HomeMy WebLinkAbout032-1036-20-100 r -
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety nd Buildi 'vi n
y g si o ,
INSPECTION REPORT Sanitary Permit No:
420435 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:
Peller, Daniel I Somerset Township 032- 1036 -20 -100
CST BM Elev: Insp. BM Elev: IBM Description:
-Z5 r�` A / j Iq `� r p f
TANK INFORMATION ELEVATION DAT
TYPE I F ELEV.
Y E MANUFACTURER CAPACITY STATION BS H S
I � Septic / � � Benchmark � � D6
Dosing Alt. BM
T ,� 1� lave o L' a
Aeration Bldg. Sewer
Holding St/Ht Inlet
Jj q-
TANK SETBACK INFORMATION S a 3S o- t- r�.�.4_� St/Ht Outlet /a�• I , o�
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
A6 _11A
Septic ! 1J I- �,,� L Dt Bottom
T as �v
Dosing H a er /Man.
Aeration Dist. Pipe/
Holding Bot. Sy stej=
g t1
Final Grade
PUMP /SIPHON INFORMATION 7 -;� ,) y
Manufacturer Dem nd St Cover
' GPM IGv• 3
Model N ber
•C'- 1 :7 BOG? 3 � , off
TDH Li f riction Loss System Head T Ft
Forcemain Length i .
SOIL ABSORPTION SYSTEM
BEDITRENCH Width / Length No. Of Tr es r"MENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1' C/ /
SETBACK SYSTEM TO Q P/L BLDG WELL LAKE /STREAM LEACHING Manufact , i
INFORMATION T e O System: Lq � CHAMBER O �"d
'f! � UNI Model Number:
DISTRIBUTION SYSTEM 3( b� D �,�
Header /Manifold Distribution , x Hole Size x Hole Spacing Vent to Air Intake
Pies 7 N
Length I Dia Length Dia ' S ni g
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over IDepth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
[J Yes jgj] No Laj Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1; {_ / Inspection #2: / !
Location: 763 220th Avenue Somerset, WI 54025 (NW 114 NE 1/413 T31 R19W) NA Lot 1 flu PaIrcel No. 13.31.19.177A
1.) Alt BM Description = � 64r 4f01 r Mt sa y'y? Z�,Aa B� � ��Y� j/
2.) Bldg sewer length = 3b / , , , • U�v �(��� tAns /C1L
- amount of cover =
&4"IA l�h ly _j0 17' 4 ;IX tM 0i;:' At I`rlaG� AAV-) , 4 Pribkdr -r a�roy&,
Plan revision Required? Yes �0 Zi
Use other side for additional information. - itr�1 /yam —_
Date Insepctor's Sign ture Cert. No.
SBD -6710 (R.3/97)
I -Jot4t, V -14 P -�# ��� e_,�
3�
l
Safety and Buildings Division County
N *is�onsirn w 201 W. Washington Ave., P.O. Box 7162 1
Madison, Wl 53707 - 7162 Site Address
Department of Commerce JD —( pZ Odf 3 Ra TT V
Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide D Check if Revision � ' 2 0
J�
may be used for secondary purposes Privacy Law, s l5. 1 m
1. Application Information - Please Print All Information EcovED State Plan I.D. Number
P Owner's Name Parcel Number
Property Owner's Mailing Address UN t . Y Property Location
14 �� ST.Cf OIXCO 1 ;S T N,R/ j ox OF�
City. State Zip Code _0fiiw1qVmber Lot N ber Block Number
1
Subdivision Name 7 )' CSM Number
1�
�s - 7-
II. Type of Building (check all that apply) DCity
X or 2 Family Dwelling - Number of Bedrooms L l DViilage
D Public/Commercial - Describe Use ownship
D State Owned a� X Qi Nearest Road
od .�
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A. IEtNew 2 D Replacement System 3 D Replacement of 6 D Addition to For County use
system I I Tank Only Exis ' system
B. ❑Check if Sanitary Permit Previarsly Issued
Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) * , "S
44 P(Non - Pressurized In- Ground 21D Mound 47 D Sand Filter 50 ❑Constructed Wetland
22 D Pressurized In- Ground 41 D Holding Tank 48 D Single Pass :510 Drip Line
45 D At -Grade 46 D Aerobic Treatment Unit 49 D Recirculating 3o D Other
V. Dispe rsal/T reatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Soil Application Percolation Rate System Elevatto Final Grade
Required Propo / Rate(Gals./Days/Sq.Ft.) (Min./Inch) 7_-I_ 7 / Elevation
��� �� � • ®� !"� � � X0 `56 ---_
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank lr l�v
Dosing Chamber 35
VII. Responsibility Statement- I, the undersigned, assume responsibility for ' u of the POWTS shown on the attached plans.
