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HomeMy WebLinkAbout040-1258-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 506337 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)]. Permit Holder's Name: City Village X Township Parcel Tax No: American Classic Homes I Troy, Town of 040- 1258 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 6 e 6 l D d 24.28.20.1376 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �� 53 Benchmark Dosing & 5 ZS Alt. M Aeration I V / 1 Bldg. Sewer � ,9 7.1 A6 T Holding i > <� St/Ht Inlet R/ s .r 9 o3l lot TANK SETBACK INFORMATION 01 Outlet y ���• TANK TO P/L WELL BLDG Vent to Air Intake ROAD Dt Inlet I - Septic O "I / Dt Bottom ��— e Q/� '^^-� Dosing N / Hea r /Man v ' 12 6 , J /Itp,37 6'I io /• 9y Aeration Dist. Pipe 7. b / • (o l 6 2 .3s di Holding Bot. System l n ,d S I 3 PUMP /SIP N INFORMATION Fi a r7 r r t -sy bn � C s /b 3. 3 S Manufacturer / Demand St Cover ^f"7 / F GPM .' 3. U Model Number / TDH Lift Friction L stem Head TDH Ft S /o Forcemain Leng I Dia. Dis . Well 9 7Z SOIL ABSORPTION SYSTEM G BED/TRENCH Width / Length + No. Of Trenches PIT DIMENSI S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S,0 1 SETBACK SYSTEM TO P/L BLDG WELL LA ME EAM - LEACHING Manufa ror: INFORMATION CHAMBER OR Typ Of System: , ' 70 4 M UNIT Model Number 6W ^ &V pJ V D!§1RIRUTION SYSTEM ader /M fold [ f� Distribution Ir / y x Hole Size x Hole Spacing Vent to Air Intake / _ / J �U —" ( Pipes t/ ^ Length l0 is J 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 Topsoil Yes No Yes I No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: t o / / b Inspection #2: 'I 1`9 Location: 339 Lindsay Road Hudson, WI 54016 (NW 1/4 SE 1/4 24 T28N R20W) Troy Village 3rd Addition L'ot 6 Parcel No: 24.28.20.1376 1.) Alt BM Description = mo of zul rh4* . 2.) Bldg sewer length = / 46 7 1 _ amount of cove r > Plan revision Required? Yes '? No Use other side for additional Information. 2 I Date Insepctor's S nature Cert. No. SBD -6710 (R.3/97) cotl'1t'1'tePce.wil.gov Safety and Buildings Division County 201 W. Washington Ave. P.O. Box 7162 C l sco Madison, WI 53 716 Sanitary Permit Number (to be filled in b Co.) Department of I C A ommerce Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form t ental unit is required prior to obtaining a sanitary permit. Note: Application forms or sj�N rot ct Address( rtTerent than mailing address) submitted to the Department of Commerce. Personal information you provid may e p urposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats, I. Application Information -Please Print All Information Property Owner's Name 1 4.VVI Par el # f1 ,1G C `nor G Sr. ccl, - s I -- ro -'apio Property Owner's Mailing Address Pr rty Location �F 0i.V4CG� �E �d� Govt. Lot City, State Zip Code Phone Number 'A AIW s4e ? /_, Section 1 t / • Wa �� �� Z S "3 (circle one Type of Building T 3� N: R �_ E ot� 11. T yp g (check all that apply) Lot # V I or 2 Family Dwelling -Number of Bedrooms .