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014-1040-60-000
Wisconsin Department of Ccmmerce PRIVATE SEWAGE SYSTEM Safety ana Suilkirg Dwi~sion INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Riniker, Ronald Forest Townshi CST BM Elev: Insp. BM Elev: BM Description: TAAII! IAICA~IIAATIAAI r~ rvwT~~u nwTA TYPE MANUFACTURER CAPACITY S tic Dosing Aeratio Holding ~ ZCSbC~ TANK SETBACK INFORMATION ~ ~- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration olding PUMP/SIPHON INFORMATION d GPM Model Number TDH Lift Friction Loss System Head TDH Ft For ain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length DIMENSIONS ~~ ~ SETBACK SYSTEM TO F INFORMATION DISTRIBUTIO a-~~rr~~w~r vr~~r~ County: St. Croix Sanitary Permit No: 395262 State Plan ID No: Parcel Tax No: 014-1040-60-000 STATION BS HI FS ELEV. Benchmark Alt. BM _ /~ /~ '/ 7 Bldg. Sewer 2.z3 = ~ Z3 X3.03 H nlet lb. 0 'l , SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover ~ ~ n ~J r / 4 PIT DIMENSIONS INo. Of Pits Ilnside Dia. CHA R OR /s~~ f~-3 ` -~' /_~ / ~,-_ UNIT Header/Manifold ~/ Length Dia Distribution Pipe(s) ~ Length / Dia ~ Spacing x Hole Size ' x Hole Spacing - Vent to Air Intake SVIL GC7VER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/_~/~ Inspection #2: / / Location: 2629 210th Avenue Clea~r(_Lake, WI 54005 (NE 1/4 NW 1/419 T31N R15W) NA Lot Parcel Nfo:/1/9./31.15.2938 1.) Alt BM Description = C'~~C~/lL QIPB' X dh ~S~ 3,~ W~w h..~~cr l~~ ~~ ~! i~~.51~2~(~a~ 2.) Bldg sewer length = b p ' -amount of cover= ~S-' ~ /•tisu~~d by fk~~r;~r p<t~~y ~r d~e~~wQy y~@x%~~` ~ Plan revision Required? ^ Yes ~ No Use other side for additional information. ~ ~ / v~ C( SBD-8710 (R.3/97) Date Inse ctor's Sin Cert. No. ~ ~~S ~~~ . Saiiftary p~# Appttcstioa ,~'~~ -_. ~~111 ~ ~ ~i• wi:. yam. cam mi v~v. ~~ ~ ~r I.tw, a. iS.~tiXm)l (tic crn~ieled ibras ~ oomnr 1# ~ it~lE D111A0fi, i Sena ~ ~ 4 x i 3 5 z ~ ~ ; sic >. I A au In[ tiet~ - Pkase Psiat ati Warn~atiea # ~ itOAi t ~ /~ ~~i~~ n LBC~OR r ~ r^ ",t '3 ~ $ lq~~ CIS w of l ® ~ Vlv-2. rn. l ~- ~" " `~ k ~~ - G~~x ,; N ~ u A odS - r N-R e srB~iia~: ~c ~ 2 F'riolEp Dam' N°` c!`8edr°°aa ~_ `. / ._ - t . a A~ i. Q New ~ ''~- ~•aopc ooac oa i%ne 8 d ~ Iicahle l - . 3 , /S: 2 3 - sj r ~• ~ wa ~$ •f Pt~WT Ste: (t~caR aii ~ t appiyj . Q ~ ~~ ~,~~ Q Sand F~itcr D Co~rucood Watland O Aaotala T ilait O Pas: p tateut Ara~Iai'ormrtt~• f .' Sc~ ~ N R N ~- ~. ~. ~ ai ,~„~ ~`ank tom' ~ Todu ~ N ~- N ~-- N ~, ,~,-~ ~ aioa tip of r ~ Peed Site Saed F~oti i'lwie ~ _ ~ - s ~~d -- a1v.v~ _~~ ~'~~ ~~~,., ~ ~°°A4~eP~mte~ Use Ogiy Q O Owep~ ~ ~ i'0° ttndrde~ Drea ~' ~~ was f~ ~ - ~ ~ ~ { ~-) 1~it Ck~S -SyS{ei,,~ s~~~~U~ PFt+~ml: '2'1.11i< ~to~~`~ ~C6ar~.~~,cr` ~~r Ce.rw.. ~.~ 33 ~ ~ iscons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LACROSSE WI 54601-1831 TDD #: (608) 264-8777 www.commerce.state.wi.us/sb www.wisconsin.gov Scott McCallum, Governor Brenda J. Blanchard, Secretary August 17, 2001 CUST ID No.285102 CALVIN POWERS JR 1969 185TH AVE NEW RICHMOND WI 54017 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/17/2003 A7TN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 SITE: Ronald Riniker - 2629 210'" Avenue St. Croix County, Town of Forest NE1/4, NW1/4, 519, T31N, R15W FOR: Description: Three Bedroom Holding Tank Object Type: POWT System Regulated Object [D No.: 807039 Identificat' Transaction ID .668606 Site ID No. 6344 Please refer to both identification numbers, above, in all cones ondence with the a enc . The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD-10571-P (R.6/99). [n the event this holding tank system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VI of the holding tank manual are complied with. A copy of this letter including instructions and information regarding proper use and maintenance of the system must be given to the owner and each subsequent owner upon completion of the project. • A u)eter, with remote reading device, shall be installed by a properly licensed plumber,.on tkte vaster sy, that Y .at. , :11~etuunt ofwater used by the structure, excluding hose bibs and rovtt114tydraMs; ~tiicte db shot discharge into tt-e s~itary system. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. • Comm 83.52(2), Wis. Adm.-Code - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. CALVIN POWERS JR Page 2 8/I7/0I • Comm 83.52(3), Wis. Adm. Code -The activities relating to evaluation and monitoring mechanical POWTS components after the initial installation of the POWTS in accordance with an approved management plan shall be conducted by a person who holds a registration issued by the department as a registered POWTS maintainer. Note: As of today's date, our records indicate that a refund in the amount listed in the FEE portion of this letter has been initiated and forwarded to a manager for review. The refund will be made under separate cover. Please expect a 6-8 week time for fiscal processing. Refunds will be made to the payer. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state slats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, t~~~%~~~ Gerard M. Swim POWTS Plan Reviewer -Integrated Services 608-789-7892 Mon -Fri 7:1 S AM to 4:30 PM j swim@commerce.state.wi.us cc: Ronald Riniker FEE REQUIRED $ 60.00 FEE RECEIVED $ 120.00 REFUND AMT $ 60.00 WiSMART code: 7633 APPLICATIflW FOR REVIEW -Complete ail pages- POWTS Bureau ~Bttil~ { 3 Check if Confirmation is Desired: ( }faxed,- { ).mailed NOTE: Personal infomtation you provide maybe used for secondary purposes (Privacy Laws. 15.04{1){m), Stais.j Confitmation of assignment tC a reviewer. 1. Private Sewage Sutxnitt ai 2. T YPe ~ Serbrnlttal: Transaction ID: System Type { )Soil Saturation ( )New Previous Related Traces. ID: Determnation R ~rt ( )Revision Estineated Completion Date: )interpretive Determination ~ Replacemerrt ~~~ ~wevver ( )Petition (attach form SBD-9890) { ) POWTS System ( ~At Grade { ) ~~e~ a~rovakf Assigned Office: Holding Tank { ) Compor~rtt Manual (Indude each Circle your choice of offices below: { ) Nonpressurired in- rsorriponent manual name, # and . { } R ~ date on tilts page of plan) Next available appointrreeret in any office, 2 Careen Bay, 3. Hayvward, Ground ( ) hidividua! She Design 4. Lacrosse, 3. Madison, 6. Shawano, T. Waukesha ( ) Maund ( ) Aerobic Tn3ahment lMi! 3. Project Fniorrriation - F 'n aN info n. { )Sand Filter Projectf5ite Name 0. t ~,t--- _ single pass Location, Ntarrber & Street of project {if nk~ioyrn, indicated reeare~ roadj ~~p c~~ o~ ~Q is Q, , Leo ( } Construcfied Wetland ~ ( ) Dry Line ~ t'E? ~ C' l/il a Town of f'`E'.S~ { )Other. Building Type (check one}: 4. After plans are reviewed. ease: (cteeck ail that a ~ PPIYI ~} Dweging, 1 or 2 family ~ Cali aistorner i, 2, 3, 4 ( nu~r)' 'Refers to .customer number from below t ~ Pt~lic/Conxnerciai i ~( ~9 P~h~ pic~(up 3 4 {circle number)` ~ ~~ ~& to cx~tom~ 2 " { ) Skat e-owned Build'mg , , ` ~ ..Gallons per Day vim' ~ ~C 5. Complete the fofiowirig desig>rerfowceerf re4~ng irdom-ation. Utilize the check boxes where 'n the sarem to sunk! _ irtormation. ' . ~ ~nforrerat3~eii~ > > , _.. ~~ _ ~ ~} _- ,_~,a, _ ,:. .. n afrjt7#erentai~a"n° ~'-- ~ Last. Name Customer Number Fast Name last Customer Number ~~ 0 Name ~ ~ oL yt Company Name ,~ ~ '~ Address ( ~Z~ {~) City State Zip+4 (9digits) Phone Number (area-gads) 5f Fax or Internet sell phone Phone Number (area cads) Fax or Irrtemet ~r S Check others ' applicab Check others if applicable Owner P r Owner Pa > t ;:=> _... .. ~ F' Name Customer Number ~ First Name tastName CustomerNUmber -t w Company Name Company. Name ~~ { ~h ifi~ Address . ~tY v ~ }~ !State Z p 4 (~g-#s) ~~-a--' Cdy Staff trP+4 (9digits) Phone Number {area cads) Fax or keternet Phone Number (area code) Fax or Iritemet Check otheB if applicable Check others if applicable { )Payer { )Payer { )Other MAKE CHECKS PAYABLE TO DEPT OF COMMERCE TOTAL AMOUNT DUE $ ea Attach Check here QnT i Hems in ~s ~nn~ ~r~rssa s+ ~..~ ..,..' .. '- _' ~ `- -- _ _ Review Code 7633 - - Plan Review Fees for Private Onsite Wastewater Treatment Systems 6 , . Type of Project (CIRCLE THE APPROPRIATE FEE SELOW) FEE ' 1. Ail treatment components are previously approved under s. Comm 84.10 {2) or (3): Design wastewater flow of the proposed system: 1,000 gpd or less ............. ........................... ..................................................... . ..............................$175.00 1,001 - 2,ppp gpd ................................................. ............................................ ..............................$225.00 2,001 - 5,000 gpd ............................................................................................. ..............................$275.00 greater than 5,000 gpd .................. .......................................,....... ..............._............. $300.00 plus 30.05/gid 2. One or more treatment components are not previously approved under s. Comm 84.10 (2) or (3): {individual site desigNdeviation fran component manuals and use of components without product approval): Design wastewater flow of the proposed system: 1,000 gpd or less .............................................................................................. ...............................$300.00 1,001 - 2,000 gpd ............... .......................................... ................................... ...............................$400.00 2,001 - 5,000 gpd ............................................................................................. ...............................$500.00 greater than 5,000 gpd ....................................................................................... ........................ ......5600.00 plus $0.05/g!d HOLDING TANKS ONLY 3. Holding tanks previously approved under s. Comm 84.10 (2) (3 Design wastewater flow of the proposed system: 5,000 gpd or less .............................................................................................................................$60.00 ... 5.001. -10,000 gpd ............................................................................................. ......................... $100.00 greater than 10,000 gpd .......................................................................................... .........................$150.00 4. Holding tanks NOT previously approved under s. Comm 84.10 (2) or (3) and site constructed tanks Design wastewater flow of the proposed system: ~~ 5,000 gpd or less ................................................................................................... .........................$120.00 5,001 -10,000 gpd ................................................................................................ ..........................$200.00 greater than 10,000 9Pd .......................................................................................... ..........................$300.00 Experimental System {additional gone time fee) .............................................................................. ..........................$300.00 Revjsiorrs to Approved Plan ................................. ............ ............... .......................................... ........ .....................560.00 ~•~ Petition for Variance (tndude form SHD-9890} ................................... ....................................... ...................... $75.00 Ravicinn fn a nrir3vinushr aneroved Pttition for VarlartCe .............................................................. .....:.........:.............. terpretive Determination Report ..........................................................._........ _.............................. .... ....$1t}O.t7tt Subtotal .. ............. ................. Priority Review: Enter same amount as subtotal .................................... Prior approval from a section chief is required for a priority review. if approval is granted, the priority will be reviewed within 6 days of receipt C7 Enter TOTAL (rounded to the nearest dollar). here ~ /0?8 and on bottom of FRONT PAGE Note: Fees are pursuant to Ch. Comm 2 and ace subject to change annually; please contact any of the offices listed below far the most recent copy of this form. Comm 2 provides for a partial fee refund if a plan action has .not been taken within the 15 days of receipt of alt required information. 