HomeMy WebLinkAbout032-2174-28-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety; and Building Division
' INSPECTION REPORT Sanitary Permit No:
488181
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:
Grand Properties L.P. Somerset, Town of 032-2174-28-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/QU OA GST 22.31.19.1483
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER A11:5 CAPACITY STATION BS HI FS ELEV.
Septic
~6~•s -4 5 Benchmark z• d /62,
Dosing ' - $ Alt. B Gam ~p (~5
.3 r✓
Aeration Bldg. Sewer q yr
J /b.J~l
Holding St/Ht Inlet
lh9?3 . a_7
TANK SETBACK INFORMATION SVHt Outlet IZ. ZS
1 1.75
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet lZ, qq 11-5('
Septic Z_-7 / Z7 cJ C / 35 / ___N DtBottom 1s.75
to . ZT
Dosing z-71 -7 / 35 / 35 / Header/Man. 377
Aeration Dist. Pipe 5.63 94 .37
Holding Bot. System .7 C. Z
Final Grade J
PUMP/SIPHON INFORMATION .7 97. Z'$
Manufacturer Demand St Cover ~!7 .35 Q
GPM
Model Number 1'4~6 34L., 65
TDH Lift Friction Loss System Hgd TDH ZFt Z. C>
Forcemain Length Dia. #1 Dist. to Well
/Sb Z
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /Gip Z ' /elv Z~]
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: n f
INFORMATION CHAMBER OR 26 Lit
Type Of System: ~ z (t UNIT Model Number:
Co 0'..u 4, a 6 ^ r :3 t
DISTRIBUTION SYSTEM Zp t-Zf~- 47(0
Header/Manifo~ r f Distribution x Hole Size x Hole Spacing Vent to Aiq[ntal~
Pipe(s) - /
Length Dia Length` Dia Spacing e, __if I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over / Depth Over xx Depth of xx Seeded/Sodded jxx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Z \ Yes 2 No as No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / /
Location: 2011 57th St Somerset, WI 54025 (SW 1/4 SE 1/4 22 T31 N R1 9W) River Hawk Ridge Lot 28 Parcel No: 22.31.19.1483
1.) Alt BM Description= i
2.) Bldg sewer length = 3'j
- amount of cover = S /
Plan revision Required? Yes o I X I_ C
Use other side for additional informati n. [1Q~ v_,-C_J
SBD-6710 (R.3/97) Date A1nsepctoe Can. No.
~ i
kAll-
Safety and Buildings 1 0
m 201 W. Washington Ave., P.O. Box 71
,sConS,n Madison, WI 53707 7162 TSanPe,i.D. mit Number (to be filled in by Co.)
Department of Commerce (608) 266-315 0 / g /
Sanitary Permit Applieati Number
-
In accord with Comm 83.21, Wis. Adm. Code, personal informati ou pr ri~
may be used for secondary Purposes Privacy Law, s15.040 m) Nl P)oject ddress (if different than mailing address)
1. Application Information - Please Print All Information
- r
~a Z/
Property Owner's Name Parce # Lot # Block #
Property Owner's Mailing Address Property Location
City, State-ip Code Phone Number -%y Section Si
circle one)
f~ a `y
T z N; R E or W
H. Type of Building (check all that apply.)
1 or 2 Family Dwelling - Number of Bedrooms < S Subdivision Name P41ot2aw1 per
❑ Public/Commercial - Describe Use 4~~Z e, r
❑ State Owned - Describe Use ❑City ❑ Vi lags O4 ownship of,
IIL Type of Permit: (Check only one bog on line A. Complete line B if applicable)
9 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other modification to Existing System
B. El Permit Renewal 11 Permit Revision ❑ Change of El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
JX 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 ❑
Recirculating Synthetic Media Filter Leaching Chamber Drip ine ❑ Gravel-less Pipe ❑ Other ( in)
V. Dispersal/Treatment Area Information: (2)1 L5A. S ~e CQ-A
t
Design Flow (gpd) Design Soil Application Rate(gpdsf) persal Area Required (sf) Dispersal Area Proposed (sf) yttem Elevation
® G~ ) _
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New E;dstms
Tars Tanks
Septic or Holding Tank G _
Aerobic Treatment Unit
Dosing Chamber /
VII. Respo sibility Statement- I, the undersigned, iiume responsibility for installation of the POWTS shown on the attached plans
Plumb ame ht Plum er's Si MP/MPRS Number Business one Number
Pl ber's ddress (Street, City tate, Zip C e)
VIII. Coun /De artment Use Onl
Approved ❑ D' Sanitary Permit Fee (includes Groundwater Date Issued i wing t Signature o Stamps)
Surcharge Fee) (6
1 41- pav- ❑ - en Reason or Denial
IX. Conditions A r preval
SYSTEM NER: 3) L M UU_A_k 1A W I R~-~-2~. v~,Q
1 S iPtic tank, effluent filter and S ~Q. j-~n~~^^ C",^^
dipersal cell must all be serviced / maintained]
as per management plan provided by plumber. GG f1
p P G~ 03 v.~ i kVAVW.
