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HomeMy WebLinkAbout040-1260-70-000 n Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix ,nd Building Divi311n ,, INSPECTION REPORT Sanitary Permit No: 479290 0 , NERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: ;rsonal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. -'ermit Holder's Name: City Village X Township Parcel Tax No: Cob Winslow I Troy, Town of 040- 1260 -70 -000 CST BM Elev: f Insp. BM Ele BM Description: ` — Section/Town/Range/Map No: CI). L ap -a C ST 18.28.19.1396 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark t Dosing V Alt. BM -- ------ - ----- Aeration r Bldg. Sewer (08 O CU Holding St/Ht Inlet • $3 m.l3 TANK SETBACK INFORMATION St/Ht Outlet • 9 q9 � TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , Z,S ------- Dt Bottom Dosing Header /Man. Aeration Dist. Pine ' ,,,� r__ z- auT 5�b Holding Bot. System IZ Z `421 z ,o`( $ • b . f PUMP /SIPHON INFORMATION Final Grade ICX)'02 r Manufacturer -- Demand St Cover 3' 8 p ' GPM D�' o I Model Numbe T 994qn Loss System Head TDH Ft Forcemain 11,6 ngth Dia. Dist. to Well SOIL ABSORPTION SYSTEM (t 8) RENC Width t Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIM S / .?; 0j0 cea• Z SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufact rer INFORMATION CHAMBER OR �`��� Type Of System: / t UNIT Model Number. f to V . �2 J ✓S �S -d S� DISTRIBUTION SYSTEM Header /Manifold (.( Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) _ Lengt Dia Length Dia 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 Topscil I - i Yes j ;;y;] No ] Yes 1 No M TS' (Include code epen "es son present, etc.) Inspection #1: b �� % tt) 7 inspection #2: / Lacation 76 Whitetail Lane Hudson, WI 54016 (01/4 NE 1/4 18 T28N R1 9W) Deer Valley Lot 17 Parcel No: 18.28.19.1396 1.) Alt BM Description= , 2.) Bldg sewer length = Z 3 a - amount of cover = 2 Lf f- Plan revision Required? Yes K No Use other side for additional information. L _� _ 1 =J - - -_ `�- Date Insepctor s Signature Cert. No. SBD -6710 (R.3/97) F Safety and Buildings Division county 1 201 asbtngton Ave., P.O. Box 7162 WI Saaiwy Permit Number (to bi filled in by Co.) De artment of Commerce � ) z 315 C7i P [l K Ap rSlwr 1. D. Number In accord with Carom 83.21. Wis. Adis. Code. perworl ' s �� may be used for se:oaert4ty purposes Privacy Law. s15. 1)(m) Address (if difTerem than trailing address) i. Apples Infermata - Please Print All mrot natinat Property Owner's Na me / Lot f, slocx A ` o Prapertp —A wna•o M ailing Adddress Ptuppty Lot abort - t SS - # . I X396 f4 State Zip Code LPho- Number i n A ` �e 10 (circle t d Type elf (check tlsat apply) p� T N; RE or. 1 or 2 Family Dwellntg - Number of Bedrooms C� r S 5 , Subdivision Name CSM Nuny�er Public /Commercial - Describe Usr- �J FF U State Owned - ribe Use - 'City—[Village * wnship of :Z1 I & Type Pertntld: KbaC t aoiy OW b" W Ow A. Cm apkte doe B V applicabk) A. K New System ❑ RePlamxmm System ❑ Treatment/Holding Tank Replacement Only U Other Modification to Existing System i B• El Permit Renewal ❑ Permit Revision [_I Change of C7 Permit Trarafer to New List Previous Permit Number and Daft Issued a Before Expiration Plumber owner -� IV. !w of P'OW'YS Syatan: tube& an ) Non - Pnessunud 1 n- Grt1110d U Mound > 24 in. of suitable soil