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HomeMy WebLinkAbout032-2157-50-000 �Y o I � I 0 1 0 N � I � I .a � I I � I h j ai 1 Z LL c 0 3 w 1 i ¢ I 3 Cl) v o Z " rn z c }' p I ° w a m N Z C I O o z v w a a z Cl) N r CL` 3 C ° . m D z Z n y c C I C O y C N V L r O W C d N — 1 2 pO r D a .o E � ~ E 3 3 U o E EL U) aaa y �i a 3 •� m' J U i o o } O L p tt- N co 0 CD Noy m C a w z in m a a d ea z ° w O L Vl N N c C O G O M 0 N LO 0 Cj C O W C N w N d> C M 0 N O E C N d C N N f M • Ai O r fQ U') d' O Z C P L U) a ` a • a y 'u y c E ` 'c c 2 � r A c°)a2 loinQ — Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453211 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)J. Permit Holder's Name: City Village X Township Parcel Tax No: Grand Properties L.P. Somerset Township 032 - 21550 -000 CST BM Elev: Insp. BM Elev: BM Description: �+ Section/Town /Range/Map No A 41 r_, .x� <<E�,' frcnStc��..� �� 12.3 .19.1 ?r TANK INFORMATION ELEVATION DATA / TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ����k� /c�c - �0.� I !b'S• �. �[� Dosing Alt. BM _ ?j /v5. 3r1 `t & '3, d Aeration Bldg. Sewer H ing — / SVHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ Septic 1 Dt Bottom \ Dosing Header /Man. \ Aeration Dist. Pipe //- q­� 13.14 i 2 9 Z. z- I Holding Bot. System a � � 9 2.. 3 Z_ `14 1"3 7 q /,3S Final Grade PUMP /SIPHON INFORMATION? 9. 9 5 - • Z-j Manufacturer Demand St Cover J GPM v3 9 0- `7 Model be TDH ift on Loss I System Head TDH Ft Fo emain Length Dia. ist. to Well OIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR ( 3 i - s - 0i Type Of System: C t� / vU UNIT Model Number: e.!t n L, � its .' c — r .(i �. SD �i 1 1 1 DISTRIBUTION SYSTEM a v ch - --r- Iv r T Header /Manifold Distribution x Hole Size Ix Hole Spacing lVent to Air Intake ' 1 Pipe(s) r- _ _ ' S 7 Length Dia Length 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 r Mulched Bed/Trench C ter Bed /Trench Edges es -- To soil � Yes [� No ;_� Yes No �� �! COMMENTS: Jude code�crepencies, persons present, etc.) Inspection #1: 3 / G Inspection #2: .._.- Location: 1694 89th St Unknown (NE 1/4 NE 1/4 12 T31 R1 9W) The Highlands Lot 15 Parcel No: 12.3019.11' 1 3.S'1 1.) Alt BM Description 2.) Bldg sewer length - amount of cover Plan revision Required? Yes k o Use other side for additional informati SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. t Safety and Buildings Division County an 201 W. Washington Ave., P.O. Box 7082 7, /10/ N evnsr Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 -6546 4 // Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide maybe used for secondary purposes Privacy Law, s 15.04(1 Xm) Project Address (if different than mas address) I. Application Information - Please Print All Information � � , Pr y wner's Name 3 ZOU4 ( Parcel # Lot # j Block # RANQ 7 _ 00 P Owner's Mailing Address f Property Location 1 GrIbin"LUr''! i i7l ZONING OFF! Ci State Arc ' /., Section ty. Zip Code Phone Number Q E / 3 yd A y �do � 'dCirde gqg) 7 T N; R o II. Type of Building (check all that apply) 3 4 �2 Subdivision Name CSM Number 11 1 or 2 Family Dwelling - Number of Bedrooms // ❑ Public/Commercial - Describe Use r // L ❑ State Owned - Describe Use ❑City_ ❑Village 111Township of Soma-Af III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' ® New System ys El 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 POWTS S stem: Check all that appl 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 Cl Recirculating Synthetic Media Filter Ching Chagoer ❑ Drip Line ❑ Gravel -less Pipe er xplain) V. Dis ersaVTreatment Area Irfforma tion: / Design Flow (gpd) esign Soil Application Rat e(gpdsQ Dispersal Area Required (sl) Di ea Proposed (s� Syste eva t D � � 5 1 � Q .a ) (�) VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fi Plastic Gallons Gallons of Units Concrete Constructed ass New Existing Tanks Tanks Septic or Holding Tank Ov Aerobic Treatment Unit h I Losing Chamtxr 1 t VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI s Signature MP S mber Business Phone Number Plumber's Address (Street, City, State, Zip Code) r - ie - i TY01 '15 VIII. ounty /De artment Use Onl pproved ❑Disapproved Sanitary Permit Fee (includes Groundwater D Iss mg ent Si nature No a s Surcharge Fee) p 4 ❑ Owner Given Reason for I nial ' � IX. Conditions of Approva easons for,pisapprov� /]� �J,� STEM v � °" /"[ Septic tank, effluent titter and��� Q 70 7Z 3.�L dispersal cell must all be serviced / maintained as per management plan provided by plumber r� ( Sj - t ✓' e.fUG� CL1Y , 2. All setback requirements must be maintained as per applicable code /ordinances Z.S Attack compkte plans (to the County only) for t ystem o paper Not less than 81/2 i (1 1 s la size q3. 