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Wisconsin Department of commerce PRIVATE SEWAGE SYSTEM County-
WW and Btilldings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) sanitamUrmitNo.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 3 03
Permit Holder's Name: ❑ City ❑ Village _EI Wwrtor State Plan ID No.:
M & G Inc., I Star Prairie Townshi
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax Nn
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S MD Benchmark O
Dosing Alt. BM �• O q. - 46 r
Aeration Bldg. Sewer I03. (3 r
Holding St /Ht Inlet ap ,
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet �--� ---�
Air Intake
Septic > 0 r / NA Dt Bottom
Dosing �NA Header /Man.
Aeration Dist. Pipe `� , E3 qb .91'
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade (0 ' 3° 100.3 -
Manufact mand S co 5
Model
Model Number GPM
TOH Friction m TDH Ft
Forcemain Length Dia. fist. To - w - e lt-
SOIL ABSORPTION SYSTE
t3EO ENC Width , Length No. enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 DIMEN I N
LEACHING Manu acturer: /
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM (¢�Q(o✓ SiaEewk
INFORMATION Type O CHAMBER M e Num er:
System: ( SBA (! r OR UNIT
t - r
DISTRIBUTION SYSTEM lD
Header / M ' fold Distribution Pipe(s) x Hole Size x Hole Spacing I Ventj o Air Intake
i
Length Q Dia. Dia. Spacing ~ 6 0
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 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes [I No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: / .2V/ C'Mispection #2:
Location: 822210th Avenue, Somers, , WI 54025 (SW 1/4 SW 1/4 18 T3 1N R1 8W) - 1831181072 Rolling Oaks -Lot 21
1.) Alt BM Description = 6a
2.) Bldg sewer length = t • t7
- amount of cover = $ '' {
Pi N o weQl! $�r t t t f�rxJ(JC� CA ( e 6 to KA
n revision re ulred? Yes No
Use other side for additional information.
SBD -6710 (R.3197) Date Inspector's Signature Cert. No.
.-0
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8 2Z - zp ' 15 AAe Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
14 SCOn. Personal information you provide may be used for secondan purposes Madison. WI 53707 -730^
Department of Commerce (Privacy Law, s. 15.04(1)(m)l .. (Submit completed form to county if r
state owner
Attach complete plans (to the count) copy only) for the S . &tern,- r,mol'j� than 8 - 1/2 x I I inches in size.
County n � State anitaryPe it Number ❑ Ch3r6Vi rpvision to previous application State Plan 1. D. Number I. Application Information - Please Print all Information 7
Location:
Property Owner Name Property Location
A
S 1/4 Sim 1 /4, S T ,N. R or
Property Owner's Mailing Address _ 3 �F !. Lot Number Block Number
/ Ci t y, State Zip Code n ne Nturber ; 1�. Subdiivvision Name � o rr• CSM Number
J /
.
II Type of Building: (check one) - RS P� y,. w ❑ City
)' 1 or 2 Family Dwelling -No. of Bedrooms: .3 _ ❑ Village
❑ Public/Commercial (describe use): ®Town of
❑ State -owned $ A ff
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 7 0 _
A) 1. 10 New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s)
System Tank Only Existing System
$) Permit Number Dak4nued-
❑ A Sanitary Permit was previously issued tr38 2tS .6 1!9. 8'. 1,D22—
IV. Type of POWT System: (Check all that apply) ( 00 Jg IA� 1
IN Non - pressurized In- ground ❑ Mound Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade r r ❑ erob'c Treatment Unit ❑ Recirculatin ❑ ther:
2 3 x 1(Q• �S" q �► 3�
V Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
to q3 v -� — .1
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
i 1 ❑ ❑ ❑ ❑ ❑
VII Responsibility Statement
1, the undersigned, assume res onsibilit installation of the POWTS shown on ched plans.
Plumber's Name (print) Pluj§berp Signature (nos 4=LRS No ) Business Phone Number
'S �S
Plumber's Address (Street, City, State, Zip Code)
Q ( - T
VIII County/Department se Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
IXApproved ❑ Owner Given Initial Adverse S harge Fee)
Determination po�oZs• o "
IX. Conditions of Approv l /Reasons for Disapproval•
A AA 5 -� 5 � �3,i ca Pa, t914-
SBD -6398 (R. 07/00)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
038 - 1077 -70 -000
Please print all information. viewed By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
M &G Inc Govt. Lot SW 1/4 SW 1/4 S 18 T 31 N R 18 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1359 Awatukee Trail 21 b f/, k
City State Zip Code Phone Number City I Village J Town Nearest Road
Hudson I WI 1 54016 1 715 - 549 - 5971 Star Prairie 210Th Ave.
