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HomeMy WebLinkAbout038-1192-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 453285 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 Permit Holder's Name: City Village X Township Parcel Tax No: Munson,Andy Star Prairie Township 038 - 1192 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: ii Section/Town /Range /Map No: 11.31.18.994 TANK INFORMATION If ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Z tV Benchmark ' /0/. J V Dosing Alt. BM Aeration Bldg. Se er 4 1 7 C16 Holding St/Ht Inlet '7 cr! cj TANK SETBACK INFORMATION St/Ht Outlet , 5. 1O - TA P TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � � � � � � � � � � Dt Bottom \ �_ Dosing Header /Man. 61-1-k � � `7 •� P.� Aeration Dist. Pipe 95. 1 (c • L `/4-9 Holding Bot. System 7- 93 19 o 7• � 9� Final Grade �7 PUMP /SIPHON INFORMATION Manufacturer D mand St Cover PM 2 . Model r mber TDH L Friction Loss Syste ad TDH Ft Forcemain Le Ia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches PIT IMENSIONS No. f Pits Ins' a Dia. Liquid Depth DIMENSIONS [,[ 7th GZ Z_ —te,��( h SETBACK SYSTEM TO P/L BLDG i WELL LAKE/STREAM LEACHING Manufacturer: i INFORMATION CHAMBER OR / Type Of System: lz� UNIT Model Number. DISTRIBUTION SYSTEM Z L 7a'oC Header /Man Distribution x Hole Size x Hole pacing Vent to Air O Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth o xx Seeded /Sodded xx Mulched Bed/Trench Center 3 (� Bed/Trench Edges Topsoil �{— No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2208 Cty HC Unknown (SE 1/4 SE 1/4 11 T31N R18W) Huntington Meadows Lot 10 Parcel No: 11.31.18.994 1.) Alt BM Description = -�� -- loo L+e--^,, 2.) Bldg sewer length = '33 �-� �'vw.3,� - amount of cover = e -- - - - - - -- Plan revision Required? I ;j Yes Y�No -, Use other side for additional informa SBD -6710 (R.3/97) Date Ins tor's ignature Cert. No. Safety and Buildings Division County L m m 201 W. Washington Ave., P.O. B 162 �J% = G 10 0 f �seons�n Madison, WI 53707 — 62 Sanitary Permit Number (to be filled in by Co.) (608) 266 -3151 /� 8 S Department of Commerce 1 State Plan I.D. Number Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code, personal i formation you provide may be used for secondary purposes Privacy La , s . Project Address (if different than mailing address) IVEn 1. Application Information - Please Print All Information # 212 C C Property Owner's Na Parcel # 9q Lot # _� ock # Q Aso a Property Own is Mailing Address Property Location �CNING OFFICE Section City fate Zip Code Phone Number rcle 2 Z /> TN; R! E o II. Type of Building (check all that apply) St bd'vision Name CSM Number �or 2 Family Dwelling — Number of Bedrooms i75' ❑ Public/Commercial — Describe Use / //t /4it ❑ State Owned - Describe Use a' 14 l ❑City_ ❑Village T wnship of�_ r'�( . 1II. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl �n - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil 11 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 Line ❑ Gravel -less Pipe V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) pets sed (sf) le !4 3.3a 7 VI. Tank Info Capacity in otal Number M ufacturer Pre a Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank .l Q ir Aerobic Treatment Unit - Dosing Chamber V11. Responsibility Statement- I, the undersigned, assume responsibilit or installation of the POWTS shown on the attached plans. Plum s Name (Print) Plumbe ' gnature MP/MPRS Number Business Phone Number um s Address (Street, City, State, Zip C VIII. Coun /De ari se Onl Approved ❑Disapproved Sanitary Permit Fe includes Groundwater Date Issued 1 uil Agent Signature o Stamps) Surcharge Fee) ❑ O iven Reason for Denial - IX. Conditions Approv / SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be eerviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not ices than 31/2 x 11 inches in size SBD -6398 (R. 01/03) it ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 7 n R t tt-) 9' /uNI nul Mailing Address Property Address 0, 4 Ch (Verification required from Planning Department for new construction.) City /State Parcel Identification Number 038 r t l ,t a - 6 - &og • vi �t y� LEGAL DESCRIPTION Property Location S '/4 , SE 1 / 4 , Sec. I, T 3 L_ N RAW, Town of S t a r Pro, r e- Subdivision 7y ��,1c �d., l�PCt �f ic , Lot # l If) . Certified Survey Map # , Volume , Page # Warranty Deed # a35 , Volume � ,53.3 , Page # ySf Spec house yes (0 Lot lines identifiable es 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. