Loading...
HomeMy WebLinkAbout026-1119-12-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 408256 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: Ziebol, Tom & Kristen I Richmond Township 026- 1119 - 12-000 CST BM Elev: Insp. BM Elev: BM /0 - 00 Description: > �SGV4yt /IYJ S TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark (,U -���/ � /a(o D I •S� ►o�t.s hod Dosing A —/0 b Alt. Aeration Bldg. ewe 5 �a Holding St/Ht Inlet lo•9.r /a �.5 TANK SETBACK INFORMATION SUHt Outlet , /S /0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet �- Septic � , ! , O � / 1 � � � Dt Bottom Dosing �-( o[ He r /Man. of Aeration �y Holding B t. t OYSLUIII t( q o /0 b ci Final rade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover 6 3 / Z Model Numh l r TDH Lift riction Loss System Head TDH Ft For ain Length a. is to Well SOIL ABSORPTION SYSTEM '( - / 7 t ;,,` 3 BEDITRENCH Width ILer)Qth,r� No. Of Trenches PIT DIMENSIO o. Of Pits Inside Dia. Liquid Depth DIMENSIONS --11`q SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manuf _ INFORMATION CHAMBER OR curer: Type Of System: UNIT C 17r� Model Number: DISTRIBUTION SYSTEM V Alf 6 Header /Manifold Distribu ' a x Hole Size x Hole Spacin Vent Air Intake !) / /1 Pipe(s) _ f'2 1 ' Lengt — 1 Dia Length + Dia � Spacing I --� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over ` Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes [] No Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 /J 67 -1 Inspection #2: Location: 1281 146th Avenue New Richmond, WI 540 (SE 1/4 NE 1/4 22 T30N R18W) Pondview Meadows Lot 12 Parcel No: 22.30.18.707 f3 ,� �� 1.) Alt BM Description = 6 �.� � �� hra�l( /Y 4-eej LJ � �1��"d"� -,��.. 2.) Bldg sewer length =, � �� 7a4a- t K-(tiP/LJ � - amount of cover = Plan revision Required? ] Yes No r Use other side for additional information. SBD - 6710 (R.3/97) Date Insepctors Si re Cart. No. A /Z at A , is � a%A6 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 lV i sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not 7 X1 -0 L Y s 3 3 L state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County �® / State San' �ermit Number ❑ Check if revision to previous a ation State Plan I. D. Number I. Application Information - Please Print all Information 1 Location: Property Owner Name Property Location r / v /' t / ' e� / e , ZOO 1/4� T , , R /'�, ; (o Property Owner's Mailing Address 3UL Lot Number Block Num /7/- �RO1X ���;GE Ci ,State Zip Code Pone ue� Subdivision Name or / CSM Number f 7 i 7 II. Type of Building: (check one) h � -pgl y �,+ ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: Village Public /Commercial (describe use):_ lZ �- own of r ❑ State -Owned X, /k p,�p Nearest Road fJ r� �` ' /� r n G t` I s^_ _f Parcel Tax Number(s) _ III. Type of P it: (Check only one box on line A. Check box on line B if applicable) J q- A) 1. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing Sys tem $) 11 Permit Number Date Issued A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ONon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment A rea Infor mation: T 1 - C - 1. Design Flow (gpd) 2. Dispersal Area 3. Dispers Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed f S4q Rate (Gals. /day /sq. R.) (Min. /inch) .4 - / � f Elevation �� r- �?�� �- - 3 � /e, /• / l S �' ' _ A!:5 / 4 VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks At ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigne assume resp onsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumbe ' gnature (no stamps): MP/MPRS No. Business Phone Number lu is Address (Street, City, State, Zip Code IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued I su g Agent Signature (No stamps) (Approved ❑ Owner Given Initial Adverse Su rc e Fee) Z Determination X. Conditions of Approval /Reasons for Disapprova • ��AIS.