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HomeMy WebLinkAbout040-1287-20-000 : Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Cr oix Safety and Building Dlvisien INSPECTION REPORT Sanitary Permit No: 408297 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)j. Permit Holder's Name: City Village X Township Parcel Tax No: Miller, Sam I Troy Township 040 - 1287 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: lZO , & of, . p = CgT gwA TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark � S(-Z 1 2 �. S q.b l i5U . Dosing Alt. BM � o i. Aeration Bldg. Sewer Holding St/Ht Inlet (o � 00 - T5 ' � TANK SETBACK INFORMATION St/Ht Outlet io. 9g �up •S� TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' SDr Dt Bottom Dosing Header /Man. a'SJ �cm•02r Aeration Dist. Pipe Holding Bot. System Final Grade P /SIPHON INFORMATION V1A, 2 s SrZU o2 - 3S� Manufacturer Demand St Cover GPM -1 Model Numb TDH Lift ction Loss System Head TDH Ft Force y Length �DslWell SOIL ABSORPTION SYSTEM U BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1 6 1 /3 SETBACK SYSTEM TO P/L jBLbG IWELL LAKE /STREAM LEACHING Manufactu r: INFORMATION CHAMBER OR �t 7 Type Of System: � t UNIT Model Number: I r/ q Z, DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake � Pi Length Di a Leng Spacing 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 LE] ] Yes No COM T1 (Include code discr penci s, per ong preseat, etc.) Insp ti �#1: `� / bZ Inspectio Loc on: 613 lover Road Hudson WI 4016 (N /4 SW 1/4 15 T28N 9W) Glover Prairie Lo r 1.) Alt BM Description 2J Bldg sewer length= '(,V p3_ • �Z 9. °► 9 - amount of cover = • 0 3 4reson .M s#a t� - s� at,A►-.. 99 36 g.Z S' Pan Required? Yes No U other sid for addition o Date Insepctor's Signature N t D , � t - 4'� Fw SBQ -6 10 7Cert. . L A 1 V (J . Safety and Buildings LAVW00 C!WY . C l 201 W. wagWigton Ave., P.O. Box 7162 Madison, W1 53707 - 7162 �sconsin &0 �°' G',3 616 er Zvi C De artment of Commerce 'r -0L sanitary Permit Number Sanjuiry permit Application�g Z- in accord with Comm ti3.21. wit. Adm. Code personal idormation you provide Q Check if Revision MR be used for privacy I.aw 815. 1 in Sdse Plan I.D. Number A L Ap p pf - m Print AD Inl R . Z / Ferrol Number / Proper Owosr's Nam �/ p -128 �-- 3 , O !:5 R k W " , ( an/" ptopany Location Property Ownses bLailiq Atklrea i.fJ H ' (t I � � N R E ST. CF X COU;,ITy s Bio Number 1 Zip Code Lot Number Z City Seat r Subdivision Name CSM Number fit{ o f �. '3Sat tr 27 k 9 LOVE A - R 4 ) 4 I F - IL Tips o[ Bundin8 ( dhsck all that apply) ocity Number of Bod,00m's ✓k' ° Qviliage 1 or 2 Family Dwelling - RTownshi T Deaaibt Use N _ / Road ❑ SM own,d , — ,� rP - k o — k� a s 3 je LZ 'S Complete line B if applicable) III, 'Type of Pertmlt: (Check twly one boat on Urx A (numbering scheme for Internal thse) A 1 cement of 6 Addi XNsw 2 Repiaoem� Sy� 3 0 Replatioa m or County use Tank Od Daa issued stem Permit Number B. 0 Cbxk d s.aitary permit �101� i:aad scheme is for internal use) �b i � D � �• � +r✓ LaR e � : � � t/ww+lr -� ,,_- IV. 'type of Permit: ((-heck all that appty)(ntunbering S0 ❑ Constructed wetland 44 Nan - ln- Ground 210 Mound 47 ❑Sand Filar t tl � N 41 ❑Holding Tank 48 0 Single Pass S 0 Drip L [ 22 0 30 ❑Other • k' ✓ [��l '/ 45 0 ht -Grade 46 0 Aerobic Treatment Unit 4Q ❑Rte anent Area Infoemation. / see levation V. Dispe rsal Area spersal il Application Percolation Race Final Grade Elev Pl (�) Requ Di proper Area SoRaa(Gals./DaydSq.Ft.) (N(in./Inch) 7� p A 0 1 0 0 d 0 1 . 