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HomeMy WebLinkAbout032-2112-30-000 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County5t. G roix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarg o.: Personal information you provice may be used for secondary purposes [Privacy Law,x.15.04 (1)(m)]. 3 K Pie le pe: ❑ City ❑ V6vpn &r�nTc6wnshl State Plan ID No.: •y CST BM Elev.: Insp. BM Elev.: BM Description: Parcel �?3P� - 30 - 000 Y s TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /L Benchmark Z d t p L Dosing Poo I d • Bldg. Sewer /0�, Hol Ht Inlet TANK SETBACK INFORMATION St Ht Outlet rz, , D � TANKTO P/L WELL BLDG. Ve lntake ROAD Dt Inlet Septic >�doi / 3 NA Dt Bottom Z ' 70_ NA Header / Man. Dosing ' > lbc� � Z 3 .� * �.3'Z e 7. /`I ir. lye M ration NA Dist. Pipe r W r6: olding Bot. System nA 10 : z PUMP/ SIPHON INFORMATION S F•�r Manufacturer Demand - Model Number S 3 � GPM 1r 120 :54 tS j - TDH Lift Friction S stem TDH Ft L �' I°I. Forcemain Length 2,Z0 I Dia. 2!" Dist. To Well , If c ire oi SOIL ABSORPTION SYSTEM 1 0 C e„3 BED / RE CH Width / Le gth No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth IME Z • .3 1 DIMEN M SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING ufacturer: INFORMATION Type O ER Mo el um er: y +l I � "� / 7Z 1 System: C UO J b — Q DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) / x Hole Size x Hole Spacing Vent T t o O,�r Intake r / Length Dia. Length -s / Dia. �� Spacing 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 InS ectio # Q yes/ []/No In �dtYen No / LWMMENTS: (Include code discrepancies, persons present, etc.) &//Z �� Location: 1635 70th Street, Somerset, WI 54025 (NW 1/4 SW 1/4 11 T30N R19W) - 1130191042 Pine Meadows -Lot 3 1.) Alt BM Description = �Ve bt y WWI f 2.) Bldg sewer length= // .") �ks� .dtctia� ���" - amount of cover = 7 1 12 4 ar— eak two Plan revision require '� [:]Yes No Use other.side for additional information. �Z SBD -6710 (R.3/97) Date J Inspector's Signature Cert No y < 0 e O l� e 0 Li 30 6' Pr•r -R M I1 REU- LOCW) 1, tJv/l/Y s W'IY 5; i T 3o . X, R lR IV tSN E.'tE" C ) ma 6`( - T'w-S0 'Wbar_aQURy , nn ► �i� �11�E M�>aflta�n/S Lb '� �5►25 �3 ��£N�', }��s rrv►TN 3C� t�1tC�� -i CAP. //l)fIL?RP�T�2.5 C R 12 U VEO R EPLACEMEOT) A RE^. 1 2 2001 W CFDX w TMo*+ce CN 5 FoR MA) r� C we-81<1S 800 eta. p K � � IV6 - 0c5 I (o0 GM, Houst WAS USZ42. �. &KTI MA R.K = TD Q ©:F t1. W S T LOT S T NKF. �l E�0 1090 11 S O L ?npljmll5 O -OL-DE - 5 Pill - PF 16 3 :5�[, s Sanitary Permit Application Safety & Buildings D ivision In accord with Comm 8321, Wis. Adm. Code 201 W. Washington Ave. , v4sconsin M sec reverse side for instructions for completing this application PO Box 7302 fHpirtmant a! Caeiirieras Personal information you provide may be used for secondary purposes son, WI 53707 -7302 [Privacy Law, s.1S.04(IXm)] (Submit completed form to county if not Attach complete plans to the c_0= oni for the em, on a not less than 8 -1R z 11 inches is size. state owned county 5T n Q i State San Pem�it N ber ❑ Check if revision to previous application State Plan 1. D. Number L A lication Information - Please Print all Information Location: Property Owner Name Property Location 1 > F< m 10- E LLE- L. UO W;6 Property Owner's Mailing r Lai Number Block Number lt`3j;L9 ���2ctiR.