�� � ' 1M t �' ""- 'r-t L'f`� � 1 S u�'S - SBD -6398 (R. 07/00) l PLOT PLAN PROJECT Tom Ziebol ADDRESS 661 Sill Dr. NewRichmond Wi. 54017 SE 1/4 NE 1 14s 22 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX 7 -14 -02 BEDROOM 4 MPRS Byron Bird Jr. 2205 DATE CONVENTIONAL XXX At' ad e COIKENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE •4 ABSORPTION AREA 1500 # of chambers 49 BENCHMARK V.R.P. top of SW lot Stake ASSUME ELEVATION 100' ; ❑ BOREHOLE O WELL *H.R.P. one as BM AT' nt SYSTEM ELEVATION T- 1= 101.6T- 2= 101.4T -3 =101.2 Sidewinder High Capacity Leaching T-4 =101.0 Chamber with 17.2 t ^2 per chamber Long 34" Elevation Alt BM Elv 98.5 top of pl satake 380'PL gage Driveway 229'PL 4 bed 146 ri n ` house ave ob pipe §0— 3 , 81' B4 75 ' c 2n 000 5� B1 33 60 ' B2 BM 52 17' S� 30' 35' 15 ' 10' 380'PL PLOT PLAN PROJECT Tom Ziebol ADDRESS 661 S.ill Dr_ NewRichmond Wi. 54017 SE 1/4 NE 1/4s 22 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Byron Bird Jr. 2205 DATE 7-14-02 BEDROOM 4 CONVENTIONAL XXX At- ade - -" NV1FNT10NAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ❑ LOAD RATE .4 ABSORPTION AREA 1500 # of chambers 49 ik BENCHMARK V.R.P. top of SW lot Stake ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL *H.R.P. same as BM Al2T, ent SYSTEM ELEVATION T- 1= 101.6T- 2= 101.4T -3 =101.2 Sidewinde r High Capacity Leaching T -4 =101.0 Chamber with 17.2 ° t "2 per chamber Long 34' Elevation Alt BM Elv 98.5 top of pl satake 380'PL gage Driveway 229'PL 4 bed 146di n ' house ave ob pipe 3 40' st 81' B4 75' , 60' BI 31' B2 BM 52' 17' 5 ' 30' 35' 15' 10' 380'PL Wisconsin Department of Industry, SOIL AND SITE E V A L U 1MON' - R - 1EP O R T Page 1 of 3 Labor and Human Relations Division of SatAy & Buildings in accord with ILHR $, may V,1tis: Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches iq ize' Plan most IA'C kf5�� but S Croix not limited to vertical and horizontal reference point (BM), direction i n of�l�pe, scale o? PARCEL I.D. # F � dimensioned, north arrow, and location and distance to nearest roa 026- 1065 -50 -000 E PRINT ALL INFOR :TION .:� . REVIEWED BY DATE APPLICANT INFORMATION —PLEA S � .�;n -goo 5 PROPERTY OWNER: PAOPMW ON' Ri rd Derrick \' GOVT. LOT SE ,14 K, / NE 1/4,S 22 T 30 N,R 18 6r) W PROPERTY OWNER':S MAILING ADDRESS T iBLOC SUBD. NAME OR CSM # 131 ' 0 Hwy 6 12` na Pondview Meadow CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE :ENOWN NEAREST ROAD New Richmond, wI. 54017 (715 2465425 Richmond 146th AVe. [ New Construction Use [ Residential / Number of bedrooms 4 [ ) Addition to existing building I I Replacement [ Public or commercial describe Code derived daily how 600 gpd Recommended design loading rate .4 bed, gpd /ft .5 trench, gpd /ft Absorption area required 1500 bed, ft 1200 trench, ft Maximum design loading rate .4 bed, gpd /ft gpolft Recommended infiltration surface elevation(s) 102.07 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material glacial drift Flood plain elevation, if applicable na It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 1D 0 �S ❑U �7S 0 RIS ❑U EIS [RU ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Botx>dary Roots Bed Trer>ch 1.- 1 -9 10 r 3/3 none 1 2fp1 mfr gw if np 1.3 - -- 2 9 -25 10yr 4/4 none sicl lcsbk mfr gw if .2 1.3 Ground 3 25 -80 7.5 r 4/6 none sl lcsbk mvfr gw na .4 .5 elev. 105 -40ft• 4 1 80-86 7.5 r 4/4 none sl lcsbk mfr na na 1 .4 .5 Depth to limiting factor 86" Remarks: Boring # 1 0 -6 10 r 3/3 none 1 2f U 2 6 -19 7 .5 3 19 -82 10 r 4 4 r 4 4 none Ground elev. 10 Depth to limiting fA factor 82 1, � v Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Ave.