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Home My WebLink About032-2147-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420719 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: Larson, Bruce Somerset Township 032- 2147 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /00 d Q- D 1 :W b PV 15.31.19.1290 TANK INFORMATION ELEVATION DAT TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r 2 Q BenchmarJQ 1n^ Dosing A It. BM A ' 6 5 ' svy- / - ! 30 Aeration Bldg. Sewer Covovv_ a:& 12c1 -(0 S; 9 1 2 3 -_7 " --- Holding St/Ht Inlet 3.30 TANK SETBACK INFORMATION St/Ht outlet 12 3 0 TANK TO /L WE L BLDG. Vent to Air Intake ROAD Dt Inlet / .r Septic �r +-I �� Dt Bottom Dosing ader /Man. Aeration Dist. Pipe 1 Holding Bot. System (� 1, ( . PUMP /SIPHON INFORMATION Final Grade 3• D / l) /• ��' Manufacturer Demand St Cover Model Number M T� P• IB 1'LI 1 I � -► � 1 - I C� v TDH Lift N System Head TDH Ft i ? Z t6 5 / _ 0 13 .1 Forcemai ength Dist. t SOIL ABSORPTION SYSTEM ' BEDITRENCH Width r Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS V - Z_ SETBACK SYSTEM TO P/L 0 JBLDG WELL LAKE /STREAM LEACHIN Manufacturer / ./ INFORMATION CHAMBER �A 7 ► • �� l _ Typ f System: ��-- //�� l ! / UNIT Model Number: L, fid ► l `1 }2� �2 DISTRIBUTION SYSTEM / q Header /Manifold Distribution1�� 1 . (, x Hole Size x Hole Spacing Vent to Air Intake Pipes) �!SU1 l / Length — Di a Length Dia pacing lit 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 �� r x ,jry,� Bed/Trench Edges Topsoil ] Yes [ No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: S / 2 / Inspection #2: Location: 2132 54th St Somerset, 7 W�l 54025 (NE 1/4 SW 1/4 15 T31N R19W) Oak Haven Lot 19 Parcel No: 15.31.19.1290 1.) Alt BM Description = S I t��t l�ov .�l�l �h 5 :; 4z e C .L �-P�S/�� 2.) Bldg sewer length =� J G JL'^- ti /GZL - amount of cover = // (fit - / - a Plan revision Required? [, Yes Use other side for additional information. ._ i SBD -6710 (R.3/97) Date � 1.prtes se Sigma ure Cert. No. Safety and Buildings Division County 1 fisponsin 201 W. Washington Ave., P.O. Box 7162 �� C 12b ))c Madison, WI 53707 - 7162 Site Address Department of Commerce 2,1.3a 5 S Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision 1 /.20 7 may be used for secondary purposes Privac Law, s15.04 (1)(m I. Application Information - Please Print All `fRECEIVED State Plan I.D. Number Property Owner's Name Parcel Number EKE LA?sw FEB 2 8 2003 )3Z a,iy 0 -o Property Owner's Mailing Address Property Location Propy ST. CROIX COUNTY L SID u 148 T/hkwjz_LA )c L!sP_IV9 ZONING OFFICE Al 'k Sv✓ S 1S T2 N, R I City, State Zip Code Phone Number Lot Number Block Number Subdivision Name CSM Number SAM �sET W/ s��ozs ��,s� - ZLi�_ sr� bflK t(flV�nl — II. Type of Building (Check all that apply.) QJI. 31 ❑City -1 or 2 Family Dwelling - Number of Bedrooms ❑ Village ❑ Public/Commercial - Describe Use / , / 0, Townshi Sd � I'Sgr ❑ State Owned Z 7� fi�fh Piet ` Nearest Road M. Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B, if applicable.) A. �g New 2 ❑Re 3 ❑ Replacement of 6 13 Addition to System placement System Tank Onl Existing System For County use B ' ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of POWT System: (Check all that apply. Numbering is for intemal use.) E�S 3 1. / CiiyYt l 44M, Non - Pressurized In- Ground 21 ❑ 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 Treatment Unit 49 11 , Recirculating 30 13 Other V. Dis ersal /Treatment Area Information: rA1Jr1#�h2L7 I I.St llflfl�tflRS = Z Design Flow (gpd) Dispersal Area Dispe Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals. /Days/Sq.Ft.) (Min./Imch) V Elevation 1 160 - 7 .- VI. Tank Info Capacity in Total Number Manufacturer Prefab - Site Steel Fiber Plastic Gallons Gallons of Tanks �,� Q , / Concrete Constructed Glass New Existing V)12 t /7 l l� Tanks Tanks y •/ Septic or Holding Tank 1Z � lZ / 10 1 I /i�- ja Dosing Chamber L (o V VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's natur // MP/ umber Business Phone Number __TEF F, calltw U' Zz3Z`12- `"7 Z7 /y1 Plumber's Address (Street, City, State, Zip itodtW Po. Roy- `Lq_, bRC_K�C_i _ W( 5 VOD9 VIII. ownty /De artment Use Onl LJ Disapproved Date Issued I mg A t Signature o tamps) ❑ Sanitary Permit Fee (i cludes Groundwater Approved Owner Given Initial Adverse Surcharge Fee) �� S 3 CI 3 Determination q IX. Conditions of Approve for Disapproval 0 '7 Attach complete plans (to the County, nly) for the system on paper not less tOh 81/2 x 11 hiches in size �'Ia,�t�av► c�l.�.,�� /��un� 0 ►1 �n��, Co 7,,t� 8 3. 3--T SBD -6398 (R. 05101) I v Q N p o / \ 2 Uli I NI r i 55 _ _ 3 V) � F- ®v o _off= z - zZ -� 3 zz m 4 -H N ro m s s � y '0 Z Z � M n r 4 J `� V ST •i � - � s • �..: f MA •• . • i ce - - WADW ILI - r II ILV ft • . iii � Y 1 • �, , � � 1 It L • 4 . � V 7T . t � 399 fi db MA _R7 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings 0134- S -Jt S ?