�.r1v p2. City, State Zip Code Phone Subdivision Name or CSM Number P 1111E AlCA bbvJS IL Type of Building: (check one) �.4 r't; 13 City 1 or Z Family Dwelling - No. of Bedrooms Q s * ,r k•. C3 village . 13 Public/Commercial (describe use):_ p s S b w� d °'� tdTown of sdM1= RSE'7' ❑ Sta -Owned , • Y - -- . Nearm Road •7Q - t - A: s PareelTaxNumber(s) Z )1Z - 3D IIL T e of Permit: Check onl one box on line A. Check box on line B if a licable O . Q A) 1. New Z. ; replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to S em tem Tank Onl Existin S em B) Permit Number Date Issued ❑ A Sani Permit was reviousl issued IV. Type of POWT System: (Check all that apply) ,95Non-pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Consnvcted Wetland ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ ❑ Aerobic Treatment Unit ❑ Recirculatin ❑ Other. V. Di ersal/ Treatment Area Information: i-Mj4 aAPAc o-/ roc_ v Il Do-re— I A1YI L7AATO KS 1 • Desrgu Flow (gFd) 2. Disposal Area 3. Dispersal Area ' ' 4. Soil Application S. Percolation Rate 6. System Elevation 7. Final Grade Regained X00✓ Proposed , /y Z ✓ Rate ( /sq. R) (bGalmeh) Elevation 1—to ✓ B58I3oL' �awo3�as .7 / 1. Z ✓ - tRs. 9 -,*' B9 VII. Tank Capacity in Total # of . Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con - Con- glass New Exis�g crete strutted Tanks Tanks 5CPT 12z) l bi9EE. ❑ ❑ ❑ 7 VIII. Responsibility Statement the undersi assume nsrbili for ' ation of the POWTS shown on ed lans. Phnnbces Name (print) s gnattae ( ). MP RS Business Phone Number �E_FH you 2 242. 7!5=241 3141 PhmdWs Address (Stns City, State. Zip Code) . I Z9 ow DL County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination # 2 O a l b X. Conditions of A pp roval /Reasons for Disa pious!: '/ 1 R ,f - M 7 L�3 niw ► U )W y SW /y S 11 T3v K 17 N/, 1x`19 ���fZ�tRE�tJ L�P� 56wcgSLT Tws Wbbo RU Ry . M t,� P19E /YIEAtbwS LOT T 55 125 E.M. 3 77 A�t1E5 v✓ /TY 3U dull L'AP SJXW)AIO& JAW ATRA - tbj2s 0 REPLAC- r a AREA D 2 " Fb K L'EMillxi C? MSb1756 WfESr-rZ C6 M.9 7"� M e A - 1130 ZA&C )- 0 0 PR PbSF'.D WCLL GA QNIE L/ IUD. NausE 4 M P2S 22 ® &A)2,q I ARIL ?Gr DF AIW L67 S TAKF g�t -c v" )OD cr -';6fL EORJNGS CuL of SAC- 7L) TH S T• &krIflt ARK To P o F" IJvU iR£NC w,� �N 1 +I IC -�tt! CflP,�Y! I CY INfIG �QA�0�2S OV L a t - 5 S I M E ELEv In � Q 2 f'o &EmAlu a 0 o a 4 WtonRO Y , AIN � ss JZIs' 11 SOI RLI ab5 SCAIE N r r GU0F s AC_ -7 OYN f�Al �,t1`t.E1c ('UnnP C��- 1A�1C�R 1 � X 1 124,0 GAL WtEKS SEPTIGTANIL w /�1 -10� 26181E iLTCf- r c� iWisZ�'isin Department of Commerce SOIL AND SITE EVALUATION 3 Divisiai of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code 9 , , Y�, Attach complete site plan on paper not I x i e. Plan must COO include, but not limited to. vertical point ( rection and percent slope, scale or dimensions, rn and disTane to nearest road. Parcel I� APPLICANT INFORMATIO ; t*ll Lup Revi wed Date Personal information you provide may LID be � A (PrivarY Lsger. 