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HomeMy WebLinkAbout022-1080-10-000 Parcel #: 022-1 080 -10 -000 03/06/2006 09:17 AM PAGE 1 OF 1 Alt. Parcel #: 28.28.18.P438B 022 - TOWN OF KINNICKINNIC Current !X, ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner KEVIN D & KATHERINE M SIPPLE 0 - SIPPLE, KEVIN D & KATHERINE M 203 LIBERTY RD S RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 203 LIBERTY RD S SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Descrip ' n: Acre 5.450 Plat: N/A -NOT AVAILABLE SEC 28 T28N 5 AC N 165' OF NW NW Block/Condo Bldg: EASEMENT 879/18 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 28- 28N -18W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 887/186 07/23/1997 879/189 07/23/1997 476/81 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 143828 345,300 Valuations: Last Changed: 08/11/2005 Description Class Acres Land mprove Total State Reason RESIDENTIAL G1 5.450 80,000 269,100 349,100 NO Totals for 2005: General Property 5.450 80,000 269,100 349,100 Woodland 0.000 0 0 Totals for 2004: General Property 5.450 40,000 206,000 246,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 524 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 429915 0 GENERAL INFORMATION (ATTACH TO PERMIT) 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: Sipple, Kevin I Kinnickinnic Township 022 - 1080 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: L 28.28.18.P438B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t . 4 � n �j c � Benchmark 2- ^3 /D !� D a Alt. BM Aeration �[ J O Bldg. Sewer t► i , ti' n / Holding St/Ht Inlet ,( TANK SETBACK INFORMATION St/Ht Outlet -5- TANK TO /L WELL BLDG. Vent to Air Intake ROAD nlet 6� R �• "Z � ottom J vr� Her r /Maw. Aeration Plpee Qi 2 .gs J Holding Bot. System � PUMP /SIPHON INFORMATION Final rase d 3 .0 Manufacturer Demand St Cover GPM .- 3 .03 Model Numb r TDH Lift Friction Loss System Head TD Ft Forcemain L Dist. to :1 SOIL ABSORPTION SYSTEM ( a �Ii BEDITRENCH Width J Length y No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS � T 1 "l SETBACK SYSTEM TO l P/L BLDG WELL LAKE /STREA LEACHING anuf rer: INFORMATION CHAMBER OR 1 Ty Of System: ` J -3 Z 7 � I / UNIT Model Number: DISTRIBUTION SYSTEM 3 HeaderlMarifol Distribution 1 t I x Hole Size x Hole Spacing Vent to Air Intake 1� Lengt Dia Length 1 Dia �L4Jcing_ -L 17 -3 � o A &P& Lo SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only �� uAQ � Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center 2 Bedlrrench Edges Topsoil Yes ❑ No [*Yes iJ No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: s l /0 Inspection #2: ! / Location: 203 Liberty Road River Falls, WI 54022 (NE 1/4 NW 1/4 28 T281* R1 8W) NA Lot -` Parcel No: 28.28.18.P438B 1.) Alt BM Description = kaW -�Pf -h� CfVLA,_ Vim. (j kw Lt U- Ct C(ha& t�'CQ�rd - COQLL�Y�4 e.�Pp( 2.) Bldg sewer length r - amount of cover Plan revision Required? I* Yes L o Use other side for additional Information. — O / �il..� S SBD -6710 (R.3/97) Date Insepctor's nature Cart. No. N V 201 W. Washington Ave., P.O. Box 7162 �/ ` / Isconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce ( 608 ) 266 - 3151 Sanitary Permit Application State Plan I.D. Num In accord with Comm 83.21, Wis. Adm. Code, personal imommmen you may be used for secondary purposes Privacy Law, 1 D Project Address ( g wow I. Application Information - Please Print All Information d, LI L30e7ll Property - Owner' a me Parcel N tot 0 Is ff / �� �/ ST. CROIX000NTY 022 ^(0RD "iQ —� �•i qvz r Property Owner's M ailing Addy Property Location X , g, 'A, City. State Zip Code Phone Number 7 1j 7��` �S 1— R ( c E ircl pnE)� H. Type of Building (check all that apply) N; v o W �� /S'T3/J� f �dl'�'L� t S Subdivision Name CSM Number 2 Family Dwelling - Number of Bedrooms Public/Commercial - Describe Use ❑ State Owned - Describe Use -14 04C1-r~ add w etzk4 A ❑City_ ❑Villa ownsbip o , i P-1 fill III. 'Type of Permit: (Cheek only one box on line A. Complete line B if applicable) A. ❑ New System cemem ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Dace Issued Before Expiration Plumber Owner IV. of POWTS System: (Check an that apply) n 4 In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Said Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter t ❑ Recirculating Synthetic Media Filter hing Chamber ❑ ev Line ❑ Gravel -less Pipe Q Other (explain) V. Dis rea ent Area Information: Des' Flow (gpd) Design Sod Application Rate(gpd,t) Dispersal Area Required (sf) Dispersal Area Proposed (sf) S � j oem Eleva S ✓ Z..c� ✓ t 2l Z, 7 ��j .3 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site eel F r P lastic Gallons Gallons of Units �/� Concrete Constructed Glass New FXisting Tanks Tanks /2 Septic or Bolding Tads Aerobic Treaunent Unit Dosing Chamber VII. - Responsibility Statement- I, the responsibility for installation of the POWTS shown on the attached Plans- P Na me (Print) Plum gnature MP/MPRS Number Business Phone Number Plumber's Addre ss (Sara, City, tate C Count /Department Use Onl A ved ❑ Disapproved Satdtary Permit F (includes Groundwater Date Issued Signs r Stamps) 1>l Surcharge Fee) �b y C1 Owner Given Reason for Denial /Z Ai'1C 2 f/ WY� IX. Conditions of Approval/Reasons for Disapproval 4. oC.