HomeMy WebLinkAbout032-2146-70-000 Safety and Building Division INSPECTION REPORT Sanitary Permit No 404921 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)].
City Village X Township Parcel Tax No:
Permit Holder's Name: 032- 2146 -70 -000
Carufel, Jon I Somerset Townshi
CST BM Elev: • � ' Insp. BM E`Elle : BM Description: W ` � '^'� 41_
l- = l
TANK INFORMATION
ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmar
Septic 1� Oro
Dosing �j✓ Alt. BM (_'i �� �� 2.`3 p ST f
Bldg. Sewer IA I �/�? o..gOt
Aeration (_
Holding St/Ht Inlet
St/Ht Outlet (' / (� , `f D •� a r
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Dt Bottom
Septic > SOi T 3
T der /Man.
Hea Q
Dosing
Aeration Dist. Pipe
Holding
Bot. System •SZ l� f
Final Gr de / c� S .46
PUMP /SIPHON INFORMATION G^
Manufac rer Demand St Cove I 'g a
M
Model Num r
TDH Lift ion Loss System Head H Ft
n Len Dia. Dist. to Well
Force 9
SOIL ORPTION SYSTEM
91!D Inside
Width Length No. Of Tre ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSI NS 3r 1 (015_
SETBACK SYSTEM TO /L BLDG WELL LAKE /STREAM LEACHING Manufact
INFORMATION CHAMBER OR
Type Of S stem: UNIT Model Number: �
DISTRIBUTION SYSTEM b Ste, P L
S acin Vent to Air Intake
Header /Manifold Lt Distribution x Hole Size x p g ' X I
Pi e(s) - 1 J
l l_ength - �r e llil
" ' Dia Lena Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only p
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
BedlTrench Center Bed/Trench Edges I Topsoil
Yes No Yes No ?�b
encies ersons resent, etc.) Inspection # � _Z�) In s pection ection #2:_
C -.; TS: (Include t�`(dD f.^t Y k--� dR= p present,
� No: 15.3 8
Location: 2129 554th Street Somerset, WI 54025 (SE 1/4 SW 1/4 15 T31N R19W) Oak Haven Lot 7 . _'�A.�j( r�00► .
S r(-1 S
1.) Alt BM Description = l � � •�
2.) Bldg sewer length
- amount of cover N,(&A4cLZ �
�
Plan revision Required? °_! Yes
Use other side for additional information �7� A� Cerl No.
Date Insepctor's Signature
SBD -6710
Safety and Buildings Division County
N v&consin 201 W. Washington Ave., P.O. Box 7162
Madison, WI 53707 - 7162 Site Address
Department of Commerce O /Le A # P' Ste.
Sanitary Permit Application , Sairi(ary Permit Number 2
In accord with Comm 83.21, Wis. Adm. Code, personal information onj f6vide Q'Gj k if Revision
may be used for secondary Privacy Law, s15.
I. Application Information - Please Print All Information State`,,P I.D. NuMLxr
t^
..:
Property Owner's Name arce ] hu"r IS 31. 1 q. 12
J ST CROtK
` OOUWTY " % 32 - 21 -arm
Property Owner's Mailing Address � O�C Location 7 �� _ 7 7 7
City, State Zip Code Phone Number Lot Number Block
Subdivision Name CSM Number
2�L -
S
H. Type of Building (check all that apply) ❑City
1 or 2 Family Dwelling - Number of Bedrooms — []Village
❑ Public /Commercial - Describe Use InTownship
❑ State Owned , I A R' t - (,� Nearest Road
2
M. Type of Permit: (Check only one box on line A (numbering scheme for intern use). Com lete line B if applicable)
A. 1 f9 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use
System Tank Only Exis ' S stem
B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply) (numbering scheme is for internal use)
44 14 Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic Trea nt Unit 49 ❑ Recirculating 30 ❑ Othe
V. D' ersaWMM atment Area Information: 4Z-le-2S
Design Flow (gpd) Dispersal Area Dispersal Ar Soil Application Percolation Rate in Elevation Final Grade
Required Proposed Rate(Gals./Days /Sq.Ft.) (Min./Inch) Elevation
VI. Tank Info Capacity in Total Number Manufacturof Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank _ _ _.X
Dosing Chamber -4-1
X /-
VII. Respopsibility Statement- I, the undersigned, a responsibility for installation of the POWTS shown on the attached plans.