Plumber's N rint) Plum s MP RS Number Business Phone Number
7 ?4 1
Plumber's Address (Street, City, S Zip Code
--- A2
VM (De artment Use Oal
Approved D Disapproved Sanitary Permit Fee {includes Groundwater D ssued Is Signature (No Stamps)
Surchar a Fee)
D Owner Given Initial Adverse 6_1 G� ^►
Determination
IX. Conditions of Approval/Reasons for Disapproval �'✓ �iG - d`Q/Z'd1 �•? i°�� �
s Ste- �.e.d� -),Z) D • - �a .,��ee�v �
sc lttOj 13 at
Q � ccM�•'�'°
Attach fete I— (w w e County M1y) for the "Mon paiper not than 8 111ncha to
SBD-6 98 (R. 05101)0 Ate"
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wisoonstn aopormwa of commorce SOIL EVALUATION REPORT Pa _ or
tiislbn of Waty and BuWlnps
in aocadanoe with Comm 85, Me. Adm. Code
Couety �
Attach cornplela a(b plan on PAPW not 100m then 8 112 x 11 in0hs4 to vu• Pt4n MO F�
lncludt, put not WnMed to: vertical and tvrbmtrl fvfarerkss pant (SM), diroeftm OW Parcel I.D.
pwcsnt e►opa, aeai& or almenvorm, north aurbM_ and location and diattnce to ncMuet toed.
faloasn print aHInformaWn. e tasty
Parwcnni bftnwmw you provme nvy be smo for semndsN >mmom% Mrwecy L—, 4 ML04 (1) (m)). w ALP
roperiy aw tier tt PMPWV tow
Gvrt. l.vt 1!4 � 114 8 j T
Proparry Owners Mailing Add-max Lot i Block 111 Subd. NenU or C OW
2() 1Cr 1
t 9istt ZIP coft Phone Nu trbbr E] City ❑ vatege f3 Town Newest Road
(� New Cvnsiruttdat Um ( R6*10 of I Nvmbor of bedrooms Cods derived design ttow rote (;PD
�] Repleorxr»nt Public or ovvvoar6al - Dosc►llia:
Parant a atonal u 1 r. r , b flood rush tlwstlon if apGcvR h.
64nars on ur � ti ( t1. 1'l lcrw • r x s7v f
artd r40omRWRt>Plf9nK . A /1 p ( jj o OC (�
cicv WP -0 y f!'.1"tT OC V 3 2002
E sort'vx � Boring / Zc! l NG OFFICE
M Gmu,%d surface elay. R. Depth to nnOnp 180W ,t 11ct:.L_ e'- 801! ApPVC~ R!14
Horizon Depth Daminsnt CWor Redrnc Dow6pson Texture struawrs Camolawles soundar)/ Roeta GPOM
In. Mufteell Du. SY. Cmt Color Or. $z Sh. 'EM 6 902
O / Q r � t I /9't t' 4 f r • Fl
ro r f s oof
z- r - m a r — - f 2.
. rl 8arinp
Pit Gmund surfete atw. Y (l_ Depth to iiffifty Imtor //,� Lt.
Hortton Depth 0 minmi Color RWQX D"010von Taxturs Cuucttrs Conststenett Boundary Roots GPEW
In . Munsen Qu. 6z. CpnL Color tar. S:. Sri. ( 'Eft
vZ
Z.
Effluent #1 ■ BOD, > 30 < 220 mWL end TSS >3% _ 1 rnp& ' Effuerd N2 1300, < 30 wQ/L and TSS < 30 moll
CST Name (Please rtnt) lure CST Nunwer
mac:
dross ta_ to to Ewa lustim Conducted Teleohone Number
S3D -R33G 'RD��G� ;
Prcpwv Owner _ Leh h P, r Pervel ID K f Qj
���[� .
[� pg t3reund 3urlsce elan, .L._. ft- Depth ro Mmiung factor ln. Sop Appilcow Rpm
:Morton Oepth Dominant Coidr Redox Descrlptkm Texture Structure Coisistence Boundary Roots GPOMO
kt_ Munssli t u. 6t. COM. Color Ot. Sx. Sh. •EM *=2
Oil z 51 / urns - M
ED Pit Ground surface Wev. R Depth to uniting fedor in.
ttou a
Hol" t► Dominant Color Ream Dosernmon Texture 9truitura Cons - k - ends Aounoery Roots GPDJW
In_ Mtsrssielr Ctt. Bz. COnt Cotta Or. W. Sh. •1rol •EIM
Boring * OWN
rounttsurbov R
0 pit G Depth to Omttfiig laotor in.