5-1 ` Prefab site Steel Fiber Plastic Capacity in Total Number Marnrficturer Man VI. Tack Into Gal Gallons Galiorer o[ Tanks �, % /r�?' if r l" � 4 /00 Coaerea Constr New Esjatjoa W / 'S +2 Tanks Taub swtie or Holding VIE. R bill Statement - i, the undsiergned, assume responsfll►q for installation of the POVYTS shown on the Busi ss Phone plain. MP/MrRS Number Phone Number Plumber's Name (Print) Plumber' signature i CJ ` 86 sr% We t4 o� � I � � -10. f af, Pi imber's Address (Street. City. Sterne. Zip Code) . Count /De eat Use Od Date issued issuing Agent Signanttt (No Stamps) S an i tar y Permit Fee (includes Groundwater / ved C3 Disapproved Surcharge Fee) Q( 1 t t7 Z 0 Owner Given Initial Adverse Z ZS- 73o t> Determination , �5 for Disa 'oval _", P - ` v p Conditions o Approva!/> °f PP ku I F 6(i &'a61«e(IA ,• t"6 b f tt dNu,r}G aa�2Mia / Hl ti fh �k `t -e .f { a - � �.,!tJ �� �+✓ p`v W4N (/'A .c.,4'"'0 5 W Off�„�,e4.O/t: taws ',a.1 c l C f v v c�i7h s P ✓�'o✓ � c be Mt c 1 � t (to the eo..q Only) for the mtm N r ant iea tbm sin a ll lae6e Y size ro�i c4� �AILu - � 10Q, 06 �(p 1 . 0� SAr} -6398 (R. 05 /01) Y!� r SA w ILt,f2 1P;•� L�,T :3F 1. = 1' - 7,D�Low q7, S'M) 0 4 ? co(. J .774.7' r J s� v I&PAO 1 Lam@ ► "" � 4 1 `{ a 107- X03 L o �✓� /�� , � 1 i 1 e �A'tf4 4� N ea,,s � fl �oN(w�ea� i ' is l � 4- brio z r� cu,�,, , i i i SAW, Iwo ItLf2 G /o ✓� h,T Z 4.(3 lz 6 L oY w2 TiL o A D r � 3 v' h - 0 r� t4�T q* 3 News 4L. �0 Wa i j f 4 i i I 7.7 7' i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ) of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST• C1� - OlX include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re' d b Date Personal information you provide may be used for. secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location GAL NW 1/4 SW 1/4 S T Z-8 N R 1 E (or w l Wwn*O& Ma!Hng Address Lot # I Block # Subd. Name or CSM# I I O) e �Z -Q�M r y t S-v U Z Gov — City State Zip Code Phone Number ❑ City ❑ Village [3 Town Nearest Road HvDSOt1-) wi I sqOLb ( - )LS ) 38b -3(3sl 77-NZ) "( GLUUQTL lzo�D (� New Construction Use: ® Residential / Number of bedrooms L ) Code derived design flow rate b O(3 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent irjterial _ - G1.f�C pV)pt S ) Flood Plain elevation if applicable General comments and recommendations: �EC�Y'�'r'L D 3 L' , of . - 3 to Z l p1jC, 1-iI I E (LOF- E sc��k,�vp � e L S �') S i e�"l. V Q(r 1/t/ l��y 1LJt) �14 �C• 6 Q * . Boring # ❑Boring ® pit Ground surface elev. )DO . ft. Depth to limiting factor. L L 2 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 �- O -VZ LO`t�Z31Z __. s • I Z, �6 Z l ��{ 1 0'� (Z -3Lto _ S l Z 6k ►�'!. `Fh c l� — .S . $ � � -� �.s `t231 — 1 s o S9 ►� r e)N � •`z t- Z �( 4 l -L l J p-I 2 q1t S O g 141 �A Boring # ❑ Boring ® pit •Ground surface elev. ft. Depth to limiting factor L 1 8 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 C) - t0" YL 3 tz _ S I 1 Z`Fs b1-i m`F- Cup z )0 -18 n-ttL316 — sil Z�sb►� mil- eW :s =$ IS p s9 wt OUJ 1 - t_2 31 -10 l '1tZV 7 q7 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ignature CST Number Arthur L. Wegerer I =0 Z' 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. 