Plum r' ame (Print) . Plumber's igna MP/MPRS Number Brysiness Phone Number
Pl is Address (Street, City, State, Zip Code)
VIII. County /De artment Use Onl VIII.
❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee) do
❑ Owner Given Initial Adverse p
Determination
T ondi ions OS�Ap — r val/ o� or Disapprovpl t
��n, ,^� nn 1 1 �.��z.w�,
Ste' tu- �! a-¢ Zo� W to t " ¢; w
plans (to the County ) fo thf a sy;tent on not less 8}fZ �
SBD 893-6 (R. 05101) S • i �'�"
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ of 3
• Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St. Cr 01X
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. din
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pending
Please print all information. iewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). r2
Property Owner Property Location
Gerald J . Smith Govt. Lot SE 1/4 SW 1/4 S 15 T 3 1 N R or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1116Q 190t Ave- 7 na Oak Haven
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Elk River MN 1 55330 ( 612) 441 -8888 1 Somerset _..,__210th. Ave.
® New Construction Use: ® Residential / Number of bedrooms 4 Code derived design flow,(at2 ` GPD
❑ Replacement ❑ Public or commercial - Describe: 7
'`
Parent material OutWash Flood Plain elevation if ap Ira e ! /Ca ft•
General comments
and recommendations: J (� , 1
F4 0
trenches @ el. 96.50', spaced to code 3.50' belwo grade'" ST`,;paX
COilN?y
2
❑ Boring
❑ Boring# 100.00 �, J ..._.- ,__... -; -�/
1 pit Ground surface elev. ft. Depth to limiting factor 90 --
_ 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
1 0 -12 10yr4/3 none sl 2mgr
mfr gw 1m .5 .9
2 12 -26 7 5 4 4 none is os ml GE if 7 1.2
Rlo •s
�{2
❑ Borin # Boring
g ® Pit Ground surface elev. 1 00.50 ft Depth to limiting factor 96 in.
2 Soil Application 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 I 'Eff#2
1 0 -35 7 5 4 4 none sl 2msbk mfr qw 1m 5 9
2 35 -45 7.5 4/4 stratified s1/1S 2csbk mvfr 9W 1m .5 .9
3 45 -96 7.5 4 6 none ms 0sq ml na na .7 1.2
S 8
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • E"02 = BOD VO mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Gary L. Steel Z. 02298
Address Date' ffvaluadon ConellIcted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 6 -6 -2001 715- 246 -6200
i
Property Owner Gerald J. Smith Parcel ID # _ pen n T Page 2 _ of 3
Boring # ❑ Boring 98.20 90
3 ® 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 /ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#,1 j 'Eff#2
1 0 -10 10 4 3 none sl 2mgr mfr gw 1m .5 .9
7 5 4 4 none is CIS9 ml 9W if .7 1.2
ms OSCI ml na na .7 1.2
Boring # ❑ Boring
❑ pit Ground surface elev. _ ft. Depth to limiting factor in.
Soil Ap lication 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
❑ El Pit Boring # ❑ 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 /ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 I `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
es services or
service provider and employer. If ou need assistance to access The Department of Commerce is an equal opportunity p Y
p Q
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.6 /00)
STEEL'S SOIL SERVICE
Gary L. Steel Gerald J. Smith 1554 200th Ave.
CSTM2298 SE4SW' S15- T31N -R19w New Richmond, WI 54017
MPRSW -3254 town of Somerset (715) 246 -6200
lot #7 -Oak Haven
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
_ '
top of mid -lot survey stake @ el.100.00'
, /alt. BM.= top of 1" pvc pipe @ el. 98.60'
i
i
3o7 $1716
Gary L. Steel
6 -6 -2001
I..8 43 PAGE 401 A
KATHLEEN H. MALSH
REGISTER OF DEEDS
ST. CROIX CO., NI
Document Number Document Title RECEIVED FOR RECORD
02 -26 -2082 2:l0 PM
St. Croix County ZgVIN6 AFFIDAVIT
EXEMPT #
Occupancy Affidavit REC FEE 11. 00
TRANS FEE:
COPY FEE: 2.00
J4 1j L CERT COPY FEE:
Name — (Owner) Typed or printed PAGES !
being duly sworn , states, under oath, that:
1. He/she is the owner /part owner of the following parcel of 1 located in St.
Croix County Wisconsin, recorded in Volume Page Document
Number St. Croix County Register of Dee s Office: Recoroin Area
Name and Return Address
A parcel of land located in th SA '/, of thesd' /, of Section ,G�, Sip �,,H sf-
T // N - R /! 2 W, Town of ,S ,y 5 - )� , St. Croix
County, Wisconsin, being duly described as follows (include lot no. and
subdivision/CSM or detailed legal description):
400 D tK �- veyi o3z /o 8o-Qao
Parcel Id Number (PIN)
03,�- - /o yo -
As owner of the above described property, I acknowledge that the septic system serving this esidence is sized for a
bedroom home, or a design flow of gpd. The design flow is calculated by assuming 150 gpd for Z
individuals per bedroom. There are currently _ occupants living in this residence; _,6_ occupants are permitted
based on the design flow. Therefore the septic system serving this residence is code compliant. However, I
understand that if there are intentions to exceed the number of permitted occupants, the system will need to be
modified to accomodate any increased wastewater flows and /or contaminant loads. I also acknowledge that I will make
this information available to any future parties interested in purchasing this property.