U Mound C 24 in. of suitable soil U At Grade ❑ Single Pass Said Filter ❑ Consauctetf Wexlaitd U Ptessuriaed In Grwstcl U Hording Tank 1 -1 Peat Filter IJ Aerobic Treaunent Unit (_1 Recirculating Sand Filter ❑ Rexircula Syatbenc Me" Filter ❑ L wh" Chamber ❑ Drip Luse Gravel -kiss 11 Other (explain) Y Area bofaraaatioo: Design Flow t Design Soil Appliat oa RaWSp" Dispersal Area Required (s Dispersal Arta Proposed W) rystcm Ble�ta�t�n Ono VI.. Tarok Info cap+rity in T Number p Maratfacturer fab Site Steel Fiber Plastic Gallons Gallons of units t S� l - ,Q� P( SZS Concrete Constructed Glass 1 New Scpcit Holding Tank --- Aerobic Tnwm m Unit - YII. Re4bomill0ft StWteaaest- I. the mdtsrtti�ted. rmwaasftifty for instal of the POW'IS diown an the attached plans. 'S Na we ( s Si lure MffMP RS umber Business Phone Number -- c s Admre ss (Shea. City. , Zi p IV 0 1 '9Q VUL cl Aw-ved ❑ l ay ---- Sudury Permit Fee ( odes Groundwater Dots Issued lssuing t Signature (No stamps) ❑ O leer Given r for Denial 7 Surcharge Fee) IX. Can iFtions - — SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber 2. All setback requirements must he maintainecl i as per applicable code /ord? Aeurat aoltlaa tds p• us Cwaka tar eie sypn: sw p ,.e is �.. attl x 11 Inch" In she __ I Ssc) cLe +v Avg 4v-.Q. SOS Vc �� f' �,tl �p P / f s ry\ ( 5 m l ' rO 7 (o LL> J40 N =rf CD� 7 6m = na.l ;n.��� 'ie.QO-C t r f � [� ti n a� \ V \V PO 3 i A00 y Pvt � N w `q N-E s rS T a� N JQ I? w I ss� ZcLr�,v\ 14vQ. sos Der UCXAl � L r / `7 rn�nV\ Q 0I - r arm-- zo-- ode U-) xas, 'p,' - - T Lo c0. I �` =o` ✓ N 7 g = na ,l ►h sue, ACC 8c too, $S' o 90 iS3 t � o � { Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 1 inc hes in size. Plan must include, but St. Croix not limited to vertical and horizontal reference poiru-(� -and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and di , nci t i4are'st road. ' ,, 040- 1071 -20 APPLICANT INFORMATION- PLEASE R1P17 ALII�NRMATIOfY REVIEWED BY a DATE Z PROPERTY OWNER: -~; = PROPERTY LOCATION Derrick Construction, In J i t ; 0OVT. LOT NW 1/4 NE 1/4,S 18 T N,R X(or) W PROPERTY OWNER':S MAILING ADDRESS S* O �(� OT # BLOCK # SUBD. NAME OR CSM # 1505 H #65 �� 1 CITY, STATE ZIP COD ' R ❑CITY ❑VILLAGE [2rOWN AREST ROAD New Richmond, WI. 54017 ) 24 3 3,, Troy E. Cove Rd. [x] New Construction Use k ] Residential / Nu 4 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 60 0 gpd Recommended design loading rate __7 ed, gpd /0 gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate —_ bed, gpd /ft 2 — _ - 8__ - trench, gpd /ft Recommended infiltration surface elevation(s) 100.90 ft (as referred to site plan benchmark) Additional design / site considerations spaced to code, 4.00' below grade Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem XXS ❑ U RI S ❑ U ® S ❑ U (OS ❑ U 0 S ❑ U EIS U U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tre d €<....1... 1 0 -10 10 r 2/2 none 1 2m r mfr c1W 2 .6 2 10 -16 10 r Ground 3 16 -31 7.5 r 4/4 no elev. 104. 4 31 -84 7.5 r Depth to limiting factor +84" Remarks: Boring # 1 0-12 10yr 2/2 none 9mar Mfr 9W 2 `' 2 12 -26 10 r 4/4 U 3 26 -30 7.5 r 4/4 none lfs osq mvfr C1W 2f .5 j.,6 Ground elev. 4 30 -84 7.5 r 4/6 none cos 1 04 . 