1- St. River Falls, WI 54022 1 - D Lj -OI 715 -425 -0165 Property Owner RST'ty —D Parcel ID # ) N G Page �' of 3 Boring # ❑ Boring Pit Ground surface elev. 1 O 3.0 ft. Depth to limiting factor > 1 Z in. Soft Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1 0 - 1Z % - Si l z'Fs bk YA4►- e-w Z \z zs tov - v 6 - Si l Z�'s N - C w 3 ZS - -7 2.3 It P- ) Af O Y 1 "Zi ©S wt ► -� �. Z ( d qv' ❑ 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 GPO /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 • Eff#2 F-1 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 /ft= 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, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD•9330 (R.6/00) PLOT PLAN Page 3 of Scale 1' = SO ' - - 1 s t 01 / ao "PC $!�� . 3 l— L U 3 iam vi Z moo\ ��- sk, rT UuE ftwk RTC `vz � � /� � �►� �Z �►-�. �� ���.� - CAS _ i o� a l or J 0 t Hrf-j t _�zdDwlt rt M._ ... __. U�TL -uT � avTwr 1 715 - 425 -0165 220254 CST Signature Date Telephone Ito. CST No. Job No. Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page 1 of 3 �. in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County STS C1Z01 X 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. t=rv�l " J G Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). Property Owner ROBEtri^ Property Location C AQ _Fr3bQ FUMT ST�1�T F L Nth 1/4 SU3 1 /4 S \5 T Z-H N R 1 E (or ow 1 Wwftie Mailing Address Lot # Block # I Subd. Name or CSM# 1 o b e. tz ATV t Dtzi Ut Z -. Gov P�z�t City State Zip Code Phone Number ❑ City ❑ Village 21 Town Nearest Road HUDSON w1 sg0L b (-) LS 386 _ 3oSi - MV3 1 1 Gt_UV lzoA D New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate 1020 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent -h terial 6LPCZ: t1•-t., pV• Flood Plain elevation if applicable fL General comments and recommendations: x V Z, S Lgyj 6 GJ I'm UX1 IT- S 13, 2 s 1 LL� . s `2 s 7L�^, L� F l v aL : ►!� I } �L g �3r�p ►� t4�C . 6c) Boring # ❑Boring ® Pit Ground surface elev. to O . ft. Depth to limiting factor 7 l 2 in. Soil App II bon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft In. Munsell Qu. Sz. Cont Color . Gr. Sz. Sh. - 'Eff#1 'Eff#2 O -IZ 10`f`Z -1L - -. _ S , I IT- : ,® Si t .S .� Boring # ❑ Boring ,... _ ® Pit - Ground surface elev. 10 - Z ft. Depth to limiting factor O a in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -.. SK iz 3l' IS' O s9 w1 040 • - 2 t - Z 31 -10 1 % ZVj S C3 - 9 J • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ignature _CST Number Art _ hur _L.... >Wegerer 'o�' 22.0254 Address (� e g e r e r Soil Testing s t II Date Evaluation Conducted T elephone Number -. 1 & P De sign gn Service 421 N. Bain St. River Fa lls, WI 54022 1 -0 4 - 01 715 - 425 - 0165 I - - Property Owner �S �RSTL'D T Parcel ID # N G Page of 3 Boring # ❑1 Boring tsl Pit Ground surface elev. 0 3. O ft. Depth to limiting factor > > Z in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1 o_)Z Z �Z Zs 1O4tZ316 — s1 1 Z�sbiL Z<$ ` 2 9 Ly O 55 - k n J cW , 7 t- Z y ab -!lz 10 �ti Ylb — s O s -'1 L .Z ❑ 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 /f 2 In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 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 /ft In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 t ' 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, please contact the department at 608- 266-3151 or TTY 608 -264 -8777. SBP8330 (K6100) PLOT PLAN Page 3 of Scale 1' = 50 ' - 1 tuz `gy 8.3 L03 I w � " o� �- Sly �'Y�I3l� PCtt� FO(2 ~�Z , - //� L►JC'i Fl�lp yl.