HomeMy WebLinkAbout026-1149-21-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
430552 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:
Weaver, Kevin I Richmond Township 026- 1149 -21 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
1 6 6 , b I / 6 0. G �
13 ✓h ( 36.30.18.1121
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic 2 67 U Benchmark 3 / s [� 3. 100
Dosing n / ` Alt. BM T � , t8 ,
Aeration _ Bldg Se /4 ��
Holding St/Ht Inlet
TANK SETBACK INFORMATION SUHt Outlet ,SC1� Lf 0 Z/
TANK TO P_ / L WELL B ]LDG Vent to Air Intake ROAD Dt Inlet
� t.vl ►�5 f
Septic lO 7 + I Dt Bot tom
Dosing ye Header /Man.
Aeration Dist. Pipe
2S R 1 ` Z
Holding — Bot. System
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover 2 i
GPM "5' -�� OZ ��
✓1 r
Model Number
TDH Lift Fricti oss System He TDH Ft
Forcers ength Dia. r t. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 1 1
DIMENSIONS
SETBACK SYSTEM TO P/L _5 BLDG W LAKE /STREAM LEACHIN Manufact
INFORMATION CHAMBER / 0{1'
Type Of System: � � �' O / ,�� Model Number:
DISTRIBUTION SYSTEM `•J o Z (C 4e
Header /Manifold Distribution x Hole Size x Hole Spacing Ve to Air I ntake
�i Pipe(s) V � � _�
Length Dia Length C> Dia Spacin
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
G . [] Yes [] No L Yes No
COMMENTS: (Include de discrepencies, persons present, etc.) Inspection #1: � / Z / ID V Inspection #2: /__ /__
Location: 1407 126th Avenue New Richmond, WI 54017 (SW 1/4 NW 1/4 36 T30N R18W) Torey Pines II Lot 21 Parcel No: 36.30.18.1121
1.) Alt BM Description = ST' _)Z_ �do' �� SVJY+i
2.) Bldg sewer length
- amount of cover
Plan revision Required?
Yes � ,:�. No I�
Use other side for additional i �
information.
SBD -6710 (R.3/97) Date Insepctor's Sig ture Cart. No.
I
3 0I=1JO JNINOZ
Sanitary Permit Application S ty & Buildings Division
A In accord with Comm 83.2 1, Wis. Adm. Code £00 I n �N 01 W. Washington Ave.
See reverse side for instructions for completing this appl ation PO Box 7302
NVisconsin Personal information y ou p rovide may be used for second u oses adison, WI 53707 -7302
Department of Commerce y p y p rpa� '�( iXcomp eted form to county if not
[Privacy Law, s. 15.04(1)(m)] �`` ��JJ���� state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8- x 11 inches in size.
County State Sanitary Permit Number ❑ Check if revi 'on to previous applicatio State Plan I. tuber
>< o a-- _.. �.
I. Application Information - Please Print all Information �' LL n - LIJ ocation:
Prope er Name ; mperty Location
n
V/ �OL r✓C Ire a j. x .'UO 1/ /4, T "'N,R r W
Property Owner's ai ng Address Vot Nupbm Block N
4
C' , State Zip Coe Phone Number ub ' ' ame or CSM Number
II. Type of Building: (check one) $ F� �- ❑ city
1 or 2 Family Dwelling - No. of Bedrooms : ry//L{,r 6 (�� Village
'' � ,� Town of
PublicfCommercial (describe use):_
❑ State -Owned
Nearest Road
Parcel Tax Number(s) 0 424 // a
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) I. ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IY. Type of POWT System: (Check all that apply)
Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: Z
Le ,. 3 r' l l fv
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
r Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) ? /_ 9� ,� Elevation
b 1 47j q e 7 7r -,A-- 7G . ? r
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks WJ� A Con- Con- glass
New Existing crete structed
Tanks I Tanks✓
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersig assum responsibility for installation of the POWTS shown on the attached plans.
lu e s Name (print) I Plumber' gn re (no stamps MP/MPRS No. Business Phone Number
Plum s Address (Street, City, State, Zip Code) h
IX. C nty/Department Use Only
❑ Disapproved Sanitary Permit Fe (Includes Groundwater D t Issued Issuing Age t Signatu stamps)
0 ❑ Owner Given Initial Adverse Surcharge Fee)
Determination 0? 0 t
X. Conditions of Approval /Reasons for Disapproval:
YSTEM OWNER:
1 ep is an a vent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback aacck requiremen s must a mamtMRled• —
'� SBD -6398 (R 07 /OO�U (_.b ve St,D ,
i
G�C S - e
r PLOT PLAN �^
PROJECT ,Vd V6, ADDRESS
1/4 1/4S /T Q N /R W TOWN COUNTY
3 � x
MPRS Byron Bird Jr 22O5 DATE
'BEDROOM
CONVENTIONAL At -Grade � CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 4� LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE O LOAD RATE .2 ABSORPTION AREA -j" 7# of chambers g
BENCHMARK V.R.P. T� G^ ASSUME ELEVATION 100'
❑ BOREHOLEO WELL «
H.R.P.