� / Subdivision Name G/ B � � S _ k � `/ I/ L � Block # 2O ❑ Public /Commercial - Describe Use / El city of Ctir� El State Owned - Describe Use CSM Number L1 Village of 9 Town of O III. Type of Permit: (Check only one box online A. Complete line Rif applicable) A. @7 New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System (explain) B. 11 Permit Renewal 11 Permit Revision ❑Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: (Check all that a pply) K Non- Pressurized In -Grou El Pressurized In- Ground ❑ t -Grade El Mounq> 44 ini f s 'table soil El Mound < 24 in. o uita e soil El Holding Tank they Dispersal Component (explain l/ Cam' L1 ment Device (explain) �` h� V. Dis ersal/1'reatment Area Information: ie 4 Q 4 - 9 101 S'L 4 - Ay 6 1 - 3 Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) ersal Area Proposed (st) Sys em Elevation 4 - /s5� o -a VI. Tank Info Capacity in Total # of Manufactyrer ✓) Gallons Gallons Units �kC {+� tstr( 1"* o y New Tanks Existing Tanks Grtw yXs' '- S1� 1 Septic ori�k 3 -/� - Dosing Chamber ((OO VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP /MPRS Number Business Phone Number e --- ZAW �7 1 -//) /� Z, �,, es- - V/ pope- Plumber's Address (Street, City, State, Zip ode) '.2 lejV117 3 &ZX "✓ wt S m VIII ount /De artment Use Onl Permit Fee „ ru Date Issued Issuing Agent S' nat e Approved El Disapproved ❑ Owner Given Reason for Denial 4, ' 1 rov Reasons to Disapproval u,�ZQ/ G2LGYiLtG bit' Q SYSTEM NER: 115 'I v� t / �Z sZUn �✓ ,� Septic tank, a luent filter and (40M jj)WA OL , , dispersal cell must all be serviced / maintained �� �z_C �? ��iz Y``� as per management plan provided by plumber. 9 Ali sethank requirements must be mainta c8ft1dpartr &h&gyos for the system and sub t to the County only on paper not less than 8 1/2 x 1 i ches in size as per applicable SBD -6398 (R. 01/07) Valid thru 01 /09G' FOGERTY PLUMBING & PERK TESTING 2473 Rolling Green Rd. , Spooner, WI 54801 (715) 468 -7000 r J�= L•T Corytr,T'/ •J` �•c..+r) Cell (715) 416 -0000 GsT 1 d #a = ,/f�B+K, ,t.�7 /•7`G•rwrr , Rir`7ftcr s� zwh yvf,I��tj � � d o.crr✓� / — �c..r� /•f carN�r • t /CGS ( s J. w, All O r r 17 QN I� G^ L /o f ® . G -3 99,C y 5?,Z it II II 'ty ~ o a ° ` : •• • •. �� \ � � ,a cl r fiQ rA W'LJ G• CD _:. _^'!•s- ...__\+ V p ONO O VA G �� A _ v� RZ cr W tOGO70 a L II 11 �\ e a klZl �,t GL�f1.rrc Fogerty Phmtbing o w "VC•R #221180 '. 28 288 McKenz+ e Rd -- //b Spooner, W1 54801 Lai 1 - (715) 635.960 Cross Section of an Inground Component Cell Using Leaching Chambers ObservationNent Pipes Finished Grade _ __ _ - .- �—, Grade Slope % _ 7 Original Grade= ,� ,_,� ,� Original Grade Top of Shell = QP, �,,' 1� - - j i System Elev. = 9, 7 ,l Treatment and Dispersal Zone Limiting Factor Observation/Vent pipes to be constructed and capped with approved materials for the particular use. Kn IM FOGERTY PL & PERK TESTING 2473 Rolling Green Rd. s / • _ r Spooner, Wl 54801 •f r � �� (715) 468 -7000 : fit, tc L•T cor�rrr, Cell (715) 416 -0000 dot G57'!! 0 ,�,�c s ,1fTB*Y, fsa /jr7�Gs/wrr, rr�nftc+c >�' 7 — xd If coi'N+r► IdtA6 Sir` Tn4CK 1 A- t �riifLlC6aT � • � W �a�� . ! ' 1 /77- , 1 t — L /' •/ . �— y PA7 r j Miscosin Dopartment of Commerce SOIL AND SITE EVALUATION 7 Page 1 of, 3 Division of Safety and Buildings in accord with Gomm 83.0 Wis. Adm. Code �fpT tnc /�! �✓ �!