¢� -f - 4 18le D 44— A (to the Co y) [ e system on fAper not less than 81/2 x 11 es in e SBD -6398 (R. 01/03) PLOT PLAN PROJECT Kevin Sioole ADDRESS 203 Libertv Rd S River Falls Wi 54022 NW 1/4 NW 1/4S 28 /T 28 N/ 1 TOWN Kinnickinnic COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 4/17/03 BEDROOM 4 CONVENTIONAL XXX IN- GROUND PR 6 CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1212 # of chambe 39 BENCHMARK V.R.P. Bottom of Garage Siding ASSUME ELEVATION 100' Filter Zabel A -100 ✓ ❑ BOREHOLE O WELL 'H. R. P Same as Benchmark SYSTEM ELEVATION 94.5/94.4/94.3 2.5' Below grade Alt. BM Top of Deck @ 100.7' 4 % 3 -3' X 82' Cells S loe with >3' spacing Property Line 200' B -1 B -4 Vents 5 ' 50'� 105' -2 System must be installed between 0' the 97' and 99.5' ' 60' Contour lines only Vents - r- 98' 97 '20' 99' 50' 100' i eeks 261_ 75' 3 5' Vent �aT � �' ,T V1/u� l� Assumed B.M. Septic area Garage To Liberty Road 25' Alt. 40, M. Existing 3 30' Bedroom House 5' Well Vent >6 » Standard Biodiffuser of Cover Leaching Chamber with 31.1 ft2 of Area Plans Designed Using a Conventional Powts >, � 11 " Manual Version 2.0 6' Long a 3 4" Grade at System Elevation I EROSION CONTROL PLAN — Replacement of Existing Septic System I Im, yz�� For 203 Liberty Road (Kinnickinnic ) — owner(s) Kevin & Katharine Sipple Under St. Croix County Zoning Code 17.70(3)(b)5: "The (Zoning) Administrator may attach reasonable erosion prevention conditions to a permit approved for issuance." The Owner is responsible for notifying all contractors performing construction on this site that an Erosion Control Plan is in effect and the following activities will be required in order to maintain compliance with the plan: 1. The main source for construction site runoff will be excavation for the septic system and any soil stockpiled until final grading and stabilization of the replacement system is complete. Excavation during installation causes temporary disturbance, but erosion can be limited by applying seed and mulch or erosion control matting as recommended in #5. Primary effort must be to contain contaminated runoff on the owner's property. 2. Divert runoff into vegetated areas by creating temporary earthen berms graded ALONG CONTOUR between construction activity and any drainage ditches or waterways. Maintain existing vegetation between potential receiving waters and exposed soil from excavation. The proposed replacement conventional system will be >500 ft. from Liberty Rd. ditch to the west or a tributary of the Kinnickinnic River to the east, which should provide adequate buffer distance to dissipate contaminated runoff. 3. If builder /excavator grades the site to create temporary berms (see #2) to contain sediment and leaves adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt fence or other approved sediment control products will be required if sediment cannot be contained on owner's property with the berms and vegetative buffers. The POWTS inspector and/or building inspector will evaluate ESC plan effectiveness and make recommendations to owner for any action required to comply with applicable regulations. 4. Construction equipment and vehicles must use only one driveway access off town road that is properly stabilized for heavy equipment; this helps avoid muddy, rutted conditions that may allow contaminated runoff to reach waterways and/or drainage ditches. This includes cement trucks, well drillers, and other contractor's vehicles that access the property during construction. 5. Stabilize new topsoil cover on septic system with seed and mulch immediately after installation — do not wait for final stabilization and/or landscaping of entire site to cover exposed soils on the system. If weather does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can get established. Erosion control matting can be applied any time of year and, if installed properly, will provide protection even if seed germination is delayed. Please feel free to contact me with questions or to request assistance with erosion & sediment control installation. Pamela Quinn, Soil Erosion Inspector #66505 Owner acknowledizement of ESC Plan requirements: / /2003 EROSION CONTROL PLAN — Replacement of Existing Septic System For 203 Libe Road Kinnickinnic owner(s) Kevin & Katharine Sipple rtv ( ) — owne_� 1 Under St. Croix County Zoning Code 17.70(3)(b)5: "The (Zoning) Administrator may attach reasonable erosion prevention conditions to a permit approved for issuance." The Owner is responsible for notifying all contractors performing construction on this site that an Erosion Control Plan is in effect and the following activities will be required in order to maintain compliance with the plan: 1. The main source for construction site runoff will be excavation for the septic system and any soil stockpiled until final grading and stabilization of the replacement system is complete. Excavation during installation causes temporary disturbance, but erosion can be limited by applying seed and mulch or erosion control matting as recommended in #5. Primary effort must be to contain contaminated runoff on the owner's property. 