oN
Horizon Oso Dominant Color Redox Dascnpfian Taxtum+r SRvctum Cuzalstence Sounostry Roots GPW
in, Munson Clu. SZ. Cont. Color Gr, Sz. Sh. •EW •EfNf1
' COMM 21 r BOD, > 30 220 ftV& Ond 7SS >30 150 rnWL • EMuent #2 600. 20 nvk and TSE < 30 cm/L
The Department ofCommeme to an equa! apporttmity service prov ider and employer. If you need assistance to access services m
need material in an •ltertwe fotmrt, plaesc contact the departtmont at 6o8 -266 -3 S 51 or 1 rX 608- 264 -87
SaDid70rlt.OtAn
SC wa4l:09 ZOOF_ 92 •qQA 'ON XUA
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HM z DESCRWIlON..11td . n �0 - a.t
SYSTEM TIEVATION . 00
ALTERNA3'£FLEVA - 1 7 ION i, 4o.06
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CIGtiATtTRF. »tires.. _.r��s -y- � __ nATI: �'
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address IS'7 S8 U EhS D(Z
Property Address �� 3 A Y ��) L iUZ �
Ve
( r7fication required from Planning Department for new construction)
City /State Parcel Identification
-�' Number
—a
LEGAL DESCRIPTION
Property Location � _ % _I)L r /,, Sec. IS T3N -R. 0 1 W, Town of SPV(-'.t,�
Subdivision Lot #
Certified Survey Map # Z ' 7 y 7 ?3 Volume J -6 Page Page # LiaGS'
Warranty Deed # Volume Jam? C3\ Pa g e #
Spec house ❑ yes 1 ' no Lot lines identifiable SJ 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 propertyowner 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 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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating t4atyour septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the ee year e p lion date. q
SIGNATLM OF APPLI ANT DATE
OWNER CERTIFICATION
/fN e) certify th all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pro ty esc
rribed a o , by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF A PLICANT VATE
' * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFO2 SYSTEM SPECIRCATIONS
Owner Septic Tank Capacity al ❑ NA
Permit # n Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS o�J Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units --t-- ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) g al/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) Q0 g al/day Pump Manufacturer ❑ NA
Soil Application Rate V 7 gal/day/ft' Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average` Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD j 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 oln- 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: ❑ month(s) (Maximum 3 years) ❑ NA
y ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
❑ month(s) (Maximum 3 year:) ❑ NA
Inspect dispersal cell(s) At least once every: J' year(s)
Clean effluent filter At least once every: ❑ month(s) ye ar(s) _ ❑ NA
ye ar(s)
Inspect pump, pump controls & alarm At least once every: 0 yea�(s) ❑ NA
' ❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) ❑ NA
At least once every: ❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carry ing 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.
Page of
START UP AND ORERATION
For new construction, prior to use of the POWTS check treatment tanks) 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
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.
❑ 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 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 replacement area is available a 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 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 A POWTS MAINTAINER
Name Name
Phone - _ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHO ITY
Name Name
Phone Phone 7f5- ` 3 96 " V g O
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
3 7 4 7 7 3
V0� 16 PAGE 4265
II ISATHLEEN N. N�AL,SN
REGISTER OF DEEDS
ST. CROIX CO., MI
CERTIFIED SURVEY MAP RECEIVED FOR RECORD
03 -28 -2002 9:30 AM
LOCATED IN THE NW1 /4 OF THE NE1J4 OF SECTION CERTIFIED SURVEY MAP
13, T31 N, R1 9W, TOWN OF SOMERSET, ST. CROIX REC FEE: 13.00
COUNTY, WISCONSIN. coPr FEE: 3.00
OWNER SURVEYOR N
TED PEELER EDWIN C FLANUM O � ' ;''
20161GLEHART AVE. NORTHLAND SURVEYING, INC, g '',t
ST. PAUL, MN 55104 P.0 BOX 14 O w O
ROBERTS, WI 54023 z Ij w w 'Q° ,�
Mf`in]G°PL�,Q`u�t ( 0D [ lG7D� �t�� w, R , ',,� SECTION 13
Qa (�nn Q ° w l� '.Q (COMPUTED
_.. ------------------- �aJ°U Uv ❑ 1� w 7 to FROM WITNESS
--------- -------- – p Z @ CORNERS OF
l'f OO L5❑ �p C�C�� O ,� ,� RECORD}
----- ----- '-'- - -, -- -- 2 Z w
N1/4 CORNER
EX
SECTIONI3I
D RIV � � 0TH AVENUE = O
RIVE --------------- - – m m
— — 889 °16'26 "E 1313 .72' — NORTH LINE OF NE1l4 —�
_656.86'
656.95'
S59 °16'26 'E 8 1313.90'
PROPOSED PROPOSED- 250' —o r
DRIVE DRIVE w}
op r, 0 �J �'.� � FIELD
�
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_., {J.,•'..<i -. .n, �.. nip
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LL t
w 30:
�I
C°3 LOT 1 LOT 2 �Oi
T r 19.94 ACRES INC. R/W N 19.92 ACRES INC. R/W
r 868,403 SO. FT. 867,751 SQ. FT.