`CLSitJV -- �„(_S� 0 Lo1 3 J 0 L 3 Htf - i __ELIO0'•O`#7N c�u TL-uT � avI T I - 1 134-- l 715 - 425 -0165 220254 CST Signature Date. Telephone Ito. CST No. Job NO. P 1 Bi S .+ • ` 1 C= CWtv tv — �1 1 Kn Universal 1 1 Av ailab l e Si zes Chamber 11" Stan• 14" High 16" High Dimensions dard Capacity Capacity r � 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 Number of Bedrooms Design Flow - Peak (gpd) �© o Estimated Flow - Average (gpd) Septic Tank Capacity (gal) f z_ SSo Soil Absorption Component Size (ft') 53 FT Z Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) Maximum Influent Particle Size (in) S Q , , 1/8 Maximum BOD (mg /L) 220 E 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 se POGAank outlet filter shall be assessed at least once every 3 years by inspection. The outlet filteO shal be c leaned as nec essary to ensuTe?�` proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the i 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. 7ha_ Pa / ; I art a : n , oz. 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S Mailing Address X S Property Address (Verification required from Planning Department for new construction) City/State P O 10S o N W / _ Parcel Identification Number D 't(d - L 8 7 Z o LEGAL DESCRIPTION Property Location u w %,, g W 1 A, Sec. I . T 1 4 N -R /I Town of T" y ,"Subdivision ro LD P RA 1 � i JE Lot # Ceifiified Survey Map # _fie S 8 O 1 S ; Volume Page # S Warranty Deed # I l Of I Y , Volume Page # 4/41 7 Spec house byes ❑ no Lot lines identifiable'-M 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 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 St. Croix County Zoning Office within 30 days a three year exp date. b 7 /al0 ATURE OF APPLICANT DATE : rOWNER CERTIFICATION ;'(we) certify that all statements on this form are true to the best of my (our) knowled e g . I (we) am (are) the owner(s) of the pro 6 . M. , described above, b virtue of a warranty deed recorded in Register of Deeds Office. • 07 /�9i o A P ' PLICANT 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 i 1 p - Y01. 1 Q/ 4PAQ 447 t � WARRANTY DEED 6695$4 STATE OF WISCONSIN — FORM 2 - PEA fHLE£N H. WALSH REGISTER OF DEEDS DOCUMENT NO sr. CROIX CO., WI RECEIVED FOR RECORD This indenture, Made this 25th dayof January A.D /l.§ 2092 01 -29 -2002 8:30 AM between McDona I d Homes . Ing, - , a Minnesota WARRANTY DEED Carnnrat i on 1341c/p6m duly EXEMPT K organized and existing under and by virt ue of the laws of the Stace of IJi�r6�s/ii, t�a ed at CERT COPY FEE: Inver Grove Heights, MN `1401 party of the firs) part, and COPY FEE: Sam E. Miller, a single person, R ECORDER FEE: 11 0 RECORDING FEE: 11.40 PAGES: I part of the second part. Witnesseth, That the said pany of the first part, for and In consideration of the sum of $367, 500. 