J
Vent SYSTEM ELEVAT N
f Standard Leaching _ qd . cS� q
Of Chamber with 31.1 �" T
COV ft ^2 per chamber G�Q� �/. g I R�
6 '
g2
Long 34„ Elevation
,..L-
W
0
/a
VUJ
io ..
?5 Jb !b
/ 1 PLOT PLAN
t
PROJECT ��"/ Z d 4 aesr ADDRESS
1/4 114S /T Q N/R W TOWN r � _ COUN ' T ' Y
DATE � r O �B ED RO O M
MFRS Byron Bird h. 22 5
CONVENTIONAL At -Grade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE - e LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 0 LOAD RATE 2 ABSORPTION AREA -j "r of chambers g
kk BENCHMARK V.R.P. // =.L ELEVATION 1
o (J' , G� ASSUME 00
❑ BOREHOLE (DWELL H.R.P.
Vent SYSTEM ELE VAT
> 12"
of Standard Leaching /_ 96. 3^ T
Cov Chamber with 31.1
ft ^2 per chamber t 4 e, J = 9 yl '
gZ r qg r
P. at Sptern
Long 34" Flevation
tf
0
L G�
i
D B�,
V / v
�o
� S
3
Gf ? 1° /e
PAGE -2 � OF
## o wXN-Y4 34 T 30 4g 1$
SCALE: 1 "= qd r C
BM 1 ELEVATION 1 - 0
BM 1 DESCRIPTION
BM 2 ELEVATION
BM 2 DESCRIPTION P a ( n f c 12 D 4L
SYSTEM ELEVATION
SYSTEM TYPE Co ^ ✓`�
CONTOUR ELEVATI
v� Jk VV
5'
o° as
Z
6'
a
r
K
S
SIGNATURE � DATE
I V 0
Wlsccrosin p epa"nt of Commerce SOIL EVALUATION REPORT Page I of 3
Division of Safety and Buildings
In accordance with Comm 85, Wis. Adm. Code
County
Atta<h complete site plan on paper not less than 812 x 11 inches In size. Plan must
Include. but not limited W. vertical and horizontal reference point (BM); direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. d 2- & j
Please print all information. viewed b Da
Personal Information you provide may be used for secondary purpo� (Privacy Law. s. 15.04 (1) (m)). ` V
Property Owner . _ Property Location
Govt Lot Sc,-� 1/4 / 1/4 S 3�o T 3Li N R / Fs E (or&l
Property Owners Mailing Address Lot # Block # Subd. Name or CSM#
3 L2-", L� A
City State Zip Code ; Phone Number ❑City ❑ V'dlage ®•Town Nearest oad
New Construction Use: & Residential / Number of bedrooms Code derived design Falb `�d A, 6 GPD
❑ Replacement 1 ❑ Public or commercial - Describe:
Parent material T (� Flood Plain elevation if appti ble - ft.
General comments
and recommendations:
F Boring # 1 ❑n� Boring .
Pit Ground surface.elev. � ft. Depth to fimiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
I
0- 10 (0 313 -- S 2ir�slok Ir c I v . 5 9
Z Ica -� m S m — . /. 2
F- Boring # ❑ Boring
-] pit Ground surface elev. d� ft. Depth to limiting factor I O � in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
I L Z I1r r C5 I v. 5 G
2 IZ -Ion Lb q k. — S rm
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
r• - 25 33C
Address Date Evaluation Conducted Telephone Number
(-7i5)Z.47 -q008
Properly Owner An y> lnwU s�l f . 0 Parcel ID# Page --Lot 3
[] Boring QQ
F-31 Boring 1". Pit
: Ground surface elevJ6' - IL Depth to limiting factor �v in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
In. Munseil Qu. Si. Cont. Cobr Gr Sz. Sh. •Eff#1 •Eff#2
0- 10 , 1p 3 3 r c 1 v - 5 -9
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
� r Soil Application Rate
Horizon Depth Dominant Color . Redox f3esc ription...... _ Texture .-Structure Consistence Boundary Roots GPD/ tz
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. � *Eff#1 'Eff#2
F Boring Pit
Boring # Ground surface elev. fL Depth to limiting factor in.