2. All Setback requirements must be maintained r; RIJ
as per applicable code/ordinances. TSB r t~
Attach complete plans (to the County only), for the system an paper not bm than 81/2 :11 inches in sim
SBD-6398 (R. 01/03)
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La ECEIVED
Wisconsin OepartmentofCommercC 1 2PRIL 11~ /ALUATION REPORT Page of
Division of Safety and Buildings
cordance with Comm $5, Wis. Adm. Code
()h County
Attach complete site plan on pape 1 ches if size. Plan must
include, but not limited to: vertical direction and
Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. a '~y,~ Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~iVv~ 1 61a
Property Owner Property Location
;Ialn /'5r//Y/1C7 /'5r//Y/1C7 Govt. Lot S LX)1/4, ,E1/4 S, T N R 9 R (or)(
Property ~ Owner's Maili Address Lot # Block # Sub Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
S6/'4t~rs Y62- 5 (752o^
[ New Construction Use:] Residential I Number of bedrooms Code derived design flow rate d~'0 GPD
❑ Replacement ❑ Public or commercial - Describe: ,Af
Parent material Flood Plain elevation if applicable /j//t ft.
General comments
and recommendations: oh C!~•~j2 0 S p/-rk Y
WA( N-J
M Boring # ❑ Boring C er Ure( 45b-pti&
~t7 -45
® Pit Ground surface elev. / ft. Depth to limiting factor \ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure C nsistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
l DYE iz AIX ZS 112,1,4 6"--- c w D~ j, 2
12-;& iZ aF~ ce s 144 -)C4 -7 QV V lS LG16lc v F~ ce J ~v 0 02
4 6 ,S"L
20`1 w-~ pis s~t
® Boring # ❑ Boring
® Pit Ground surface elev. 9Z. 9 ft. Depth to limiting factor -4~bG 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
! a-ll /a~~3/z ~ S~ `2r1s 6~ m~~~ c L-- lrz D 9
2
~
5Z- 2 r1sik
7 7, S7/W i' /v G. c a6 017 J A lag 0,-7 1,2
5 ~=6G 7s.. S ZS 0,7 /02
6 6-y() 2,sY S 2, 0,~.
30
' E uent #14& BOD5 > 30 < 220 mg/L and TSS >30 150 mg/L 7 ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signat CST Number
r 'u Cl/ i Z3 13 1q
Address Date Evaluation Conducted Telephone Number
3 9L~ /~Z ~ ~ e So/1-~ tvrs t ~2- /s 3 ~S= ZY7- ,32-03
SBD-8330 (R07/00)
Property Owner r6i -le Parcel ID # Page of
a Boring # ❑ Boring
® Pit Ground surface elev. ft. Depth to limiting factor S6 in.
Sal 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
D__ -3/2 A, F. C W Yt, i 11 Of q
3 3y D/`; % /Y~ 0,-5- Of y
39 5-6 7s, L Z s 0, 1.
s- 6-7 2,srlf c2 ~Y~SiZ S'i~ D fr - O,O D'a
❑ 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/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 -Eff#2
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/112
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 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)
I
Frye- 3o 3
'Name .1-orn Bl 'I/e cs , 9 313/ y
Address (/,?F-
Date ~ oZ~ lS- D>
Bench .ma:- 160, o Vo,V T~ enc e Oc -6j, ~5 G ~'•ie
Bend?n?ai~'_c ?
%3. Top iyal /-0"-
Soil
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S uilaC1C a r•_°a
F= 40 ' Scale
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Dose Tank Information Locking cover with warning
label and locking device and
sealed watertight
Electrical as per NEC 300 and No Comm 16.28 WAC 4 in. min.
Disconnect _
Tank component is properly vented E-- Alternate outlet
location
Forcemain diameter
1.4 Manufacturer 2 in.
Capacity 800.00 Gallons
Volume 21.76 gal/inch A
_ Weep hole or anti-
Dimension Inches Gallons B siphon device
A C
B Pump off elevation (ft)
D_
D
Total
D .
Dose tank elevation
Alarm Manuafacturer~
Alarm Model Number
Pump Manufacturer f s
Pump Model Number L
Pump Must Deliver C~ cjpm at ft TDH
/go -may 3~
~-~2 77-2
S~Y- 156 moo
I
41 f
Performance uocnersioje tmueni
Gu rves Pumps
'ALTERS FEET
t MODEL 3885
z5 - SIZE 0/4" Solids
WE1SH
70
?0 WE IOH "
wE07H
i s 60
40 WE0SH
i
10 ~wE03m
---f I
S
10
I
7
o u
0 10 20 9b q0 S 6 ~G bG 90 100 110 120 GPM
Q 10 ~J 50 m'ih
CAPACITY
ANN" Adollow
MGOULDS PUMPS, INC,
wpl C FMS hew Yck 13A 6
METER$ FEET
120 MODEL 3885
_ - SIZE '/4 Solids
10 WEISHH
r,
a v C I
so
70
20 --t-
60
O ~.b..... I . ..tip. I. _i«.._}~_.. ....p.