9 ft. Depth to limiting factor +84 Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715 -246) -6)200 Address: 1554 200th. e. New Richmon WI 54017 Signature: Date: 6 -11 -99 CST Number: m02298 PROPERTYOWNER Derrick Construction SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # 040 - 1071 -20 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouind3y Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends ................. .................. ................. .................. <' 3..... 0 -17 1 1 2msbk mfr qw 2c .5 .6 2 17 -35 10 r 4/4 none sil 2msbk mfr gw 2m .5 .6 Ground 3 135-ICO 7.5 r 4 4 none cos oscl ml na na .7 .8 elev. i 1 Depth to limiting factor +84" � toy • Remarks: Boring # 1 10-12 10 r 2/2 none 1 2mgr mfr gw 2c .5 .6 €'.4....< 2 12 -16 10 r 4/4 none sl 2mgr mfr gw 2m .5 .6 Ground 3 16 -84 7.5 r 4/6 none cos osq ml na na .7 '.8 elev. 99. $t. — Depth to -- limiting r qfP "D factor +84" Remarks: Boring # 0 -6 10yr 2/2 none 1 2m r mfr 2c .5 ' .6 : 2 6 - 10yr 4/4 none sl 2mgr mfr gw 2m .5 .6 Ground 3 24 -84 7.5 r 4/6 none cos osg ml na na .7 .8 elev. 1 _ ft. Depth to limiting factor q�,o Remarks: Boring # Ground elev. i ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) ° STEEL'S SOIL SERVICE Gary Steel 554 200th Ave. �' Derrick Construction, Inc. Inc CSTM2298 NW4NE4 S18 T28N -R19w New Richmond, WI 54017 MPRSW -3254 town of Troy (715) 246 -6200 lot #17 -Deer Valley This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. o 0' BM nail in Iron tree C el. 100.00' t. BM.= nail in Oak tree C el. 103.70' a� 1 0 6; te �. N Gary L. Steel 6 -11 -99 I 1 to►v-I'Slow Cbb D.�., UCL��Ie Lo EZ1203H VVV v sv o v v o r- 'lr• '�. .`a ''�, , v v s e vvosvov '.\+ . t:.' svevvvv vve ..°sv�.ovv 1211 2411 1 osv ovv vvv pOe 4 62 `11 aoo svv U .J V sys vvv VVW v° 1 tt * •' 1/2 Circ. = 18.84" vvv vvv vveovv p• vvv eo V WV v vvv Tvo eve WV WV vovevs • vvvv O°eovvv oee vvovevv v v vvvoeov at eevav Oa aO VOa�° vaevepp a ev0e ep 0 24 - ----�- Bottom 36 12 -1/211 DIA.. (typ.) Void Coefficient in Aggregate given at 57.4%. Soil Inte Ar . III:. LO Ft � Ft O.D. of 4^ pipe — 4.625 inches Sidewall (2 Sidewalls) 2 * 18.84in Void volume per linear ft. = 3.14 • 2.3125u� ' • 12in — 3.14 Ift = 0.117 f -- r 12in N t !f[) Bottom 18 O.D. of Center cylinderffiT2,5 inches 2.00 Total Soil Interface Area Void volume in aggregate ofcenter cylinder =(3,14.r a.zsin _ 5.14 SQ.FT t tt atasi„l 12inlft) - 3.14•( --- •.574 =.422W 12in / O.D. of outside cylinders= 12 inches f7 I Void volume in outside cylinders = 2.3.14{ bin , Projected Trench Area Void `1 12init;) = R' Sidewall Height = 12 in. "2 = 2.00 Sq,Ft. volume at bottom betwe ain Bottom = en c'I' _, cy linders bin 6[n l 36 in. = 3.00 Sq.Ft. = [(12b"r, +l2in /f[)��3.14( ) =Q,215ft' 12inlft Projected Trench Area = Void volume at outside bottom corners (112 ofvoid volume between .00 Sq.Ft. Total void volume = 0.117 + ee" cylinders) 0.215 ! 2 = 0.108 ft , + 0.901 + 0.215 + 0.108 = 1.763 cubic ft / ft Gallons per ft = 1.763 X 7.48 = 73,2 allons r linear ft. —E ne t/ EPS /{ Trench EZ1203H ystem am Y Rin InduStrial Group =flow 65 Industrial Park Rd. Oakland, TM 38060 ... Sc� Flu: 1+we: EZt203H —v,t 11-27 -01 stJel r t m [ 7 PO WTS OWNER'S MANUAL & MANAGEMENT PLAN page --� of . T'IONS z WFORINIUkTM , SYSTEM BPEgff(C1�1 `.e S -p- rs " 014A t14Mrrer Tank Manufacturer permit q Z tA Septic [3 Dose .13 Holding V ol. g al a>~ : 1 o 0 NA Tank �tautwfac Dot