� in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must St. r X horizontal reference point BM direction and _ include but not limited to: vertical and hon re ere Parcel I . D . 2 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 1r, --v - l 4 �C� Please print all information. le by Date Personal information you provide may be used for second ry purposes (Privacy Law, s. 15.04 (1) (m)). �3 Property Owner Property Locatio o 12- Jd Govt. Lot NE 1/4 SW 1/4 S 1 T 3 1 N R 19 f,)(or) W Ct- - ra 1 (1 T - qm i i- h/ vuA't &±� . Property Owner's Mailing Addre Lot # Block # Subd. Name or CSM# 190 th, Ave. 19 na Oak Haven City State Zip Code Phone Number ❑ City ❑ Village X❑ Town Nearest Road Elk RiverA MNI 55330 (614 441 -8888 Somerset 210th Ave. ✓ jj] New Construction Use: Ek Residential / Number of bedrooms 4 Code derived design flow rate '6 0 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material pu t- wa -h Flood Plain elevation if applicable % r ": 1 D r ft. General comments and recommendations: ( J U F. trenches @ el. 97.03 spaced to code 3.00' below grade, ST (;Rax COUNTY RM Boring zol Boring # ® Pit Ground surface elev. 100.0 Depth to limiting factor +96 in /_,\` Soil4 tion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roo GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 none sl 2mgr mvfr gw if .5 .9 7 5 r4 6 none ms osg ml na na .7 1.2 q7. 3 Boring # F1 Boring to limiting factor Boring 100.20 +86 2 Pit Ground surface elev. ft. 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 *Eff#2 sl 2m r mvfr gw 1f *9 -74 7 5 r4 none ms osg . mvfr gw na 7 1.2 no ne fs osg mvfr na na •4 *6 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L Wt #2 = BOD < 0 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature ST Number Gar L. Steel 02298 Address �EEal&ation ConEdu6ted Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -2 -2001 715 - 246 -6200 pend Page 2 of Property Owner Gerald J. S mith Parcel ID # _ --- --3— F -31 Boring # I —I Boring u€ Pit Ground surface elev. 96 ft. Depth to limiting factor +90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fY in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 1 0 -4 1Oyr 4/4 none S1 2mgr mvfr gw if .5 .9 F-1 Boring # ❑ Boring — ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A plication 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 F1 E] Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit 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 `Eff#2 < Effluent #2 = BOD < 30 m /L and TSS < 30 m L _ > < 220 m Land TSS >30 150 m !L ` Efflu _ g 9/ 'Effluent #1 BOD 30 _ 9 s 5 — g/ — 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 /00) e Property Owner Gerald J- S mith Parcel ID # pending Page – 2 —of - - Boring # ❑ Boring a Q pit Ground surface elev. 96.60 ft. Depth to limiting factor +90 in. sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 I `Eff#2 1 0 -4 10yr 4/4 none S1 2mgr mvfr gw if .5 .9 F] 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/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 I `Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil licetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/If In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 Effluent #1 = BOD, > 30:5 220 mg/L and TSS >30 5 150 mg/L ` Effluent #2 = BOD, < 30 mg& 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.6100) r c , v � STEEL'S SOIL SERVICE Gary L. Steel I Gerald J. Smith 1554 200th Ave. CSTM2298 NE'SW' S15- T31N -R19W New Richmond, WI 54017 MPRSW -3254 town of Somerset (715) 246 -6200 lot #19 -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 1 =40' BM.= top of 1" pvc pipe @ el. 100.00' Alt. BM.= top of 1" pvc pipe @ el. 101.90' M o� �� 4- 0 1� m Gary L. Steel 6 -2 -2001 02/'26/2003 16;42 7152473638 BELISLE EXCAVATING I PAGE 01 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer RPVZZ Z-A)Qe Cf Mailing Address ��R - 17ME0 — ZLAkJr bA1L :; Property Address (Verification required fram Planning Department for new construction) City/Stat; W/ Parcel Identifications Number 6:12 - a 1qZ `10 00 LF.GA, r .. ESC QN Property Location 9F 1/4, & W y;, Sec. S T 2j N _R 9 W, Town of SQA6E&S:2L Subdivision Nk , Lot # /9 Certified Survey Map # , Volume f Page # Warranty peed #a9 of ,Volume !'a . ".