� i Environmental By Desigr, Pr Af Attach complete site plan on paper not less than 8'/2 x 11 inches in size. Plan m \r' County 77 include, tart not limited to: vertical and horizontal reference point (BM), direction > ? St. 77C percent slope, scale or dimemsions, north arrow, and location and distance to t road parcel 7 7. APPLICANT INFORMATION - Please print aH information. W "0 Personal information you provide may be used for secondary purposes (Privacy Law, s. 1 (m)). ST GR�'Nx e y l r� D 8 9 S Property Owner P Continental Develo meet Govt. t ° itN NW 1/4;{ S ' 1/4 S 24 T 28 N,R 20 W Property Owner's Mailing Address Lot # P4Z"_ ulfd a or CSM# 12301 Central Avenue NE, Suite 230 116 Troy MftViffag City State Zip Code PhoneNumber u City ❑ Village Town Nearest Road MinneWfis MN 55434 Troy 1 Lindsay Road Z New Construction Use: Ej Residential / Number of bedrooms 4 ❑ Addition to existing building E] Replacement [] Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate •7 bed, gpdff trench, gpdff Absorption area required 857 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd/ff •8 tr ench, gpd/R Recommended infiltration surface elevation(s) 98.5' & 107' ft (as referred to site plan benchmar Additional design / site consideration Multiple trenches, grade so as to meet code requirements Parent material LOESS OVER OUTWASH SAND Flood plai elevation, if applica Na ft S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system f ®S ❑ u ` ® S Cl U ® S❑ u ❑ S M U EIS N U , F1 S2 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/fi? goring# Horizon in. Munsell i Qu. Sz. Cont. Color Texture Gr, Sz. Sh. Consistence Boundary i Roots i Bed Trend 1 l 0 - 10 10yr3/2 sl i 2msbk i mvfr i cw i 2f i 5 6 2 10 -32 10yr416 - L sit 2msbk mfr cw if . .6 Ground 3 f 32 -88 7.5yr4/6 - s Osg ml - .7 .8 elev 101.45 ft Depth to ! limiting factor >88 Remarks: 2 1 I 0 -16 I 10yr3/2 - I sl 2msbk mvfr I cw 2f .5 .6 2 16 -48 10yr4 /6 - sit 2msbk mfr cw i if i .5 .6 Ground 3 48 -90 7.5yr4/6 - s Osg i mt - i - i .7 .8 elev 104.60 ft Depth to limiting factor >90 Remarks: CST Name (Please Print) Signature: Telephone No. Thomas C. Nelson 715-246-2 Address Environmental BY tgn Date CST Number Ref # 1432 120th Street, New Richmond, WI 54017 2/17/99 227387 99 PRQPFRTY 0,WNER: Continental Development SOIL DESCRIPTION REPORT ® Page 2 of 3 PARCEL I.D.# Enviromnental By Desian Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary I Roots , GPD/fh in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ! Trench 1 0 -20 10yr3 /2 - sl 2msbk mvfr cw 2f 5 6 2 20 -56 10yr4/6 - sil 2msbk mfr I cw if .5 .6 Ground elev 3 1 56-120 1 7.5yr4/6 I s Osg ml - - .7 .8 111 75 ft Depth to I eY limiting factor >120 Remarks: t i i i i i i 4 1 0 -10 10yr3/2 - sl 2msbk mvfr cw 2f .5 .6 2 11 10 -27 1 10yr4/6 - t sit 2msbk tnfr cw I if .5 .6 Ground elev 3 1 27 -90 7.5yr4/6 - t s ow ml 1 .7 .8 113.10 ft Depth to I I I I f limiting I f factor >90 Remarks: 5 1 0 -19 10yr3/2 - sil 2msbk mfr cw 2f .5 6 2 19 -53 10yr4/6 - sil 2msbk mfr cw if .5 .6 Ground i i i i i i I I elev 3 53 -90 7.5yr4/6 - s osg ml - - .7 .8 115.8 ft Depth to limiting factor >90 Remarks: 1 t 0 -10 10yr3/2 - sl 2msbk mvfr cw 2f 5 .6 2 i 10 -28 10yr4/6 - i siI 2msbk i mfr cw I if T 5 .6 Ground elev 3 1 28 -100 i 7.5yr4/6 i - i s Osg I ml - - i .7 .8 112.97 ft Depth to limiting factor I >100 I Remarks: II r f i [KV1 i 1132120" STREET, NEW Ri AMP, A(6 % 1161 5AVO 6Y M- 2a6 -20a TROY BURNE VILLAGE - Lot " NW Y4 SE v4, SECTION 24 T 28 N, R 20 W Troy Township, St. Croix County, Wisconsin Page 3 0 aV 17% 4M ���•�' � d� Q � `� d f tc 3•�3 0 d, 62 s-- �� SCALE I"=40 Tom Nelson BM 1. SE LOT CORNER Top of iron pipe ELEV. 100' 227387 BM 2. S`+1i Lot Corner surface of ground next to lath ELEV 115.98' � ERVI �Y 0[51 1431110 STREET, NEW MAN, WOW