_✓l New Construction Use: 16 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
I Replacement J Public or commercial - Describe:
Parent material Pitted glacial drift Flood plain elevation, if applicable NA
General comments
and recommendations: Conventional System. Possible system elevation 95.50'. (.4 g /sgft/day Rating)
M W1 Boring # I Boring
Pit Ground Surface elev. 100.00 ft. Depth to limiting factor 96 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
1 0 -8 10yr3 /3 none sil 2msbk mfr gw 2m .5 .8
2 8 -14 10yr4 /4 none sil 2fsbk mfr gw if .5
3 14 -30 7.5yr4/4 none scl 2fsbk mfr cvv - - - - -- .4 r�
4 30,84, 10yr5/4 none ms Osg ml cw - - - --- .7
9� 5 84 -96 7.5yr4/4 none sl 2msbk mfi - - -- - - - - -- .5 ,
Boring # -j Boring
lei Pit Ground Surface elev. 100.09 ft. Depth to limiting factor 9 6 in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Stnicture Consistence Boundary Roots GPD/ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -9 10yr3 /3 none sil 2mgr mfr gw 2m .5 .8
2 9 -19 10yr4/4 none sl 2msbk mfr gw if .5
3 19 -36 7.5yr4/4 none scl 2msbk mfr cw - - - - -- .4 6
%� 08 4 36� 7.5yr5/4 none ms Osg ml cw - - - - -- 7 ,
5 73 -96 7.5yr4/4 none sl lmsbk mfi - - -- - - -- .4
,08 .08
* Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < mg /L
CST Name (Please Print) Signature: / CST Number
Thomas 3. Schmitt 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
Somerset, WI 54025 10/11/00 715 - 549 -6651
r
Property Owner M & G Inc Parcel ID # 038 - 1077 -70 -000 Page 2 of
3 ]
F Boring # J Boring
J Pit Ground Surface elev. 98.00 ft. Depth to limiting factor 97 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3/2 none sil 2msbk mfr gw 2m .5 .8
2 8 -19 10yr4 /4 none 5 ; L 2msbk mfr gw if .5 .8
30
3 1 -38 7 . 5 yr 4 / 4 none Icos imsbk mfr gw -- - - -- . 7 1.2
4 38 -56 7.5yr5/4 none Is imsbk mfr gw - - - - -- .7 1.2
5 56 -97 7.5yr4/4 none sl 2msbk mfi - - -- - - - - -- .5 .9
30
4] Boring # Boring
i/ Pit Ground Surface elev. 98.40 ft. Depth to limiting factor 98 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3/3 none sl 2mgr mfr gw 2m .5 .9
3 y 2 8 -15 10yr4/4 none St 2msbk mfr gw im .5 .9
?a$ 3 15 -30 Syr4 /4 none sl lfsbk mfi gw - - - - -- .4 .6
4 30 -98 7.5yr4/4 none sl imsbk mfi - - -- - - - - -- .4 .6
❑ 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 GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *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
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. nlease contact the dena.rtment at 609 -266 -3151 or TTY 609- 264 -R777.
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Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3 T9
Number of Bedrooms
Design Flow - Peak (gpd) �0
Estimated Flow - Average (gpd) CrD
Septic Tank Capacity (gal) „
Soil Absorption Component Size (ft) 6 q3 Z --V
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) (o la 2. z
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The lu 2b, shall be cleaned as np ��ary to ensur
proper operati n. The filter cartridge sh rem oved unless provisions are made to
re ain so ids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with C I'll $' .09; W ., Adm. Code
Attach complete site plan on paper not less than S 1/2 x 11 inches in size Plan must-, -
County,
include, but not limited to: vertical and horizontal reference point (BM),,,airection and ' - • Cy l
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel 1. D #
APPLICANT INFORMATION - Please print all information. Reviewed,rby Date
r
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1),(m)).
Property Owner Property Location
r s U Goyt. Lot � f it4S(,j 1/4,S �� T 3� ,N,R �� E (or)WYJ
Property Owner's Mailing Address Lot # - �- Subd. Name or CSM#
135 r. zi 2o � I�n no-
city State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
dsan I W/ 15 W 7/'5 )0"`f l31 I -i5 e zoo
® New Construction Use: Residential / Number of bedrooms 3 _`� Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6o U gpd Recommended design loading rate _ bed, gpd /fi trench, gpd/ft
Absorption area required bed, ft 75 trench, ft Maximum design loading rate bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) UDOe r 0 ft (as referred to site plan benchmark)
Additional design /site considerations 4 f . vPPe r �// CE O L.OW r 8'7. 4 10
Parent material � L' I 1 Flood plain elevation, if applicable If,-"t ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S ❑ U ®S ❑ U ® S ❑ U I E[ is ❑ U ❑ S U ❑ S P U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD/ft
;....
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
MOM 0 2,
l '4( - 313 — t_ l m sb LS
!p r 41 L
Ground
elev.
ZO ft.
Depth to
limiting
factor
'Ab in.