� gc # Spec house C1 yes no Lot lines identifiable V" yes Cl no S_YFT I ENTAN Improper use and mairrtenar,ceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank ever; three years or sooner, if needed by a licensed pumper. What you put into the. system can affect the function of the selftic 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 masterplumber, journeyman plumber, restricted plumber or a licensed ptunper 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 t$rtk is less than 113 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system. with the standards act forth, herein, as set by the Departtnert of Commerce and the Department of Natural Resources, State of Wisconsin. Certification storing that your septic system has been maintained trust be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT -- -�—='^ DATE 4WNE) !CERTIFIC4,T10N • I (we) certify that all statements on thus 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, SIGNATURE OF APPLICANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. • *• + ++ *+ Include with this application: a starnprd warranty deed from the Register of Dccds office 2 copy Of the certified survey map if reference is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page � of FILE INFORMATION SYSTEM SPECIFICATIONS Owner RKoe'r LtI Ro Septic Tank Capacity al ❑ NA Permit # "T Z� 1 Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS 1 Effluent Filter Manufacturer LC ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A- 10 ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal NA Estimated flow (average) yet gal /day Pump Tank Manufacturer ;&NA Design flow (peak), (Estimated x 1.5) 61 gal /day Pump Manufacturer IA NA Soil Application Rate ,7 gal/day/ft' Pump Model Ri NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit " 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: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) :530 mg /L X Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) _ :30 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 51 W 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'., I L Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA :Kx ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Ins Inspect dispersal cell(s) At least once eve ❑ month(s) (Maximum 3 years) ❑ NA P P every: years) ❑ month(s) ❑ NA Clean effluent filter At least once every: - Z IXy ear(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) 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, 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. GMW (4/01) L �. B Page — Z'-0f UP AND OPERATION ' For new construction, prior to use of the POWTS check treatment tank(sl 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 outatges 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 Se to a Servicing P A 9 9 P • 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 p 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. �al �inal not been a to ify a itable replacement ea. Upon fai PO te l he sr st be pe rmed t o able lacement a. If ent area is available a holding tank a last resort to r the failed PO ❑ 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 POWTS MAINTAINER Name Name Phone S 2 31 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name C o&tW Y Phone Phone $-- This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(OW and 83.5411). (2) & (3). Wisconsin Administrative Code. J 1' 29`1 ilf STATE BAR OF WISCONSIN FORM 2- 1999 8 3 x 9 2 WARRANTY DEED KATHLEEN H. WALSH Document Number ST. CROIXOGo. , W I This Deed, made between F orest Oaks Condos, In RECEIVED FOR RECORD - 07- 02-2002 11:00 AN RWJM DEED Grantor, and Bruc J. Larson and Kelly K. Larson, husband and EXEMPT i) wife, _ _ REC FEE: 11.00 TRANS FEE: 131.70 _... __.. COPY FEE: CERT COPY FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of isconsin (if more space is needed, please attach addendum): Recording Area Lot 19, Plat f Oak Haven, Town of Somerset, St. Croix County, Wisconsin. Name and Return Address rt► Pt 032. 2147 -90 -000 _ Parcel Identification Number (PIN) This is not - homestead property. (X) (is not) Exceptions ryt�o warranties: Easements, restrictions and rights -of -way of record, if any. Dated this _ v d ` ay of _June _ _ 2002 Forest Oa Condos, In • Gerald J. Smith, Pr ident AUTHENTICATION « ACKNOWLEDGMENT Signature(s) Forest Oaks Co Inc., by Gerald J. Smith, STATE OF WISCONSIN ) President, ) ss. 7 _ County ) authenticat d th' day of June 2002 Personally came before me this _ day of the above named « Kristin and 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.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY « Attorney Kristina Ogland __.......___ _ Notary Public, State of Wisconsin Hudson, WI 540 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ___ . __. _.._ I—. ___ •) « Names of persons signing in any capacity must be typed or printed below their signature. inrom,afion Proreasio is Comp". Fond du Lee, W WARRANTY DEED STATE BAR OF WISCONSIN aao455-2021 FORM No. 2 - 1999 02/26/ 2'003 10,42 7152473035 BELISLE EXCAVATI14G I PAGE 03 ` . .I........ oil i I � 1 I i I i i �p S Q F � � x 4 a of 25 */I As 3K1 -ivo 0 P4 X ?N/7 1, M I i SONb�� G311b'1dN11 s T L ] r