00--------------------------- - - - - -- to II paid by the said part V of the second part, the reccipl whereof is hereby confessed THIS SPACE RESERVED FOR RECORDING DATA and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed NAME AND RETURN ADDRESS and confirmed, and by these presents does give, grant, bargain, sell, remise, alien, convey and First Federal Savings Bank confirm unto the said part y of the second part, h i S heirs LaCrosse— Madison anc ass.gns forever, the (nllowing described real estate, situated in the County of 201 Second Street fit Croix �State of Wisconsin, lo ti: Hudson, Wisconsin 54016 040 - 1061 -60 and 040 - 1061 -50 PARCEL ID ENTIFICATION NUMBER Lots 1 through 7, inclusive, Plat of Glover Prairie in the Town of Troy, St. Croix County, Wisconsin. (IF NFCFSSARY. CONTINUE DESCRIPTION ON REVERSE SIDE) Together wnh all and singular the hereditaments and appurtenances thereunto belonging or In any wise appertaining, and all the estate, ght, title, interest, cl or demand whatsoever, of the said party of the first part, either in law or equity, either in posst•ssion or expectancy of. in and to the ahove bargained premises, and their hereditaments and appurtenances. To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said part' _ of the second part, and to his heirs and assigns FOREVER. And the said McDonald Homes, Inc., a Minnesota Corporation party of the first part, for Itself and its successors, does covenant, grant, bargain and agree w and with the said par of the second part, his heirs and assigns, that at the time of the cnscaling and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in Inc law, in fee simple, and that the same are free and deal from Jhincumbrancrswhaiever,_ except easements, reservations and restrictions of record, and that the above hargained premises in the quiet and peaceable pnssessiotl of the said par of the second part, his heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and DEFEND. In Witness Whereof, the said McDonald Homes, Inc., a Minnesota Corporation, party W the ills[ part, hasctused these pre by Todd A Bierstedt its Vice President afLtl�J��tlJdf� {LLLl1L1 /l / // / /1/ / / / /// 111111 /ll / /L / / / / / / / / / / / / / y fErE�lr s ! It Hudson W ixonsln, and its corporate seal to be hereunto affixed this —255 h day of January ,,D_ tc 20 02. SIGNED AND SI ED IN PRESENCE OF MC c s HO S r1� ota Cp rporate N„ ea>� . V ice President ODD A. JER T COUNTERSIGNED, Secretary Stale of Wisconsin, St. Croix County ss Personally came before me. this 25th day of January _ AD,� 20 02 Todd A. 6jerstedt, _ grmu President(, lrA/ //////// / / / / / /f/ // / / /// -Zll-& / // / / / IWzfl,r of the above named Corporation, to m e - ins who executed the rig Insnumcnt, and to me known to be such President and Secrctar� of said Corporation, an wle c xeeuted the fot' oin< its umern as such u(ficers a Te decd of said Corporation, by Its authority ' ry ` yy y / 4a THIS INSTRUMENT WAS DRAFTED Y' A N O , l K N STE J , DUNLAP tly cote n ssio,l iSt �Ls) (is) County, Wis la ,, }003 Hudson, Wisconsin r�` h, 'cl h, R: us h' J n' Sruon 1�+5 i., 1, 'y I„ n: ,,. ,I11,. Ora, "1., ),:.�r ,,, 1,I; i1 I 1 J IuJ ,F, n. ui , � Jl bi t -r e.J ,IP „`rnr.. . ,ryJ or „r i, i l„ .i „ S T IT E , 0F 1V I SU>N I.N .� � W sc ohs n LU9al 8111. Co., Ir \\ARMA�TI Dt.FD -fly (.nrFUrI1,Jr1 I urm NL 2 M, Maukae, Wis. 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