7. Appointrrrerrt, Scheduling urfo. and Plan Submittal CheckUsts. P04YTS scheduling is not available. Plarrs'wiU be assigned to a reviewer after reoegst of plans. If you wish to receive confirmation of the assigned. reviewer arm estunamd completion date please dredc the box in the upper right comer of the fry page. Ado note in file same lac~ion that you can designate a specific office for review. if you sated a speaflc office your estknated comp~tion date may be considerably greater than what would be possible in another office. Submittals received without a specif' is office indicated on the form may be assigned to offices other than the receiving office deperaiin9 on reviewer availabfiity. To obtain a sutxnfitat cheddisi call tfie material order unit at 6U8-266-1818 or wre of the ftdt serve offer listed be~a• pldOiS~1,70eDU no~swai wa+v 201 W W~hington A~ 10541N Ranch Rd 4003 N Kinney 1340 E Green Bay 2331 San Luis Place 401 Pilot Court 53703 Hayward W154843 Coube Rd Shawano Wf 54166 Greert Bay. WI 54304 Waukesha Wt 53188 PO Booc 7162 Madison WI 53707-7162 7i5-6344870 I..aCrosse WI 54601- 1831 715-5243626 920-492-5601 2&2-548-86~ 6138-2663151 Fax; 71534-5150 Fax: 715x24-3633 FAX: 920-492-5604 -Fax: 262-548-8614 Fare 608-267-9566 Email: haywardsch~ 608-785-9334 Email: shawarmsch~ Email: gnsenbayseh~ Email: waukeshaseh~ TDD 608-264-8777 corrimerce.state.wi.us Fare608-785-9330 carr-mert~e.state.wi.us oortvrneroe.staUe.wi:us commeroe.state:rvi:us Email: rriadisonsch~ Email: tacrossesch~ oornrnerce.state.wi.us canrneroe.state.wi.us PAGE~OF~ HOLDING TANK FOR A~BEDROOM RESIDENCE LOCATED IN THE ~If'E 1/4 OF THENW 1/4 OF SECTION~T~N,R 15W, TOWN OF -~,~.Q~'rt , S"t` ~.ro;~_COUNTY, WISCONSIN. INDEX PAGE 1 OF 5 PAGE 2 OF 5 PAGE 3 OF 5 PAGE 4 OF 5 PAGE S OF S TITLE SHEET PLOT PLAN CROSS SECTION HOLDING TANK AGREEMENT HOLDING TANK SERVICEING AGREEMENT ((~~ PREPARI~D FOR a~ as a~v~ A~ C\.~ ~f=.k-~.. ~ ~ ~ ~s~r ~~s PREPARED BY CALVIN POWERS #220537 DATE: - i -~ ~ chq~ ~~ 9G~ C~ G ~~ `~O~ ~~ ~~~ ~ ~~ /` POWERS EXCt\VATING INC. 1969 185'(~H AVE. NEW RICHMOND, WISCONSIN 54017 ~•Q•W~.r.~~ 715-246-{ 135 Cvttditiona~t~ RovEa ~~ ~E11T OF COMMERCE DEP~RTM ~~~ pWtSiQN 4f f~ {iNCG+ ~~ ~~~~~ ~~~:.~,~ tom. ~L s ~ ~~ s aaoa ~~~ ~I~t~~~ ~ ~~k ~ ~ ~~~ ~, Se~A~ ~ ~ ~E~~ ~~a~53,~ ~.: !-b! ~'~~~ "~~'- ~ ~~ ~® -~, ~~ ~'4' ~~ s 1~ t a ~~ 1 1 a ~ ~~ cam' Z,bdo ~aL. {io~D~a~TariK x--:~,. ~~ ~PME '~?~tS'rtNCy SEPT~G SY3T~M MJST $~ gga~DON~~ ('ER Ca~,w1 83.,33 Mlat.t. ~-~ ~F E~o~DWb TAhiK MUST E3~ 4NGNORED PER GOMM $3.~-3C8x9~ WA.G. ~~ ' ~ i i1nLDIl~G TANK CR(IiSS-SECTION ANA SPF.GIFICATIONS ~, .~. .t ~~proved __ Approved Locking €,nt Gap ~ Heather Proof Manhole Cover Junctfon Rox .. i 2 ., M i Final Crade` ~ _ 1 t / i i /Approved Joint `' +~ ---~+- j,s. _._ i c 1 High Water Alarm Switch.~~ . ---~ ,~ SpFCIFIC:ATIONS TAiZK Manufactuter:~,~,~~°~``.Qi~'_ _~_.-_-- -~ ____ Tnnk Size : QUO Gallons ALA_RM_ Manuf acturer: ~.~_ Model Number : 1(S~ W 5w i t ch Type _ $r ~-~,c~`t' ~ NUMRF.R ©F REDR(}OMS: 4" Min 1$" Min i Approve Joint w C.I. Pi Ex t end'i 3~' Anna Solid ~S r~:i.J NER ' S NAME : _____~~ ` -'~ ~ -- _ - .?:GAL DISGRIFTIOh: ~~k.}~2,y? k.Sec.~9, .T ~i+R_~.~W {~sJNSiIIPjMUNICIPALITYz ~~„ :,AUNTY: ~ ~.~ -~ C.I. n ~ -- t'z~>.t Pfpe HOLDING TANK AGREEMENT 5afetyandBuildingsOivision Bureau of Buildings acrd Water Syste This agreertteni is made between the This space reserved for recording data governmental unit and holding tank owners} { Tank rt~j sa ~^ .a~~ ~~r ~~ atoms` We acknowledge that application is being made for the installation of i'a} holdi 9 tantc;s} on the following property. (Provide legal land description} ~fsconsln Department of Industry, t.ebor and Human Relations ivo_ Agreement or total Governmental Unit ttetwrn TO ar that continued use of the eaeisting premises requires that a holding tank be installed on the property fior the purpose of proper containment of s~nrac ~~ the Property: cannot now be served by a mvnitipal sewer, ~ arty other type ofi private sewage system as permitted under t]r. ItFlR $3, Wis. Ads Code, or Ch.14S. Stats_ As an inducement to the County of ~j#" ~,Y~[~~~1~ toissue a sanitarp permit for. the abrnre described a P* perry, we agree to do the following t. Owner agrees to conform io a!I applicable requirements of Ch, ILHR 63. Wis, Adm. Code relating to holding tanks. If tht owner fails to have ti holding tank Properly serviced in response to orders issued bl' the mrxsitipalrty to prevent or abaft a human health hasa:d as described in s. 254.5 Slats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced arxi tharge the ownerbl- ptaci: the charges on the tax. hilt as a special assessment for current services reexdered. The charges wiR be assessed as prestrs3red by s. 55.60. Slats, 2. The owner agrees, pursuant to s. ttHtt 83.1$ (401. Wis. Adm. Code, to have installed in a new buBdinq or crew structure a water meter approved 1 the County and State. The water meter shall: be instaNed by a camber authorized by the State to conduct suds instaHatioess„ with said insiallatic complying vrith State regulations and menu#acturers specifications. The owner agrees to be frnanciatly responsible for the purchase, irutatfatio maintenance, avid repair of the mater meter, and agrees to altow the municipality to enter the above described property ore a regular basis to yet andto* inspect the water meter. 3_ Owner agrees to pay all charges artd cost incurred by the municipality for inspect~n, pumping, hauling, or othervrise servicing and mahrtaineng U holding tank in such a manner as to prevent of abate any human health hazard caused ~ the holding tank. The municipality shall notify the owrsi ofi any costs which shalt be paid by tree owner within thirty. {30; days from the date of notice. to the event the owner does cwt pay the costs witfr thirty {30) days. the owner SpecilicaFly agrees that all tAt pests and charges may be placed ort the tax r,rdl as a special assessment for the abatemetrt t ahvman health hazard. artd the tax shall be collected as provided by leer, 4. The owner. accept as provided by s. 146.2013;;d1, Slats., agrees to contract with a person who is licensed under Ch. PfR t 13,11frs. Adm.. Code. to fsa. the holdmg tank serviced and to file a copy of the coistrad or the ow»er's registration with the municipalit~r. The owner further agrees to fife a oop of any changes to the service tontract, or a copy of a new servtte contract, with the municipality wittrin ten Ito} business days from-the date t change to the service contract. §. The owner agrees to contract with a person licensed under Ch. NR t 13. Wis. Adm. Code, who shall submit to tine rnunic~ality on a semiarusual basis. report in accordance with s. ltFtR 83. t 8 {43 ta) 2., wis: Adm. Code,.. for the servicing of the holding iaank. to the case of registration under s.145.20 (? (dy, Stets., the owner shall submit the report to the municipality. The municipality may seater upon the property to mrestigate the condition ofi th holding tank when pumping reports and meter readings may indicate that the holding tank is not being property maintained. 6. This agreement vvitl remain in effett only unt,t the bcal governmental umt responsible far the regulation of private sewage systems certifies drat th property is served by either a mur-hipal sewer or a soil absorption system that complies with Ch_ R.HR B3, Wis. Aden. Code. to addition, th agreement may be canceged by executing ae>d recording yam certification with reference to this regimen! in such manner sNhicfir will eriistence of the certificatiwr to be determined ty reference to th+e property. ~ ~K th 7. This agreement shah be tending upon the owner. the heirs o! the owner, acrd assgnees of the ovmer. The owner shall submit the agreement to ttr register of deeds, and the agreement shalt be recorded by the register ofi deeds in a manner which wilt permit the txistence ofi the agreement to tr determined by relerence to the property where the hoMing tank is irrstalied. - Qrint •-" and sYVOrn to befiore me on this date ~ .~c~.QCS f !.~ \ Q €'~, ~ C* ~ ,. ~~.- .r-~ . . ~ ' ~ ~~ - _--- l~lotag fwbtr C.~ ~ ~ .-~ Municipal Of fiitiat Name -print ~ Municipal O fica Signature .~ * : ~ -.e . M G~ ' f" ~ s turyr pommi~s%gr-expires: Municipal Of icial Title -Print ~. ~d ' , n~~~t The information you provide maybe uzed by ether government agency programs IPrivaq t' ~>°~ SB©-5133 {R. 04194) ~>rtttalttttttts~ ~r HOt_DtNG TANK SERVICING CONTRACT '~ lontract Date ~~ ~ ~ ~~~ ~ This contract is made between the Holding Tank Ow er{s) Name{sy ~ and ~ Pumper's Name J l~~~S~ j,~~% f 1.~9{~' ,.;, e t^ i`~c~v- ~ a~t rs t.~~`~ ~~ 1 /~~~ J rf iE ~~ m ~n ~ i (.t1 We acknowledge the installation of (aj holding tank(sj on the following property: (Provide fegat description:] ~ ~ F yy ~,~.,'~~ S ~. -~ ~ i u 121s ~ _ _ _ ~~ 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4j {b},Wis. Adm. Code and with the Gounty of SAC 2. The owner agrees to have the fiotding tanks} serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank{sj. The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tanks} with the pumping equiprie~~t. The owner further agrees to pay the pumper for aft charges incurred in servicing the holding tank{sj as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4} (b), Wis. Adm. Code, and to the county, a report. for the servicing of the holding tanks} on a semiannual basis. The pumper further agree to include the toilowing in the semiarmual report: a, The name and address of the person responsible for servicing the holding. tank; b. The name ofthe owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract the owner agrees to fife a copyt of any changes to this service contract or a copy of a new service contract with the municipatit and the County named above within ten (it)j business days from the date of change to this service contract. Owner(s) Name{s) rant} ~ Owner s 5ignature(s} /~o,~G~ , 11,/J~'~~ ~ ~` ' ~ i' ' `'i- ~ ~~~ t ~t ~~ ~ Subscri nd s orn to before me on this date: ,.fir ~ ~ ~d t '~~~ ~ 11~~~M otarr YUinper S Mama (rnnc~ ~ • .-.••r-. - - a _-,-__ _ ,ti` ~'U,S ~~r //' r • • p~ ~ r ~+V •* Pumper's Registration Number e ~ .,, • ~ • ~ • ~~' • seDaS~a tR. o9~et3y This instrument was drafted by the Stat~~'vYi`gp'ent of industry, labor and Human Relations-, ~ ~ ~ _~ - s 4 ~. ~ ~ ~~ ~~:~ 1G~~ ~QsM _ PAG~ ~ . ~ ~ ,,/ ~, _ ~ Document Number /Loein e.~ °OCt° ~ ~ Y~A~iHLEEN H. WALSH kEGISTER OF DEEDS ST. Cf<OIX CO., WI RECEIVED FOR RECORD 06-03-2001 9:34 AM HOLDING TANK AGkEEMEHT EXEHDT M CERi COPY FEE: COPY FEE: TkAHSFER FEE: kECOkDING FEE: IP,00 PAGES: 2 Reeocding Area Hama aad Rq~ Adder (~ a (v~.q Z.co~ C~...~ C' 1.e~~ `fie. , c..a~ S~ oc~ 0 ~- f(~VO - l~ c7c___~ __- I w Pared Tdcun6eauon Nmnpea. 0'~ FF "THIS PAGE IS PART dF THIS LEGAL DpCpKENT - DO NOT REMOVE^ Thin iaforautioo aarq be coa4~d by abmiac. err rht drm~dnd elawrei, 4jal ~+crrP~, ue. att< mm~e & ream add :li and ~(N (/^~Q~cd). Odin oizwdoa iveh daaanrnt JLo_.~ U+c of rho oaMrr c °~' ~ placed on thlr JGrt pack ofrht doaanp,r ~ ~ ~ Pad addr one Pad c m Yawn docronaw and 52.00 W the rcrne~ ~ plaecd err addCa(paal pades of do - Wueauin Swuvul, S9S17. WRD,( 2./P6 ~L '~ ~consin Department of Industry Labor and Human Relations Document No. /Plan Identi (ir.u.,., u.. ...y.