2. Divert runoff into vegetated areas by creating temporary earthen berms graded ALONG CONTOUR between construction activity and any drainage ditches or waterways. Maintain existing vegetation between potential receiving waters and exposed soil from excavation. The proposed replacement conventional system will be >500 ft. from Liberty Rd. ditch to the west or a tributary of the Kinnickinnic River to the east, which should provide adequate buffer distance to dissipate contaminated runoff. 3. If builder /excavator grades the site to create temporary berms (see #2) to contain sediment and leaves adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt fence or other approved sediment control products will be required if sediment cannot be contained on owner's property with the berms and vegetative buffers. The POWTS inspector and/or building inspector will evaluate ESC plan effectiveness and make recommendations to owner for any action required to comply with applicable regulations. 4. Construction equipment and vehicles must use only one driveway access off town road that is properly stabilized for heavy equipment; this helps avoid muddy, rutted conditions that may allow contaminated runoff to reach waterways and/or drainage ditches. This includes cement trucks, well drillers, and other contractor's vehicles that access the property during construction. 5. Stabilize new topsoil cover on septic system with seed and mulch immediately after installation — do not wait for final stabilization and/or landscaping of entire site to cover exposed soils on the system. If weather does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can get established. Erosion control matting can be applied any time of year and, if installed properly, will provide protection even if seed germination is delayed. Please feel free to contact me with questions or to request assistance with erosion & sediment control installation. Pamela Quinn, Soil Erosion Inspector #66505 Owner acknowledeement of ESC Plan requirements / /q; : • : J •'�� a �� �. 1J .�-_$ I � o' u \ ' / •II a II / 9.82 I _, 1009 � O I _ -- �� � V l �92 � � _ 109ST,� ./025 _ r �V 17 967 1 /1286 O ownhal • 952 o° _ o I �j� ._ - 0 �° - � : 939' —936 I% —4— -_ _ _ _ — -Y II 932 927 SS J • 927 ' -_.� • 946 2 1 - - - - - - -- 1 77 ti� g - n 1 982 it I I I V`q 1 .�. • _ 938 _ . _ _._.. - ____._- _ _.... 923 ___ 942 �O •�C 922 i q1 _ 92! ?. r�29 • '969. i II 1 q, /0/ QuarryR 01 - 3 !//4 5 31 5 32 1 330 000 FEET 1 35' 5 33 5 34 (RIVER FALLS EAST) 5 35 2473 / SE published by the Geological Survey SCALE 1:24000 0 P Wicrnnsin niv(s(on of Hiehways i - - - - -r — r- -- - z Wisconsin Department of Commerce SOIL E AL "0 Page of Divis;an of Safety and Buildings in accordance with Comm Wis. Adm. Code I� 7 unty �' D Attach complete site plan on paper not less than 8 1/2 x 11 inches i size. 06A Viu' 4 include, but not limited to: vertical and horizontal reference point (B ), direction and rcel D. percent slope, scale or dimensions, north arrow, and location and d tanoCtp r (gsgrpa Please print all information. «•'`' �' OFvie ed y Date Persona l infor ation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m) I ? Property Owner `` Property Location J Govt. Lot IVO 1/4 ut04 T9 Z N R E (t� Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM# 2 f z Z State Zip Cod Phone Number ❑City ❑ Village oad IN Town Nee est T.� �1 Oar- ( 7l�) 26- s sg � �' ❑ New Construction Use Residential / Number of bedrooms Code derived design flow rate GPD J!f Repiaoement ❑ Public o merclal - Describe: Parent material c c� Flood Plain elevation if applicable �/ 1 ft. General commen and recommendations: 6 y �} 1 1 9 ! J, / // y a Boring # Boring G round / L� n Pit Ground surface elev. fi t. Depth to limiting factor _� /s2� . Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. I 'Eff#1 •Eff#2 Tf. sa Borli # .0-P • it Ground surface elev. �° ' ft. Depth to limiting factor in. Soli Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ©2 2 / ' M cl e . S Z 20 AA ?