WSt SAvfl 6YTHW5 NELSON 715 TOM NELSON *1 TC51Q 227367 --- RfbiSZ O SANiI ON 5W713 Troy Village -- Lot NW Y4 SE '/4, SECTioN 24 T 28 N, R 20 W Troy Township, St. Croix County, Wisconsin Page 3 a sk 3 A �] N . S�-e ` Y "� 9- e � CJ L) n- S 99,s' 1 00.5' 107 SCALE 1" =40 Tom Nelson BM 1. SE lot corner top of iron pipe Elev. 100' BM 2. SW lot corner surface of ground next to lath ELEV 115.98' bzr 1 JLU 1 AN& MAI NI ENANC E AUKL{EMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ /¢/tria�,irc f /N�1' l LG Mailing Address , Property Address 3 �9 7 d3 (Verification required from Planning & Zoning Department for ne onstruction.) City /State 1 Soh/ Parcel Identification Number 410 . -✓�5�8 �Yo��a c.��.y 0�`r LEGAL DESCRIPTION Property Location * iv %4 , S,� Y 4 , Sec. ?�/ , T _ N R 8 Town of Subdivision ©v It Lot # //0/ . Certified Survey Map # , Volume =— , Page # Warranty Deed # 777 3Y� , Volume Page # /7e Spec house yes w Lot lines identifiable yes ,no" SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle washes. 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 Planning & 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. 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 maittained must be completed and returned to the St. Croix County Plammig & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 5 Z�ae"' "' : 9 1GNATWE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Depart=4 * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed 0mv. 08 /05) ruvv r a wvvrvcn TILE gi1FORMp►TfON SYSTEM SP6CITlCAT10NS - - Septic Tank Capacity O NA Owner �� �.nr�S _ Permit # - Septic Tank Manufacturer El NA l ffluerrt Filter Manufacas z� O NA DES PA�1M �- El NA ESogApplicatim f Bedrooms O NA Effluent: lamer Model 2 �NA LSan�Sl j 13 NA Number f Public TettY Units NA Lflowfaversge) d Pump Manufacturer NA S x 1.5) A allday/ft Monthly werage* Unit NA ent 0ua6ty ❑Peat Film Fats. Oil &Grease (FOG) 53O m9n- O Wetland Biochemical Oxygen Demand (BODJ 5220 mg/L O NA [3 Mechanical AeraUon Total Suspended Solids fTSS) �� °� ❑ Disinfection O Other. Month average Dispersal Call(s) ❑ NA Pretreated Effbe►t Ouua ty 530 =mg a i tg<a Yl O M- Ciound (Pr�uSzedl g nicat Oxygen Demand (BODs) E3 Mound Suspended Solids tTSS) �3O 'NA ❑ At -Grade <10 cfu /100rN /� ❑ Drip Line O Other_ -. Fecal CoGform (geometric meant — Other. ❑ NA [tMaAmtan Effluent Particle Size Y in dia. ❑ NA ❑ NA Other. ❑ NA Other. [3 NA *Values typical for docnesuc and tank efthrecrt_ MAINTENANCE SCHEDULE Sarelce RequencV Service Event ❑ month(s) (MevurKrrn 3 Years) [] NA inspect condition of tank(s) At least once every: 1t s) where combined crud scum equals Dire Uwd (Y� of tank vohxne 0 NA Pump out contents of tanks) 13 rrorrdh(s) (Mo6mm 3 years) O NA Inspect dispersal ceN(s) At least once every: 3 yeartal ❑n owd" .O NA t, Clean effluent f�ter � 1 1 fl ri S At least once every: ❑ rnonUs) ` p year(s) A Inspect pump, pump controls & alarm At least once every: ❑ r anth(s) [Y NA Rusty laterals and press" test At least once every: ❑ year(s) O monduls) _ NA Other:- At least once everry. ❑ year($) EjNA ether: MAKFENANCE NSTRUCT IONS one of the foNowing licenses or ins: Inspections of tanks and dispersal cegs shah be made by an individual carrying Smvici ng Operator_ Tank Master Plumber, Master Plumber Restricted Sewer, POWTS t or% POVV7 S Mamntaiuuer; Septa9e sacks