~s Igt(o_ t.,n _c~d HOLDING T6ANKPAGR8EMENT This agreement is made between the governmental unit and holding tank owner(s) ~n~d K~t~~K~r^ We acknowledge that application is being made for the installation of (a) holding tank(s) on the following property: (Provide legal land description) Salety and Buildings Division Bureau of Buildings and Water Syster space reserved lo. r.rn.e:.....,_._ or that continued use of the exndng premises requires that ~ hWding tank be installed on the ro rt for the ur ~b~4 a 10 , ~ia,~ Also, the property cannot now be served by a municipal sewer, or an other t D ~~ ~' ~r sYa Code, or Ch. 145, Scats. Y YDQ of rivate sewage system ss pe~mrtted under ChtILHR 83, Wn wAdgm As an inducement to the Countyol _ Cj-[' l .nn~ ~' to issue a sanitary permit Tor the above described property, we agree to do tlx following; +. Owner agrees to conform to all applicable reQuirements of Ch. ItHR 83, wis. Adm_ Code relating to holding tanks. t! the owner faits to have the holding tank properly xrriced in response Io orders usued by the municipality to prevent or abate a human health hazard as described rn s. 254.59. Scats., the municipality may enter upon the property and service the lank or cause to have the tank to be serviced and charge the owner by placing the charges ors the tax bill as a special assessment for current services rendered. The charges will be guessed as prescribed by s. 66.ri0, Scats. 2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter a the County and State. The water meter shall be installed by a plumber authorized by the Slate to conduct such insWAalions, with said imtallation complying with State regulations and manufacturers specilrcations. The owner agrees to be (inanciaR res DProved by maintenance. and repair of the water meter, and agrees to allow the municipality to enter the above des<ribednDroDertyton sregular bas s ttoaread and/or inspect the water meter. 3, Owner agrees to pay all charges and cost incurred by the municipilily far inspection, pumping, hauling, Or otherwise serricin of an 9 and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner y costs which shall be paid by the owner within thirty (30) days from the dale of notice, In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges maybe placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be cWfected as provided by law. 4. The owner, except as provided by s. 146.20 (3) (d), Scats., agrees to contract with a person who is licensed under Ch. NR t 13, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract or the owner'f registration with the municipality. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contratt, with the municipality within ten (10) business days from the date of change to the service contract. S. The owner agrees to contract with a person licensed under Ch. NR 113. Wis. Adm, Code, who shall submit to the municipality on a semiannual basis a report in accordance with s. ILHA 83.18 (4) (a) 2., Wis. Adm. Code. for the servicing of the holding lank. !n the case of registration under s. 146.20 (3) holdin (d), St 9 lank when pumping retwrtssandpmete~read ngs may indicate th t trhe hlolding tanktis not~bernhe property to investigate the condition of the 6. This agreement will remain in elkct only until the local governmental unn respansyle for the regulation of p ilvateasewagedsystems certifies that the properly is served by either a municipal sewer or a sot) absorption system that complies witA Ch. tLHR 83. Wis. Adm. Code. In addition, this agreement may tit: cancelled by executing and recording said certification with reference to this a regiment in uch manner which will existence of the certification to be determined by reference to the propnty, q s permit the 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the a r register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the propertywhere the holding tank is installed. 9 Bement to the the inlmmatiun you provide maybe usuJ by other government a enc SBD•li)23(R.04/94) 9 YProgramslPrivacy ~.x c-~'n~:~ ~ ;;~ s:. ~.it_ ... :~i3 :t.,. Ci~l V : ~. aaage 1 or ~ rnch _~, it . r._.,..' ~ ;~; `~ ,:c<.i < °~` ~ _; `_ ... , _, , :' t r ,...,. _... --:? rz:~•<: ~' t.a. 01~ ~0-000 1040 ~.~u 3a.,..ttan ei}J ~istc~nns:e 4v nearest rand. n~, tlt ts.~vr sordltzterrsions srr ~ccni siopQ - - , , , . p.. Pa-spn„t i~ sanftctlan ya gtw[dm mry ho a9~d to S^,CCR~LtY F="ca {i'rivary Lmr+, 0. 25.04 {I) {m~). ^tVr.y ~:1C1'~rar Pro~,+ertytocation lot N~ tt~ r"~ ~t4 s 19 T 31 N R 15 ~ {or} W Govt ~n7zs ta~z Piopsriy CArtnr>;r's Maliiras Address . t_ot ~f t31oGc it sped. N cr Cstvl# 2528 210 th, Arc, r.~ na r ity Staia . Zip cads Pt,orro rltu~~ D C!Zar ~3 . ~ TanvR Nearest itoad Clear L-t'.~e Y~I. 54105 715 2a3-21371 wrest 21Qth. Ave. © tQew Constcudton use: Cl Rasidentlal ! Numenr of btdrooas~s _~_ Code derived d flow rate ,_ 450 GPD ®ftoptaoomerrt ^ Put>sic or oommerei~ - Qesctibe> Parent materiel [tlaci~l ~ r3 ri Ft-_ Flood 1~ ~evall~l'- N na a soil borings in area did not show anything other th~i a A+O" soii C~aaidition. At this time the only systen ailoPwable is a hoidiny tarok. ^ ea>~ 1 80~ ~ ®pit Ground sins env. na tG ~ Dept i4 Ihrdt+urg iac@or . 5 in. ~ Rata p~ Q Rarfooc Descripion Textue S6uduna Cot>sistexe 'SourdarY Roots irr. Murrse8 4u. Sz Dart: Golor t1r. sz. Sh. 'EffN1 'EtftF2 sil 2~ 2 5-9 1 r~ 3 d 7.5 r5 6 3: 9--24. 1Oyr5j3 ~2 7.5 f8 sil 2msbk dsh If 4 4-55 7.5yr4/ c2p'17.5yr5,/6 sci M na na na • 2 ~ p~ t,roturd surface elev. na 1i. Ea rnit~g factor ~ in. 5oN Bete ~~ # ~ ~~ t+ue sl~ Gons~anae 8otmdar~- Roots GP DII! F{orixon &-. Darair~td Cotes Mtufsef R tau. Sz. Cont. Color Texhxe ue Gr. sa. Sh. •EtMt 'EtT#2 1 0-8 1 3 3 txme 2 b-I5 10 r3/3 c2d 75. rS/8 it M 3 15 ?.5yr4f4 c2 7.5 r5/8 sc3 M na na na EttMaent #1 = 8~ > ~ _< 220 mkt. attd Ts.S >~ <_ 1 50 mglt. E.1'Ch~ent #2 = BOQ _ 30 mNil. and TSS _< 30 argil. ~, t+~sre ~1 ~ . CST Nurtrer Gar L, Steel > 0229$ Astdress Oa3a E Telephone alulrrber 1554 200th Ave lbw Rictmtond WI 54017 ~ _ 715-246-620 •r r Property Owe D. iut,Z p~ ~p # 014-1040-60-000 p~ 3 a ~ 1 6 I ~~ ~ Q na ~, . ~~ r'u ...w..w......~.e~e.. ra. aivNu~ w s.wwy uw,aw ^F 1~lorlaon Daptlt t)omin~t 1iAd01c t~e3ot1p1f0r! Tezetrra St~ues t:oneleBwrcoe 8ot3Rlary 8+0013 GP QAI~ ti. ~L $2. 1`i01R Ci010r ' t'la'. 'fit. 'Sit. •E1fA~1 `~ 1 0-6 10yr3/3 none L 2msbk dsh yw 2f .5 .$ 2 6-23 10yr5/3 ~2d T.5 r5j9 siI if 3 23 7.5 r4J4 c2d 7.5 r5 8 si ( -~ u j Sapp M ~ ~ [~ p~ Ground s~rf3as slay _. na ~, DeDO-1o imMrg ~1or 0 ~ Soil R3~r tiorFxon Depot Domb~# Ratat Gesal80cx- Tsxluro St~`e ConsMlawa 8ot~r Roots E3P I~IM' U. Mur~ai Qtit SL Cant ColOt Gt: Sz Sh. 'EflBi 'ElN2 i 0-15 i r2 2 ncaie 2 15-25 IOyrS/i c2p T.5 r5/8 sil M zw n ~10f130rt Dap11t DOerirMltrR RadDx Ossplpbrt Te~ttte StftrG'ltaa QOId~nOa 6t0131dIrY RoOb In. A~Itefaei ~ SL t~OrM. C~OIOf Gr. Sz. ~ "fti81 'Eti1 2 0-3 10 r313 none L 2msbk deh w i 2 3-20 i0yr513 c2p 7.5yr5/8 sil M na na na .0 .2 E.efluent #1 = ElOOf > 3D < ~p ~ and TSS a30 < 1SD mp1t. • E'1~rent R g 8i0Da < 30 mpA, and 7SS ^ 30 mdL The Department ofCom i3 an egaal opportunity senricc provider wd employ+sr. If you Hood assistance oo aocass setviaes or need tai in as aitxraata format, please eomact the dcparearent at 6Q8-266-3251 o~r'ITY 608-?.6~4-.8177. . , .STEEL'S SOIL SERVICE Gary L Steel _ 1554 200th Ave. CSTM2298 Dennis ~~ New Richmond Wl 54017 Mf'RSW_3254 xtvw~ si9-z~31rt-RZSw (715) 246-6200 toxn of Forest 20 acres ~ ~ ©~ ~~. g X`~ t'r ~1 ®~ 8 ~ ~- ~~~, ~~+`' ~~ ~r~ 0 5~" s~s a ~~~ ~`~° ~ ti ~,~ 3 i a ~~ ~~ ~r ~ fl~ '~ Gary L. Steel 9-29-2000 .< Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page 1_ of ~ ni aoauroance wnn wrnrn oo, vns. r1am. ~.uue County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan must S t. C R O i x . 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 ar siistance to nearest road. 014-1040-60-000 Please print all infor~ ~~iJ~ ~ _~.,_ ' ! Reviewed y Date Personal information you provide may be used for seco oses (Privacy Law,'5.:1~.04 (1) (m)). Property Owner ~ ~, Pr "efYy ovation Denn1S LUtZ c-` ~ >Lw Govt.`~lot '', NE 1/4 NW 1/4 S 19 T 31 N R 15 ~E (or) W Property Owner's Mailing Address -- ~ , ,a t # - ock # Subd. Name or CSM# 2629 210 th. Ave. ~•~ CILj na ~ na na Ci State Zi Code Number ', ~ .~~ ry P , , ~.~L~;,, , . ^ ~~ty ': ^ Village ®Town Nearest Road ~ ~~ Clear Lake WI . 54005 ( ) 6 '~~` ~ ~ ~``'• Forest 210th. Ave. ^ New Construction Use: ® Residential /Number e~gb'rps~rGode derived design flow rate 450 GPD ® Replacement ^ Public or commercial -Des G ----~ ~-`'".~ Parent material J1aCia.l drift Flood Plain elevation if applicable na ft. General comments and recommendations: s011 bOringS in area do not show anything other thatal a A+0" soil .condition. At this time the only systelrm allowable is a holding tank. AIrP/[~ ~/ u 1 Boring # ~ Boring ® pit Ground surface elev. na ft. Depth to limiting factor ~ 5 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 1 sil 2msbk dsh 2 / 2 5-9 10 r~ 3 c2d 7.5 r5 6 sil 2msb ~ ~ 3 - 9-24 10yr5/3 c2p 7.5yr5/8 sil 2msbk dsh if .5 ~ .8 ~ 4 4-55 7.5yr4/ c2p~i7.5yr5/6 scl M na na na .Q ~ .© ~ ^ 2 Boring # ~ Boring ® Pit Ground surtace elev. na ft. Depth to limiting factor_~ in. Soil lication 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 - 0-6 10 r3/3 none sil 2msbk '~ ~ 2 - 6-15 10yr3/3 c2d 75. r5/8 sil M na if ~' ~ 3 - 15-40 7.5yr4/4 c2p 7.5yr5/8 scl M na na na .0 `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) Signature • CST Number Gar L. Steel > 02298 Address Date Eva uation Co ducted Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 =.9-29-2000 715-246-6200 Property Owner _ D. Lutz Parcel ID # 014-1040-60-000 • ~. t , Page 2 of 4 3 Boring # ~ Boring [~ pit Ground surface elev. na ft. Depth to limiting factor © in. Soil lipfion Rate th D nt Color in D Redox Description Texture Structure Consistence Boundary Roots GP D/Ff Horizon ep in. om a Munsell Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 • 0-7 1Oyr4/3 c2df~:~.~5 r5/6 L 2msbk dsh "w 2f .5 ~ .8 r 2 - 7-20 1Oyr5/3 c2d 7.5yr5/8 sil 2msbk dsh w if .5 / .8 / 3 , 20-40 1Oyr5/6 c2d 7.5ry5/8 2,sci1 M na na na .0 r .0 / 4 Boring # U Boring 3 [~ pit Ground surface elev. na ft. Depth to limiting factor ~n• Soil liption Rate l tion dox Descri R Texture Structure Consistence Boundary Roots GP D1ff Horizon Depth in. or Dominant Co Munsell p e Qu. Sz Cont Color Gr. Sz. Sh. 'Eff#1 'Etf#2 1 0-3 10 r3 3 none / / 2 ~ 3-11 10 r5/3 c2 7.5 r5 8 sil 2msbk ~ 3 11-23 1Oyr5/3 c2p 7.5yr5/8 sil 2msbk dsh ~w na .5 .8 ~ 4 .' 23-40 7:5yr4/4 c2d 7.5yr5/8 cl M na na na ~ ~ 5 U Boring BOn"g # Ground surface elev. na ft. Depth to limiting factor 4 in. ® pit Soil lication Rate i ti Texture Structure Consistence Boundary Roots GP D/ft° Horizon Depth in. Dominant Color Munsell p on Redox Descx Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 - 0-4 1Oyr3/3 none _ sil 2msbk dsh ~ ~ 2 - 4-17 1Oyr5/3 c2~ 7.5yr5/8 sil 2msbk dsh w if .5 ~ ~ 3 17-30 7.5yr4/4 c2d 7.5yr5/8 cl M na na na .0 / .0.~ 'Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mglL 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. sen-saw ta.~noo> • . Property owner D . Lutz Parcel iD # 014-1040-ti0-000 Page 3 of ~ 6 o ~~# o ~ Pit Ground surface elev. na fl. Depth to limiting fates 6 in. Sofl lotion Rate iioriaon Depth Dominant Redox Description Texture Structure Consistency Boundary Roots GP DIff in. Munseti Qu. Sz Cont Color Gr. Sz. Sh. 'Eff#1 'EtT~2 1 0-6 10yr3/3 none L .2msbk dsh yw 2f .5 / .$ ~ 2 6-23 10yr5/3 c2d 7.5yr5/8 sil if 1 r 3 23-4 7.5 r4/4 c2d 7.5 r5 8 sl M .< / ~~ # ^ Bores Pit Ground surface elev. na R. Depth to limiting factor ' ~ tn. ~ ~~ Rate Horton Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF , in. Mtuueli Qu. Sz Cont Color Gr. Sz Sh. 'Eft#t `EtT#2 1 0-15 10 r2 2 none 2 15-25 10yr5/1 c2p 7.5yr5/8 sil M na na na .0 ®Pit Ground surface elev. na it. Depth to leniting factor ~ in. ~~ # ^ ~~ Shc [cation Rate Horizon Depth Dominant Color Redox Description Texture Stnxxure Consistence Boundary Roots GP in. Murrsell t:kr. Sz Cont Color Gr. Sz. Sh. 'Eft#1 `EA#2 1 0-3 10yr3/3 none L 2msbk de w if .3 2 . 3-20 10yr5/3 c2p 7.5yr5/8 sil M na na na .0 .2 / ' Etfkrerrt #1 = BODE > 30 _< 220 mgtL and TSS >30 _<-150 mglL ' Etliue~ #2 =Bobs < 30 mgA. and TSS <_ 30 mgfL 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. sac-uwtx.sroot • , property Owner ParcellD # Page of ^ Baing # ~ ~°^^~ ^ Pit Ground surface elev. ft. Depth to limiting facto' in. Soft tis~ tion i R d D Texture Stnxxure Corisistenoe Boundary Roots GP D/lE Horizon Depth in. Dorrdnant Color AArrrraell ox esrx p e t1u. Sz. Core. Cobr Gr. Sz Sh. 