15.04 (1) (m)). Propertylowner S ZORAt'A " -_ Property Location / Govt Lot 1/4/ 1/4,S T O ,N,R ) /(o(LjP Property Owne Mailing Address 3 Lot # Block# Subd. Name or CSM# 71 State Zip Code Phone Number ❑ City El Village E] T own Nearest Road 1 / ( 1 New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd* gpW* Absorption area required _ bed, ft 7S� trench, ft Maximum design loading rate gpdt(t A g g iZ bed, trench, gpd Recommended infiltration surface elevation(s) S ft ( s referred to site plan benchmark) Additional design/site oonsid I Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound I In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system �l] s❑ u 0S ❑ u ®S ❑ U 1 j@ S E U I CIE U ❑ S M U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Motties Texture Structure Consistence Boundary Roots GPD/11 ` in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed , Trench Lobe Ground S / elev. Lft Depth to limiting factor . Remarks: Boring # Ground i elev. ft Depth to limiting factor >_2,, Rem rks: CST Name 1 e Pri Signa e Telephone No. Address Date CST Number i C IPyON REPORT / PROPERTY OWNER SOIL DES � ��- Page � of -� PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 reuv 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench e LJ Ground el elev. Depth to � limiting 3Z. y factor Remarks: Boring # Ground elev. Depth to limiting factor . -) 9 Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # AIZ z A. 7 Ground S- SAS e ev. � Depth to limiting factor , �� — Remarks: Boring # E3 Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Ate ��'Ie Gs o Ad �� - sc�� s�� /�- 7�/✓- �/9'dJ 7s Jefy�ks \ 30 3G S i O 3� ®t Page Of COMBINATION SEPTIC TANK /PUMP CHAMBER (No Scale) 4 Cl Vent Pipe with .Approved Locking Manhole Cover Approved Cap, +25 With Warning Label Attached From Buildings R Weatherproof Approved _ L Warning Label Junction Box Vent Cap �Ii nimum Final Grade -, 6 Minimum 4"Minimum 6" Maximum -- r 4" C.I. Quick 18" Minimum T Insp. Pipe :_ __ Disconnect I 1 /4" Weep Hole Baffles n Approved Joint i w /C.I. Pipe A T Extending 3' Alarm fL Onto Solid Soil On 6 ,1 B Approved Joint w /C.I. Pipe C . 3' Onto Solid Soil Off Q' D Conc. Block 3" of Bedding Under Tank-J ank - ' Note: Pump and Alarm Are On Separate Circuits Number of Doses: Per Day Gallons Per Day/ o Doses: 1 12,S Gallons Volume of Backflow:.......+ z - 1 Gallons Tank Manufacturer: �11rI�SE2 Total Dose Volume: ........ /-= Gallons Tank Size - Septic /Pump: I'ZSl� ?Sb Ga ons Alarm Manufacturer: _rA. X - ALER.1 Model Number: 11)1 V Capacities: A 33 inches or `)9S Gallons Switch Type: ME RCU y + B 2- inches or 3o Gallons Pump Manufacturer: Gv ULD S + C-9—inches or X35 Gallons Model Number: C pb � + D om - inches or 96 Gallons Minimum Discharge ate: 130 GPF1 Total .....= 5() inches or DSO Gallons Vertical Difference Between Pump Off and Distribution Pipe: /) Feet Minimum Required Supply Pressure:. . .. . .....+ --Feet Bo Feet of Force Main x /.54 Friction Factor /100Feet: + -7 f — Feet Inch Diameter Force Main Total Dynamic Head:...= 13 Feet Internal Tank Dimensions: Length Width Liquid Depth GAL AN). Signatur License Number aa.3ayz Dates /d bl 95 -11 - 99 97:44 CROSS COUNTY ID= 7152943138 P.92 ��;�rV �•� Zhu `���iovuc� I T% b rV w it l v M ODEL DVP03 MO vertical • Pump ■0 ■0 Su bmersible EffluenP S •.r ur1 METERS FEE ""• '' MODEL: 3871 ois *,'wy Pte' < ti r t . ,4 ,• ' • . . 