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County 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 Department m9iin 30 days of the three year expiration date. SIGNATURE OF APPLICANT 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 prop e crib d above, by virtue of a warranty deed recorded in Register of Deeds Office SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTMCATIO1 FORM _ ' 6 2 owner/Buyer h Mailing Address o? LJ Property Address o (Verification required from Planning Department for new construction) City /State Parcel Identification Number 0 -3 LEGAL DESCRIPTION r � Sec. m .SE ya, l . T 3l N -R W, Town of Property Location � /,, Subdivision Certified Survey Map # �— , Volume = Page # Warranty Deed # ,� 3 5 , Volume ��� Page #�� Spec house ❑ yes (T no Lot lines identifiable fi� 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 property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, 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 that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of th hree y expirati te. ffvim ,i �, wbda SI OF APP ICANT j) SE 5 DATE t V1 OWNER CERTIFICATION the owners) of I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) t above, a of a warranty deed recorded in Register of Deeds Office. / / D� APPLICANT DATE « « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Dep artment-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 o � l0 ��Gci►, / r � ��/ l � � c /�uJs l � e l l ly q Ad 1�eu o ok �s' r C v py � y l0 1�cc,oq / r / %�e c /outs 7 l r ll�a /Z 0 eq (i�5 V/ C � y Wisconsin Department of Commerce SOIL AND SITE EVALUATION 10vision of Safety and Buildings Page of Bureau of Integrated Services in accordance with m 83.09,,Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in a Plan must County include, but not limited to: vertical and horizontal reference oint W G�'d p ( j; ilir'ection / X ar`td � percent I p t s ope, scale or dimensions, north arrow, and location anditance to nearest road.:'.' Parcel I. D. # APPLICANT INFORMATION - Please print all infoAm8tion. Reviewed by Date Personal information you provide may be used for secondary purposes (PH v y law, S. 15.04 k1� (mJJ _ _ 7 0 Property Owner / '15606r'VLcpation Govt. Lot '1/4 - -1/4,S T& N,R E ( W Property Owner's Mailing/Address ' Cot :# Bl Subd. ame or C M# U Ci State Zip Code Phone Number ❑ City E] Villa a own Nearest Road lid x ��e O/ ( lam N11:;0 .�_Y'� 1 � f��-� E4-New Construction Use: .Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate �� bed, gpd/ft? trench, gpd /ft Absorption area required bed, ft 2 7 1 1�0 trench, ft Maximum design loading rate _ ,gy bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) ?9- 3 ft (as referred to site plan benchmark) Additional design /site considerations Parent material G- v Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system I 'ti�g ❑ U 'JfFS ❑ u ,E S ❑ U Ltg ❑ U ❑ S .29-U ❑ S 491U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots <z „u, in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench `..< h .d Ground el v. Depth to 9-1 limiting qz/ factor j Remarks: Boring # LAO 1 Ground elev n. '(• Depth o limiting factor in. Remarks: CST Name (Please Print) Signatur Telephone No. Add5W6 Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER � 6' E*"� Page of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground elev. Depth to limiting • Z g Z factor Remarks: Boring # r ��_ �► -7 v "t Ground 101, F elev Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ,)c �P Ground elev. Depth to S g} limiting factor 0 41n. Remarks: RorTng # [3 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -833,0 (R.9/98) • Soil Test Plot Plan Prc�lect Name /h Byron Bird Jr, Address P r�/ STM o�02 S 7 Lot l D Subdivision �t /4,-J;�r1 /4SZT�� N /13.5�W -,- Township I3oring O Well PL Property Line County BM or VRP Assum a tion 100 ft, System Elevation *HRP �� 9 kf rip 9 V Scale 1/4 = 10 Ft. Men Dimensions aren't stated POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner � Septic Tank Capacity �6 m a l ❑ NA Permit # Septic Tank Manufacturer �Gt ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units A