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HomeMy WebLinkAbout032-2144-60-000 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 487994 0 (ATTACH TO PERMIT) GENERAL IWFIURMATION State Plan ID No: Personal information you provide may be used,/ - secon6ary purposes [Privacy Law, 6.15.04 (1)(m)]. ( 12109/7— .14NS • / Q. Permit Holder's Name: City Village X Township Parcel Tax No: Mont petit, Earl & Maureen Somerset, Town of 032- 2144 -60 -000 CST BM Elev: Insp. BM Elev: Description: /� Section/Town /Range /Map No: .0 /&D BM 'J 07.30.19.1261 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Lj ` � 2 )0Z30/6, Benchmark d L 16q y Dosing + f Alt. BM `7 Aeration Bldg. Sewer Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > r 6 0 -51) r _ _ DtBottom ' �z•I + Dosing « <+ ti �q / [leader /Man. Vp S r Aeration ! Dist. Pipe to • Z o + 4,s�� 6• �va • 3'S Holding Bot. System 4 .30 9 9 •D 3 F' al Grade it PUMP /SIPHON INFORMATION kw,e l t S C601tr -0a ) Manufacturer /J� Demand St Cover (4-0 o•. oT , t s + B.t,.JCdL GPM 2.0 + +�►�- / �qC* ass" um Model Nk�gr 4� �pD • �j� Lo n �o.� r � c0 • s g + TDH Lift Friction Loss System Head TDH Ft 3 S , - �.o 1.SI 3.zS 11- vvt (t(P db•v Forcemain Length + Dia. Dist. to well 0 1 2 SOIL ABSORPTION SYSTEM S = I.13 d.. &9Z or -D epth Width Length No. Of Trenches- PIT DIMENSIONS No. Of Pits Inside Dia. Li ENSIGNS / -1 aJlA/ s SETBACK SYSTEM TO 1O P/L BLD LAKE /STREAM LEACHING anufact INFORMATION CHAMBER OR Typ0) Of Sys > 50 + NIk UNIT M el ber: DISTRIBUTION SYSTEM V (\ �( `d - Ae t Header /Manifold Distribution p x Hole Size x Hoe Spacing Vent to Air Intake Length 3 ' D t Dia 2 of Length 3 J 0 0 L_� Spacing - O 3 1 J�p r+ JO It 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 Edges Topsoil ]Y�e Bed/Trench Center Yes No ��No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection # : �� / ZZ / a 5 Inspectio 2: __V_ (o� [1 .. Location: 1612 40th Street Somer WI 54025 (SE 1/4 SE 1/4 7 T30N R19W) St. Croix National EstateNorth t 6 Lo Parc No: .30.1 .1261 + 1.) Alt BM Description = r ' �� 11� � 2.) Bldg sewer length = SI I Qtly .� -amount of cover= `f 2 -t r,� �-°' ` -; ( l eC � Y�� •' r•� v� 3) M tLa �C lns.�� S -- \ Plan revision Required? , s No Use other side for additional information. _ . 2 7,0� _ - - - -- -- Cert N o -- Date Insepctor's Signature . o. SBD -6710 (R.3197) I Safety ulldings Div County NPI S consi n 201 W. Washintn Box 7162 5 Madison, WI 53707 - Sanitary Permit Number (to be filled in by Co.) (608)266 -31 De arg of Commer e � L l $'�j Sanita ,, Permit Applic d o c�ce Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal in alien you provide q 12/ q may be used for secondary purposes Privacy Law, s 5.04(1 l 1 ) z� eject Address (if different than mailing address) I. Application Information - Please Print All Information COU � jP2 ST CR IQ0O ICE Property Owner's Name r Parcel # Lot Block # Property Owner's Mailing A dress Property Location City, St at Zip Code Phone Number Y., %., Section_ t / (circle one) Z pil T, N; RI E or W II. Type of Building (check all that apply) ok CL 5 C $u rn r C I or 2 Family Dwelling - Number of Bedrooms / / n/ / Subdivision Name CS Number El Public/Commercial -Describe Use - �� T '�' 1 ❑ State Owned- Describe Use (a * 6 ❑City_❑Village Township orb III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - 0 6 A. New System ❑ Replacement System ❑ 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 Date Issued Before Expiration Plumber Owner / IV Type of POWT System: Check all that apply) U r ❑ Non - Pressurized In- Ground Mound >24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ V. Ais ersaUTrestment Area Infor Other (explain) 72— m ' � Design ow (gpd) Design Soi , p)j n