'Eff#t 'Etf#2 ^ Pit .Ground surface elev. it. Depth to Ikrrdng factor in. Shc Rate 6 D Texture Structure Cortsistertce Boundary Root GP D1(f Horizon Depth in. Dominant Color Mutrsefl on Redox esa~ Qu. Sz. Cont. Cobr Gr. Sz Sh. •EtT#1 'Ett#2 ~~ # a ~~ Ground surface elev. tt. Depth t4 limiting facer m• Soil ication Rate t T Structure Cor>siaterxe Botvdary Roots GP Horizon Oeptl- in. Dominant Color Mansell Redox Description Qu. Sz. Corn Color ure ex Gr. Sz. Sh. 'Eff#1 •Etf#2 'Effluent #1 = BODs > 30 _< 220 rtrg~L and TSS >30 < 150 mglL 'Effluent #2 =BOO, _< 30 mgl~ and TSS , 30 mgA. The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an altert-ate format, please contact the department at 608-256-3151, or TTY 50&264-8777. senasw cx.srom ~ ~ ~• ' STEEL'S SOIL SERVICE Gary L. Steel CSTM2298 MPRSW-3254 Dennis Lutz NE4NW4 S19-T31N-R15W town of Forest 20 acres ... _ -rti A, fl' 1554 200th Ave. New Richmond, WI 54017 (715) 246-6200 ~ Gv~-~lpt~ K~ ~.~ ~1 .4~2 ~~~.r ~~ ~~~ ~~` ~ ~ ~q~~t ~~a ~ ~ ~,- 3 !3 ~' r ~,~o ~y i~ ~'"7 Gary L. Steel 9-29-2000 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND ' - _ OWNERSHIP CERTIFICATION FORM OwnerBuyer -KD~n \C~ -~`~ ,r~~, ,r~ t~ Mailing Address ~~~-q ~.((~~ ~~ ~ ~ ~,,~~~~~ ~ ~ \~ ~oS Property Address ~ ~ ~ _ (Verification required from Planning Department for new construction) City/State Parcel Identification Number ~_~ - I by Q -~00 -~~ LEGAL DESCRIPTION N Property Location _~ ~/.,, ~9~w ~/a, Sec. ~ ~ , T ~ (~N-R,~SW, Town of ~o (~~e5~ Subdivision N ~ ,Lot # N A- Certif ed Survey Map # Volume ,Page # Warranty Deed # _ ~ ~ ~~ c~ ~~ Volume / ~ ~ .Page # 3 Spec house ^ yes ~t no Lot lines identifiable Oyes ^ 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 fixnction of the septic tank as a treatment stage in the waste disposal system. ~"" The property owner agrees to submit to St. Croix Zotung Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewaterdisposalcystem is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/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 syste~as been maintained must be completed and returned to the St. Croix County Zoning Office within 30 ~____ ~a .._ ., - _ w ~/ DATE I (we) certify that all statemen s on this form are true to the best of my {our) knowledge. I (we) am (are) the owner(s) of * the pr ry~ii es ri end, ab v , by v' of a warranty deed recorded in Register of Deeds Office. ~~55 ~// /O SIGNATURE O APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. "***** ''* Include ~~:ith 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 decd • . HOLDING TANK SERVICING CONTRACT Cor~3ract Date ' J ~\Y ~ ~ aOd ` This contract is made between the Holding Tank Ow[~er(s) Name(s) ~ and I Pumpe(r's Name r--- ~ a9 at oT~~ U.Q I r01~"~ ~I yc~( -S`~ ~y~~? We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) ~~a~ NF`~ti NwY~ S~ -r3i Al RtS~ ` _ _ _. ST C,ro , ~ (~~:~ ~ ~w.~ P~ _ _ ._ Y _. ............ 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which ha: signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of _~T ~ ~,;X .f 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and tc enter upori the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agree; to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement;will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract. the owner agrees to file a copy of any changes to this service contract or a copy of a ne>.v service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(_s)~rint) Q I Owner's Signature(s) y ~~ ' ~ Sa , ~`1i ~~ Subscrib nd s orn ~ 1 to before me on this date: ~ 1 Zed I -_ i Pumper's Name (Print) I Pumper's Sign ure ``~~~111 I I11f/~~ Notary u Pumper's Registration Number ° _ SBD-7574 (R. 09/88)~' .• ' ~~ .rd .;,' This instrument was drafted by the Stag:df~s~i4s~Dep~~trilent of Industry, Labor and Human Relations ;~; ;,; ~ t~'s.a' r .• Document Number v~~, 1556Pa~_368 STATE BAR OF WISCONSIN FORM 2 - 1999 WARRANTX DEED This Deed, made between Dennis L. Lutz and Kathleen D. husband and wife Gran,~toyr~,~~nd Ronald L. Riniker and Sandy K. Riniker 45 , -.-S.LL- ~1:~ 1 .~ Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): The North half of the Northeast Quarter of the Northwest Quarter of Section 19, Township 31 North, Range 15 West. St. Croix County, Wisconsin. ?~ acres 2000 -!~~,~ + Dennis L. Lutz • Kathleen D. Lutz ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) (is) A~idQ Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this _~~" day of October + - AUTHENTICATION Signatures} Dennis L. Lutz and Kathleen D. Lutz, husband and wife authenticated [his~day of October 2[100 (l.~ t-- + Krishna 0¢land TITLE: MEMBER STATE BAR OF WISCONSIN (If no[, authorized by § 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hudson, WI5401 _ ___ (Signatures may be authenticated or acknowledged. Both are no[ necessary.) • Names oC persons signing in any capacity must be typed or printed below thei WARRANTY DEED 633025 Y.A'THLEEN H. WALSH kEGISTEk DF DEEDS ST. CF.OIX CO., WI RECEIVED FDR RECORD 11-03-2000 3:00 DM YARRAHTY DEED EXEMPT M CEkT COPY FEE: CODY FEE: TkAN5FER fEE: 435.00 RECORDING FEE: 10.00 PAGES: 1 Recording Area Name and Return Address '~U Q~l~E-C "C 1T ~~ 1~~p 1 C~.~1 e r oad 1~ud513q, 11.J~ Syo1~o Oly- Hoye -- tab -- ooc~ Parcel Identification Number (PIN) This is homestead property. Personally came before me this day of the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. r Notary Public, Slate of Wisconsin My Commission is permanent. (If not, state expiration date: __ J 18tnfe. Information Profeasonale Company, FonO tlu Lao WI ecoass2ozt ~v STATE BAR OF WISCONSIN FORM No. 2 - 1999 - ~ ~~ ~~~ .,„~~~> ~ ~,.., ,.~ ~f N~IINNN^ rrrrr ;':~ r.~. -.~ ~".. -~---= ,- , ~,:: ~-- _,= ~ . NOTICE OF VIOLATION August 20, 2001 DENNIS LUTZ 2629 210TH. AVE CLEAR LAKE, WI 54005 RE: Failing septic system at 2629 210th. Ave Town of Forest - St. Croix County, WI Computer # 014-1040-60-000 Parcel # 19.31.15.293B Dear Mr./Mrs. Lutz: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 FAX (715) 386-4686 As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 254.59(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code, and Article 15.04 of the St. Croix County Zoning Ordinance. This system has failed under the definition in § 145.245(4)(b) Wisconsin Statutes (Category I). This violation was first noted on 08/20/2001. The violation noted is septic effluent discharging to zones of saturation. An on-site inspection on 08/20/2001 did reveal the septic effluent discharging to the zones of saturation. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed as of 08/20/2001 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQUIRED ACTION: By October Ol, 2001, contract with a certified soil tester to have a soil evaluation conducted. The soil evaluation will determine the type of septic system needed and it's location. Then contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The septic system must be installed no later than June 1, 2002. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. I look forward to working together to resolve this matter. Sincerely, w~- ~~~ on Sonnetag Zoning Technician cc: file ~ ~ ~scons~n Department of Commerce August 29, 2002 Dennis Lutz, Sr. 292 Staffenson Amery, W 154001 ., r %, -----~..,e- .,._ ETY AND BUILDINGS DIVISION Field rations P. O. x 2538 Madison, Wisconsin 53701-2538 Scott McCalltxn, Governor Phillip Edw. Albert, Secretary 608/267-7113 Re: Wisconsin Fund -Private Sewage System Replacement or Rehabilitation Grant Program Eligibility Dear Mr. Lutz: I regret to inform you that you are ineligible to receive an award for your private sewage system. This decision is based on s. 145.245(5)(a)1., Wis. Stats., and Comm 87.40(1)a., Wis. Adm. Code, which require that the applicant be the owner of the principal residence. The records indicate that you were no longer the owner of the property when the system was replaced. If you believe this decision does not correctly apply the law to your circumstances, you may wish to request a hearing. A hearing can correct errors of the department in administering the Wisconsin Fund. However, it cannot create exceptions to the laws and regulations governing the property, modify program requirements, or make payments not authorized by the legislature. This decision will become final unless a written request for a hearing is received within four weeks from the date of this letter. Hearing requests should state the reasons for appealing this decision. Please send the letter to Wisconsin Fund, Safety and Buildings Division, PO Box 2538, Madison, WI 53701-2538. For further information, feel free to contact me. Sincerely, Jean Joyce, Grant Specialist Wisconsin Fund -Private Sewage System Replacement or Rehabilitation Program J Joyce ~ commerce. state.wi. us 608/267-7113 cc: St. Croix County -,~~ NOTICE OF VIOLATION August 20, 2001 DENNIS LUTZ 2629 210TH. AVE CLEAR LAKE, WI 54005 RE: Failing septic system at 2629 210th. Ave Town of Forest - St. Croix County, WI Computer # 014-1040-60-000 Parcel # 19.31.15.293B Dear Mr./Mrs. Lutz: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 FAX (715) 386-4686 As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 254.59(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code, and Article 15.04 of the St. Croix County Zoning Ordinance. This system has failed under the definition in § 145.245(4)(b) Wisconsin Statutes (Category I). This violation was first noted on 08/20/2001. The violation noted is septic effluent discharging to zones of saturation. An on-site inspection on 08/20/2001 did reveal the septic effluent discharging to the zones of saturation. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed as of 08/20/2001 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQUIRED ACTION: By October Ol, 2001, contract with a certified soil tester to have a soil evaluation conducted. The soil evaluation will determine the type of septic system needed and it's location. Then contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The septic system must be installed no later than June 1, 2002. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. I look forward to working together to resolve this matter. Sincerely, w~ Jli~.y~,,,r„y. on Sonnetag Zoning Technician cc: file .t ~- If the owner feels they are eligible and would like to apply, they should now complete Part A of the Wisconsin Fund application. The applicant will be instructed to supply the county with a copy of their federal income tax form if applying for a principal residence or their federal profit and loss form if applying as a small commercial establishment. Income is verified with tax forms for the year of or the year prior to the order or determination of failure. /Income tax form verifying income, Total cost of system replacement, -/ Onsite report verifying that the system has been installed and is working in compliance with the state plumbing code, ~'Y p pp ~ Copy of the approved plans, ,~~ Verification of ownership, If there were unusual circumstances surrounding the application, additional documentation would be required. For example, a real estate sale would require a copy of the deed verifying dates of ownership and a copy of the sale contract, paid receipts or canceled checks showing the applicant incurred the cost of replacement. Another example is a trust or estate. Keep a copy of the agreement on file. 4. A certified inspector for the state or county, with a physical inspection, verifies the failure. An enforcement order or determination of failure is then issued to the owner. 5. Once the enforcement order or determination of failure has been 'issued, the system can be replaced. An owner is not eligible if the physical replacement of the system began prior to the issuance of an enforcement order or determination of failure. 