pbM! ETERS 0 Dow p Holding VOL gal Number of B DNA O Number of Pubic Facility (hilts D NA Effluent Filter Manufaeturar �`y CD� 0 NA Estimated (average) flow Effluent FVW Model Design (peak) flow - (Est metad x 1.51 1 — i gm Pump Manufacturer O NA Soil Application Rate . /ft' Pump Model Unit DNA Standard Mf uenuEffluaM Vi Guallty Mlorutt>�i e . Pretreatment E3 Sartd/G� Filter D Peat Filter Fats, ON A Grew (FOG) s30 mg/L 0 NA ❑ Mechanical Aeration 0 Weiland a20 mg/L Biochemical Oxygen Demand ii'�s1 ❑ ; Toted Suspended Solids (TSS) Al 60 MOIL 0 Disinfection Pretreated EHlusnt Mon av rage Manufacturer ❑ NA Biochemical Oxygen Demand (BOD `- 530'►n9n' Gallia) ❑ NA ]� in- Grotan�d tgrauvitY) ❑ ku -Ground (pressurized). T Suspended Solids (TSS) !930 mgt i` ❑ Mound Fecal Conform tg mean) ow dull ooml ❑ At -Grade O y in die. 0 NA 0 Drip -tea C] otter. Maximum Effluent Particle Size O NA Other: ❑ NA Other: ❑ NA •Values types for dornsstia wastevvatw axed seppc tank effluent. MAINTENANCE SCHE Sew Fteitluency Servk* Event oI }ts) (� 3 tears) ❑ NA erect condition of tank ev s) At least Once ery- When combined sludge and scum one -third (Y,) of tank volume ❑ NA Pump out contents of tank {s) When to water alarm is activated D rruonth(as) (M � 3 yews) C3 NA Inspect dispersal cells) At least once every: (s) rruanthts) ❑ NA tr� MCI Glean effluent f At least once every: tai 0 moms) D NA kispect.pump, pump controls & alarm At least once every: D ) p.nww"s) 0 NA Flush laterals and pressure test At West once every: O ye via) 0 month(s) 0 NA Other: At !Best once every. p s) 0 NA MAMITENANCE INSTRUCTIONS one of the following licenses certifications I of tanks and dispersal cells shall be made by an individual carrying g Operator (pumper). Master plurrnber: Master plumber Re�+cted Sewer. POWTS Inspector: POYVTS MainZRt , identify an y cracks or to identify any missing or broken hardware Tank inspections must include a visual inspection of the tardcts) of effluent on the ground leaks, measure the volume of combined sludge and scum and a check for any back or Pam and to check for any calls) shall be viauadly � to deck the effluent levers ku the observation pipes condition and surface. Thefluenar indicate a felling ponding of ef fluen t on the ground surface. The ponding of effluent on due ground surface maY requires the immediate notification of the local regulatory author". equals When the combined accuurnu� ion of sludge and scours in any treat O t tank of in o accordance . _ with chapter NR 1 Me entire contents of the tank shall be removed by a Septage+ Wisconsin Administrative Code. i or pressurized components, pretreatmerr All other services, including but not limited to the servicing of effluent filters, machanica units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. within 10 days of completion of any service event. A services report shag be provideed to the local. regulatory authority within GMW (2IO2) l START UP AND OPERATION L P age for For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and /or damage the soil dispersal call(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 shy not occur when sod conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above mammal highwater levels. When power is ramrod the excess wastewater will be discharged to the dispersal call(s) in