❑
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/ft=
in. Munsell flu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
Effluent #1 = SOD, > 30 < 220 mgA_ and TSS >30 < 150 mg/L * Effluent #2 = BOD, < 30 mg/1 and TSS < 36 mg/L
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.
SBD4330 (R.07100)
` PAGE — LOF _
NAME # o L L DESCRIPTION 4 w X i4 34 T 3 N /$
SCALE: I "= y d ,
BM 1 ELEVATION l U a O
BM 1 DESCRIPTION & D o l OJ c- P 4
BM 2 ELEVATION T k. a
t
BM 2 DESCRIPTION 4 e.1 ( _P p e
SYSTEM ELEVATION �, � 5 o
SYSTEM TYPE C u � ry 11 ,ti,-
CONTOUR ELEVATION
0� p�
0.
Z
6'
10
l b
SIGNATURE DATE
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page —/_ of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner V t ea ex,, Septic Tank Capacity �a 6 ,p al ❑ NA
Permit # Septic Tank Manufacturer C f ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ,�Q 0 G ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) B a gal /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer ❑ NA
Soil Application Rate r gal/day/ft' Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) S30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L An- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ year(s)month(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume 3 3 NA
Inspect dispersal cell(s) At least once every: ❑ year( )(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA ❑ year(s)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
O month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once every: 0 earr(sl(s► ❑ NA
Y
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
Page Z -
START UP AND OPERATION '
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and 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 prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer 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. Do not drive or park over, or otherwise 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; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
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 chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall 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
replaciament 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 by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement 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 replace the failed POWTS.
The to s not be a luated to ' entif a suitabl eplace nt area. U n 'lure of th PO TS a so' nd site
evalu ti n ust be erform to I ate a sui ble r acement ar . If n placem t are is availa folding nir
ay b insta ad a a last reso replace the failed POWTS.
❑ Mound and at- rade 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 INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER 1 7 POWTS MAINTAINER
Name Name c —+,� t�fc G'
Phone ��6 �� C Phone
SEPTAGE SERVICING OPERATOR (P MPER) LOCAL REGULATORY AUTHORITY
Name i Name �'b/ X O.z r z
Phone �' �'� Phone 6
This document was drafted in compliance with chapter Comm 83.2212►(b)(1 )(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �'�` d G y'
Mailing Address 015 ef n
Property Address
4�w 4 44
(Verification required from Planning Department for new constructs
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Loca /., Sec. T N -R W, Town of
tion � '/4, AV ' D
Subdivision D ` (/ C--s Lot #
Certified Survey Map # . Volume . . Page #
Warranty Deed # �' 6 ��� , Volume Page # o
Spec house ❑ yes Zno 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
m astcr plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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.
I/we, 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 year expo 'on date.
SIGRATtJRE OF CANT DATE
OWNER CERTIFICATION
I (w) fy that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the prope above virtue of a warranty deed recorded in Register of Deeds Office.
SI&AfURE OF APPLICANT DATE
****** Any information that is mss - represented may result in the sanitary permit sag y � 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
U 2453P 606 '746316 rr
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO.. WI
This Deed, made between Ames Investment Corporation, a RECEIVED FOR RECORD
Minnesota Limited Liability C omoany Grantor, 11/11/2003 10 : 30AN
and Kevin D. Weaver and Sandra J. Weaver, husband and wife WARRANTY DEED
Grantee. EXEMPT #
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. r ix County, State of Wisconsin REC FEE: 11.00
TRANS FEE: 179.78
(if more space is needed, please attach addendum): COPY FEE:
Lot 21, Plat of Torey Pines 11 in the Town of Richmond, St. Croix CC FEE:
County, Wisconsin.
PAGES: 1
Recording Area
�' - e and Return Address
026- 1149 -214W
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights - of - way of recor , if any.
Dated this _ day of November , 2003
J
* * Ames ]Vestment Corporation
-* s
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) f STATE OF )
(� ) ss.
���� County )
authenticated this d� ,yGy , Q
S Personally came before me this A of
November , 2003 the above [tamed
Ames Investment Corporation, a Minnesota Limited Liability
* Company
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the per (s) who executed the foregoing
authorized by § 706.06, Wis. Slats.) inst ent and ac owl th e
THIS INSTRUMENT WAS DRAFTED BY � �
Attorney Kristina Ogland
Hudson, WI 54016 Notary Public, S e f
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) --1 )
* Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, wl
STATE BAR OF WISCONSIN 800- 655 -2021
WARRANTY DEED FORM No. 2 -1999
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