leaks, of the tanktsl m iderttifY any missing or broken hardware, ide oy amt► inspections must include a visual iapectar► of e ffluent measure the volume of combined sludge and scum and to check for any back up or rniti g fluent on the ground surface. and m check for any ponding cell(s) shall be Y inspected to check the effluent levels in the obsevartice afa condition and requires the The dispersal surface- The pr�n9 of effluent on the ground surface may indicate a failing of effluent on the ground immediate notification of the local regulatory authority. _ v o lu me . When the combined accumulation of sludge and scum cn any tank equalsdn ) of r n �accardance with chapter the entir contents ;any e tank shall be removed by a Septage Servicing Operator rued components, pretrea t All other es, including but not United to the servicing of effluent filters, mechanpOWTS Maintainer. units, anservicing at inteuvals of 512 months, shall be performed by a certified . A service report shall be provided to regu uxy ANT UP AND OPERAUION of products or other chemicals For now const urn, prior to use of the POWTS check treatment tankls) for the presence painting that may impade. tihe treatment process and/or damage the dispersal cxro(s1• if hi Co n c entrations 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 sop conditions are frozen at the infiltrative surface. the excess wastewater will be During power outages pump tanks may fill above normal highwabtr levels• When Power is restored discharged to the dispersal call in one large doSe• overloading the coots) and may resort in the backup or surface tdisdtargeo ng rest effluent. To avoid this situation have the contents off the pump tank removed by a Servicing P power to the effluent pump or contact a Pluatuber or POWTS Maintainer t assist .au manwaNll 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 arm within 15 feet down slope of any mound or at -grade soil absoption area. true and the life of the Reduction or elimination of the following from the wastewater stream may decrial floss; diapers; disinfectants; fat; POWTS: antibiotics: baby wipes. cigarette butts; condoms; cotton swabs: degreasers; . herbicides; meat scraps; medications: oil; foundation drain fsump pump) water; fruit and vegetable pegs: gimme; grease' painting products: pesticides; sanitary napkins; tampons, and water softener brine. - ABANDONMENT anently taken out of service the following steps shall be taken to insure that the system is When the POWTS fails and /or is perm 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 shalt 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 - compdant m: replacement system: A t syste replacement area has been evaluated and may be utized for the location of a replacement sod absorption turbmm and compaction and system. The replacement area should be protected f m di should not be infringed upon by o rimed setbacks from existIM and structure, lot fines and woos. Failure to protect must result in the need for a new serer and site evaluation to establish a suitable reRtt comply with the rules in effect at that time. El A suitable replacement area is not available due to setback and /or sod Tmnitanons. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. . The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement eras. if no replacement afea is available a holding tank may be installed as a last resort to replace the failed POWTS. D Mound and at -grade soil absorption systems may be reconstructed i place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that tune. < <WARNING> > ANDIOR a 11T OXYGEN. - DO NOT SEpT1C. PUMP AND OTHER TREATM�IT TANKS MAY CONTAIN LETHAL D ANCES. DEATH MAY RESULT• RESCUE OF A BITER A surriC. PUMP OR OTHER TREATMENT TANK UNDER ANY C PERSON FROM THE WTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE- 0221180 (715)_- 1 P POWTS MAINTA NER OWTS INSTALLER i �l Name F E Nerve Phone �dD� 1O"e SEPTAGE S� OPB ATOR 1 _ LOCAL f llIATORY AUTNORf7Y Narne Name _ Phone Phone This document was drafted in compuence with chapter Comm 83.22121(bl(11(d{ &(fi and 83.54(11. (21 & (3). wesconsin AdMkistrative Code. U, 2678P 17y 777346 STATE BAR OF WISCONSIN FORM 2 - 1999 WARRANTY DEED EISER S. DEEDS R Document Number REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Dale R. Selzler. and Roxanne C. Selzler, RECEIVED FOR RECORD husband and wife Grantor, and American Classic 10/18/2004 01:00PH Homes LLC Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to EXOPT # Grantee the following described real estate in St. Croix County, State of REC FEE: 11.00 Wisconsin (if more space is needed, please attach addendum): TRANS FEE: 630.00 COPY FEE: CC FEE: Lot 116, Troy Village Third Addition in the Town of Troy, St. Croix PAGES: 1 County, Wisconsin Recording Area Name and Return Address 040 - 125840 -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 J day of October , 2004 X2,1e , _ * Dale R. Selzler * Roxanne C. Selzler AUTHENTICATION ACKNOWLEDGMENT Signature(s) Dale R. Selzler and Roxanne C. Selzler, STATE OF ) husband and wife ) ss. --t4- _ __ _ County ) authenticated this (,o day of October 2004 Personally came before me this day of the above named * Kristina ( TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 106.06, 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, WI STATE BAR OF WISCONSIN 800-655 -2021 WARRANTY DEED FORM No. 2 -1999 \ Z r 0, 1 / O/ / o v NO s / �j ' / w cn 0 0 1 14 1 � = L- O / I-OZ 1.000 ACRES i�, i 0 43,562 S.F. �. 26 �- Z w Ix i m -Z LLJ J �? / CS C L 113 �� ��� w 1.026 ACRES 44,674 S.F. .;� j NE -SE LE x / II WON LEGEND m "' f / COUNTY SECTION CORNER MONUMENT, I BERNTSEN CAP UNLESS OTHERWISE NO• RES / / 1.0 9 RES o 0 2" X 30" IRON PIPE WEIGHING 3.651 SET. 1 X 24 IRON PIPE WEIGHINI F , 4 ,373 S.F. FOOT SET AT ALL OTHER LOT AND OU F . 0 1" X 24" IRON PIPE WEIGHING 1.681 FOOT, SET. • 1" IRON PIPE, FOUND. ? ?s S &" I N 0 2" IRON PIPE, FOUND. � /o // I N — • ---- 10' WIDE UTILITY EASEMENT. DRAINAGE EASEMENT, WIDTH SHOWN. 116 - BUILDING SETBACK LINE, 75' UNLES 1.184 ACRES I 51,592 S.F. I OUTLOT 9 TROY VILLAGE SURVE , °t9. I THAI e'' I LOCATED IN TI- SE 1 /4 , AND 1 4r / CRO I X AND STI 'V C THAI h j BENCHMARK: TOP OF 1" IRON PIPE I c 'E � a OF CONTINENT/ ELEVATION= 885.06 I -o MORE OR LESS: COMMENCING Al I 3 6 3 N 1 " D 2 T V BE 1 7 0 BEGINNING; Tf N C .. ' 2.760 ACRES I - a w N co THENCE S 89 / 120,223 S.F. 66.00'; THEN( -� °00 M E S 41 0 00'00" V "o E ` E 39.70'; THEN( 1 3 N o f, ' Q 610.84'; THEt N 74 V CONCAVE SOUP N 66.00'; THEN( E EASEMENTS OF THA' �? v ai BOUNDAR i ES Of cd THA' h -0 t WISCONSIN ST) I E-. con U U THE COUNTY Of 1 ff O y 11,000, 000010 .00or 10000' 100001 400 do 40 � co ft 0 � • dew low sooloo 0 dp Oal� L \N%