one larpa dose and may overload them resulting 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 Pkamber 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 with 15 feat down slope of any mound or at -grade sail absorption area. . Reduction or ♦, � elimination of the following from the wastewater � s t ream may improve the performanc and prolong the life of the P antibiotics, baby wpm. carett butts; ;, swag degreasers; dental ,loss; diapers; disinfectants; f at; foundation drain (sump pump) discharge; fruit and vegetable, peelings; one; grease; herbicides; meat scraps; medications; oil; painting products; Pesticides; sanitary napkins; tangents; and water softener brine. ABANDONMENT When the POWTS falls and/or is permanently taken out of service the following steps shed be taken to insure that the system is properly and safely abandoned in compliance with chapter Corium 83.33, Wi =onsi n Administrative Code: a AN 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 property disposed of by a Septage Servicing Operator.. • After pumping, all tanks and pits shall be excavated end removed or their covers removed and the void spare 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: �j A suitable replacernent 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 co mpactim and should not be infringer) upo by required setbacks from existing and proposed structure, lot fines and weft. Failure to protect the replacement area will result In the need for a new soli and site evaluation to establish a suitable replacement area. Replaceinernt 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 Folding 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 rat area. If no replacement area is available a bolding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade sod absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Recce 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 ii rnMOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAICTAiAER E w , Name 5 t� Plane SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATOftY AUTHORITY Name Name S i 11 Phone Phone ICS This document was drafted by the staffs of the Green Lake, Marquette and Waushars County Zoning and Sanitation agencies in com0lance with chapter Comm 83.22(2)(b)(1) (d)&(f) and 83.54(1). (2) & (3), Wisconsin Administrative Code. j 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Ojl w s t-° `N L4 r- 12) Mailing Address 15 S O 4-&j A\dez- SOS 101, /U k/ 1 15 S t // G Property Address - 7 to GC. gi L �- (Verification required from Planning Department for new construction) City /State ©So' "C GcA.L Parcel Identification Number O 1�0O - 7O - ' 00 , 0 LEGAL DESCRIPTION Property Location IVAJ %,, At 1 /q, Sec. , T N -R W, Town of Subdivision ���° VA u-C Lot # Certified Survey Map # , Volume , Page # Warranty Deed # g . Volume Z 8 3 L , Page # Spec house ❑ yes no Lot lines identifiable ❑ yesXno 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 masterplumber, journeymanplomber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (Z) 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 Office within 30 days o ee three expirg�n dad,. WJ� 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 pe desc ' ed above, virtuta of a warranty deed recorded in Register of Deeds Office. 