6. The county representative then processes the application, which includes completing Part B of the Owner's Application and the Grant Worksheet. A completed applicant's file will contain: `~ Owner's application, ~~ Grant worksheet, ~ Sanit ermit a lication 7 To be eligible for an award in the next fiscal year, applications sent to Commerce must be postmarked by January 31. Information submitted to Commerce for each eligible applicant would include: Copy of the owner's application, ~ Copy of the grant worksheet, Copy of the sanitary permit application, Copy of the approved plot plan, ~ Copy of the final inspection report, if available, and .Additional information when it is necessary to determine eligibility. ~,r "~' ST. CROIX COUNTY r' ~' `~,~~ ""``= --~, WISCONSIN '~ "` ,^.„^„^;; -~_ ~-- ZONING OFFICE ..... - ST. CROIX COUNTY GOVERNMENT CENTER .~_~:.~-~ -,-•- - 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 • Fax (715) 386-4686 December 10, 2001 Dennis & Kathleen Lutz 2629 210'' Avenue Deer Park, WI 54007 Dear Mr. & Mrs. Lutz: Your application for Wisconsin Fund Sanitary System Replacement reimbursement was received by this office. I have checked items on the list below that are still needed from you in order to process your application. ^ $100 filing fee Copy of warranty deed showing ownership of property 0 2000 Wisconsin income tax form (total taxable household income must be less than $45,000 for the fiscal year in which you apply) ^ Cancelled check or copy of any paid receipts showing the amount you paid for the cost of the replacement system Please submit the necessary information before December 26, 2001, to St. Croix County Zoning Office 1101 Carmichael Road Hudson, Wisconsin 54016 Enclosed is a copy of the Wisconsin Fund brochure for your information. Should you have further questions, please call me at (715) 386-4680. Sincerely, Judy Olson Zoning Secretary Encl. ' SAii~bt'1 PerouIt Appl~ci40A ~~ ~ Dnrisioa la aeoond ~ L1Dmm 13.21. Was. Adno. Gbde 201 W. Watbinaeon 7304 ~s~,pnt~in ~ _~ ~ ~ ~.pa~, Mme,, w< s3~.~ o.o:~.- .~ r,~,. Aecs°n'I ~ too pnwjae a~- be osea for s~sr~r p~ s. iS.00(Ixm)j (Prlracy Ltrr e ~ ~ oo~mt~- u ewe , :ate owned. A tba d~a tlnn i -1r2 x ! iwshes Cfeok ~~ i. A IititlOA Iat atbtt - P leas! P[lnt s11 IntOPlOatl011 ~' tIOA: ~ ~ i ,~~ ''i ~ ' ~' '~ W ,/ _r l UM S 1 T R 0..,~..n. _ ~ ~ ~ f' ~1 1 _ _ [~ yWp ~l~.irl . Y '~ ' ~~ ~ Q VJew t~~AY~ N-R .. oQS , ~ / _ •_ Typo o[ SAildlaig: ° (sheet one) ~ t DavalUn - Ato of Hodroeas ~ 1 ar 2 Famll ~ ~ + ~ ~'''~ , p D wee t _ . y .~: -. ~~~jjj PuWicliCoamadd {des~ibe u~~ onto of ~ ~p~•.e,s~ o sa~o«ned '~` itaaa lp Q,~ ax l -lao III. T of Parmia: t~ect oms boat on line A. Qiodc boat on isae B i!' licaWa ! . 3 . / S: 2 3 /-dd to /~) t. i~x 2. R+apisomasnR 3. R ad S. Tank B) N Type of POWT Stem: (C3eeet ap d~u apphr) O d GR~tand O Momid ^ Smd FOter O Caauuaod Walar+d ~ ~~od t D+pond ~Hoid~ Tauk D ~ D ~ ~ ~ O PRar D O Aembisllreato:esrt flak O D Ot1~c: Y. D t Ara iutisno atiosa• ~ !. f ~ SC7 ~ + kegr6od ttaposed Rsls (Gs>:J~Asi/iq. ~3 ) ~~ N A N f 4- N~ N ~-- N~ W: '~`aAlc / to Total * of ~ Peelib 3~ S~ ~- ~~ j t tt T k Q0°' ~0n' ~s tam:uos >. o~ an s tlsAom . d ~ stns~ Aim ~ Tanks Tads ~, a o a o 0 0 vcII. Responsiblllllr Stataneat ~>~~~~ PMia~eer~wddms(StEeat. stanzzlpaea~ l ~ , oc. CoasgnlDcpsrtmea! Use OAt7- D INsapprared Saaedory i+aadt Feo (tadudes Oio~d^+ra Dave Israiet J-eak ~ ~) ~Zt >~rorod o ow,~r c~A Initisl ~~ ''~~ ~ ~ v +t. ~dltioAS o! ~rsval tReaso~ [br Dtaspprmt: - v ~ ~~) t~~ eX~'s!„~, sys,~~,~ s~Q// ~P ~~Q,..~ahe1~ fie,- Cow.w` ~.~ 33/ `/ '2'-~ ~< 1to~o/i. y 5 ~l~ ~~ ~*~C~.o/-eqr ~ ~r ~ ~ a-- ~ 3 - ~ 3 C ~x ~, State of Wisconsin WISCONSIN FUND -PRIVATE SEWAGE SYSTEM Safety and Department of REPLACEMENT OR REHABILITATION PROGRAM ~d ~~~ /~y~/ Buildings Commerce ,~~ ~o~~ ~/~ Division OVI~NER'S APPLICAi'iON ~?!. ~ ~'~;,-, instructions For Prope Owners: TO BE ETED Y COM RCE You may apply for a grant award for up to three years after you have received Appli tuber £C to Received _. a determination of failure and after you have obtained a sanitary permit. ~ E~VED Complete Part A of this form, attach evidence of your annual income explained 'I in section #?, and send those items to the governmental unit listed below. D~~ ~ _.~ i.- r c~X _. coin .~ ZoiviMa n~ „_ / ~. %'~~ ~~~ PART A. TO BE COMf~i_ETED BY THE PROPERTY OWNER Owner Name' . Sodal Security No."' - ' Additional Owner " Sodai Security No."" ' j ~ n i ~, f .~.~~ 3 y ~ vzs- U 6P L ~ ~. ~ h lie n ~ 6~ .3y ~3 yd Address ~~ aq a ~ 07`x (~v~ _ Attach documentation of additional owners if needed. , City, State Zip Code Telephone Number (indude area code) ~ ~-k ~u; s yov~ ~`~~ z~~s~~~ ""Note: Your Sodal Security Number may be used to verify your "Grant awards will be issued in the name and address of this owner. income and status of child support or maintenance payments. 1. ,W-as the failing Private sewage system serving the prindpal residence or small commeraai establishment constructed prior to July 1, 19?i3? tpJ' Yes ^ No 2. Th is application is for (complete both if appiipble): ~ / LT Pri d l R id ^ N D IJ~Y n pa es ence es o o you occupy this residence at least 51 % of the year. ~. .R_r:.Jl ~w.~1 ~i+'~~•..:•.:... r..•. ..v Jw.. .. _ ... ::SC~d:: :r~:ili1.141U7t 1.Jtuw11...1 :fIR...~..i t':-~J~.~ V 1 !J v. 41.• ~t'!fl. LJ IC.rJ L~~ 1~~ Small Commercal Establishment Name: Desai 'on of Small Commerdal F~tabiishment ((arm, restaurant, etc.): ,~ , / 3. Was the private sewage system replaced as part of a real estate transaction or change of ownership? Ud'1'es ^ No If . explain: ~ O ~~ d l ~~ ~I.) 1 Q v"1' ~ ~? W ~Q ~ I ~.t, ~ i s T 4. As the owner, are you a licensed plumber or contractor engaged in the business of installing private sewage systems? ^ Yes ~o 5. Wil a portion of this system be funded by another source? ^ Yes No If lain: ram? 6. How did you hear about the Wisconsin Fund-Private Sewage System Replacement or Rehabilitation Pro g T-~'~ ~ 'S ~~ I ~ J~'f IG ~~'~- u.l ~ ~ C.~ vLt d 7. Evidence of income. Attach a copy of your federal income tax return for the year of or prior to the enforcement order or determination of failure if you are applying as a principal residence. If you are applying as a small commercial establishment, submit a copy of your federal profit and bss forms for the year of or prior to the order or determination of failure. If you were married and filed separate forms, you must also include your spouse 5 Yelii111 ~ r the sums ;mar. ~ol~ must include evidence of income for each owner (and for each owner's spouse) listed above. Evidence of income will be kept on file at the governmental unit and is subject b verification by the Department of Revenue and by the Department of Commerce. If you or any owner listed above were a rt- ear resident or did mot file an income tax return, contact our governmental unit for further instructions. S. Property Owner's Certification. I certify that, to the best of my knowledge and belief, the information I have provided on this form and all attachments are true and oomect. is Signature Da te Signed Co-0wners Signature Date Signed f t'er50n81 InTOf1ria11on yOUpfOVlde/~ t>B used for secondary purposes [Privacy Law, s. 15.04(1)(m)). `" "'/ 1 SBD-9163 (R. 1/2000) / PART B. TO BE COMPLETED BY THE GOVERNMENTAL UNIT 1. VERIFICATION OF OWNERSHIP Does the owner(s) name(s) as listed on the document used to verify ownership agree with the name(s) of the applicant(s) on Part A of this application? ~I Yes ^ No ~j/ ! S S'Iv What document was used '' --11 / Document or t if Ll/Q~ o ver y ownership? 2 ~~(. Page Number If the applicant answered yes to question 3 on Part A of is application, did the applicant own the property when the order/verificatlon of failure was issued or the s stem installed and incur the cost of replacement? ^ Yes ^ No 2. Is this application for a replacement structure? ^ Yes ~ No ff es, have all uirements outlined in Comm 8720 4 ,Wis. Adm. Code, been met? ^ Yes a No 3. Is a ublic sewer available to this ro ^ Yes No 4. Has a previous grant been a:~rarded for'h':s ;~r?pe;~y ii..der tiYis ~ruyrd(il f ^ Yes ~ No 5. Prinapal Residence evidence of income.. Please indicate applicable annual income: $ /.3~, 7~10- Federal income tax form /OS~OA- , Line / ~f .Year DOd Affidavit of ,Year Other form used ,Line ,Year Small Commercial Establishment evidence of income. Please indicate applicable annual gross income: $ Profit & loss form used: ,Line ,Year 6. Date of Order or Age of the ~ .. -- ~~ // Oeterrnination of Failure: ~ ~ ~ ~~ ~ existing failed system: ~ 3 S (~.P•l~~ Separaiir•.g.i?}sstan~ ::^^m t;~e bcttorn of ~9 existing failed system to a 19miting fac 7. Privat a swage system failure caused by discharge of sewage to (check all that apply): Surface water or roundwater ............................................................................................................... ^ e Categ 0~1 A zone of turatio .......................................................................................................................:... ^ _ A drain ple or zone of bedrodc ............:................................................................................................. ^ Category 2 The surface of the ground ..................................................................................................................... ^ Category 3 Badc-up of sewage into the structure served ....................................................................................... ^ 8. Replacement System Type: ^ Conventional ^ In-ground Press u re ^ At-grade ^ Mound Holding Tank == ~ y LI Gxper~mental Jy.Miteirl ^ IYI(7r~IlorS .. a ^ Viler, eY.plain ? Uniform Sanitary Permit Number 3~ 5 ~ Z Date Issued 9 ~S~o l Plan Approval Number ~o ~o p (Q 8~ ___•_ Date Approved g / ~'~o _ .~.. __~_ _ ~ J ---^ Experiment Approval Number Date Approved 9. Eli ible ^ or Ineligible ^ Reason ineli ible: 10. Governmental Unit Representative's Certficatlon. I certify that I have reviewed and verified all infom~ation provided on this form and attachmerrts and that the are true and correct to the best of m knowledge and belief. Signature of Authorized Governmental Unit Representative Title Date Signed ~ . 29 ?.~o J P'P°`/ State of Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM REPLACEMENT OR REHABILITATION GRANT PROGRAM GRANT WORKSHEET Safety and Buildings Division Owner's Name: Governmental Unit: j PART "1 ~ GRANT !~`UNbING' T~-BLES A. Site evaluation and soli testln Grant amount $250. $ o? SD . O v B, installation of a replacement or additional septic tank. Minimum Gallons Required Grant Amount 750 ......................................................................................................... ...........$500 975 ......................................................................................................... ............550 1.200 ......................................................................................................... ............650 1,425 ......................................................................................................... ............725 1, 650 .....................................................................................................................750 1,875 .....................................................................................................................875 ~(' 2,100 or more ........................................................ ..950 $ / 1 C. Installation of a pump chamber and lift pump or siphon: Number of Bedrooms Grant Amount 1 or2 ...................................................................................................... 3 or 4 .......