Rate(gpdsf) D' rs ea Required (sf) Dispers Area Propo System v on 1511� VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units / Concrete Constructed Glass Tanks Tanks g D / (✓ r CJl / o /C.. 625 r 1 Septic or Holding Tank f (\ Aerobic Treatment Unit / J Dosing Chamber VII. Responsibility Statement- I, the undecdigged, assume respon ibility for installation of the POW'I'S shown on the attached plans. Plumber's Name (Print) Plu r' ignature MP/MPRS Number Business P ne N ber Plumber's AddreS�tiFe S C eh LiJ VIIIIIXoun epaxtwmitUse On Approved proved Sanitary Permit Fee (includes Groundwater Date Issued u Issing t Sign lure o s) Surcharge Fee) 4L C /' �� r Disap Owne n Reaso or Denial J IX. Conditions ofAppro..UReasons ft lsapp -oval r WSTEMOWWR: 3� �o,nd�: b-, s �• 6 e t �G�c. e l•� -c.� I. tank, eflltom NRer and c.. ( 2 , r. 6!_X J - L.)1 4 - dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code / ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) � 1 s t 0 o �> � E r t f i g a rtzy > e . £x Ct r 1 e. ci t Mc.; OO S e C �J O'J�a - J V`�ie S2G' �' y�LC�o,.�Odr+.� ° /1 NC• V°� r / � �io^. f•O VCS Mvt �it? � p t•,�- /- Y _ r j Q ✓ .�.-C ih car �' a u��T Q.l�6 r..0 phopCt - �b • ems �� �✓�.. i '-S , /Dt ¢S'OS- e 7 ' W - T ) *f3 -3,!5:4 a t i Safety and Buildings PO BOX 7162 commerce .wl.gov MADISON WI 53707 -7162 TDD #: (608) 264 -8777 isconsin www.commer www.wisconsin.gov www.wisconsin.gov t iepartment of Commerce Jim Doyle, Governor Mary P. Burke, Secretary November 07, 2005 CUST ID No. 220673 ATTN.• POWTS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER EXCAVATING, INC. ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/07/2007 Identification Numbers Transaction ID No. 1210912 SITE: Site ID No. 706841 Earl D & Maureen Montpetit - Dwelling Please refer to both identification numbers, 40TH St above, in all correspondence with the agency. Town of Somerset, 54025 St Croix County SETA, SE1 /4, S7, T30N, R19W Lot: 6, Subdivision: St Croix National FOR: Description: New Mound System / 450 gpd Object Type: POWTS Component Manual Regulated Object ID No.: 1049038 Maintenance required; 450 GPD Flow rate; 25 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /01), Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01 /01); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. ROA The following conditions shall be met during construction or installation and prior to occupancy or use: Con 11 —� This system is to be constructed and located in accordance with the approved plans and with the component manuals listed above. pEP NT I A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of EE CORRE. construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. CHARLES L WEBSTER Page 2 11/7/2005 Sincer Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 eter E Pagel Private Sewage Plan R f630 r, , Integrated Services WiSMART code: 7633 (608)266-2889, M - F, - 1500 Hrs pepagel @commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 r Webster Soil Testing Et Sewer System Des' ;, 4harlie £t Kris Webster, Owners � QUO N5815 77e Street, Ellsworth, W1 54091 Telephone: (715) 273 -3434 Fax: (715) 273 -4181 W1 Licenses: MP22067 s", ST220673, ST 261669, PE18803 POWTS Index Sheet Page 1 of 8 IMound System for a 3 Bedroom Residence Property Owner/Project Name: Earl D. & Maureen Montpetit SE % SE % S7 T30 N F 19W Town of Somerset, St. Croix County, WI Contents Page 1 of 8 Index Sheet Paine 2 of 8 Plot Plan Pale 3 of 8 Plan View Cross Section Page 4 of S Distribution Pine Layout Page 5 of 8 Pumping Chamber Layout Page 6 of 8 Pump Performance Curve Page 7 &8 of 8 Management Plan � NS CROWN WE"TSA o E<lawos�+ w s to Component manual used: al b Name: Mound Component Manual for POWTS Version: 