~ WE06Hrt _
40
1p 1
1-7 -1
0 I 20 90 4U .7. '60 70 60 OQ 100 110 120 0%d
ru..., , .
p _ 20 x min,
t !?8S Oeu~cf Pvmp~, Ir.; Enrow# vv,, a>
: POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity gal ❑ NA
Permit #
Septic Tank Manufacturer S ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ;01014 0 NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units 0,NA Pump Tank Capacity gal ❑ NA
Estimated flow (average) gal/day Pump Tank Manufacturer 1 ❑ NA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ❑ NA
Soil Application Rate gal/day/ftz Pump Model G - 5ZZ'/- ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ONA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 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 (BODS) 530 mg/L AIn-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L /i~ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Y8 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: O month(s) (Maximum 3 years) ❑ NA
EY-year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Oyear(s)
Clean effluent filter At least once every: 11 month(s) ❑ NA
~ 1ff year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
JZFyear(s)
Flush laterals and pressure test At least once every: ❑ month(s) ANA
❑ 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 (Y3) 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,
I 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
START UP AND OPERATION Page CI-2 of
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 ar
of the tank(s) removed by a septage servicing operator prior to use, a detected have the contents
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 Servicin O erator
power to the effluent um or 9 P prior to restoring
p um p t o 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; painting products; pesticides; sanitary napkins; tampons; and water softener brine grease; herbicides, meat scraps; medications; oil;
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:
,0~/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
i
POWTS INSTALLIAII/ POWTS MAINTAINER
Name Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
EName Name
Phone Ste, _ 1
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.
ST CROIX COUNTY
SEPTIC "TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer C~Y' A1-`9 _ -r
cn'ip
Mailing Address '1 1-1-
Property. `ST" to r
Address ;),011
^ ? C
(Verification required from Planning Department for new construction)
City/State 'l'n~P r 4~ ll~ i Parcel Identification Number -,-,)/7/-28'-000
LEGAL DESCRIPTION
Pro era} Location, <jJ 4 T,3 N-R W, Town of-)o Mm> 1
subdivision 1 k I 0+ -A
Certified Survey Map , Volume , Page #
Warranty Deed # Volume,,-2,? ~ 7 -,Page l+2
Spec house A yes ❑ no Lot lines identifiable^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 syster
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, restrictedplumber 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 I/3 full of sludge.
I/wc, 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 Zotebtg office within 30
days oft three year expiation date.
Llcyt,~V- , 4'11w~ -
SI NATURE C(F APPLICANT DATE:
OWNER CERTIFICATION
I (we) certify that all statements (in this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pro" described ab ve, by virtue of a warranty deed recorded in Register of Deeds Office.
/ / al
SI NATURE 6r -.APPLICANT DATE
Rft4«•
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 (tic certified survey map if reference is made in the warranty deed
05/08/2006 MON 14:44 FAX 715 386 4687 ST CROIX CO REG OF DEEDS Q002/002
V 2837P 293 -7 g!5 10 A
State Bar of Wisconsin Form 2-2003 XATHLEEN H. YALSH
WARRANTY DEED ST. CROIXOCO ,EMI
Document Number DocumcntNamc RECEIVED FOR RECORD
07/86/2005 10:1501
VARRANTY DE=
THIS DEED, made between Progressive Estates. LI~C EMPT #
("Grantor;' whether one or more), REC FEE: 11.00
and Grand Pr9nerties, LP TRANS FEE: 898.50
("Grantee," whether one or more). COPY PEE:
CC FEE:
PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant Recotdmg Arta
interests, in St. Croix County, State of Wisconsin ("Property") (if more space
is needed, please attachh('%"dum): - Name and Return Address
Lots 21, 23, 24, 25, a 2~~8, River Hawk Ridge, St. Croix County, Wisconsin. Esfteen & dglgnd
304 Locust Street
Hudson, W164016
I SI
Port of:032-1875A0-t00 & Pan of. 932-1059-80.000
Pw=1 Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights-0f--way of record, ifany.
Dated t e7(e /7, 40-!~ _
y (N., d/ • e tJ c~;ar~ (SEAL) k (SEAL)
William E. Hawkins, Member * T auras )F. Belisle Mem er
SEAL aC' (SEAL)
* *Scott LaFavor, Member
By. Thomas.F. Belisle, Attorney-in-Fact
AUTHE14TICATION ACKNOWLEDGMENT
Signature(s) Progressive Estates, LLC
By: Willi m E. Hawkins, Member, Thomas 1F.Relidr, STATE OF )
Member and Scott abvor. Member ) ss.
COUNTY )
authenticated on
Personally came before me on
the above-named
*Kristins O Ian to me (mown to be the person(s) who executed the foregoing
TITLE; MEMBERS ATE BAR OF WISCONSIN instrument and acknowledged the same.
(If not,
authorized by Wis. Stat. g 706.06)
w
THIS INSTRUMENT DRAT: fED BY: Notary Public, State of
My Commission (is permanent) (expires:
Attorney Kona Ogland
Hudson, WI 54916
6
(Signatures may be authenticated or acknowledged. Both are not necessary-)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE C EARL
WARRANTY DEED O 2003 STATE BAR OF WISCONSIN
* Type name below signature6. INFO-PRO"' Leg
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