'y 1 Soh, W .! m �m�. ` •.. ', � �; :�.::,�, �. Single phasa:115V ' Materials of consikuglon Brass/thermoplastic'' rass/thermoplasdc ,6 Features and Benefits o - -Top suction eliminates 9 ' impeller clogging. : s e •Corrosion resistant , construction. o �� • Float actuated switch. o : 4 s .ti CAPACITY Mona ovPOa Pump Specifications Features and Benefits ' /,• and 'It HP • EPO4 impeller- semi -open design Up to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seal. 0 ` ,6 Discharge size 1 =" NPT • EP05 impeller - enclosed design Solids:' /.* maximum for improved performance. s • Rugged glass - filled thermoplastic ' . AlMotor motors feature ball wing and base desi provides ° o bearing construction. superior strength and corrosion a s 70 IS 0 a a + do LL&M resistance. os 6 ; w.rs Single phase: 115V .Cast iron motor housing for GPACIi1l Materials 01 Construction efficient heat transfer, strength, Cast iron and durability. Thermoplastic . Corrosion resistant threaded Stainless steel stainless steel shaft Available for automatic and manual operation. • GSA listed models available. All Models are designed for continuous operation and feature stainless steel hardware. I Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms Design Flow - Peak (gpd) ('! Estimated Flow - Average (gpd) C Septic Tank Capacity (gal) IQ50 Soil Absorption Component Size (ft') Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) C- Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the ' 4 Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 • , M Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 04/24/01 TUE 06:45 FAX 9 Dari F'uusT. 1 1111F' 1 65 r46 34,SO P. 0l. - 01 ST CROIX CO VMy SEPTIC T,4,N •:. MAII`rIEMANCE AGREE AND O WTM F R,3H P CERTIFICATION FORM Ownexl$uy� ��' �•� A NA n���S'. f � t•�riwl� Mailing Address % t.'¢ / V,�=.x' P.roperry Address r .S '7 T H T (1 r csifr[aticYrt rcqtrtied from l';nansrxg Dcpaecatcnt for aGUr er�r�structicss�) City�State _ - ' - )aMEfL 9I r W1 _ ?Parcel Id , -ntificzatioa Nlumbet 673 7--- 7- l J Z -3 d LFGAL DESCRTMON Property Lucticn l` W, Town Af S O/i(IERS�T Subdi El-,,V6 c� A li Lot �- ✓ Certified Survey NZap 9 T `volume _ , Page �3 70 166 r Warranty Deed # vol=e 4 Page y SSptw, Lo use p ye's p o Lot !in- idcndtable D''yes 0 no SYSTEM HENCE 1rni?[up�I rise $ild tr�int�tlantroT ya, zr ascpy% �wr-m could r salt in it ptrmatt>ic far�uie to harrdlc v+n i tre Proper mainTCa�ce consizu of pu=xng out the s eptic tank evaty Llra:: ycmn or ;ooacr; if n-c&d by a hcewcd ptmTper_ w7w you put rote the system Cass aticct the fitacrion of the septic rank a a Ln�tmcrr 2zge in 6i& e: ste 3ispo::l system Il a Fropert3` 01wner ag,xzn-s to submir Ev :Sr Croix ?o!ozg Dup rtmear a "ni.fication fnrrc6 sirncd, by the owner zud by a MasscrpiumbcT, j*"q,mn2nplumber, imsrdaTcd r,:IGtmbez or x li_c - , cd ry P`�l'c etif}+ing that (1) t]a on -stile tuwr&o.ater'da4p0sal systems is m pre -per dperaring coadiRoa andlor (2) after i ection Ind pumping (if ItecessarY), the %p& DL*k is less tbaa Ili full of sludge. Vwvc, the undersigned bsvc read the ahavn and agrrc to maiayain [lw