$1,100 .................................................................................................................1,200 5 or more ..........................................................................................................1,250 D. installation of anon-pressurized or in-ground pressure soil absorption area. $ 1. The following table shall be used for systems sized according to percolation tests. Grant amounts determined by number of bedrooms. Percolation Rate Desi n Loading When Properly Rate in Gallons Filed with County Per Square 1 2 3 4 5 Each Addl Before 7-2-94 Foot Per Day Bedroom: Minutes Per Inch 0 to less than 10 0.7 or more $800 $1,100 $1,225 $1,400 $1,725 $150 10 to less than 30 0.60 to 0.69 900 1,175 1,400 1,800 1,900 30 to less than 45 .0.50 to 0.59 1,050 1,450 1 975 650 1 950 1 250 300 \ „ - x , , , 45 tD less than 60 0.49 or less 1,150 1,900 2,200 2,250 2,275 300 ` / E. Installation of an at-grade or mound soil absorption area. Grant amounts determined by number of bedrooms. Type of Design 1 2 3 4 5 Each Addl Bedroom: At-Grade $900 $1,300 $1,475 $1,825 $1,950 $250 High Groundwater Mound 2,250 2,325 2,550 3,400 3,775 250 High Bedrock Mound 2,350 2,950 3.000 3,400 3,525 275 Slowly Permeable Mound 2,900 3,100 3,250 3,400 3,650 300 Mound with less than - 24" of suitable soil or greater than 12% sb 3,050 3,400 3,475 3,550 4,500 375 $ F. installation of a holding tank. Number of Bedrooms: 1, 2 orQ 4 5 6 7 8 Addi Bedrooms Grant Arrourrt: $2,250 2,925- 3.100 4.000 4,200 4,750 $225 $ ~~ ~ ~ D Q G. Installation of a Replacement Exterior Grease Interceptor by Gallon Capacity . Gallons: Up to 1,249 1,250-1,499 1,500-1,749 1,750-1,999 2 ,000 or more Grant Amount: $550 $650 $750 $800 $900 ~( $ ~aaanw~ anv~meuw~ yw prvvpe may De USHQ TOr8800flGBr)I purpp3@S [PflVeCy LBW, S. 15.04(1xm)]. SBD-9167 (R. 1/99) . ' ,, ' .; PART~1. GRANT FUNDINGFTABLES continued ; H. Installation of an F~cperimental System. Amount Requested For Installation: The Department on acase-by-case basis reviews installations of experimental systems. If you are requesting funding for an experimental system not covered by the grant funding tables, $ please submit a copy of the plan approval letter and experiment approval letter with con+esponding identification numbers signifying that the experiment has been acxepted by the Amount Requested Department of Commerce. For Monitoring: list the total cost of the experimental system and monitoring that is being requested separately at the ri ht. Co ies of aid invoices must be submitted with this uest. $ 1. Installations not Covered by the Grant Funding Tables. The Department on acase-by-case basis reviews installations not covered by the Grant Funding Tables. tf you are requesting funding for an installation not covered by the grant funding tables or listed in Sections A-H, please explain your request here, attach a copy~of the paid invoice, and request 60% of the cost of the installation at the right. TOTAL PART 1. $ o)~ .5 U :=:PARTY2. `GRANT:AMOl7NT`CALCULATIONS ,~ __ A. Enter the total from Part 1. p~03 `5~C/ $ B. Is the applicant a licensed plumber or contractor who installs private sewage systems? ff yes, enter 2l3 of the amount from section A or $4,667, whichever amount is ` „ less. /Yli $ C. Enter the smaller amount listed in sections A or B. ff this application is for a small oommerdal establishment and the annual gross income of the business that owns the small commercial establishment is less than $362,500, this is the total grant award. Carry this amount forward tD section F. ff this application is for a ptindpal residence and the annual family income of the owner(s) is less than $32,001, this is the total grant award. Carry this amount fonnrard to section F. ff this application is for a prindpal residence and the annual family income of the owner(s) is greater than $32,000, goes to section D. ~ ~ 5 If this a lication is for an a rimental s stem, ca this amount forward to section F. $ j . D. Enter 30% of the amount by which the applicant's annual family income exceeds $32,000. _ Annual Family Income Subtract - $3 ,000 Subtotal X .30 = $ E. Subtract line O from line C. This is the maximum grant amount for this applicant. Cany this amount forward fA section F. (The amount in section E must be at least $100 to be eligible for any grant award. N the amount calculated is less than $100, X enter $0.00 in section F. $ ~~ S v ` d~ F. Total grant award requested for this applicant. $ ` Wsoonsin Department of Commerce SOIL EVALUATION REPORT Page 1 of ~ Division of Safety and Buildings in accortlance with Gomm t35, wis. Aom. cone - C°t'"H must i Pl i l h 8 1 2 11 i h St. CRoiX an es n s ze. ess t an x nc Attach complete site plan on paper not / inGude, but not limited to: vertical and horizontal reference point (BM), direction and ' Parcel I.D. 014-1040-60-000 tance to nearest road. percent slope, scale or dimensions, north arrow, and loca tion a~ / Please print all Infor 'ate a l J r j ' Reviewed y Date Personal inionnalion you provide may be used for seco es ( rivacy l.aw; g 1.04?(1) (m)). ~( ~t~~~ Propertyowner ~ Prdp~ ovation ~ J DenIl1S Lutz c~ ~ Govt.V,ot~ NE 1/4 NW 1/4 S 19 T 31 N R 15 ~ (or) W Property Owner's Mailing Address ~ --~ ~ r ~ . il:.ot # ~- -Block # Subd. Name or CSM# 2629 210 th. Ave. -"~ L1~j na-: na na City State Zip Code hpri'e Number -+r fit.-.~1 ^ ~~ty ^ ~Ilage ®Town Nearest Road ~ ~~ `~ ~"~~ Clear Lake WI. 54005 ('~9.5~),,263-28~~ '`!~-~ ~~Forest 210th. Ave. ^ New Construction Use: ® Residential / Numbei~f e~lroiims. ~-Code derived design flow rate 450 GPD ~ s ®Replacement ^ Public or commercial -Des -- - Parent material glacial drift Flood Plain elevation if applicable na ft• General comments and recommendations: SOll borings in area do not show anything other thail~ a A+0" soil condition. At this time the only system allowable is a holding tank. t ~_ u 1 Boring # ~ Boring ® pit Ground surface elev. na ft. Depth to limiting factor - 5 in. Soil licaflon Rate H i th D l D i t C Redox Descri tion Texture Structure Consistence Boundary Roots GP D/ftz or zon ep in. or om nan o Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 sil 2msbk dsh ~ '' 2- 5-9 10 r~ 3 c2d 7.5 r5 6 sil 2 f~ r r 3 - 9-24 10yr5/3 c2p 7.5yr5/8 sil 2msbk dsh if .5 .8 ~ 4 4-55 7.5yr4/ c2pi7.5yr5/6 scl M na na na .fl) ~ ~ 2 Boring # ~ Boring ® Pit Ground surface elev. rid ft. Depth to limiting factor _~ in. Soil licaflon Rate H i th D t Color D i Redox Descri tion Texture Structure Consistence Boundary Roots GP D/ff or zon ep in. om nan Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 1 - 0-6 10 r3/3 none sil 2msbk '~ ~ 2 - 6-15 10yr3/3 c2d 75. r5/8 sil M na '' ~ 3 - 15-40 7.5yr4/4 c2p 7.5yr5/8 scl M na na na .0 ~ • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L tmuent rr~ = rsw ~ su mgs~ anu ~ oo _ ~u r~y~~ CST Name (Please Print) Signature • CST Number Gar L. Steel ~ 02298 Address Date Eva nation dulled Telephone Number 1554 200th. Ave., New Richmond, WI 54017 '9-29-2000 715-246-6200 Property pWner D. Lutz Parcel ID # 014-1040-60-000 Page 2 of 4 3 ~ Pic Ground surface elev. na ft. Depth to limiting factor 0 in. Sal ication Rate Horizon Depth Dominant Color Redox Description Texture Stnx~ure Consistence Boundary Roots GP D/ft= in. Munsell Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 1 • 0-7 10yr4/3 cZz~a~~5 r5/6 L 2msbk dsh ~ w 2f .5 ~ r 2 - 7-20 10yr5/3 c2d 7.5yr5/8 sil 2msbk dsh w if .5 ~ .8 / 3 , 20-40 10yr5/6 c2d 7.5ry5/8 t,scil M na na na .0 ~ .0 / 4 ~~ # ^ Borng ~ Pit Ground surface elev. na ft. Depth to limiting factor " 3 in. Sal igtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP O/ft= in. Munsell Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 1 0-3 10 r3 3 none r / 2 3-11 10 r5/3 c2 7.5 r5 8 sil 2msbk ~ ~ 3 11-23 10yr5/3 c2p 7.5yr5/8 sil 2msbk dsh ~w na .5 .8 ~ 4 23-40 7:5yr4/4 c2d 7.5yr5/8 cl M na na na ~ ~ a Boring # ~ Boring ® Pit Ground surface elev. rid ft. Depth to limiting factor 4 in. Soil liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft: in. Munsell Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 1 - 0-4 10yr3/3 none sil 2msbk ds ~ ~ 2 - 4-17 10yr5/3 c2p 7.5yr5/8 sil 2msbk dsh -w if .5 ~ ~ 3 17-30 7.5yr4/4 c2d 7.5yr5/8 cl M na na na .0 / .0.~ 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mglL 'Effluent #2 = BODS < 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-8330 (86/00) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Dennis Lutz New Richmond Wi 54017 MPRSW-3254 NE'~NhT'~ S19-T31N-Rl_°~w (715) 24fi-6200 town of Forest 20 acres 2 i©~ ~~. ~ ~w~~n~ ~~ 5'~. ~~c 8:~ ~~,~.~ ~~ ~ ~ ~,1 4 r 1V V J~ 0 ~`~ e.s Gf ~~~° ~ ~~,~ 3 v ~~ ~ ~ -~;~ Gary L. Steel 9-29-200t) ~~ ~~Q V-~ ~o~~o.\c, ~ n`~~.~.r (~ £ Y4 N ~v ~~~ S t ~{ T 3 / dJ r2 IS ~.i ` i ~ S 3~-~y' ~~ aaoo ~~~ l~~t~~. ~~ ~~k ~ ~ ~.~~ ` ,, SC~~-t`c:- t = LtCa ~~CS3 _.~ ~~~~~ ~~ ~® ~~t~ ,~ a~~ t~ . ~ ~° ;~~. C~ S~ ~~~, S Z~opo 6dL. EiOl.btaG.TbJ~tK _ s. ~~ THE tiXIS'~"t-~~' SEPT~G SYsT'rGM htJST g~ gga~taoN~a PAR ~~ 83.33 w ~~ ~~ f~o~DIN 6 TANK MUST E3~ Q11~NOR~D P&R GoMM $3.'x'3 C$x9 ~ WA• G. atio~~ p-~ ~c~f ~4~, ls.iS.-- S ~ oo S ooa ~ I~~ca~. ~ ~~k w : ~.~ a ~ ~ 1~ f `jC~ci~- t = L~L7 -~ ~a~s3 ~ `~ : i-al f ~ .~. ~ ~ ~„ -- T ~~ ~ ° ___ . ._---- ------ _ - -- J --- ~----- ~'~ ~ ~ S>~ ~ ~~ps37 (` ~ 1 J U ~t s \ ~ t` ` ~ ~ S~g~, ~~ ~}'" Z~dvo G,,~L. Hol.b~at-Td~K S~ ~ ~ f.1~tS"« f>Jty SEPT~~ SysTf~M rc~sT B~ Aga~~oN~,~ PAR ~~ 83.33 ~._~ ?-~ 'rH~ ~{vl.plN t, TANK MUST 8~ Qrl~ttoR~D PAR GoMM $3.`t'3 CSx9 ~ WA. G. u • /~ HQLDIhG TANK CRASS-SECTION ANA SPECIFICATIONS r ~-droved _- Approved Locking ":ant Cap ~ Weather PcooE Manhole Cover Junction Rox -,'~ ; . I . 1 2" Min ~ t',_;>.t Pipe • Final Grad ~ ~ 4" Min e i - - ._ ~ l~ ` f.. . r ~ ,f ~ /Approved Joint ~' 1$" Min F•----~ ~ + ! i i - i _ - ,.. . ,~~ - - ~ H i ~; h Water _____T_ Alarm Switch ~~ ,~ ----+ ` \ - Approve SPF.CtFICATIONS TANK Manuf ac [u[er : ~~ t° ~Q~-~._ ~._.. !~ Tank Size : ~,pp0 Gallons A_L_A_RM_ Manufacturer: 1'~ Model Number: inE W Switch Type ~j~-, '"iC NUMRFR OF REDROOMS:~ Joint .w C.I. P1 Extend'i 3•' On~,o Solid ~S __ .~ "~ NER ' S NAME : ~ -~ ~'' ____ - '.'-:GAL DISCRIPTIOh: ~~ k,f~w k,Sec.~_.T N,R_J~W ^1~NSilIP/MUNICIPALITY: ~ -^< _:'1UNTY : ~ ~ ,r~y~ + 4 ~~ ~ 1556PA~= 368 STATE BAR OF WISCONSIN FORM 2 - 1999 Dacuroent Number ~'~rARRANTX DEED This Deed, made between Dennis L. Lutz and Kathleen D. Lutz, husband and wife Grantor, end Ronald L. Riniker and Sandy K. Riniker t{5 a Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): The North half of the Northeast Quarter of the Northwest Quarter of Section 19, Township 3l North, Range I S West. St. Croix County, Wisconsin. ~ @.crr5 633025 M.A'iHLEEN H. WALSH kEGISTEk OF DEEDS ST. CkOIX CO., WI RECEIVED FOR RECORD 11-03-2000 3:00 PM YARRAHTY DEED EXEMPT II CEkT COPY FEE: COPY FEE: TkAHSFER FEE: 435.00 RECORDING FEE: 10.00 PAGES: 1 Recording Area Name and Return Address 'guQ~NE"C 'T 1T1„~ 1~~D 1 Cpt.~1 e ~ oad ~uc~Sa~~ l~ SLaolly Oty- tayb ~ ~b - ~o~ Parcel Identification Number (PIN) This is homestead Property. (is) O'6JQ00 Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this _~_~" _ day of October 2000 t ~ .>< Z _ _ • Dennis L. Lutz • Kathleen D. Lutz ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) Personally came before me this day of the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. • ----- Notary Public, State of Wisconsin My Commission is permanent. ([f not, state expiration date: J AUTHENTICATION Signatures} Dennis L. Lutz and Kathleen D. Lutz, husband and wife authenticated this~day of October 2000 (~~ ~-' • Kristine Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Q 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hudson, WI 5401 ' (Signatures may be authenticated ar acknowledged. Both arc not necessary.) ~v • Names of persons signing in any capacity must be typed or printed below their signature. tn«mxbn ForesaanN. compeo,. Fina w+tx, wt STATE BAR OF WISCONSIN ~~~~~ ~i'ARRANTY DEED FOR111No.2-1999 BURNET TITLE MF File 00-24900 RE File TI File 197199wi RELO File 'iI Closer: T. J. Swanson Property Address: 2629 210th Street RE Closer: Kristi Ogland Deer Park, WI 54007 Date of Settlement: 10/06/00 Seller Gross Proceeds: S 145,000.00 CERTIFICATION FOR NO INFORMATION REPORTING/SUBSTITUTE 1099-5 FORM This information is necessary to determine whether the sale or exchange should be reported to the seller, and to the Internal Revenue Service on Form 1099-5, Proceeds From Real Estate Transactions. If the seller properly completes Parts I and II, and makes a "true" response to assurances (1) through (4) in Part II, no information reporting to the seller or to the IRS will be required for that seller. If the seller makes a "false" response to any of the assurances we will be required to report to the IRS and a copy of this will be given to the seller as a Substitute 1099-5. Part I. Seller Information Name of Seller: #1. Dennis L. Lutz Forwarding Address of Seller: #1 /~~~.