A' LU 19.44 ACRES EXC. R/W rn 19.42 ACRES EXC. R/W L'
C i 646,725 $0. FT. 846,073 SO. FT.
N LEGEND a
�11 C IO
1 "IRON PIPE FOUND
�
!Z W o0
x ■ 0
1 3!a" IRON PIPE FOUND z
0 2" IRON PIPE FOUND
0 1"X 24" IRON PIPE SET WEIGHING
n
i NOTE 1.13 LBS. PER LINEAR FOOT z
LL LOTS 1 AND 2 ARE ENTIRELY BUILDABLE _
O, ww UNDER THE TOWN OF SOMERSET ( PREVIOUSLY RECORDED DATA LL
z CONTIGUOUS BUILDING AREA O
100 ROADWAY SETBACK
w a;
ORDINANCE EXCLUDING 20 PERCENT z
U) SLOPES AND BUILDING SETBACKS. AREA EXCLUDED FROM CONTIGUOUS
3
+ BUILDING AREA
' ♦ SOIL TEST
1718'+/- HUNTING
.44' SHELTER 23.4' +!• 17.3' +/•
N89 °21'36" 0 1320.88'
SOUTH LINE OF THE NW 1!4 OF THE NE1 /4 ttN S 3.5' +/- EAST
OF LOT CORNER
a D a D NOTE:
MGv][ _1[ I
N - ---- 44�D dQ D AREA LYING SOUTH OF SHOWN
QO WH[29 EV QQN [9p@ FENCELINE MAY BE POSSESSED BY
S OTHERS. CONTACT ADJOINING
SCALE IN FEET I" = 200' PROPERTY OWNER OR AN ATTORNEY
PRIOR TO REMOVING FENCE.
S1 /4 CORNER 200 0 200 400
SECTION 13
THIS INSTRUMENT DRAFTED BY MICHAEL ERICKSON JOB NO, 01-80 DATE: 1.14-02 SHEET 1 OF 2 SHEETS
Vol.16 Page 4265
U 195ZP �f9 $
� 4S — ' 7
KATHLEEN H. WALSH
SEGISTEIJiO DEEDS
RECEIVED FOR RECORD
�, M► 55(a -a-- 08 - 20 -2002 8:00 AM
WARRANTY DEED
EXEMPT # a
REC FEE: 11,00
TRANS FEE:
COPY FEE:
CERT COPY FEE:
PAGES: 1
Warranty Deed
Individuals to Joint Tenants
(Reserved for recording data)
State Deed Tax Due Hereon $ PID NO. 03 D. - 0310 ra o - 0 O
Date: August . 2002
FOR VALUABLE CONSIDERATION, Robert T. Peller and Lorraine F. Peller, husband and
wi e, Grantors, hereby convey and warrants to Robert T. Peller and Lorraine F. Peller and Daniel
T. Peller and Marybeth Szaj Pellet grantee (s) as joint tenants, real property in St. Croix County,
Wisconsin, described as follows:
Lots 1 and 2, Certified Survey Map in Vol 16, Pg. 4265, located in the NW 1/4 of the NE
1/4 of Section 13, Township 31 North, Range 19 West, Town of Somerset, St. Croix
County, Wisconsin.
together with all hereditaments and appurtenances belonging thereto.
Seller certifies seller does Rob .Peller
not know of any wells
on described property.
Lorraine F. Peller
STATE OF HLfSMSOTA )
) ss.
COUNTY
The foregoing instrument was acknowledged before me this day of August , 2002, by
Robert T. Peller and Lorraine F. Peller, husband and wife Grantor(s).
NOTARIAL STAMP OR SPAT, (OR OTRFR 7TMF. OR RANIQ .
91EN1, E J. SCHUL7Z Notary Pubfic Minnesota
ommission Expires Jan. 31, 2005
Signature of person takffig acknowledgment
THIS INSTRUMENT WAS DRAFTED BY Tax Statements should be sent to:
WAYNE D. ANDERSON Daniel Peller & Marybeth Peller
ATTORNEY AT LAW Wis.ID#1028273 1575 B Clemson Drive
106 S. MAIN STREET - P.O. BOX 18 Eagan, Minnesota 55122
STILLWATER, MN 55082
(651) 439 -4697
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