2.0 SBD -1069 1 -P Date: January 30, 2001 1 Ne Name: Pressure Distribution Manual for POWTS SPON�E E Version: 2.0 SBD10706 -P Date: January 30, 2001 Paged . Of Approved Synthetic Covering F�ST`t'1 C- 33 Distribution Pipe Medium Sand Topsoil _H_- _�_ = F G Elev =, 7 G es 3 I E ! p 3 t % Slope 7 �- Bed Of Force Main Plowed 2 — 2 %2 Aggregate From Pump Layer Cross Section Of A Mound System Using � A Bed For The Absorption Area F— -Ft �` J G © - Ft. A Ft_ H - ' Ft. Linear Loading Rate =S y - -GPD /LN FT B 74 Ft. J ' Design Loading Rate= 0- 2 6GPD /SQ FT0-6 I 15 Ft. o Z 1- c J) �4cce5s box d 7 Ft. CCt r ��) x Tc, Tl� red f //u K Ft. /t e,t / d' / L . 74— Ft. .,� e o _ W 2 6 Ft Observation Pipe K A s (�^ /y S 10 I r -•_—F— ------------------------------------ - Distribution Bed Of %2 — 2 Pipe Aggregate l Observation Pipet (Anchor securely) �I. SC'6-ti� Ilse.: �J•�{'S �� Rr�Y�' /Z /l:h. fryt G, l.-. /- e! °y,:r _�M O /7�,/ [� /hC�C'i �L Lrs -aV. V. Go- .,f 7 t _ - <'',";.;�-,� ^ � -fi I�i1�/N. 7�h�,bo7f6/�ri C�EG'C�CS �aT•fP�! lL ,GCE 3'cCt.cteX Plan View Of Mound Using A B For The Absorption Area Tr Page Of Perforated Pipe Detail Ertd View Perforoted PVC Pipe Z"O" i f `- Holes Located On Bottom, Are Equally Spaced e J s e / PVC Manifold Pipe Disteijulion r.. r o Z ' ci i P 36 Ft. .� 7 i oc 4 Distribution Pipe Layout C S Ft. X Inches . s Inches Hole Diamete Inch Lateral Inches) Manifold Inches Force Main " Inches # of holes /pipe /o /"' x7 Invert Elevation of Laterals y9 ?, rFt. 4- Place lst hole / ? /' ,O_ from center of manifold with succeeding holes at 38,h intervals _ i P age Of , � 4 d � •.rr �t .S � (No Scale) ol d 9 p /.,sr :� rein 0�7 P .Approved Locking Manhole Covers Pe, >i i With Warning Labels Attached � Weatherproof Approvedn cr'r I�yj ,, ,; , /y� ✓� �/��� Junction Box Vent Cap 12" Minimum F, / ' 4" Minimum Quick 18 Minimum Disconnect ce 9 1/4" Wee Baffle Hole Al a rm Qq B O n al C a,.'>l,•���...�� *APPROVED Off 6' S 0.4 coy e} to JOINTS WITH PwV.o�e a« :s APPROVED PIPE D 3' ONTO Conc. Block SOLID SOIL 3" of Bedding Under Tank pet-* �wa•„P �c�t/ 'a-�^ m o,�1 � �-� all;�rt� Number of Doses: Per Day Gallons Per Day /f -Dose 7'K Gallons Tank Manufacturer: Volume of Back fl ow:fl:fg — Gallons G/ <�� C',..w < -�:z� �'r�•d�,c7�'- -Z�h�- Total Dose Volume .......... _ Gallons Tank Size- Septic /Pump: rou-2 /C G allons nlarm Manufacturer: 4,,.,/ ? /a,G,, Model Number: z k Capacities: A a3 inches or 9 / Gallons Switch Type: sl 4!? 1 + B _20 inches or 3 4 Gallons Pump Manufacturer: ra' + C inches or Gallons Model Numb + Dinches or 13 6 Gallons Minimum Discharge Rate: 31 MM Total ..... inches or Gallons Vertical Difference Betw.een Pump Off and D? bution Pipe: 7�.� Feet Minimum Required Supply Pressure: .... :�::s. . , ,, +3_� - Feet S - O Feet of Force Main x �_f{ Friction Factor /100 Feet: + / 8 eet Inch Diameter Force Main ,t Total Dynamic Head:...= lz.�Feet Internal Tank Dimensions: Length ; Width Liquid Depth = t f ` e .�. � e1 ,.� /�(,� , f t!/7,f C I �• zi kt �C?G. a� � �! e✓ ,Ej l� � � (_ G r„r�,...� � ��j„ �\ r — ? f� 11 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- * Homes components. Available for and tic cover with integral handle •Farms Motor: and float switch attachment EPO4 Sin manual operation. Automatic • Heavy duty sump gle phase: 0.4 HP; models include Mechanical p oints. • Water transfer 115 or 230 V, 60 Hz, 1550 float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■Bearings: Upper and 'lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, FEATURES Pump: EPO4 built in overload with ■ construction. EPO4 Thermo- • Solids handling capability: automatic reset. AGENCY LISTING 3 plastic Semi -open design /4" maximum. • Power cord: 10 foot with pump out vanes for • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. CP- Canadian SiandudsAssocia6on • Total heads: up to 24 feet. with three prong grounding • Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (GSA listed model numbers • Mechanical seal: carbon- length, 1613 SJTW with plastic enclosed design for end in "F" or "AC.) rotary/ceramic- stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). 