7� V. SBD -6398 (R. 08/02) • S - -i !- ° -- -- - - l ad -- -mot Gtr ' r I P RP I - I I I _ i I q I � Al /00 i= c lit 2 - 3 i � ✓ -- ! 9z C� - - -- qL ay � Lfin��Il I i I • ! _ - I I z `_— • -- '_ r 9/7 t - _:.ion /- ac r_��` - -�C � /oo,p' ! - ate, T_ q .- y O• —! --~— 2 3 R i ff ^3 .4 - /aA y - 1 6; r/rc -w I _._. _._ ____ __ . __. __... �d Y Wisconsin Dv.)artment of Commerce SOIL EVALUATION REPORT Page I of Division of Safety and Buildings in accordance with Comm 85, Ws. Adm. Code C I Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County C --7t X include, but not limited to: 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. 0 3.2 — 7 S 69-) Please print all information. iewe y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 7 3 Property Owner Property Location 3 �j Govt. Lot /�j 1/4 �{j�1/4 S) Z T ( N R ) E (or) o Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1353 � 5 City State Zip Code Phone Number ❑ City ❑ Village [irrownJ Nearest Road [ New Construction Use: Residential I Number of bedrooms 'J Code derived design flow rate i1!S'a G c U GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material (J d 4 a S Flood Plain elevation if applicable General comments and recommendations: GEC u� 3 0 n'Yti °,s n D f �k ! of arh try s'h6 .wL on S u 6 d vnala . P i Boring # ❑ Boring "' ST CF OIX i�pUN?Y - v a ® Pit Ground surface elev. ft. Depth to limiting factor 1 l in. on e Horizon Depth Dominant Color Redox Description kTex ture Structure Consistence Boundary cots. G . in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. d - l2 Z. m� cs lV� S 2 Q -41 �`t — Zrn -r cs 3 i -II9 IC) C4lu — oss ml — J - ► Z k 7 y3- =" yo' Z Boring # E] Boring ❑ pit Ground surface elev. 9. / 0 ft. Depth to limiting factor 11 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I 0-1'4 1 1 Z ----- s t 1 Z Ofr CS I - 5 ? Z 14- (C) s i cI Z bk M Tr C- -5 — 1 14 �0 3 10 Ico — ms yOv� – " Y7 fn, * 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 A clam Schu o- 25 Address Date Evaluation Conducted Telephone Number 2 SOt 51-: W1 51646 16 - 36 -al (7,$) Zy7 g64r i SBD -8330 (R07 /00) v Property Owner S�Clo - Parcel ID # Page of 3 [7-1 Boring # ❑ Boring q 3 ! fed ft. Depth to limiting factor �� in. Pit Ground surface elev. 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 'EffQ I p -I p Z Si) Z Z I - 41 Ip 14 S Zmslbk r (- 3 U I -119 10 r L{ /(, --- ►-ris O s rn Boring # ❑ Boring ❑ Pit Ground surface elev. 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 F1 Boring # ❑ El Pit Boring Ground surface elev. 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 ' 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.07 /00) r ' f PAGE 3 OF - 3 NAME c5 40 0 LOT# LEGAL DESCRIPTION A)F Y4,0 F- t o ,S 17— T 7 ,D N R 19 E(oot SCALE: 1 "= �(O BM I ELEVATION l • O BM 1 DESCRIPTION V 0-� 3 ,f� D� :O2 BM 2 ELEVATION 0OC� O BM 2 DESCRIPTION 45o a -C SYSTEM ELEVATION 0 G�wtr Q3,00 ALTERNATE ELEVATION CONTOUR ELEVATION qS.00. 9 bOO r Q $,OO 1 d �/71c3 CAM ` "Z- - 61 GSA ^ m SIGNATURE DATE PAGE 3 OF 3 NAME <S �Z J � LOT# (s LEGAL DESCRIPTION A)r %u E X ,S 1 Z T 3O ,N,R, 19 SCALE: I "= qd BM I ELEVATION _ y , • O BM 1 DESCRIPTION 6po� & D,rG o� e T BM 2 ELEVATION loC - o I BM 2 DESCRIPTION j e a SYSTEM ELEVATION jo �,o 0 Gb w s r , o b ALTERNATE ELEVATION L* q2_. 0 l ov� r q (• a o CONTOUR ELEVATION qS %oo, gl,oy , q (3M \ gM Z • I M 4�• °° 6' oc ".) V*\ Q SIGNATURE DATE I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Cr 12 A ly �/ 6, 0 2 r /rtS Mailing Address 7/2 fii U A2D 5' Property Address & I o - J ' S (Verification required from Planning Department for new construction) City/State S O/9E/1S�r /� Parcel Identification Number 02; LEGAL DESCRIPTION Property Location' /,, -M' /,, Sec. ��, TL3_N- R_Z.W, Town of �'o�c�Ir�T Subdivision 7��= /��`� -l� G,g� S . Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # ��a'L�S�/' , Volume ,2. SG 8 , Page #- S 8? Spec house 10 yes ❑ no Lot lines identifiable N yes ❑ no SYSTEM NANCE 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 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 septickystem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 daysoTthe three veapexpirat?gn date. SIGN II E O • PLICANT DATE OV,r ER CERTIFICATION I (we) 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 property descri 0 above; by virtue of a warranty deed recorded in Register of Deeds Office. i y r 5` NA :A1+LICANT DATE • « « «4• « « « « «« j Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. f «« 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 l POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _L of FILE INFORMATION SYSTEM SPECIFICATIONS F _ Septic Tank Capacity a l El NA �- 3 Septic Tank Manufacturer — S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms O NA Effluent Filter Model A _ ❑ NA Number of Public Facility Units ® NA Pump Tank Capacity a l ® NA Estimated flow (average) . QQ gal/day Pump Tank Manufacturer ® NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ® NA Soil Application Rate gal/day/ft' Pump Model Z NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit M NA Fats, Oil & Grease (FOG) 530 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: i Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L i In- 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: :O�N A 11 MAINTENANCE SCHEDULE ! Service Event Service Frequency ❑ month(s) ' Inspect condition of tank(s) At least once every: ■ ear(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once'every: ® mon 1(s) (Maximum 3 years) ❑ NA ■ month(s) ❑ NA Clean effluent filter At least once every: ❑ year(s) Inspect um um controls & alarm At least once eve ❑ month(s) year(s) ®NA Ins P pump, pump every: ❑ years) ' ❑ month(s) M NA Flush laterals and pressure test At least once every: ❑ year(s) i ❑ month(s) Other: At least once every: ❑ year(s) ®NA 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,`:-' ;5 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 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. i Page of 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; meat scraps; medications; oil; II I foundation drain (sum um) water; fruit and vegetable peelings; gasoline; grease; herbicides, p , , P P P 9 P 9 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 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 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. 0 A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be ins ed as a last resort to replace the failed TS. he sit a not b en uated ide tify a s stab replac men area. pon ail re of a PO S soil and ite vi o ust a er rm to ocate a suita a repl em t area. If replacement area a ilable holdin t k y be ' sta led as I st res rt o replace ailed PO O Mound and a -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>> O INSUFFICIENT OXYGEN. DO NOT NT IN LETHAL GASSES AND/OR 1 PUMP AND OTHER A SEPTIC, O ER TREATMENT T ANKS MAY CO 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 POWTS MAINTAINER Name Name Phone _ Phone �l _/ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S/e G/20/ _ Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. I 2 b 6 8 r 5 S T" 762 1 sje+ � `STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. MALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., MI Document Number RECEIVED FOR RECORD This Deed, made between _ 05/10/2004 02:00PM RICHARD 0. STOUT and JANET P. WARRANTY DEED STOUT EXEMPT # and wife Grantor. REC FEE: 11.00 and r P ROVER!P TE nT LP TRANS FEE: 188.10 COPY FEE: CC FEE: PAGES: 1 Grantee. !j Grantor, for a valuable consideration, conveys and warrants to Grantee the following ii described real estate in St Croix County, State of Wisconsin: Recording Area I' Lot 15, Ptat of The Highlands, Town of Name and Return Address Somerset, St. Croix Coutny, Wisconsin. ` x(111 q (j2r rill iWill i 7 11 {�, .rntib ST2. Sib 2-S i i 032- 2157 -50 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) t i i I I Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 1 Q t h day of May 1 2004 chard O. Stout (SEAL) /- (SEAL) * * Tanet P Stout (SEAL) (SEAL) * * ii ii i A UTHENTICA TION ACKNOWLEDGMENT �I i+ Signature(s) State of Wisconsin, !' St. Croix County. authenticated this day of _ Personally came before me this 1 0th day of May 1 7004 the above named i Ri c- hard n S r?t and .Tanet —P \ \1 \111111 // Stout GULL • 1 `' TITLE: MEMBER STATE BAR OF WISCONSIN ��� • O;y:. to (If not, 2� . �� AAY • -jC me known to be the person �_ who executed the foregoing authorized by §706.06, Wis. Stats.) s U instrume ; _ �( . z =: a d acknowledge the same. i V THIS INSTRUMENT WAS DRAFTED BY %� . pUg~` • G02" ©Y� Jane Stou 1 353AwatukeeTr. ��� % Hudson, WI 54016 Notary Public, State of Wisconsin My commission is permanent. (If not, state expira-tio..��n,,,,date: (Signatures may be authenticated or acknowledged. Both are not la /I G�� 1 necessary.) Names of persons signing in any capacity must b3 typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. •X� - . .1 70TH AVEN U - In op THU NMI Al i ion INN a WE 9 PRI A 0 A e • , r , • r • , • I ~ UZ AW SIR .r