4/6 Wane ,none si]. co. s 2eas~lc . Osg mfr arl gW na if na .5 ~ .6 - 7 • $ 1 -13 10yr3/3 none 1 2,tost9c mfr yw 2f .5 .6 2 334 10yr4/4 acme sit 2msbac m~Er yFr if .5' T.6 3 4-9fi 7.Syz4/6 none cos Osg mi na tea .7 ~ .8 • 6-15-1995 5:56PM FROM P-2 -.- ' `- STEEL'S SOIL SERVICE Gary L. Sreet ~Cerr~ east 1554.20i3tt~ AvB. CSTM2298 N&~,SE'~ 510-T29N-R19W N6W F'~~ChfflO~d, Wl 54017 MPRSW-354 tarn of Nudejoa (715) 246-62oQ •lot NOpfcins Prarie 'his soil evaluation was conducted to satisgy a ~!-~ s~quit~ it may or mxiy not be sul.tabie Por your use. The locatfoxt of tI~ test ma~Y- of may rapt be ae sAv~+n ae permanent lot lines; ~~ ~ establistred at the tide r.Ae. test xa~, aarLdue~Ced_ N 1"=40' B1~1.~ top o£ 1" pvc pipe @ el. 100.00 Alt. ffiK.= Lop of 1" pv~c pipe ~ el_ 101.00 ~~t. . ~-q" 1 ~~•. ~'"l: ~. Gary. L..st®ei. 11-T6-99 %, s ' o'~.s . ~~ ~~ ~~ ~~ ~.~ L~ ~7 1 SOr •~,~ ~q. 6r' Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Desian Specifications Sanitary Permit Number + 3~Y o 5 Number of Bedrooms Design Flow -Peak (gpd) Estimated Flow -Average (gpd) Septic Tank Capacity (gal) Z8O Soil Absorption Component Size (ft2) 5"ao ~ Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance 5cneauie Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason wifhouf being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficulf or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shalt include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the sail and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FGiZM Owner/Buyer Mailing Address Property Address ~n ~~s-I- ~~5 -Nns ~~ P~i~s P~~c-~~ P`"' (Verification required from Planning Department for new construction) CitylState ti-~SCYI ~ ~~ Parcel Identification Number ®2 a ~ ~ ~ 6 D '~70 -Oda LEGAL DESCRIPTION _ Property Location N~ '/a, Sr'~ '/a, Sec. ~ ~ , T ~~ N-R~~W, Town of ~~~'~ Subdivision t'1"Ub~n s Lot # ~ Certified Survey Map # ,Volume .Page # Warranty Deed # ~r, ~J~c..~ (~ ~ ,Volume Page # Spec house O yes ~ no Lot lines identifiable ~ yes D no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Pmper 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. The property owner agrees to submit to St. Croix 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 oa-site wastewaterdisposalsystern is in proper operating condition and/or (2) aRer inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~~ ~ 7 ~~~~ SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I {we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the p perry desc ' ed above, by virtue of a warranty deed recorded in Register of Deeds Office. ~i~~ ~ SIGNATURE OF APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ~~~.1436Fa,~ 516 60556$ Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Daed, made between, Jean M Hendrickson ~~~ ~ RE~Rn Grantor, 06-21-1999 8:30 AM and,Kernori J Bast and Donalda J Speer-Bast yA(Y pip husband and wife, as survivorship marital property Grantee. EIEI~T M CfRT (bPr ~' Witnesaeth, That the said Grantor, for a valuable conskleratbn of one dollar and COPY FEE: other valuable consideration conveys to Grantee the below described real estate in TRAi'I.~ER ~; yy0,00 St. Croix County, State of Wisconsin. RECORDIHS FEE: 10.00 PAGES: 1 This is not homestead property. Together with all end singular heredftaments and appurtenances thereunto belonging; And Grantor warcants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Rewrdi Area aascmants, covananta, and restrictions o£ record, Name and Retum Address FIRST FEDEttAI, SAVINGS and will Warrant and defend the Same. (Parcel Identif<cadon Numtrer) 201 SOUTH SECOND 020-1010-7U HUDSON, WI 54016 Part of the NE'/. of SE'/4 of Section 10-29-19 described as follows: Beginnin g in the center of Scott Road at the NW comer of Lot 1 of Certified Survey Map, filed in the office of the Register of Deeds for St. Croix County, in Vol. " 3", Page 651; thence N89°48'13"E 561.0 feet along the N line of said Lot 1 to an iron pipe mo^ument; thence Sly along the E line of said Certified Survey Map to the SE corner thereof; thence N89°48' 13"E 759 feet to an iron pipe stake; thence Nly parallel to the E line of said Section ] 0 a distance of 924 feet to an iron pipe monument; thence W 1320 feet to the center of Scott Road; thence Sly along the centerline to the point of beginning. Dated this ~ day of tl`~' 1999 G ~ h c, M I-Iendrickson AUTHENTICATION Signature{s) authenticated this _ day of .Zy. c~ si J CJIt r 'f type or print name J TITLE: MEMBER STATE BAR OF WIC (If not, aulhodzed byli70H.06. Wis. Stets.) THIS INSTRUMENT WAS DRP Robert F. Wall (Signatures may be audrenticated or ackna necessary.) ACKNOWLEDGMENT STATE OF WISCONSIN COUNTY ST. CROIX Personally came before me this ~' day of ~^ ~ 99 >~ above named Jean M Hendrickson to me known to be the person(s) who executed the foregoing instrument and acknowledge the ' wm ~ ~. ~1>~ ~~~f type or pdnt name ~7~~' ~~F.YIC_ -.~G Notary f''ubBc County, . S~ ~My cammis~~ ~ permanent. pf not, state expiration date: !J , ~• ) of persons signing in any cepadty should be typed or below their signatures. ~a I V C ~~'pCp b 7~ N W pMd I U O U+~. C N u w N p a! n~,v •o~ - 1SV3 SONItlY36 M„b4,SL.00S .^.» O dG~NJ2 3 I C~ ~~ __--NU_0..L.. a-iT J1 Z~ ~...m ,-• ~,-o, ..-^--..^-^.-. .. .~.^-. ^...^- i ~ ` tl L S?I~H,LO .Cry Q,?l~TdO ~ Stl,?H.LO .IB Q3NA10 SQNY? 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