0 Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 i I • Capable of running - -- -� y dry without damage to s 30 components. ! r Pump: EP05 s • Solids handling capability: c 25 3 �4 maximum. W _ • Capacities: up to 60 GPM. s 20 �! --- • Total heads: up to 31 feet. • Discharge size: 1 NPT. a T • Mechanical seal: carbon- c 5 15 ~r — � rotary/ceramic - stationary, _j 4 ; BUNA -N elastomers. o • Temperature: 3 10 104 °F (40 °C) continuous p , �,�z 7 f 140 °F (6VC) intermittent. l � 2 5 1 � j I � 0 00 10 20 30 40 50 GPM L 0 2 4 6 8 10 12 ma/h ( 7 APAcrrY ©1995 Goulds Pumps, Inc. Effective May, 1995 83871 • ` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page FILE INFORMATION SYSTEM SPECIFICATIONS Owner _ !.: rr. G f` �t;-} Septic Tank Capacity ! U O a l ❑ NA �, Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Fetter Manufactu rer 1 / Y 10K ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model" ❑ NA Number of Commercial Units NA Pump Tank Capacity A Estimated flow (average) 306' al/da Pump Tank Manufacturer 6 es --j ❑ NA ,,..tt� ' Design flow (peak), (Estimated x 1.5) - T gal/day . Pump Manufacturer f oN s✓ ❑ NA Soil Application Rate 0- al/da /ft Pump Model P )PO ❑ NA Influent/Effluent Quality Monthly average' Pretreatment Unit )(NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 420 mg/L ❑Mechanical Aeration ❑Wetland ❑ Disinfection ❑Other. Total Suspended Solids (TSS) 5150 m /L Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD,) 530 mg /L ❑ In- ground (gravity) El In-ground (pressurized) Total Suspended Solids (TSS) :530 mg /L ❑ At -grade XMound Fecal Coliform (geometric mean) 510' cfu/100ml ❑ Drip-line ❑ Other Maximum Effluent Particle Size Y inch diameter Values typical for domestic (non- commerclao wastewater and septic tank effluent. ** Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months ' (year(s) (Maximum 3 yrs.) Pump out contents of tanks) When combined sludge and scum equals one -third (Y,) of tank volume Inspect dispersal cell(s) At least once every ❑ months )<year(s) (Maximum 3 yrs.) Clean effluent filter At least once every JKmonths . ❑ year(s) Inspect pump, pump controls & alarm At least once every ..S ❑ months S( year(s) ❑ NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA S-Alee =` Other. At least once every ❑ months ❑ year(s) J9 NA Other. At least once every O' months ❑ year(s) ANA 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatfinent components, and any other maintenance or monitoring at intervals of 12 months or less 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 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. f P ag e of System start up shall not occur when soil conditions are frozen at the infiltrative surface. Y e excess During power outages pump tanks' may fill above normal highwater levels. When power is restored th wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) a nd ank removed by a e backup or surface discharge of effluent To avoid this situation have the contents of the pump er to Septage Servicing Operator prior to restoring power to the effluent pump or contact n Pl umber or pOWTS Maintain assist in manually operating the pump controls to restore normal levels within the pum 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. performance and prolong the life the or:elimination