Dated this - - 9- 0 day of
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
)ss.
authenitcated this day of St. Croix County. )
Personally came before me this day of c° y
G d Z the above named
* oJo h (t o. k �ej
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) ��� t 1 �� instrument and acknowledge the same.
THI INST MENT WAS DRAFTED BY y1 .• I�
)ash
Q ' J u/�lsti
�• � um� / eew
O J Notary Public, State of Wisconsin
(Signatures may be authenticated or acknowledged. 'both afinotQ �` My Commissi n i permanent. If not, state expiration date:
necessary.) Date: ?�
"THIS PAGE IS PART O Hf8 L AL'DOCUMENT — DO NOT REMOVE"
This information must be completed by submitter.• document title. name & return address. and PIN (if required). Other information such as the
granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the
document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517.
POWTS OWNER'S MANUAL a MANAGEMENT PLAN Page / of 12
FILE, INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity 1 1115 ga l ❑ NA
Permit # Septic Tank Manufacturer °,� S ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms D NA. Effluent Filter Model ❑ NA
Number of Commercial Units _�9 NA Pump Tank Capacity gal 1a NA
Estimated flow (average) gal /day Pump Tank Manufacturer J2rNA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer 1.5) Z NA
Soil Application Rate gal /day /ft' Pump Model -I!9 NA
Influent/Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil 8t Grease (FOG) :_30 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODs) x220 mg/L ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) x150 mg/L ❑Disinfection ❑Other:
Manufacturer
Pretreated Effluent Quality ' ❑ NA Monthly average ** Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) <30 mg/L it In- ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) s30 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100m1 ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size � inch diameter
* Values typical for domestic (non - commercial) 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 .9 year(s) (Maximum 3 yrs. )
Pump out contents of tank(s) When combined sludge and scum equals one -third (A) of tank volume
Inspect dispersal cell(s) At least once every ❑ months M year(s) (Maximum 3 yrs.)
Clean effluent fliter At least once every ❑ months 0 year(s)
Inspect pump, pump controls ax.alarm At least once every ❑ months ❑ year(s) 12 NA
Flush laterals and pressure test At least once every ❑ months ❑ year(s) 19 NA
Other At least once every ❑ months ❑ year(s) .® NA
other. At least once every ❑ months ❑ year(s) 0 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Maste
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 (Ys) 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, pretreatement 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 chemical
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 sentage servicing opera paor to use,
Pile ' _�2 of
System start up shal not occur when soil condltivns are frown at Ow InfuVadve surface.
During power outages pump tanks may 1`111 above normal highwater levels. When power Is restored the excess wastewater will t)v
discharged to the dispersal cell(s) In one large dose, overloading the cells) and may result In the backup or surface discharge of
effluent. To avoid this situat,lon have the contents; of the pump tank removed by a Sepwp Servicing Operator prior to resto' n.
power to the effluent pump or contact a Plumber or POWTS Malnulner to assist In manually operating the pump controls to
restore ncimai levels within the pump lank,
Do not drive or park vehicles over sinks and dispersal cells, Do not drive or park over, or otherwise dlswrb or compact, the Area
within 15 feet down slope of any mound or at-trade soli absorption area.