6� V i ^ S GNATURE 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 �4 19 9 .00r ai VicVln Lov nnv Vr uLZUo IIZJVV1 /VV1 798893 � U. 2 B 3 2 P 3 3 1 KATHLEEN H. W ALSH REGISTER OF DEEDS ST. CROIX CO., MI THIS DEED made between Doer Valley Partners ("Grantor') RECEIVED FOR RECORD and Winslow S. Cobb and D eborah A Cobb husband and wife, as 06/29/2005 08 1 - 30AK survivorship marital property ( "Grantee ), WITNESSETH, that the said Grantor, for valuable consideration Y DEED conveys to Grantee the following described real estate in St. Croix WARRANTY County, State of Wisconsin: REC FEE: 11.00 TRANS FEE: 298.50 Lot 17 seventeen), Plat of Deer Valley In the Town of Troy, COPY FEE' Recordn Area CC FEE ; Croix County, Wisconsin Name and Re 040- 1260-70-000 (Parcel kienlificallon Number) This is hot homestead property. Grantor, Deer Valley partners, a Wisconsin Umlted liability Partnership, Is an affiliate Of Derrick Homes, LLC, a Wisconsin Limited Liability Corporation. Grantor develops land and Derrick Homes, LLC is a home construction contractor. Grantor agrees to sell this lot to Grantee on the condition that Derrick Homes, LLC will be the builder of tfte home for Grantee, If Grantee does not commence construclJon with Derrick Homes, LLC as the contractor /builder within two (2) years of the date of sale of this lot to Grantee, Grantee gives Grantor the irrevocable right to re- purchase the lot for the same price as Grantee paid Grantor for It when Grantee bought it from Grantor. If Grantee desires to sell the lot to another purchaser before constructing a home upon this lot, Grantee gives Grantor the right of first refusal to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. Dated ttti3 24th day of Am 20JE. I * k affrael r Steve ' AUTHENTICATION ACKNOWLEDG NT Signatures STATE OF WISCONSIN ST. CROIX COUNTY Personally tame before me this 24th day of,[ rm 20DL the authenticated this _ day of 20_ above named Michael R. Stevens and Ronald L. Derrick, as n of Deer Valley Pa rs to me known to be the rsons execut for oing instrument and slB�l °re acknowledge he same. type or print name TITLE: MEMBER STATE BAR OF WISCONSIN sig kfis (Ifni, Wo or print narT g e PAM LA J. RUTLME authorized by' 706.06, Wis. State.) Notary Public St. Croix County, Wisconsin, 7 1 Pubft My Commission Expires: September 27 , 2QM, of WliileoWn THIS INSTRUMENT WAS DRAFTED BY 'Names of persons signing in any capacity should be typed of Deer Valley Partners printed below their signatures. PO Box 445 New Richmond, WI 54017 T Q 0) J. �_ Q O X to m N w O O , r r 0 0 0 0 O p N CO CO fn co O J cl ° Q J CO Oo O Q) J O � Q T J 0 ° U O � d M p (A CO CO a) co t0 r C0 J (u O E p N Q O CO co Q co m Q M N s p (!� T p o r O CE „.. O Q �1 a . d fi QO O fi x O fit? in L .=� N M M G3 0 ' a) C7 O U Q Its D Q � 0 > ti N W 1— N M N U �$ w -41 t O LL ' ti w r f J r r e— Z; w UNPLATTED LANDS a , OWNED BY OTHERS o' m w Q N _J W . r— a: Zj CV Z: 's O N N8918'02 "W 1322.74' HAL 669 9a U NT RtLID y x'611 ACRES o ' v li3,H1G SC;. F T. cn 1005 �'2' W 5g 1 51 . / C 9' i (c 8 ;s 1� 7 0 0 . 750' , C9 � '`�:Sg•..�,. 11..'•31 ,,, f7 I 29 o .r on A W ` P J r ./ Y1 n. .r` / 9 ...... L. ,o b 20 rl. 1 i p t; i ! ;Ni,y �H. r +1NALif f A%F NI Ni F' 40' DRAINAGE EASEMEN �' u :ASEMENT ' �- "� :6' N89'27'09 "E 1191.57' i S . I 295.7: I I I � I PARCEL I