�Z -- ' G' ' o 11 .SU ' Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < ' Effluent #2 = BOD 1 30 mg/L and TSS < 30 mg1L CST Name (Please Print) nature CST Number Addrs Date Evaluation Conducted Telephone Number I _ _ Property Owner Parcel ID # Page 2 of 3 5 Boring � # Y� . Pit Ground surface elev. ft. Depth to limiting factor uri Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. //�_ 'Eff#1 •Eff#2 i �^ `� r I s ,72 9 5fl Boring # ❑ Boring O pit Ground surface elev. I J ft. Depth to limiting factor in. Soii plication Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 o 31z m e - - F Boring # O Boring 11 Pit Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 Effluent #1 = BOD > 30 1220 mg1L and TSS >30 < 150 mgll. • Effluent #2 = BODS < 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. S804330 (RAM) Soil Test Plot Plan Project Name Kevin Sipple Shaun Bird Address 203 Liberty Rd River Falls Wi 54022 CSTM 226900 Lot ------ Subdivision - --- - -- Date 11/2/02 N W 1 /4 N W 1 /4S 2 8 T 28 N /R W Township Kinniddnnic F1 Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Garage Siding System Elevation 94.5/94.4/94.3 *HRpSame as Benchmark (Alt. BM Top of Deck @ 100.7 4% Slo e Pro ert Line 200' -B -- 5 105' 5' B-2 System must be B -1 installed between --" 0' the 97' and 99.5' ' 60' Contour lines only 98' 97' 99' 50' 100' 75' Vent T Assumed 5' *B.M. Septic area Garage To Liberty Road 25' � Alt 40' LB.M. Existing 3 30' Bedroom House 15' Well I a a I . A1GR133AtT $HMC TAIL MAMTHRAMM AM OWNERSHIP t�LtT1FiCATit�N �URM O S.w or ply (Vaificatimm9dwd fivm Pbmuft Dqpabmmtfw U -- chyfsbft pmml M Nbmber D 22 - /D Pb - 10 —06b y�sL DZSC ' � IJ V, S W . Town _ Lot - cwrwnd gay MV # . volm to - p4p # W ` `Ko -3 -- vobmw g � � - p # ! �� no Spec how D yes_ Lot rmw i D 7 p�mcoe�d�ea�t�ibpo�ei�ia�etuLmtbi '�oper�da�oa.�o cowi�e afp�e� a�at�re sq�tic�aicatacy�eey�s acsaooeS ifaoededbya vblt7=vmtbftia cnaAffl.otdw os�*roe gap bmtas & I in do -ml dkpoedsydem. The pmpe�4Y aamec aaiaees t� to St. Cbdu Z eot a aed�iar6eafiaoa�. b' ire aad by a p �d�ciodpiaml�ecara mmilip I "mda Nvdal 1-IftOd is &L a p gcoaditiosaadlar(� Sam imll dpa�npigB � �a aep$ctiotis 1asr�rm i!3 ibdtatab�. y��yOd�neeadd „a,d�oae set yob. Leoeeas as setby � c�clommr�ae and nr� na�N.maaBao.�, � of w3.00.ao- 1^� „° �m® tbecampietedaad� +olatoae4todse MwviUha.3o � o3 DNM aw"m �� ti'°°m°ed:)of „boMq by of a wmmn,► DA18 1URB tt?F s�ssss pny a8mt � mie�eeet�budmay amtttt bt dra 9P� ravaioodlry 8w2oamg' „ ,� � a ammped vmdm'�y deed fc+am ��gisteraf Deeds office s copy of dra certifiodsmcvrrymoPbz ama° in sro �ram�rety deed i I I Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan 1. If system fails, determine cause of failure, use alternate area and install new system or install system at a lower elevation. 2. Replace any other failing components as needed. Plumber: Shaun Bird 715 - 246 -4516 St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 4 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to cer X"7_" iy that I have inspected the septic tank presently serving the � /.� residence located at: n 9 N, Section ', T R W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: Did flow back occur from absorption system? Yes X No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ? /000 Construction: Prefab Concrete Steel Other Manufacturer: (If known) : Age of Ta If known) ( ature) (Name) Please print i e) (License Number) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding a 'sting septic tank condition, I certify that the tank to the be f my knowledge will conform to the requirements of ILHR 83, Wis m. Code (except for inspection opening ove outlet baffle). �-- Name_ �<c, � Signature MP /MPRS *OOCUMENt l,10 W ARRANTY DEED THIS {PACK R9111XV90 FOR RKCORDIRe DATA STATE BAR OF WISCONSIN FORM 2 - 19M 46443 _ vc ( _� FAQ 1 __.___� _ _ REOIS OFFICE V. CROIX Co W1 ...C.al�in..K,...suxt.Qn.. axed... ere. yer. 1Y. .1�....�ux.�Q�, ... ............. ... hush. arid.1 nd.m i. re:. .wi ... su�ryinnih.�R ... ma-rlt_al ............. f'�t'd fV Reciltd � ._ 1p . op. erty .........................................................::. ............................... iio �0 ....... ........... ... ............................... .... ....... ................... ..... conveys and warrants to ..... Ke.v. ia.. D.. ...Sipple..and- .Katherine.. /r ba .bana.- and..w ife_.. as ...maxi.t.al.......I.......... I amrvI-vor_s hip.. g rap er. ty .... .................. ............. •-• ......................................................•-----................... ............................... .......... ...........................................................__...... ...`........................... R[TURN TO ........ .................................................. St ... .. {' the following described real estate in ........................ ........................County, I =_— State of Wisconsin: Tax Parcel North 165 feet of the NWk of NW% of Section 28, Township 28 North, Range 18 West. ( Q) TOGETHER WITH an easement for purposes of ingress and egress described as follows: the South 33 feet of'the North 198 feet of NW% of NWT of Section 28, Township 28 North, Range 18 West. Also, together with an easement way for vehicula.- and pedestrian traffic over the West 100 feet of the South 220 feet of the North 418 feet of the West l 660 feet of the NWk of NW% of erection 28, Township 28 North, Range 18 West, all in St. Croix County, Wisconsin. 4� SAY i s not homestead property. This . - -- • - •-• -- (is) (is not) Exception to warrant—es: easements, restrictions and rights -of -wa S(�t of record, if any. Dated this -- -- . C 40 ••---- - --- --- - - — day of _.... Tlovember------- -..... ..... 