privzty sewage deposal, System r*i& tl 4 =rds 5Ct fjor L he=it4 AS '= by 171- DGI? ;7Mt v:{ and the Dom* A - tMeat ofNa r4 RtsanFCCS SMIC of Wiscowizz. Cefd 146dY stating tb2z your scpcc -�,yrsre= lry heir IIl:,i art ,,A;, mx t }; cyarpIctcd nad recmned to the Sr, Croix Goumy Zoning Qfl within 30 dais o t3trec car cxpiratinrt d2t -- �a I, QF A.PPLIC`,;T`T DA'T'E DER CE ' `ICA I (wc) GerTify that all itatcrneats <in the lorM a1c trite to the best OCmyr (avt) knti ledge I (we) am (arc) rbec vwaer(s) of the pr»perryr dcsc ' a e by vizrsc of n wai:anry dc� McCord d to Rtgzster of Dacds Office. AT[JFtF [� AI PLiC DATE ..w..= Atl�/ itxl4Cir�,tnoII Z11?t I � IIzi: -. -Z' gY^,'k1Cr!'':L r ..,•; r _..__ �p - I � =. �1, in '� �;�aizacy pr. -nzait berg rcv�kcd by nc� �nuia� Deparrlue[2r. " 'a Iadvde Rirb this apph[Ati4n; a sr d w. +�tSar':Yv dCd from t}IC jti'ePLbCr of Dcods o{fiet a ccr3y of ?lie :ccr;rrcd st'r ' Y MAP if rcfa'iccct is rttldc in the wartaaty d" TUTt L P. C11 04 -24 - 00 05 = 42 I VED FRC)DI = 9 P - 03 10 voi. 1567PAGE 245 tFWa527 STATE BAR OF WISCONSIN FORM 2.1999 KATHI. EFN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document RECEIVED FOR RECORD Number ST. CROIX CO., WI This Deed, made between Shawn M Breault _ - -- — I2-14 -2000 10:30 AM - - - - _— ..- - - - - -- - - - -- WARRANTY DEED EXEMPT W Grantor, and Peter J. Ludwig and Michelle L. Ludwig, husba and CERT COPY FEE. -- - - -- -- COPY FEE: TRANSFER FEE: 195.00 - - -- _ - -- - - - - -- RECORDING FEE: 10.00 - - - -- - - - - -- — PAGES: I Grantee. Grantor, for a valuable consideration, conveys to Grantee t following described real estate in St. Croix n' State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 3, Plat of Pine Meadows in the Town of Somerset, St. Croix County, Name and Return Address Wisconsin. First National Sank of New Richmond PO Box 89 New Richmond, WI 54017 032. 2112 -30 _ - -- Parcel Identification Number (PIN) This is not — homestead property. Dj) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of December - -_, 2000 ------------ ` - - - - -- • Shawnah M. B reault — — _ - -.- -- + ACKNOWLEDGMENT AUTHENTICATION — STATE OF WISCONSIN ) Signature(s) - - Shawnah M. Breault — _ - -_ - -.— __ } ss. - -- — - - -. - -- County ) ti e mber 2 day of authenticated this L_day of — Dec Personally came before me this Y �• � a the above named w Kri O_gland TITLE: MEMBER STATE BAR OF WISCONSIN co me known to be the persons) who executed the foregoing (If not, — — instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) _-- ^.--- - - - - -- THIS INSTRUMENT WAS DRAFTED BY ` ___—_---------- -- ey Kristina O gland --- - - - - -- Notary Public, State of Wisconsin Attorney W1 54016 My Commission is permanent. (If not, state expiration dat (Signatures may be authenticated or acknowledged. Bolh are not necessary.) — -' — InlorRWlion Profaasiona4 Co'npany, Forio du Lac. W1 * Names of persons signing in any capacity must be typed or printed below their signature. 800.855 -2021 STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 . 1999 IT =60 00 -TT -bO ;.!i 3M1 JO 31Ji1 1S1f3 �� �� AF rn Ln t� e f1 ^� l x CV CD `v t . 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