~ ~ w ~ S~~f vU I PHONE : ~ ~ ~~ ~ Z Co ~/ ~ ~~ ~ (a Social Security Number: #1. L~ ~ U ' ~ ~ ' ~ U 2 (Taxpayer I.D. Number) Dennis L. Lutz Part II. Seller Assurances Check "true or false" for assurances (1) through (4). f True False (1) I have owned and used the residence as my principal residence for periods aggregating 2 years or more during the 5-year period ending on the date of the sale or exchange of the residence. (2) I have not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of the residence (not taking into account any sale or exchange before May 7, 1997). (3) I have not used a portion of this property for business or rental purposes ( or my spouse if I am married) after May 6, 1997. (4) The above referenced transaction sold for less than $250,000.00 for individual or $500,000.00 for married seller. Part III. Seller Certification Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale off,exchange. ... c _ ,. _ # 1 . %7/G-~ Dennis L.~Lutz To Be Completed by Closing Agent Only: Report NO YES Real Property Tax Allocable to Purchaser (Line 107 of HUD) $ MF File # 00-24900 TI File # 197199wi Closing Date 10/06/00 Closer T. J. Swanson CERTIFICATION FOR NO INFORMATION REPORTING/SUBSTITUTE 1099-5 FORM FOR ADDITIONAL SELLER This information is necessary to determine whether the sale or exchange should be reported to the seller, and to the Internal Revenue Service on Form 1099-5; Proceeds From Real Estate Transactions. If the seller properly completes Parts I and II, and makes a "yes" response to assurances (1) through (4) in Part II, no information reporting to the seller or to the IRS will be required for that seller. If the seller makes a "no" response to any of the assurances we will be required to report to the IRS and a copy of this will be given to the seller as a Substitute 1099-5. Part I. Seller Information Name of Seller: #2. Kathleen D. Lutz Forwarding Address of Seller: 'l,C~ ~ ~Z'~11-/- PHONE: ~~~~'Z~V ~70~~ 0 Social Security Number: #2. ~ ~r' O ~` ~~ 7 ~~ Kathleen D. Lutz Part II. Seller Assurances Check "true or false" for assurances (1) througta (4), True False (1) I have owned and used the resider~Ce as my principal residence for periods aggregating 2 years or more during the 5-year period ending on the date of the sale or exchange of the residence. (2) I have not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of the residence (not taking into account any sale or exchange before May 7, 1997). (3) I have not used a portion of this property for business or rental purposes (or my spouse if I am married) after May 6, 1997. (4) The above referenced transaction sold for less than $250,000.00 for individual or $500,000.00 for married seller. Part III. Seller Certification Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange. #2. Kathleen D. Lutz ..- To Be Completed by Closing Agent Only: Report NO YES Real Property Tax Allocable to Purchaser (Line 107 of HUD) $ __ Wisconsin Real Estate Transfer Return VI. TRANSFER fie. GrantorlGrantee X None Parlnerehlp Femiry y If Femlly or Other, ExplNn relstbnshlp b: eholded Other ~ Financial b sldlary Su ~. T ~ Sale (Includes Exdran a Deed Nr Other Tra~irshr X odginel lend g satisfaction of (explain) ~ contrecQ GNt land contract 41. t>•rnsnhlp Interest Full Panlal Other M~kkneferted X (explain) (explain) -) l)wnenhip interest transferred may be a toll interest of a full ownership; a full interest of a partial ownership; or other (explain). 42. Uwe grants retain earr~~yy of tM folbwlnq X' None Estate Easement jexplain) ~ l h t r g te IZ. GnMOr It: }~ Indivldusl Corporetbn Trust PaAnerehip LknNed Liability Other (specity) •~ Company VII. GRANTEE'S FINANCING FManciellnstkution- FManclallnstilution- Obtainedlrom Aaaumedexlstfng Other 3rdpady Wotlnanckrg 44. Cheek boxy for all Hnanelnq types that apply X Conventlonel Government cellar financing Ikwrekrg Mrvofved VIII. PHYSICAL DESCRIPTION AND GRANTEE'S PRIMARY USE OF PROPERTY I5. P pa of Land ony Condominium o PKtY Lenda X ~D ~ bulktM a 0l) ( •cNYI lea. Predominant Agrkukurel, N so, db the Yea 46b. Cheek N GrsntN's Un X Sktgle famiy MuNi•famlty ~ No. of Time Share UnN grentor own proper for X pr~ery paaldana UnNs less then 5 yean7 No Commercial Miscellaneous If any bozea et left ere checked, oxpleln use here y UIN Manuladuringl m' Teleplane Company IIa. Lot Slxe (ROUND TO NEAREST WHOLE FOOT) 47b. Total ACree IS. MFUPFCIyyTL AC/es 4S. Fast of Water Frontage 47. Eetlmated Ifcondominlum, lend aro ehwk here end X O R 2- prweed to Ilne 50. FEET FEET ROUND TO TENTH OF AN ACRE ROUND TO NExi WHOLE ACRE 51. EzeluslonCode•~ NW11, 52. NW12provWadoaumerdnumberwhenreeorNd IX. ENERGY Yes 50. le thle property eubjeet to the Reeldentlsl ~xp nation N N N W l i d ~ W' 1 o, prov e exc us on co e) Rental Weathalutlon Stendarde, COMM677 X o ( X. CERTIFICATION-We declare under penalty of law, this return has been examined by us and to the best of our knowledge and belief It is true, correct and complete. 59. Agent fo- 61. Agent's Neme (N agent Involved h seta) 56. TNephow Number 6rentor Gremee 56. StreN or Flre Number, If any 56a. Stresl name, PO Box, or other address (enter "PO Box" and boz number) AREA coDE 57. City 50. Stah 6l1. ZIp Code 60. Preperer's Nrw or Firm Name N. TeNptror» Number KRISTINA OGLAND 715-386-1850 AREA CODE SEND TAX BILL T0: 52. wme 67. SUeet a fire Number, H any 83a. Street Neme, PO Box, or Other Address (enter "PO Box" and Box Number) 64. Clfy 66. Sate K. Zip Code 67. Gnmor's SUeet or Fke Number, N any 67a. Grantor (where grentor can be reached fn the luture) Street Name, Po Box, or Other Address (enter "PO Box" and Box Number) 2~~' S~ l4 ~ ~= ~f'v~v rv 6S. City 6e. State 70. Zlp Code ~~~tL-~( w l 5~4 ~ ~ l 71. Dated 72. TNephone Number 74. Dated 75. TeNphow Number lv a~'20vU ~-i sZ~~ ~a~~ ~vvCo`~dvv ~~t ~~Z zvG t MONTH DAY YEAR AREA CODE MONTH DAY YEAR AREA CODE P SjG~fATURE WITHIN BOX) 76. Slgndun of Grantee or GrenUPs Agent (PLEASE ATTEMPT TO KEEP SIGNATURE WITHIN BOX) 73. Slgnatun of Granter rx Gnntor9 Agent (PLEASE ATTEMPT TO KEE / ~ ~ /~ ~~~ ~ ATTACHMENTS Wisconsin HERE Real Estate Transfer Return - conflaentlal To complete see lnstruct/ons for Real Estate Transfer Return PE-500A. Submit original form to Register of Deeds with document(s) to be recorded. Completely (III in all appropriate areas. TYPE or PRINT clearly In BLACK INK, and use ALL UPPERCASE LETTERS. If typing form, type through vertical character lines. I. GRANTOR (Seller) If more than ONE (1) grantor, check box at left and list on attached addendum. Note: Lines 67.72 must be completed with grantor's address. t. Your Lett Name or Company Hans Note: For fhb purpose a married couple (a one grantor N tame lest name (set line 2). LUTZ 2. Your First Nema(t) end Ylddle Inltial(t) - If a married couple, show both first names and middle Initials. 3. Soelal 8aeurNy Number or FEIN DENNIS L. & KATf~,E~V D. LI G~ ~ 3 ~ ~ U ~ ~ II. GRANTEE (Buyer) If more than ONE (t) grantee, check box at left and list on attached addendum. 1. Your Lsst Name or Company Nama Note: for this purpose a marred couple is one grantee S same last name (see line 5-. RINIKER S. Your First Nama(t) and Yiddle InNial(t) - II a married couple, show both first names and middle Initials. S. 8oclal 8aeurity Number or FEIN RONALD L. & SANDY K. %' ~ 7 ~ ~¢ S ©~O 7. Strati or Fira Number, II any 7s. Strati Nama, PO Box, or Other Addrate (enter "PO Box" and Box Number) 2629 210TH a. City t. State 10. Zip Coda DEER p~ WI 54007 ~ TO RECEIVE TAX BILL AT ANOTHER ADDRESS, shack Kara end complete Sacllon %, pegs 2. III. PROPERTY TRANSFERRED tt. Inakste: c+ty village X Town ~ ChaskRaddltlonNpaeelsandlltlonanaehadaddendum. 12. Nama of the CIIylYillagalTown 13. County Nama FOREST ST. CROIX 11. PhytkY Property Addrate or Rosd Addrau (detcriptkn) 2629 210TH 1b. Ta Pawl Number a N appNre on Property Tax bill (tea Instructions) . f 1a. Properly Dacriptlon: bt -block-plat, CaANbd Survey Map (CSM), or otMr daslgnalon; N datcrlption will not fN hare, add aNachmsnt (tea Inttruetlont) THEN 1/2 OF THE NE 1/4 OF THE NW 1/4 OF S19T31NR15W 17a. Sectbn (primary) 17b. Townthlp (primary) 11c. Range (pdmery) Cheek Kara If more then one lot and block, or a legal datcrlption la mate: and bounds a earlNlad survey map; attach legal datcrlption n sn addendum (tN Inttruetlont). IV. COMPUTATION OF FEE OR STATEMENT OF EXEMPTION Dot.uRS CEMa 1a. Total value of REAL ESTATE hantfanad (round up to the ~ marnt =106) 145, 000.00 IN WHOLE DOLLARS 1a. Trsntfar lea due (Tina 10 X .009- a 43rD . 00 Z0. Trantfs- Exemption ZOa. N you enter "003" or "Ot7," It it 30b.Date of Original land Contract Number, SEC 77.25 mandatory to provide your previous dor:ument numMr. - MDNiH DAY YEAR Z1. Valw o1 penonal pr tranafavad but EXCLUDED ~ ~ 44. Vdue of property exempt Mom locd property tax gt YYtWLE a 0 DOLLARS from Iles 13. DOLLARS INCLUDED on Tina ta. V. TO BE COMPLETED BY AUTHORIZED COUNTY/LOCAL OFFICIAL Z3. Doetunmt Numba- 21. VolumalJackat 4b. PagaRmaga 26. Data Recorded 27. Data o1 Comayanee MONTH DAY YEAR MDNTN DAY YEAR 2S. Comeyenca Warrenttyyf Land Ouk Cbkn Other CoM Condo Oaad Contract Deed (explain) '~ i 2a. County (t) 30. YuntelpslRy (1) 31. County (2) 32. Nunleipality (2) Check If more than Iwo (2) munkipall- 33. b fhb a tplN pareN7 for If w, nbr to Inttruetlona: ~ (tu Instructbns) Yes No 34. Einar numbs of-aeret for aaeh 1 (Raeldtndaq 2 (Commercial) 3 (ManufaclurMg) 1(Agrkuxuraq S (SwrmpiWadq i (Foreu) 7 hMd pareN elattNleatlon and cheek t q 3 4 S S 7 a preeeding box to show predominant clnaMknlon. 3S. Mtwsmant Yaar 36. Land 37. Improvemantt 3t. TotN Attastmad WORK COMPLETION ESCROW AGREEMENT Questions or Release Procedures, the following: Burnet Title 1501 West 80th Street Bloomington, MN 55431 Attn: Escrow Release Department (612) 886-6732 please contact Date: 10/06/00 MF No:'00-24900 TI No. 197199wi Property Address: 2629 210th Street Deer Park, WI 54007 Estimated Completion Date:. 04/01/01 Escrow Amount: 4,500.00 Escrow Fee: $50.00 (FEE CANNOT BE WAIVED WITHOUT THE APPROVAL FROM Total Escrow Amount: 4,550.00 THE ESCROW RELEASE DEPARTMENT) As a requirement of closing the parties to this escrow agreement have request- ed Burnet Title to hold money in escrow. All escrow funds shall be deposited in a non-interest bearing fiduciary account. Burnet Title shall be liable only as escrow agent. The parties hereby indemnify and hold harmless Burnet Title against all costs, damages, including but not limited to, attorney fees or, costs which may arise by reason of any action, written notice, request., waiver or other document believed to be genuine and taken in good faith in compliance with this agreement. The parties herein assume this responsibility and will pay amounts due upon demand or amounts may be deducted from the escrow funds at the option of the escrow agent. + Work to be completed: Items to complete: Seller to pay for new updated septic system which according to perk test will be a holding tank based on an estimate of $3000. Buyer agrees topay for any costs associated with seeding or soddi~f the disturbed area once the septic system is complete. Subtotal $3,000.00 X 1.5 is equals $4,500.00 Total Escrow Amount This escrow is being held solely for the above items, release of the funds cannot be withheld due to other circumstances. The work is to be completed in a good and workmanlike manner on or before the specified completion date. After the work has been completed, Burnet Title will require written approval from buyer and seller to release the escrow funds. IN ADDITION TO WRITTEN APPROVAL HURNET TITLE REQUIRES ORIGINAL INVOICES (INCLUDING TAX IDENTIFICATION NUMBER) FOR ANY LABOR OR MATERIAL TO BE PAID FROM THE ESCROW FUNDS AND/OR LIEN WAIVERS FOR WORK PAID IN ADVANCE. Escrow funds not disbursed on or before the completion date shall incur an additional service charge of $10.00 for each month beyond the completion date, to be deducted from the escrowed funds. ...:: 1"~""O". , .,,,~,.,,. Burnet Title does no„<~ rantee the ca~pletion of the improvements, or that sufficient fund to c ete th' N rovements, or that improvements auc'e-;;. rdan 'th plans and specifications; nor does it insure or assum n Iia ~ity a the sufficiency or accuracy of the Affidavits or Certifications of any inspe s, architects, or general ~~ contractors. It is the responsibility of the parties he to monitor this escrow agreeaa~~'i completion date. If the escrow has not be isbursed ~r~~-eopipletion'iy " RnrnPt Title. at its option, is hereby authp ed by the parties to take whatever j !