-,New Richmond,/WI 54017 Signature: Date: 4_22 -99 CST Number: m02298 PROPERTY OWNER Richard Derrick SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D. # 026- 1065 -50 -000 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundeiry Roots GPDlft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 3< {<{ 1 0 -9 10 r 3/3 none 1 2 9_24 10 r Ground 3 24 -50 7.5 r 4/6 none sl lcsbk mfr 9w na .4 .5 elev. i 10 4 50 -82 5 r 4/4 none sl lcsbk mfr na na .4 .5 Depth to limiting factor Remarks: Boring # 1 0 -9 10 r 3/3 non .2 2 9 -24 10 r 4/4 n ne .3 Ground 3 24 -82 7.5 r 4/6 none sl lcsbk mfr na . na 1 .4 ! .5 elev. 104.60 ft. — Depth to - limiting factor 3 ` 82" Remarks: Boring # 1 0 -9 10 r 3/3 none 1 2f P1 mfr gw if n .3 2 9 -19 10 r 4/4 none sicl lcsbk mfr if .2 .3 Ground 3 19 -80 7.5 r 4/6 none sl lcsbk mvfr na na 1 .4 .5 elev. 10 4.80 ft. Depth to limiting factor 80" Remarks: Boring # Ground elev. i ft. Depth to limiting factor t Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Derrick 1554 200th Ave. CSTM2298 SE4NE4 S22 T30N - R18W New Richmond, WI 54017 MPRSW - 3254 town of Richmond .(715) 246 - 6200 lot #12- Pondview Meadows This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. N 1 =40' - Brn.= top ofSW lot stake C el. 100.00 Alt. BM.= top of NW lot stake C el. 98.50' CT' (ell 030 \ n � lv l Gary L. Steel 4 -22 -99 POWTS OWNER'S MANUAL a MANAGEMENT PLAIN pa or FILE INFORMATION SYSTEM SPECIFICATIONS Owner B f f ,( �� Septic Tank Capacity. ® gal ❑ NA Permit # L Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer� , ❑ N A DESIGN PARAMETERS ❑ NA Number of Bedrooms I ❑..NA: Effluent Filter.Model Tank Capacity gal L-1 NP, ❑N A Pump p Number of Commercial Units 13 NA Estimated flow (average) gal /day PT:mp Tank Manufacturer .;: of /da _... ❑ NA Design flow (peak), (Estimated X 1.5) g' y, Pump Manufacturer NA Soil Application Rate gal /day /ft Pump Model ' Tj t Pretreatment Unit ❑ NA Influent/Effluent Quality Mont y average* S a n d /Gravel Filter ::❑ Peat Filter: Fats, Oil 8t Grease (FOG) :530 mg /L ❑ Mechanical Aeration [],Wetland Biochemical Oxygen Demand (BODs) _5220 mg /L p Disinfection ❑ Other. Total Suspended Solids (TSS) 5150 mg /L Manufacturer Pretreated Effluent Quality ❑ NA Monthly average * *. Dispersal CeI1(s) Biochemical Oxygen Demand (BODs) _530 mg /L" 1n= ground (gravity) 0 In- ground (pressurized) Total suspended Solids (TSS) _530 mg /L At - ,ade ❑Mound Fecal Coliform (geometric mean) 5_10 cfu /100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size A inch diameter e ' * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event ( .Service Frequency At least once every >❑ months �year(s) (Maximum 3 yrs.) Inspect condition of tank(s) _ 9. pump out contents of tank(s) When combined sludge and scum equals, one -third (3�) of tank:voiume inspect dispersal cell(s) At least once every ❑ months ears) (Maximum 3 yrs.) Clean effluent filter At least once every ❑months 'tyear(s) 0 s 0 N Inspect pump, pump controls R. At least once every. At ieast once every.: " ❑ montfis ❑ yea (s) � 'NA Flush iaterais and pressure test onths ❑ ear s) .. ❑ ❑m Y Other: At least once every, - r'Y ; Other At least once every ❑months' ❑ year(s) '1" ❑'NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one "of the foilowing Licenses or certifications Master • aster Plumber Restricted Sewer; POWTS inspector, POWTS Maintainer; Septage Servicing Operator Tank inspections Plumber, M sin "or broken hardware, ldentfy any leaks, reasure the must include a