19..9.Q... ........... (SEAL) ...v�' :.......i...... ... .... (SEAL) ,Calvin K. Burton Beverly' . Burton ............... .(SEAL) - - -- -- .. ........... ............... .........................(SEAL) • ' -- ..__ .............. ............._....•- ---- ......I ..... AUTHENTICATION ACKNOWLEDGMENT Signature(s) ............................. ............................... STATE OF WISCONSIN ss. ........ Sti...---CrQ_.X ........ County. i authenticated this ........ day of ........................... 19...... Personally came before me this 4 5?0 -day of KQvlemter ............... 19._40• tie above named '• - - - -- ----------------------------••-------•-•- •------------------ •---- - - - - -- -------- ca.lY- ,n -- - K••---Bua' aeMerl.y •K-• ..... TITLE: MEMBER STATE BAR OF WISCONSIN D.urt.2n... -_ -•• (If not . ........................ .......... .• ,. ".... ..1� *-• authorized by ¢ 706.06, Wis. Stats.) . Q .. ................... to me known to b rson 9 executed the f going instru d, edg to ame. THIS INSTRUMENT WAS DRAFTED BV 1 fA Kristina Ogland Lundeen ... . •.. - ----- ... - - - ------- • ---------- A torriey-- -at._. Law--------------------------------- - - - - -- •.,A11c.e...Joy z ... Q� ....... ............ - ------ -- ---- - -- - --••----- Notary Public -` ______________ _ -- --- _ _ . _ _ .. ._.t_..: .yt`� • °. COPnty. W13. (t (Signatures may be authenticated or acknowledged. Both My Commission is permai+e ot, state expiration ` are not necessary.) July 12 . 19 93_..) - — date... ...._.. .... _..._.. - ` ` their signatures. Wisconsin Legal Blank Co. Inc. Alilwaukee. Wis. S + ST. CROIX COUNTY a, WISCONSIN ZONING OFFICE > ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 _ (715) 386 -4680 Nov. 15, 1990 To Whom It May Concern: An inspection of the Calvin Burton property, located ` at the NW4 of the N144 of Sec. 28, T28NIR18W, Town of Kinnickinnic, St. Croix County was inspected on Nov. 13, 1990. At the time of the inspection this septic system was found to be code complying for a three bedroom home. Should you have any questions, feel free to contact me at this office. Sincerely, j Thomas C. Nelson Zoning Administrator cj 1 ti FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER (�Zdl') i /ee;r7)N TOWNSHIP /2 /xJ KJ e /v/ C. SECTIO T_,2 N -R ! 1 5 W . P4';2 f-� 0 22_ logo - I oaox> ADDRESS 2-03 L+' �� ". S ST. CROIX COUNTY, WISCONSIN I& VC4- -54,0 SUBDIVISION 11J/ 14 LO LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN FEET OF SYSTEM r � O J ) a 4 o I INDICATE NORTH ARROW DENCHMAR.K Elevation and description: Alternate benchmark SEPTIC TANK:Hanufacturer : ,'�!,? -'k�S Liquid Cap. % G7�) rj Rings used: ? Manhole co � cov elev. Fin al grade elev: S, _ Tank inlet elev.. i Z Tank outlet elev.: No. of feet from nearest road:Front , Sided - , Rear Ft. From nearest prop. line: Front , Side _ Rear V Ft. 110. of feet from: Well Building : �! (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REV • ERSE SIDE J ' PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons /cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front, Side_, Rear Distance from: Well Building SOIL ABSORPTION SYSTEM . fit Bed: Trench: Seepage Pit: Width: Length ! C.�� n Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: Ty / No. feet from nearest prop. 1ine:Front Side , Rear Ft.,` No. feet from well: L'� No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6 /90:cj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR HUMAN RELATIONS DIVISION P.O. BOX X 7969 „ ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON WI 53707 NE 4 i NW 4 ,Sec . 2 8, T 2 8 R18 f S s gned D. Number: Town of Kinnickinn ❑CONVENTIONAL ❑ALTERATIVE L • in Holding Tank ❑ In- Groun Press ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: C,qlyin Rii �314 Pleasant St, Rohejrts, WI H-/3-?d BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: RE O. PT. ELEV.: CST PER PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: lLyle My,-rs 6219 St. Croix 12R762 SEPTIC TANK /HOLDING TANK: MANUFAC URE LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER T ^/ _ / n � -i . �� PROVIDED: PROVIDED: /• 1f�V ^/ v G / i L N'YES ❑ NO ❑ YES QdNO BEDDING: VENT DIA VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINr/ / AIRINLf E] YES NO ❑ YES NO NEAREST ­ • 77 ( p DOSING ICH AMBER: MANUFACTURER: BEDDING: LIQUID C PACITY/ MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: - 1 YES ❑ NO 1 0 YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: P MP ND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ) ❑ YES ❑ NO NEAREST --* SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: !� M/ RIAL: PIT DEPTH: DIMENSIONS D d !