Pump Tank Capacity al A Estimated flow (average) Pump Tank Manufacturer L�_NA gal/day Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer 1K-NA Soil Application Rate 7 al /day /ft2 Pump Model "A Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 'IKNA Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD _ <220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) _ <150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD _ <30 mg /L - 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 ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA years) Clean effluent filter At least once every: ❑ month(s) ❑ NA J- 4 - year(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ 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) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls► 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 I t resort to replace the failed POWTS. The site s of bee valuate identif a sui able rep cem nt area Up n failure f t e PO WT a soi and s t a ati mu t be erf rm o to ate suitable repla ent ar a. no rep cem t area av ' ble a holding tank may be install a [as ort to re ce the faile TS. • 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 c - 1f0/L Phone �� Phone SEPTAGE SERVICING OPERATOR (PM ER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer j'+ c/'�' e -. "' Mailing Address 02 G I G- �` ` S� o /7 Property Address O C� (Verification required from Planning Department for new construction) City /State Parcel Identification Number O 3 atrO LEGAL DESCRIPTION _ r , Property Location SC i/4, Sec. l . T �: N -R-2-2�W, Town of <' Subdivision l 7��c .� •? 50-t-8) ' © cy S , Lot # ' Certified Survey Map # �- , Volume Page # Warranty Deed # 7 D o 3 S , Volume r�. Page # ! ' 1 � Spec house 0 yes pr no Lot lines identifiable JX yes 0 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 mastorplumber, 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. 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 that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of th ; y :� expirati te. ' : SIG A OF APP ICANT j) 1� DATE OWNER CERTIFICATION 1 I (we) certi that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the ProPerW above, a of a warranty deed recorded in Register of Deeds Office. / - / 0 SIG ATURE 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 stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed r U 2553P 451 760235 STATE BAR OF WISCONSIN FORM 2 - 1999 WARRANTY DEED KATHLEEN H. WALSH Document Number REGISTER OF DEEDS ST. CROIX CO.. MI This Deed, made between CI1y Edin RECEIVED FOR RECORD and Andrew C. Munson Grantor, 04/21/2009 09:30AN Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXEWT # the wing described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00 (i ore s ace is needed, please attach addendum): TRANS FEE: $2.50 5 Lot 10, P at of Huntington Meadows. St. Croix County, Wisconsin. COPY FEE: CC FEE: PAGES: i Recording Area Name and Return Address get S CL, 1-� (C� c.J ��{ �' o 038 - 1192- 60-000 Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this 1 day of April _ 2004 - � -- - - -._— —� — —* clay i idin AUTHENTICATION ACKNOWLEDGMENT Signature(s) _ CA— (�p(�c STATE OF — } ) ss. t County ) authenticated this S�day of 1 -- -- � — — Personally came before me this day of April _ 2 004 the above named Clay Edin ----- - - - -- -- -- 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 Kristin Ogland Hudson, WI 54016 _ Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, Wl STATE BAR OF WISCONSIN 800 -655 -2021 WARRANTY DEED FORM No. 2 - 1999 • — — — — — — — _ O ,',�aa I}oaj �,looul ,LO'90S 3 « SS L£09 SV PQPio ,£t. N ` ��>, �J C73 40 ' ,00'Z� ,,£� I,££ +W ,9S' l6l A. J /O� .� loo 1N35PUSV7 - w '+ i - - - - \ \ s9 � �0 l .0" w w I L,0 99 J �`�6 ......I ....................3 «SS - OON ........... y�60 �y J ...a .................... �? I 1N3W3SV3 o •'. •.� O �1 8y U �VM3AIao LNio ,99 I Y o It o O�� _ O N p Q N N N �W I I N I N U W� II W OV / 00 M W W z> W 3 H a + A L yV W - M �- < N O ^M N J (^ 1 N all 0 oo z I I N 1 I W O + ,00'ZOZ ,00'6ZZ I Ito 3 «ZI,99.00N a� ,Ol'£6l 3 „SS,£ -k.00N _°0 3 „99,MOON • I n I W '� ,9L'lll ,b£'l8 1-: i I ``+ W v J I L44 W I "pp •U O> I N r U . Q r z j I z . ^� W W � W :� N I N V Cd Q In Q I O I Q l 00 d' d p a . 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