visual inspection of the tank(s) to identify anymis g e of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface: "dispersal efftuent volum observa p and to check for any,ponding to check the effluent levels in the obsery p P shall be visually inspected a immediate cell (s) ices th O and surface may indicate a condition and requ ,. ondin of effluent on the ground Y d surface. The g the ground notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (15) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing ch. NR 113, Wis Operator and disposed of in accordance with consin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components,. pretreatement.componeni s, and any other maintenance or monitoring at in of 12 months or less shall be performed by a certified POWTS Maintainer onty within 10 days of completion of any service event A service report shall be provided to the local regulatory auth . START UP AND For new construction, prior to use of the POWTS check treatment tanks) for th epresn a of pals are detected have the contents . tv,% t rp tration 2 p apa 2 of System start up shall not occur when soil conditions are frozen at the infiltrative. surface. — During power outages pump tanks . imay'fill above normal highwater levels. -When power is restored_ the excess: wastewater will be discharged to the dispersal celi(s) in one large dose, overloading the cell(s)' acid may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator: Pi I to restoring power to the effluent pump or contact a Plumber or POWTS. Malntainer.to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells..bo not drive or -ark ever, or ot her wise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms,'cottori' swabs; degreasers; dental floss, diapers, disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peellrigs; gasoline; grease; herbicides; meat scraps; medications; oil; Daintinz products; pesticides; sanitary napkins; tampons: and water softener brine. ABANDONEMENT When the POWTS fails and /or is permanently taken out of service the'' following steps shall be taken to insure that the system is properly and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of ail tanks and pits shall be removed' and properly disposed, of by :a Septage Servicing Operator. • After pumping, all tanks and pits shaii be excavated `and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon b) required setbacks from existing and proposed structure, lot lines and webs. I Faiiure to protect the replacement area will result In the need for a new soil and site evaluation to establish a suitabie' replacement area. ; Repiacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to repiace the' failed POWTS. The site has not been evaluated to identify a suitable replacement area: Upon failure of the POWTS,a soil and site evaluatlon must be performed to locate a suitable replacement area.. if rip replacement area Is available a holding tank may be installed as a fast resort to repiace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be' reconstructed in place following removal of the biomat at the Infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time*. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICT' OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT:. TANK CINDER'ANY'C!RC IEN CIMSTANCES. _ DEATH MAY RESULT. RESCUE OF A PERSON FRO I .THE IN TERIOR ; OF,;, TANK MAY B "BIFFiCULT OR IM IZURiF.. _- . ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER,_ Name :l�7/� Phone _ Phone SEFTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY' S� � °/ X' 6 >4 Name I %��- O�-_ /j`v�6'�76 Agency /, ST CROIX COUN'T'Y ,SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ 7C A- ' O l rc Mailing Address 6 � S /`�2 11 ��'= Properly Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION ` Property Location Ste /.,' /., Sec. :;2 Tj�LN -RI-fiCW, Town of rG�1s�a� Subdivision Ad n Wr/ r Certified Survey Map # , Volume . Page # Warranty Deed # / , Volume /�` - vzS . Page # Spec house ❑ yes)2r-no Lot lines identifiable ;-yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, journeyman plumber, restricted plumber or a li cense d pum verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Zo ning Office within 30 days o e three 7!y xpu - ation. , ' d9te. GNA F 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 owners) of the pro rty described above f a warranty deed recorded in Register of Deeds Office. GNATURE 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 r �I i.1525 506 w STATE BAR OF WISCONSIN FORM 2 - 1999 Es26�3AL WARRANTY DEED REGISTER OF DEEDS Document Number I ST. CROIX CO., WI This Deed, made between Richard L. Derrick, individually and as RECEIVED FOR RECORD attorney -in -fact for Loren D. Derrick, Rose H. Derrick, Richard L. 07 -12 -2000 9:20 AN Derrick, Joan L. Derrick and Robert J. Derrick, under Power of _ Attorney recorded in Vol. 1454, Page 425, as Doc. No. 609877, WARRANTY DEED Grantor, and Thomas R. Ziebol and Kristen D. Ziebol, husband and CERT ERT C i COPY FEE: wife, COPY FEE: —� TRANSFER FEE: 86.70 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 12 at of Pond View Meadows in the Town of Richmond, St. Croix Name and Return Address ty, Wisconsin. EAGLE VALLEY BANK, N.A. 1301 Coulee Rd., Unit 2 Hudson, WI 54016 026- 1065 -50 Parcel Identification Number (PIN) This is not homestead property. (tt) (is not) Exceptions too w arrranties: Easements, restrictions and rights -of -way of record, if any. Dated this 7 7 vv day of July 2000 + Richard L. Derrick, individual) and as attorney -in -fact for _ Imert D. Derrick, Darr= • • rrxTrrlx3 in ts++ 1454 429 1W b+- FnW AUTHENTICATION ACKNOWLEDGMENT Signature(s) Richard L. Derrick, individually and as attorney- STATE OF WISCONSIN ) in -fact for Loren D. Derrick, Rose H. Derrick, Richard L. ) ss. ii,,,, yf 4 tr� 7 FQ - County ) aut enncallh I ay � . 20M M . Personally came before me this _ day of the above named • Kristine Ogland — TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by § 706.06, Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY • __�_ Attorney Krishna Ogland _ Notary Public, State of Wisconsin Hudson, 16 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) _. _.__ —. + - - -- - - - - -') • Names of persons signing in any capacity must be typed or printed below their signature. Iro matron Pmre"iomr aompenr. Ford du Leo, Hs soo4ssao21 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 -1999 Icv ¢ 2.004 ACRES o n j ; cu i o 87,313r S0,FT. 1 0 ........ _ 4.. ... , .... . LLI c� o ¢ 100' 273.73' 1 ' - —19 7.81' I ' n w � .- - - 75.92 " 8.25' i N89 ' 3 ?.73' S89'43'03 "W 380.66': `'' _ C 8 4 T W 1 A • � V E N U t 33' 33'� • ' I 12 co o N ' • �'"cu (U .. L 4 2.005 ACRES �,D W M S 87,318 SQ.FT. C_ °o , 3 ( ' IN 3 • 00 tti ; ' V. 10, PG. 2745 S89 "W 380.68 ^ c') OWNED BY OTHERS `1' 17.2'•+ �D v -------------------- - - - - -- -- ` i Q 1 .-, " - -- o U� o Z cu r M C:) t Z c I � 1 3 CD i I W N M N 2.005 ACRES 6' J � 87,323 SQ.FT. © S89 "W 380.70' - i I P on c V � e ti � I C"S I -- Z&o r sz zy�' OD 14 ` Tom zr•cbo! N : co 2.005 ACRES N 87,348 SQ,FT. .. �t y, V. 10, PG, 2 ------------------------ \ \ OWNED BY 0 y 22.2' + /— 15 -• ,- . _ _ _ 1 2 .006 ACRES S� ,' '' 87,362 SO N89'39 SOFT P .� i i �c. 4C i 73.33=- - i «89 39'31 "E Ck cs ' 2,003 At:F2F - S r;. 17