/ . J C 0-- GRAVEL DEPTH FILL DEPTH DISTR. PIPE I DISTR. PIPE DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WELL: BUILDIN VENT TO FRESH BELOW IP S: ABOVE ER: E � V. INL E END: - PIPES LINE: AIR T: ��� f • J p §16 / NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW [- ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: I � E:1 YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE I MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: ER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO COV ❑ YES ❑ N COMMENT PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILD G: I FEET FROM LINE: (� ❑ YES ❑ NO ES ❑ NO NEARES A l 5.3�,v s. s y3.s'� �l n �� � S �3• �� (� Sketch System on Retain in county file for audit. " 1 Reverse Side. SIGNATUR TITLE: SBD -6710 (R. 06/88) TL OILHR S ANITARY PERMIT APPLICATION couN In accord with ILHR 83.05, Wis. Adm. Code STATE SANIT RYPERMI # — Attach'complete plans (to the county copy only) for the system, on paper not less than ❑ �/ ��� 8% x 11 inches in size. k i evisionto pre us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRLIRTY OWNER P PERTY L ION G! e' /a '/a,S ,N,R E(o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK if l a c-<jr:5,�.I j ts STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ; 3Z II. TYPE OF BUILDING (Check one) CITY - NEAR T ROAD State Owned � VILLAGE EZ ❑ Public g1 or 2 Fam. Dwelling -# of bedroom - PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 600 d 1 ed C)tjv 1 ❑ Apt/Condo 2 El 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 in line A. Check line B if applicable) A) 1.0 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 ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 El In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 91�sv I Vq < — REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gal /d / sq. ft.) (Min. /inch) ELEVATO S �{) ? _31 0 Feet 9! ; - , g ;_ - set VII. TANK CAPACITY r Site in oallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con Steel glass Plastic App Tanks Tanks structed Septic Tank or Hold Ina Tank 11CIC1 0d ' C �— C Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. PI u bar's Name (Print): Plumbs 's SignatureINStamps) MP PRSW No.: Business Phone Number: s ls ��� P u is Address (Street, City)Stats, Zip C *E fox c S . S IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Iss ing Agent Signature (No Stamps) I K Approved ❑ Surcharge Fee) Owner Given Initial / j C Adverse Determin X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: L SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1 /2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) ki U- o„-, rs N � QL ---0 - T DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 MADISON W 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: SHIP/ Y: OT N .:BI- O.: SUBDIVISION E: ���/ /T 'N /RIE(o W �� t OUNTY: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMM R IAL ASCRIPTION: A ESTS: Residence =� UNew ❑ Replace s / � -, 1. c i RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: - GROUND SYSTEM -IN -FILL OLDING TANK: RECOMMENDED S STEM:(option CIS DU �7$ DU IN Ll$ DU D$ U 0S 5QU ESI If Percolation Tests are NOT required D If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: �(,' ATE: Floodplain, indi Fl elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIUMST TO BEDROCK IF OBSERVED (SEE ABBR . ON B r2 s , �� 1 e_ s B <2 �Z g. vn c e J S, �� 1 /91 f s 4 15 ,6e1 , rn C C S B&3 '7 9 '50 /'_Cf 2 > W c2 0 8 ;1 ; s G s c R E_ /s B- 7 �I1.,.�C1 r , B� 7 �T� t�.'� C �, ' I 0K 13,r� m�4 0a E�v� B- 6 7Y' 7r,�6 > 7g 13 0K 6a , ned� C / a� mods PERCOLATION TESTS EST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERJ 1 PEUrIOD 2 P R D 3 PER INCH p- Z2 f 1 / P__ 2 Z / 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 q 3 -PY t ^ I __� ,� __ �n P4 , tj - ( 9 I N �. _. . f w J _ � - 1 I I, the 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 n )it : ITESTSWEREC MPLETED (N�j:/y � 7 0 ADD CERTIFICATION NUMBER: R(optional): +- q 5 C�c> 5'�z I PHONENUMBE C� 3 a CS PTU E: �r r w ' DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) – OVER – — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over V') BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well fs — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand — Less Than 'I — Loam Bn — Brown 'sil — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay Ill — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit The sanitary permit must be obtained and posted prior to the start of any construction. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY DILHR STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO TY OWNER (( ( PFOPERTY LOCATION r -'/4 '/4, S ,! Tom- N, R E (o� PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR GSM NUMBER is I MP ; — ) ,6 -- II. TYPE OF BUILDING (Check one) F State Owned 0 VILLAGE NEAREST ROAD ❑ Public 1 or 2 Fam. Dwelling## of bedrooms PAR EL TAX NU BER Ili. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo ; c I- 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 in line A. Check line B if applicable) A) 1. 0 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 ## — 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 i[ SeepageTrench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA $. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE �f REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /da /sq. ft.) (Min. /inch) ELEVATION V . _r S' C' � L I 4 �— Feet 7 C 2 Feet VII. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete structed glass App. Tanks 1 Tanks Septic Tank or Holdin Tank P3t9 -� Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' Signatur P : (No Stamps) / PRSW No.: Business Phone Number: zj�- 62 l� / c' s 2e Plum er's Address (Street, Citf, State, Zip CoddV e r E r IX. COUNTY /DE T ENT USE ONLY isapproved Sanitary Permit Fee (I nclude g roue water ate Issued Issuing Agent Signature (No Stamps) ❑ Approved 4 RAdverse Owner Given Initial De termination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber I� . I 4 INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 - 266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for al/ septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vill. Responsibility statement. Installing plumber is to 611 in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department use only. X. County /Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R, 11/88) SANITARY PERMIT APPLICATION =:ZqLHA I n accord with ILHR 83.05, Wis. Adm. Code COUNTY wr STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous application --See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION % Y4,S T ,N,R E(or)W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING (Check one) ❑ State Owned VILLLLAGE NEAREST ROAD ❑ Public Ell or 2 Fam. Dwelling - # of bedrooms_ A Ax BE III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check 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 # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -in -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION Feet Feet VII. TANK CAPACITY Site !no allons Total #of Prefab. Fiber- Exper. INFORMATION New istita Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks I Tanks strutted Septic Tank or Holdina Tank Lift Pump Tank/Siphon Chamber El EJ � El El 1 0 F] Vlll. 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: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) r Surc h a ge Fee) ❑ Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) C O c,N ile • N O n O �O V N o r� �0 m m 1� �. o �►m N C :Y o %A N A v q y a . C = O c � 2 q c Ed ..c a w d O 0 C 1601 a LL ° w r Q1 a r0 C m d Q O � � m O d i A a d M > C N r c CJ � V w a 8 OC vi Q Q >" 0 N & C V w 0 d GG w N N Z c N q O O V 0 C a p !! E & a V �- ° 1 r Y J a v LA m UJ NV� d o M O W W Q O O ;� V �/1 A C 0 Id VN Q s j V ... w 6 c C < b r $ k N O C o•-, 'E to C N ( O ? ~ m e t 'o n. E ° a E w 7 n d d �0 ✓ Cb 0• Q d ] C „ 01,• U. Z ° w C` v ar q s p O N C e OMO O E co o c 1 r t V x (J Q O J !Al �2 vl V � O v s to l9 � r I �1 Aj Z a to G � Z L 1 Y ,- I., lip roil n N VVVJJJ a� � W C� ► to o �� 1 � � u N ( (L � � ►�( i 7DEPAAT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS 6STRW, DIVISION OR AND PERCOLATION TESTS (115) AN RELATIONS MADISON WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWN IP/ t Y: OT NO.:BLK. N : SUBDIVISION NAME: N 0 NT MAILING A DRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: I COMMERCIH SCRIPTION: A EST S: Residence 13 XNew ❑Replace 1 O 7 3-1 `l RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: �S MOUND: IN- GROUND PRESSURE: SYSTEM -IN -FILL OLDING TANK: RECOMMENDED S STEM:loption DU ZS ZS 0 U ❑SWU ❑SOU Diu If Percolation Tests are NOT required DESIG TE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: �� r Floodplain, indicate Floodplain elevation: N � PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, E LEVATION OBSERVED HEST TO BEDROCK IF OBSERVER (( SEE ABBRV.ON BACK.) B- Z0 /,r�J *'!o 3 n 5 � lJ S2 S� o? /1 B- .J 8 1Z S � n, s, n s, 3 a me- s n...sl, s� l i2 s o 9 a �e s B-3 .95,9112 4OU-1 B -q 17& 33 > 2 s! �� � s, a� ,t AG s ns , 111611 / n s� 02 7 n e aC s &s1 2 7 6 1L /7 n s a 8 &ez 117) e s PERCOLATION TESTS TEST - DEPTH , WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. 10 1 PERIOD PER19LD3 PER INCH P- / 34, O / 11'.5116 P- �S ' i l6 P- .3 O Z � ' 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 9 Z O i f � E 1 3 3 E e J f i rr d € i E i t _ i i A i i II t _.. _. _....._ .._..... __ _...[. _. i_._.__ ._. _._._ �z. _._ F.. _...._ _'A __ ._ __.a I, the undersigned, hereby cer& 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 R I C6,rcE t. TESTS WERE C ON: _A / ADDRESS: CERTIFICATION NUMBER: NU MBER(optional): 1 PHON_ F 02 CST S06NATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 (R. 10/83) — OVER — j INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 1U) BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well fs — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand 'C — Less Than 'I — Loam Bn — Brown 'sil Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red - v sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. • + APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owners) 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. OwnerV property L(I I ��a'rAt, r� Location of property J�J /4 k_ i /4, Section, T Z N g W Township — Mailing address Address of site t/ Subdivision name Lot number Previous owner of property W C a P. L 0.v- a �_ Total size of parcel � 11 )vc_ _ QC fe-S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this ert being developed for resale (spec house) ?Yes No Volume and Page Number ) 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• a pq ecorded in the Office of the County Register of Deeds as Document No. ; 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 be dl recorded in the Office of the County Register of Deeds, as Document No. ). Signature of Owner Signature of Co -Owner (If Applicable) C1 C) Date Signature Date of Signature I STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County � OWNER /BUYER g \ U 1 ) CT E Y 1 U a V--\ ROUTE /BOX NUMBER .