Reduc(lon or elimination of the following from the wastewater strearn may Improve the performance and prolong the life of c-N
POWTS: antibiotics; baby wipes; cigarette butu; condoms; cotton swabs; degreasers; dental floss; dlapers; dlslnfecunu; fat;
foundation drain tsump pump) water; fruit and vegetable peelings; gasoNne; grease; herbiddes; meat scraps; mvdicatiuns; oii,
Painting eroducts; uesucldes: sanitary napkins u mpons; And water softener brine,
A6ANDONEMENT
When the POWTS fails and /or Is permanently taken out of service the following steps shall be taken to Insure that the system o
properly and safely abandoned In comptlance with ch, Comm 83,33, Wisconsln Administrative Coda
• All piping to sinks and pits shall be disconnected and the abandoned pipe openings scaled,
• The cvntenu of all tanks and pits shall be removed and properly citspowd of by a Septage Servicing Operator,
• Aner purnpint, all tanks and piu shall be excavated And removed or their covers removed and the void space filled w;lr
soil, gravel or another Inert solid matrrial.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be uken, W provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be udlhed for the location of a replacement soil absorption
system, The replacement area should be protected from disturbance and compactlon and should not be Infringed upot
requlred setbacks from existing and proposed strvcwre, lot (Ines and wells. Failure to protect the replacement area wil;
result In the need for a new soil and site evaluation to escabllsh a suitable replacement area, Replacement systvms rnwt
comply with the rules In effect at that drne,
0 A suluble replacement are 4 not available due to setback and /or soil limlut,lons. Barring advances in POW $ wchnolo,
a holding tank may be Insulted as a last resort to replace the failed POWTS,
0 The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and situ
evaluation must be performed to locate a suluble replacement arta, If no replacement area Is available a holding unk r-,
be insulted as a last resort to replace the failed POWTS.
O Mound and it-grade soil absorption systems may be reconstructed In place following removal of the biomat at the
InflluaQve surface. Rv<onstruaIotu 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 TK-9 INTERIOR OF A TANK MAY 6E DIFFICULT OR
ImpntclRI c.
ADDITIONAL COMMENTS
I
POWTS INST L R ' POWTS MAINTAINER
Name N ame
Phone r PAM
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL R GULA TORY AUTHORITY
Name /rncy
Phnn�
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer �� (4gAA'FeC,
Mailing Address /2 C'4t"La(_f-fi LA C
Property Address a l D ✓
(Verification required from Planning Department for new construction)
City /State 5 Parcel Identification Number o32- Z /�10- : 7 0 "cm
s Cd25"
LE GAL DESCRIPTION
Property Location_ Y4, ' /a, Sec, _L,;;L T / _ N -R_Zj_W, Town of
Subdivision
Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume -,17 , Page # !2
Spec house O yes 4 no Lot lines identifiable 0 yes O no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper, What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
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 /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of a three year expir ion date.
�� 2 // /vz_
SIGNATURE OF AYVLICANT DATE
OWNER 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office.
/
SI ATURE PPLICANT DATE
* * * * ** 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
�L 1786FE 19
664626
STATE BAR OF WISCONSIN FORM 2 -1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Forest Oaks Con Inc. RECEIVED FOR RECORD
12 -10 -2001 9:30 AM
-- — WARRANTY DEED
EXENPT i1
Grantor, and Jon C. Carufel and Jen M. Carufel, husband an CERT COPY FEE:
wire __ i:P` FEE:
---- - - - - -- 'ANSFER FEE: 122.70
FEE: 11.00
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix — _ County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 7, A Haven, Town of Somerset, St. Croix County, Wisconsin. Name and Return Address
WESTconsin Credit Union 0
P.O. Box 269
New Richmond, Wi. 54017
Ptof032 -1043- 80-000 & 032 - 1043 -40 -
Parcel Identification Number (PIN)
This is not — homestead property.
%) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this _ day of _ November — 2001
Forest Oa Condos e.
y — - - -- _ - - - • Gerald J. Condos
eaide —.—
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) Forest Oaks Condo Inc., by Gerald Smith, ) ss.
--
President, _ — _ County )
authenticaVdt is ay of Nove Personally came before me this _ day of
_ the above named
• Kristine Ogland _ — __._ —,.— —. —._- - -l _ - - -- -- --
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing
(if not, _ _ _ __ - instrument and acknowledged the same.
authorized by p 706.06. W is. Stats.) THIS INSTRUMENT WAS DRAFTED BY — . - - - --
Attorney Kri stine Ogl and _ Notary Public, State of Wisconsin
Hudson, W 5 — _ - -- My Commission is permanent. (If not, state expiration dat
(Signatures may be authenticated or acknowledged. Both are not necessary.) — —
IrdwMatio praNSs p
lonsls Comwy, Farad du Lao, W1
+ Names of persons signing in any capacity must be typed or printed below their signature. 900465.2021
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1999
o
I I '
i
- - - - -- - -- .
- 208.78 - -208.78' -
NMI '50•w 1491.8 ._ , — — —
w
• -- - - --- 212.03' - - -- - - 212.37'-
I
• I I
........ .............. ...... ...............1...............
N
O
v �
s N a
1
V
21202' � �
212.36'
UNPLATTED LANDS