of the following from the wastewater stream may improve Pe floss diapers; Reduction s• cotton swabs; degreasers; dental Pe of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; asoline; grease; herbicides, meat disinfectants; fat; foundati on drain (sump pump) water, fruit and vegetable peelings; g esticides• sanity napkins; tampons; and water softener brine. • painting products; sanitary oil P scraps, medications; , p 9 P . _ ABANDONm ENT 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 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 replacement system: • A suitable replacement area has been evaluated and may be utilized for the location of a replacem t should not absorption system. The replacement area should be protected from disturbance and compaction 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 iavail available as a last resort to and/or ace the POWTSng advances in POWTS technology a holding tank may be • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no repa is available a lacement are holding tank may be installed as a last resort to replace the failed POWTS. Mound and at -grade soil absorption systems may be reconstructed in place following removal m at with the rules in effect at t the infiltrative surface. Reconstructions of such systems must comply that the time. <<WARNING>> DIOR SEPTIC, PUMP AND OTHER TREATMENT TANKS M MENT TANK UNDER ANY CIRCUMSTANCES EATH MAY OXY GEN . DO NOT ENTER A SEPTIC, PUMP OR OTHER TREA RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER GCti h`� �— ' Name �o x Name Phone 7A S ° � � �` — 9 C? Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Agency ------- Name ,f Phone Phone Z ,5- This document was drafted by the staffs of the Green take, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not GMW (2/01) guarantee the performance of the POWTS. RECEIVED Wi3consin Department of don m erce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Building OC 3 1 2005 in accordance w' 9 om, 5, Adm. Code County S"T C P o i,X Attach complete site plan o pape$ oIDWYn POPYc 11 i =cdriirec�fion st include, but not limited to: v rtical ar�IdFforff 15 WWen int (BM)d Par cel I.D. percent slope, scale or dimensions, north arrow, an oca ion an est road. 031 -;L)4 - 4 O ^ 0 0 O 6 - Please l7/111t all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 121 Z 1 Property Owner / Property Location 1 Gevf.+et >E 1/4 5W 1/4 S 7 40 N R/! p Lot # Block # Subd. Name or CSM# Property Owner's Mailin Address a2? 70 to rkv e - st C', o,X City sy State Zip Code Phone Number ❑ City ❑ village TSTown Nearest Road f ie (rQ u�G 1 i 6-f/17 e- New Construction User Residential / Number of bedrooms 3 Code derived design flow rate 4 SCE GPD ❑ Replacement ❑ Public or commercial - Describe: IVA d Parent material GA? c j'> ! 7 E1 Flood Plain elevation if applicable �7 t _ - — ft. General comments r,p,tQ s f �� � �. e� rh -utv, tL� f S Q'', and recommendations: r /r>>` 4,--t W t Y OY1�l�.ti71M T�s S /C�l` CMG s esf ¢.��1 ¢kph C ih 7 t.� e ` K c.h: 7�Gt �j E� or�.c %S fjP��,otc al. Boring # F] Boring ��qq © 0 c Pit Ground surface elev. t 7 ! q ft. Depth to limiting factor � � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ,Z .���` .,z /'� c I- 3 4 . — � . ps r►, / — . -'k r4 s ids a6 wt 1 v Caat� �rd M h rs i ❑ Boring Boring # r-1 7 e- LV Pit Ground surface elev. ( ft Depth to limiting factor o.. in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 t o Ao 3 P aG 6 C7. 