- I T_ P 1 `eA Cc FIRE NO. CITY /STATE Y n JOe s'A S , _ ZIP "NO 2.3 PROPERTY LOCATION: hJ W 1/4 x_ 1/4, Section , T Z ? N, R 12 W, Town of 1c, k - , nr�� C , St. Croix County, Subdivision , 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 e tank as a you put into the system can affect the function of the septic Y P Y P 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. S I GNE 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 ' ^;I DOCUMENT NO. - J T STATE BAR OF WISCONSIN FORM 1 -1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED I ari 1 I; 0�.�02 8'79 r'�c� 189 - _ - - - -_- - -- : - - - -. - - -- -- -- _ _____ - - - -� i -• REGISTERS OFF � This Deed made between ... M; L ehi , ei .. E .. ... M cLaugh110..... ST CROIX CO. ' W! f and..D.iane.- T MG.L.augh�.:a., kl and Wf e----- • - -••• ReC' for Record II - ...•--------•-_......_...•-•-• ... ..................... ... •-..... ..........I Grantor, A 04 1 199 0 �I and . -...Ca1_vin._K.._..Bur.ton -_ and._ Beverly ._K._...Bur.ton,.._....... at 8:55 A. M I I husband.- and... wif. e ... as --- sureivo _rship_.marita.l .............. d -- pr. opert. y ----- -- ---------------------------------------------------------------------- - - - - -- - Register of Deeds , Grantee, Witnesseth That the said Grantor, for a valuable consideration...... i .. ... ............ ........ ...... ............................. ... .................. ........ .....: ............ P ­RN TO conveys to Grantee the following described real estate in ...�.t..__.CXQ1_X.._._.... �i County, State of Wisconsin: I' �I North 165 feet of the NWk of NWk of Section - _ — `4 28, Township 28 North, Range 18 West Tax Parcel No: ----------------------------------- TOGETHER WITH an easement for purposes of ingress and egress described as follows: I' The South 33 feet of the North 198 feet of NWk of NWk of Section 28, �'. Township 28 North, Range 18 West. Also, I I TOGETHER WITH and subject to all easements and rights -of -way of record. I I I 1 I; I This ... is.. 110t homestead property. (is) (is not) 11 Together with all and singular the hereditaments and appurtenances thereunto belonging; I j, And.._._..M.. -fin and..Dan. L . McLaughlin .... ......... 1 warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except i easements and rights -of -way of record, and will warrant and defend the same. Dated this .8 th. 19-.9Q. .............. ...... •- •------ ---- -- ...._... day of ....-- -...- .. .--•-•--©•---•-•-•--- 19 s /.rte ..- .- - -- •- --- --• -- --• ... ... .................(SEAL) -..._: (SEAL) Michael ... E� ... McLau h_li;n.- ••- • -•... i -----------------------•--.-.-.-.-... _------ •- ---------------- - - -• -- _(SEAL) �-r-A- �..... d._. i ) ............................................................ *Dian....T� McL �_...... i AUTHENTICATION ACKNOWLEDGMENT II Signature(s) ............................. ............................... STATE OF WISCONSIN ss. -----------------•---------..---.-----.------------•------•----•---------------- .... County. authenticated this ........ day of ........................... 19_.:... 6 ersonally came before me this .... ath ..... day of I � ... .... ......AUgUSt............... 19 -.90. the above named y I Michael E McLaughlin..and....... jI . I. ............................... ---- •- •.....- •- •••...... -• -• •..... -•- ••Diane.. _. •. McLaughlin li TITLE: MEMBER STATE BAR OF WISCONSIN II (If not . ............................................................ ................................................... ............................ l authorized by § 706.06, Wis. Stats.) to me known to be the person ..§ ........ who executed the foregoing 'nstrument an knowledge the same. THIS INSTRUMENT WAS DRAFTED BY. _..._ _..... ... .... .... .. ........................---.._. _G_,...L,._.Gaylord Attorney ........................ * 4J 12 E �•_--------------- - - - - -- I River Falls,__.WI____.54022 Notar Public --- .___ -_ _ ._...- -....- y, ......••• ............ .. ...........••.... Count Wis. (Signatures may be authenticated or acknowledged. Both My Commission is rmarent. (if not, state expiration are not necessary.) Y) date: . - - - -•- - -• - - - - • .. .................. . ..... 191t.) *Names of persons signing in any capacity should be typed or printed below their signatures. �I I I WCrr1�� STAT BAR OF WI FORM No. 1 1982 Stock stock No. 13001