Remarks:
Boring # / 0 -24 ( 5L I bk
Z 2 zy 314 51- l m bk r c-S I • `�
Ground
elev.
93• �d ft.
Depth to
limiting
V fact r
in. Remarks:
CST Name (Please Print) SipWre Telephone No.
Address Date CST Number
Zl t 3 �ntb ry, e(�e•4 w y4 o z� -!S _eX) 25 3309
PROPERTY OWNE SOIL DESCRIPTION REPORT Page ?— of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
� l ` . 5
Ground 3 1 `{ LJ vy) ml r
elev.
95.�a ft.
Depth to
limiting
factor ,
9La in.
Remarks:
Boring #
q..:f I o-t$ r X13
'` 2 it-4 lb `t14 SL rv 4, r C , 5
3 42 -`0 16 `{ �D — LS
Ground
elev.
Y7. z o ft. '
Depth to
limiting
factor
'90in.
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 # I
rN 3 S. Irr, k CS '.3
5 k 2 ►Z- 5L Z MY r c s • `f ' ,s
ko lb�r L A�tz LS c) (Y)) CS -
Ground
elev.
Depth to
limiting
factor
9.[_in. Remarks:
Boring #
YW`k 1
Ground
elev.
tt.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R.9/98)
PAGE 3 OF
NAME LOT# ZI LEGAL DESCRIPTION I fST 3� N R/ £f E (or&
SCALE: 1 "= In U
BM I ELEVATION
BM I DESCRIPTION I Z " p.'�e ev/FIG"
d
BM 2 ELEVATION ( U U -3
BM 2 DESCRIPTION h I ,- n >; gJ,* ia c,,54 /
SYSTEM ELEVATION � r 9`/ 0C) C 1
ALTERNATE ELEVATION u✓ ?� y t
9�0 ���y39g �
CONTOUR ELEVATION t x
3t
Z(v s I-
SIGNATURE DATE �� ��
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERS141P CERTIFICATION FORM
OwnerBuyer
Mailing Address
Property Address �o� ;3/0
(Verification required from Planning Department for new construction)
City /State �S01ev 5 -, - T Parcel Identification Number 0S9 ' - 7 - 2 - 0 - 000
LEGAL DESCRIPTION
Property Locatior�—� '/4, '/ Sec. , T Town of
Subdivision ILiJ L.ryl >N (a a A S , Lot #
Certified Survey Map # , Volume , Page. it
Warranty Deed # 6,30332 , Volume , Page #
Spec house > yes ❑ no _ Lot lines identifiable I yes ❑ no
SYSTEM ,MAINTENANCE
f your septic system could result to its premature failure to handle wastes. Proper maintenance
r er use and maintenance o yo ep y P
�P o ..P
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
pump verifying that 1 the on -site wastewaterdisposal system
master lumber 'ourne an lumber, restricted lumber or a licensed ( )
P � J Ym P P . P
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sl
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 the three ye expiration date.
SIGITATURE Ck 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE O ' 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 decd from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
I
b
STATE BAR OF WISCONSIN FORM 2 - 1998 60332
WARRANTY DEED KATHLEEN H. WALSH
�(
REGISTER OF DEEDS
Document Number w, 1544PAGi 474 ST CROI CO., WI
m
RECEIVED FOR RECORD
This Deed made between RICHARD O. STOUT and
JANET P. STOUT, husband and kARRAN
wife 2000 12:30 PM
IfARRRHTY REED
Grantor, EXEMPT A
— - - CERT COPY FEE:
and M R C, INr _ COPY FEE:
TRANSFER FEE: 119.70
RECORDING FEE: 10.00
PAGES: 1
_ Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Cr iX County. State of Wisconsin:
Recor,iing Ama
Lot 21, Plat of Rolling Oaks, Town of Star
Prairie, St. Croix County, Wisconsin. Name and Return Address
�3S' Pvr..Twln, +t T R.
�sr�D40'N lr 1
S'�1Jt V
038 - 1077 -70 -000
Parcel Identification Numow (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
D ated this ( : day of September 2000
(SEAL) /�' (SEAL)
- Richard O. Stout Janet
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
l
Signature(s)
State of Wisconsin,
I�
ss.
ST. Croix County.
authenticated this day of Personally came before me this 20th day of
Rppt,P_mhL -r , 1.0_0-ft-. the above named
Richard O Stout and Janet P_
Stout
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If not, me known to be the person q— who executed the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same.
CHERYLJACOBSEN
Notary PUbfic
THIS INSTRUMENT WAS DRAFTED BY State of W isconsin
Janet P. Stout
1353 Awatukee Tr.
Hudson, WI 54016 Notary Public. St a of WI onsin
My commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
' Nar s of persom signing In any capacity must be typed or printed heiow their stgnature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Go., Inc.
WARRANTY DEED FORM Na. 2 - 1999 MO.Aukea, Wie.
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