3 16 -? G !a yR S' /t/ 3 2 0- r-- G -� 0 - 6 7 4 z6 -;8 Ao R 6AK ' Z+" Si £3 S 3 - �' 7sYR 3 /4 �vs S _ _ 0.7 �, �6 > 7 A -t� cc- s 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). • Si nature � j � � Number p � � �4 ay rGs �.. W a 6.stn' Address Date Evatu Concluded. Telephone Number .. t s 944 sfiy Ells w.,Y � yll r S �4 0�1 l c� �� -� /��� 7/r- X73- Property Owner P a h h � oh fi e �• Parcel ID `0 � ��- Page � of ® Boring # Boring / tL� Pit Ground surface elev. ft. Depth to limiting factor / in. Soil Applicaticn Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff4 I - Eff#2 +' a.( k 6 o - f3 C 0,6k F -1 Boring # E] Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appl ication 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 Boring # ❑ Boring . ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Descriptior. Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Coic•r Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L *Effluent #2 = BOD < 30 mg/L and TSS <30 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. SBD- 9330(R.07/00) RECEIV 0 S E P 2 0 2006 ST. CROIX COUNTY ► LOT 5 >IiMV&YOR'9 RE-901 1 R= 458.21' I N89 °18'00 "E 458.54• I 184.75' 154.30' 119.49' I � I o Y O Z ; I a o .3ItK w LOT 6 o A o I • Co - I :m t • 2 _A o � 0 o m I -` I� P m I UNPLATTED ®' W m i I 1 LANDS '® I 1 1 ii P 2� PROPOSED HOUR_: I 108' ®W t I Z = N I W 81.40' 139.89' 99.50' S89 320.79' R= 320.11' I z LOT 7 I w = a NORM \\\tttltUpUi11i1tiUjjJJg I J •° Z O TYR. �� Z0 5 W DODGE p Q S -2484 ; P Z N s CLEAR LAKE, f < — 1 O� U wl D x g w LEGEND '��,,,t oQ.w o (n Cn Z = 4 =SET 1"x18* IRON PIPE OU 1= OO =FOUND NAIL 1, Ty Dodge, Registered Wisconsin Land Z U) Surveyor, hereby certify that this =FOUND 1 1/4" IRON PIPE Stake —out Plan was prepared under my ® =WOOD HUB SET AT 10' OFFSET direct supervision and Is correct to the Z ( — • • • • • • • • =MINIMUM SETBACK (9 best of my knowledge and belief. = NM 1 - 0 r O a S 1 9 �ara�e -£xa� ' � N o�*r� ellmeh S.'on.4' aj-t 1 �p not /tke elm I {� I i 4 y P C a qs'� �rCg .. too iC't- fin + � ®�- fit• � n.. Pr�� p *opl.ne. G ,a r, kEY -Scale, _ - B Al = To I { io. p vc P, 7Tp fl proper p,h . 'A II . a/, c a tQS ro i IresY" pit G PS Co �Ol�di Md1ls r pt d [y 4S ° oS. X97 ` W ?Z °¢3.3 ' 4 A Pr b lQ � 7r f'/ �FL�f f.ne. i Wiftons Department of Commerce SOIL EVALUATION REPORT page )i of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST. CV-0 LX include; but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and locatien -and. distance to nearest road. Parcel I.D. q 2 - -- (Q0 - (2(a I Please print all in forma tion Re iewed by Date Personal information you provide may be used foI ;seconds " rY Purpies (Privacy Law, .15.04 (1) (m)). Property Owner t - Perty Location J • ��. Go L� 1���C�ch air .' � S E 1/4 S 7 T 3D N R) q E (or W Property Owners Mailing Address x _ �ot +# Block # . S or CSM# 601 . City State Zip Code \ .,Phone rOr-FIcE City ❑Village ®Town Nearest Road i 111. 1 �'01�/1 -r )R. N IV SS 3�1 3 , 61 ). 3S - © b S O M L l - a New Construction Use: ® Residential / Number of �_ Co derived design flow ❑ Replacement ❑ Public or commercial - Describe: Parent material G L }fit, T1�-U r Flood Alin elevation ifapplipble General comments C b}- 3 X 6z, S ' LZvQ G and recommendations: � S L 3 C �-L5 w l p UJ J t - r'S O F 1 R Cf - - *ve -1 S 1 DE)Jln.J D L et?tL- , 07- Zl�Rrt sR-S 1b !3� S D� ZQPegji� or`1 ly' - * l jute s Lo�ON � b Boring aq S u Ibi pit Ground surface elev. ft Depth to limiting factor > I � � in , �`'(5 # 2 r 3 • Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roo -- in. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 •Eff#2 Z 10 Z�( 10' -11t 31 b — S1 I Z`F Sbk vvl- -- C-S 2 • S . 8 3 24 - 16 KQ--. Sly - Gt^ s 1 � esbk 1M . 1 4 . ka St G- o s m _z r`� n 1 V 1 S c w u S 1 o c' t-I)T3 c a a Boring # ❑ Boring ® pit Ground surface elev. 9 9 . S ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 q - b 1b -lv- 6 _ Si ( 2 - - PS b M aW 3 1b -U1 S`2R31 G>,• 9 ` � e shk ►nit. Ci'j L -6 - 1 - �.SLBUL _ s .� j 61. �•S Y -1. • 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) .. „Signatu CST Number Arthur L. 'Wegerer o - C Y b � - � 2202 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 I1. Main St'. River Falls, WI 54022 l�— �2.7 -VU 715 -425 -0165 i Property Owner S• P• �OL� 1"'1i hJ !`� G�`Z 7 - Parcel ID # i� jG Page Z of 3 Boring # ❑ Boring ® Pit Ground surface elev. '0 1. S S ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 iO trz-3Lz - s i I Z`Fs bk vvl.�i- (a , , j 2 Z 1 = Zq( 10 3 2-4_y V L - s 1 Zrns k W-6- t-)6 -6 10tirz- F I T Y Q - sl id F— L ) ] Boring # ❑ Boring Pit Ground surface eiev. 102.. S ft. Depth to limiting factor 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 I •Eff#2 1 o—1 l )D` l �Z �! )1 - Z� s ►n'R- C.lv Z t[ -3y rpHR alb — �> > Z� sbk m`fi- �� •5 .8 3 3y -�! �.S 2� G� s� `�sbr -c n, f-F eti, -Lf -6 Y - 7 s K c> C) S g 3 S e F-sl 12. a Boring # ❑ Boring 9 8 • - ® Pit Ground surface elev. ft. Depth to limiting factor ? �l' � fin, Soil Application Rate - Horizon Depth Dominant Color Redox Description Texture 1 Structure Consistence Boundary Roots GPD /ft' In. I Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 0-1Z )ts-1tZ31? sl y Z`f Sb� m`F►� LLU Z`{�' • -� 3 r -4y -�.s�rz3! 6rS 1cSb►z »1 'F►^ — . L[ V 3 SP4Y1 )vph� S 3� 8 J. . S7o.o y' °IZ.oCf • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 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. SBD•8330 (R.6=) Property Owner S- P- CZOLr M !t Gam" lC3VT Parcel ID # lit /V G Page Z of 3 Boring # ❑ Boring ® pit Ground surface elev. Ic ts••S ft. Depth to limiting 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 1 o -ly tD`ir� 3L2 — sil Zsb12 n���- ew z'� 41 TV 3 ��! -�!b 1���31[. - ' s i 1 Z yn..sb ��>, s — . s • 4� L? 6-6 0 ! oy lz- :- / fl-P --) .S Y r sl8 N ) L Boring # ❑ Boring Pit Ground surface elev. 1 p Z' S ft. Depth to limiting factor -2 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 1 t)--t 1 1 b H �2 �! — j 1 Z`F s bk ►� `�- C tv z . S -� z q 3 3YA/7 �.s 2 — G�s1 1 �sb►z ni �►�, _ .t_1 ,6 3 S e N o i-L As 3 prfi 3 t Fs-1 Boring # Boring ❑ R 8 ® p I Ground surface elev. ft. Depth to limiting factor ? 9 6 (n, 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 o- z- 16 31? - 1 S 1 I Z`FS bk Yn ` li- 0- 3 Sf�"T Mo12` S 3 nr Z? J . Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 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. SRO-8330 (RAW) I Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page 1 of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x i 1 inches in size. Plan must County ST. Cpl Lx include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. PE1vt]I IU G Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location x, 1 Property Owner' 1/4 S 7 T .3D N R Owner's ailing Address 9 E (or W Lot # Block T�11�Name or CSM# SLUE CL� LC DtZ. . CR.Utx � City State Zip Code Phone Number ❑Cit ❑ �Ilage Town NN�u 3 ® Nearest Road (6t Z) a3S _ go go S p)`-1 �Z S (=-T' 1 Lp `Tli- -� a New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate boc7 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent tliaterial L Wrc. Tt�.0 Flood Plain elevation if applicable General comments C ai- 3 X 61. S 6� ft. and recommendations: ) �S 1. 3 C LL5 w I p u� j ITS 0 F- 1_� 6R 1 S 1 11Au D LY? t aE tj Doti, DosF a Boring # ❑ Boring [� pit Ground surface elev. q-a . S ft. Depth to limiting factor _ L 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 Z 10 Z� to�ln:3lb - sl I 3 Z�f -�t3 �•S`�►Z3ty - GV s I les W 4 Qj--,-j - .k4 • 6 � u3 -1U8 �•S YR = S�Gr- p � m I - - .� >. _Z R1 s o C W u S 1 o 6t- TS C i t= r� �►- 1 s Boring # ❑ Boring ® Pit - Ground surface elev. 8 ' S ft. Depth to limiting factor b 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 0 -9 W%112-1 Ll S11 z4mloh a -l 1�`•t1t316 sir - L - ps� 4 3 ld -U1 S`lR31 G>,• 91 1 0-Sbk ►nor C.c.) - .�( .b L) ) -46 3 - ) -3y23 _ s- s►- u s 5 6122 S LA23 �1-�- �. S Y -2 S l8 L p,,,,� m)- , Z, •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) ignatu � CST Number Address Arthur L: Wegerer (3 0 ` � t 22 0254 STNum W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Hain St'. River Falls, WI 54022 715 -425 -0165 ' o 3 PLOT PLAN Page 3 o f Scale 1'= S(3' 41 (n 13 N m �e V* z ) go o '• s to R - LN12gNPrTE i5 , x 6 ZS � N lTtp -t.. ab goo • 1 0Z C — uvr U ►v i u0 7) S T, m - - L - L=.. toU,O Utz 4 'H t6ll 31y "b1fq_ Puc,Pt PE w! LqW - It ft 14 �O.13I�: r Le"T Is' F S tiaTe" Pl'� .. -- J�LL k ti y So' '� t t) C) 715 -425 -0165 220254 QU -Z 3�- 6 CST Signature Date Telephone No. CST No. Job NO. PLOT PLAN Pa;e 3 of 3 Scale 1' �Y o 4f m N m �9 l Z qb a.s 14\ LTA ATE AjL� m S x 6z.S ' Boa • 0 2 SM* K- Lc T U W DL O 7) S T, - 31- V"bIA___wc_P! PE w! LA - _A sT l S' Fi�-1 S its `p`�"l - i9't�Li'A Sol 715 425 - 0165 220254 Qo - CST Signature Date Telephone No. CST N6. Job PTO. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ P_i4n2i. _t� 11A 0 U T -P1✓ -T T Mailing Address Z2 7V f�A_1z C­t ( � M4N �55 11 Property Address l (Q Q 0 S'( S d r1 j iy @ (Verification required from Planning & Zoning Department for new construction.) City /State t�S( . Parcel Identification Number 03z, Zjy y (pp -- 6j p LEGAL DESCRIPTION Property Location '/4 , '/4 ,Sec. 67 T T 3o N R Town of ` o m c� 7 Subdivision S a e 20 i 1< N h'r cav,�4L q �, eel Z t2> '� c 1 2 - 7 H ,Lot # (d Certified Survey Map # , Volume , Page # Warranty Deed # L/ q 0 0 / , Volume � ) , Page # u Spec house yes no Lot lines identifiable ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the 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. i 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the described a bove, p ro p erty b e, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNA OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) U: 2 9 12 P 13 8 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIK CO., WI RECEIVED FOR RECORD Document Number Document Name 18/19/2005 02:40PI1 WARRANTY DEED EXEMPT # THIS DEED, made between Integrity Custom Homes, LLC REC FEE: 11.08 TRANS FEE: 381.80 ("Grantor," whether one or more), COPY FEE: and Earl D. Montpetit and Maureen Montaetit, husband and wife CC FEE: PAGES: 1 ("Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ( "Property") (if more space Estree & 0914ind is needed, please attach addendum): 304 LOCUSt StMet Lot 6, Saint Croix National Estates North. St. Croix County, Wisconsin. Hudson W! 54016 tsq l 032 - 2144 -60 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated O/ (G O Integrity Custom H mes, LLC (SEAL) (SEAL) * *By: Dave Hedin, Member (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Integrity Custom Homes, LLC By: Dave Hedin Member STATE OF ) authenticated on jW ) ss. COUNTY ) v� %ristina O land Personally came before me on TITLE: MEMBER SATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Oeland Notary Public, State of Hudson. WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 " Type name below signatures. INFO -PRO'" Legal Forms 600- 655 -2021 www.infoprofomis.com ILI m e m 0 ° r ; cn o r. l Qo Z N' < OMQ N I 1 m f ,. r r L> - r r' r r 210 / M «00,91..69S '�- 2 2 LL I ,r fi �Ir ` U pry O ; Q � F f Q .O LO � Nr ` in N N ci 1f W ' I , 24S w � C CA i ,LZ *99t, ice'. V I C co M.,00,91.695 �' 22 _ I '207' l I O ��^� ��Z " �--- ,00'99 206 W a o° 208 W l OM ci h Co w I Weal ° ON z N (O W 0 Ch N M N to N � Ir' d U)° II pal �,, vN`0 t L'OZT 205 M„ 00,91.69s 22 s a °oN c $mm o c c Q N N 204 'm 3 ` v, 4 -p 3 *MM, N , I CN