~7i JUi CGt~t~ UJ. t~ ! 1JC4h~iiScl II_11')I! fillt~ i_f~~Jl~IIRY Rl-`r FAGE E12 •S~p-3d-oo O$.55A Town 3, Country rzraa 1ty 715 246 9821 p_O2 APPr'evod by t-r6 Wis~nsin paparvhent of ReyulaGon en4 Lfob(TlrinB 7'1`99 (Opteonal Uaa Da6a) 1-1-0p (Mandaeery use pate} Tuwa & Conntry• Rcalr WB-40 AMENDMENT OTOT p~'FE qT PURCHASE cu~n,,~; use a W~-~ro arrrano?tn'ertt l~8oeh Perilsv3 fJsa A ws,~t Natfce NA Party ~ Grv~ Wlfl eo Agr~sp/pq To Modfl~. TJ're terms or Trie Qtyser. ~9' A Notice VN/rkb oees Not ftequ/re Ths t7tltsr Pa 1 Buyer and SeNer agree ro Amend the Offer dated 9 ~Ya ~-~n>rent 2 the purchase and gale ar real eetate at .~ -~~~~" ae -- , _2000 ,and accepted sept,.,®r~r 3 .-.- _. ___------.-~¢?;t Y 10th llva . D,g~t p 11 , 2000 ,for ..~~_ 1ri ~.. 4 (~) Closing d&te Is changed from oCTO~R 3EtD 2000 ~ '••'~~~ as follows: 5 ( ) Purcttese Rrlce is changed fFom ~ -.... `--------.--..., to -, oc~ro~ 6 2000 6 ( )occupancy date is changed from -------~-- ---_ `_ __y to 3 ~~-'• • ~ ~ ) C~pancy char8e is changed from ~ _, -...._--' "_"__~-_- !o -• -~.-~ . 8 (x) Ott+ar.1. 91LLLBR TO lPA? pOR ~ ----- to S _~ ~ . 9 >aOLtazxc T UrD~ esrrsc szsTSY~ lnlscuc A,ccO~n ,.. ~_`-~. . 1rSYCFt >~>VD ON Z TIY9-T>C 1rzLL ~-~---- TO PERK TES7r wIL~ BE # 10 TY~=R ED8 YYtTO ,AYr RsCR01- ~~,p 3 00.00. SELL>rR oRUaS !o R139ERVE ,1800.00 11 ~TS#ti 1~JiZL O1. ~n ,.t~siL T8E (iOLDLb1~ ~ IS ~ -- - 0=. ALL >bt~- pr L~TRD. R@ZCIY_AtAl' ar_ Np 12 ti -292 s'1'~~ZN302t 1~RY bI SdOp~~~ ~' ~Q !ri .-~=..,Bi--lrt-Ilrt-ILtD i'O D 13 _ ~----~-~$,~~lQ1~RI3L1~ 718 Y?OLLOxs • •-------`-~ 15 cR#riv a a~D e~-s s ~ .N/I'0~R' z '~~zleBa, la-Y-uas s a>a~. ~- 16 _ 1riI.L AE Ts~ A COIlvEINA'NCIE ~ T R T~I• ~$'~~-.a-lD~e~_ 17 0. "~--4-- - 1e .. _ _ 22 ~~ - ?4 ~ --.~_. .. .. ----~- .~ 2ti 28 ~~ za - -----' ~ .. ~~ -~--____ 81 `~-- _ 3T --~--- _____-,.~ ~ ALA OTHER 7£RMS aF 7HE OFFE TR p .- _ 34 Yhfs Amendment is bind) PURCHASE AND AN RIPY pfi AMENpM~N S REMAIN THE SAFE. n9 oPon Seller antl Suter only if a copy of the accepted Amendn~eM is def;vered tcs the ?~A„y o~in9 - 35 the Amor>'drrtent on or betvre g$ ~ Del'very °f the s~A~d Amendment me ~ 2000 Y be made in an ~~ ------ (lime is oPthe l=seance). 37 pravlded in lhia A~ndmeflt. AfOrE: Tfte y manner specified In tAA Offer t0 Purchase, unless otherwise ~ tb acceptance •nd dW ~~' ~~ llrlg A+rt+n~>6ltent mfy wfflrcytw t-+e ofhred Amen(tmoet prior Mry as provided at ffttsa 3t to 3T, 40 Thia Amendment was dtaRed by ~ c#Rtxx>c 1<. p#~soN s0ltlr a CdUPTRY ~uT>; `on 09/Z9/2000 , 41 This Amendment was presented by ~ rr ~~ Mn4 Flan t` 4? U S ~ Cct~~ W ,p e_,~ OaYa l t.icenaee and Flan / Pow/l n -~~. '~ OaYS 1 41 f3uyar S' ~ \ 45 b ~ ~ B 5iQna 41 bats 46 s ' nopr(a 8 .. c ~~, c G., 8 Yera S naturo 8 ~•'O NOT': AT1-ACI~f TNlS AM,~NOME'NT ~p THE OFFER TO PURGHA E, pate 'CO~w A CyunoY Il~rb gf rW.sSrW ~>t PIOO~c~C WNtt ZpFm11w y WmoM b,a 10005 FAtMn Mny fi4Ba Giraory rownalN MiUfi 70r 1, New N~aro wr f•W i )•?~yS R p1 bWS, (eG013x}a(ti5 Pha~c(>I~aµs010 Pia. r71212aM@f ~. r~9/3i~/2888 X9:08 7152459821 T04JN AND COIJNTRY RTY Sip - 30 - 00 O$ : 85.q Town 8. Country RQa, l ty 71 5 246 9821 APfa'avod tsy tNe Hillso0neun Oeparv-,ent d Rayulation artd Liebnairl0 7.1-99 (Optional tJoa W 09) 1-t-00 (Mondatdry use tote) ~_ _ WB-4Q AMENDMENT TO OFFE TR Q PURCHASE PAGE 02 P.02 Tuwa & Country Rcallt; Cat~orr; iLCse a 4Vg~0 Anrw,dbrrrvrft KBoEh Pertitss Wlli Be A flee A N~2-4•i Nofifee NA f~arty !s GIv~9' A AMaice N~k~b o+o~s~~ To Atodrly rrre terms tx rriQ Qlflor, Rsgr~lrs The Other' Pfrri{y a gA,gl,,,0emens: 1 Buyer and SeNer agree to amend the offer dated S.o 08 2 the purchase and sale of real ee3tate at ,~ 2000 ,and accepted se, ~at,.~ber ii , 7000 ,for 3 _ 20 ?10th ]1vw. b$~R r111tx, AI ._,.~ 4 (z) Cbstng date is changed from ToasnR 3RD 2oao as Ioaows: 5 ( ) Purcriase prk:e is changed from S ,,,,,i `~----~ to ocTO~le a 2oo~p 6 { )Occupancy date is cfienged from ~ -~---~ to ~ ' ~ { ) O~pancy charge i8 changed frorrl$ _„_, r !o S _~ ~ , ' 8 ~ X) dther: i . 9~LLBR Td 9'A? YOR ! UPDA~ BBPTIC szyTCff tilltYC,tti J~CCOftDIffG TO P$RK Ti;'$'! frILL i3E ~- 9 $ LAAtG T M8YCi1 RA3ttiD ON i TI}Oi'1'R 1r+1;LL 3 00.00.... Sitla~R 01tt>:ES !O RB$ERVE /'00.0 ~'ROtrt 70 '1'~IR $DS xi1fT0 ,AIf R C 71CC0~ L Ttdi NOi1~LbrG +~ `r$~x xipRxL az z o=. ui, _ - x~ Is a rtrts~c s+a=ce ~ea-~a ix~ rra 1Z E -292 3TA~~~ JItf~R! 'MT sQ001 ~ ~D If ~ 'i'O Bi )f+-TLtD TO_~-.~~g ~~p?AI.tiLtf_- t3 __ 14 2.~ z 71S iroLLOxr~, ~ R ~/=,p~R, ,z ~~_~~~ IOeroata srRean Z n7-corta 75 6 a AtfD qJ~B T 1rtLL AL 7.>:i"T X - 7'fitaT 7u~a ..~ , Lar~e~ , . tti _ _ COf~rv6l~tiCSt ~ T 0. ~r _ ,. 19 '-"' - 21 - 22 .. 23 T •-. ?5 26 _. 2r ~ .-. ' za ~' 2~ - ..~.-.. -...,..._ ~ W---.,.~.-~_.`_ --..,~.. at ._ 33 ALA OTHER TERMS pF THE OFFER TO PURCHASE ANO AN RPRP IY OR AMENOjyEN g FtEMAtN THE SAtidE. 34 7h19 Amendment is binding upon Seller antl $uyer vniy if a Dopy of the acaeptad AtnandtstM is delivered to the pa:!y s!!axj~s~- 35 the Amendment on or before „ s$g Z9, 2oob 36 Delivery of the aooepted Amendment ma ~ -.--.~. (lime is of the l:saence). 3r praulded in this Amendment_ NOtE: They ~ made in any meaner sAecrfied M the t~ to Purchase, unless otherwise ~ b acceptance •.rd ~~ oAtariM~ !/rl~t I1,oarrrJmvnt rilNy ~-d,sw the Oflltred AllferfarrJOei prior 4WNery sa provided at !/nee 3t to 3l, 40 This Amendment way drafted by ~ t:~RRTS x. p~-vLSOet ~~ s ODOMrTRY ii~uTY ,.._on_Q9/?9/2000 , ~' Lbsnses and Frcm ~ ~ /0,o~f®~4, 41 This Amendment was presented by ~ ~'~ U Sa-v\ Ce9~ W .pati,~ ~Lo , ~~LL4L.f~l~ . 4? Licen3ee and Firm / Oafs l 41R t ~ bf;l S~ + . Deb 46 s ' noturc ~ 4 Yens 5 Mituro /, 'aU Data NOr~: Af'7"ACH TH'rS A~~ENOMENT rio rHIE OFFER TIC! PURCHASE. •nw, ~ a.,.wy i<~Iy zet ~+u~sfreh ~ !e~ trma~e.u wNn 7+paaRnw~ M va,noa~ ho f tOQS F4-een ~. ~Ol GHbnn ra.ntMp M;d~.+ ~w6, t+GO 33ssao5 WWf f~01)•21y4 ~ ! o~.: his) a~.soro P~.. n~~ ~~~ 'IcOrm l Department of the Treasury -- Internal Revenue Service 1040A U.J. Individual Income Tax Return 2000 IRS Use Only--Do not write or staple in this space. OMB No. 154s-0085 Use the IRS a DENN I S LUT Z label. a KATHLEEN LUTZ other- ~ 292 STAFFENSON AVE WIS@, H please R AMERY, WI 54001 print E or type. Presidential Election Campaign ' Note. Checking "Yes" will not change your tax or reduce your refund, (See instructions.) Do vou, or your spouse if filirla a joint return. want $3 to Do to this fun Filing 1 status 2 3 4 Q Check only one box. 5 n Single Married filing joint return (even if only one had income) Married filing separate return. Enter spouse's social security rlurnber above and full name here. - - Your soclal security number 468-34-4025 Spouse's soclal security no. 468-34-2398 ~ IMPORTANT! ~ You must enter your SSN(s) above. You Spouse Head of household (with qualifying person). (see instructions.) If the qualifying person is a child but not your dependent, enter this child's name here. - - Exemptions 6a ~ Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 6a. b Souse C Dependents: 1) First name Last name (2) Dependent's social security number (3) Dependent's relationship to you (4) if qual- ;fy;n9 cnild for child tax credit (see instructions) No. of boxes checked on 2 6a and Bb No, of your children on ec who: • Hued with you _ ~ did not live with you due to divorce or separation (see inst.) Dependents on Bc not entered above Add numbers d Total number of exemptions claimed entered on lines above 2 Income 7 _Wages, salaries, tips, etc. Attach Form(s) W-2. 7 7, 7 4 3. Attach Form(s) W-2 here. Also 8a Taxable interest. Attach Schedule 1 if reauired. 8a 21 1 . attach b Tax-exemat interest. Do notinclude on line 8a. 8b Form(s) 9 Ordina__ry dividends. Attach Schedule 1 if reauired. 9 1099-R If tax was withheld. 10 Capital pain distributions (see instructions). 10 11a Total IRA 11b Taxable amount If you did not distributions. 11a (see instructions). 11b get a W-2, see 128 Total pensions 12b Taxable amount instructions. and annuities. 12a 5, 8 0 6 . (see instructions). 12b 5, 8 02 . Enclose, but do 13 Unemployment compensation, qualified state tuition program earnings, not attach, any and Alaska Permanent Fund dividends. 13 payment. 148 Social security 14b Taxable amount benefits. 14a (see instructions). 14b 15 Add lines 7 through 14b (far right column) This is your total Inco me. - 15 13, 7 56 . Adjusted 16 IRA deduction (see instructions) 16 grOSS 17 Student loan interest deduction (see instructions). 17 income 18 Add lines 16 and 17. These are your total ad)ustments. 18 19 Subtract line 18 from line 15. This is Vour ad)usted gross Income. - 19 13 , 7 5 6 . For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see Instructions. Form 1040A (2000) SMA 1040A1-0001 T1108 DEivi3IS & KATHLEEN LUTZ 468-34-4025 F~,~. ~ 1040A (2000) Page 2 Taxable 20 Enter the amount from line 19. 20 13, 756 . income 21a Check You were 85 or older Blilld Enter number of if: ~ Spouse was 65 or older ~~ Blind ~ boxes checked - b If you are married filing separately and your spouse itemizes deductions, see instructions and check here ............... . .................. - 21 b 22 Enter the standard deduction for your filmy status. But see instructions if you checked any box on line 21a or 21 b or if someone can claim you as a dependent. • Single -- $4,400 • Married filing jointly or Qualifying widow(er) -- $7,350 • Head of household -- $8,450 • Married fjlirig separately -- $3 675 22 9, 050 . 23 Subtract line 22 from line 20. If line 22 is more than line 20 enter -0-. 23 4 , 7 0 6 . 24 Multiply $2,800 by the total number of exemptions claimed on line 6d. 24 5, 60 0 25 Subtract line 24 from line 23. If line 24 is more than line 23, enter -0- This is your taxable Income - 25 0 Tax, 26 __Tax (see instructions). 26 credits, 27 Credit for child and dependent care expenses. and Attach Schedule 2. 27 28 Creelderly or the disabled. payments Attaon scneaule 3. 28 29 Education credits. Attach Form 8883. 29 30 Child tax credit (see instructions). 30 31 Adoption credit. Attach Form 8839 31 32 Add lines 27 through 31. These are your total credits. 32 33 Subtract line 32 from line 26. If line 32 is more than line 26 enter -0-. 33 0 34 Advance earned income credit payments from Form(s) W-2 34 35 _ Add lines 33 and 34. This is your total tax. - 35 36 Federal income tax withheld from This is the amount you overpaid. 41 2 02 Have it directly 42a Amount of line 41 you want refunded to you. 42a 2 02 deposited! See - b Routing instructions and number - C Type: Q Checking ~ Savings fill in 42b, 42c, and 42d. - d Account number 43 Amount of line 41 you wantapplled to your Forms W-2 and 1099. 36 2 0 2 37 2000 estimated tax payments and amount If you have applied from 1999 return. _ 37 a qualifying 38a Earned Income credit (EIC). 38a NO child, attach Schedule b Nontaxable earned Income: EIC. amount - and type - 39 Additional child tax credit. Attach Form 8812. 39 40 Add lines 36 37 38a and 39 Total payments - 40 2 02 Refund 41 Ii line 40 is more than line 35, subtract line 35 from line 40. toot estimated tax. 43 Amount 44 If line 35 is more than line 40, subtract line 40 from line 35. This is the you OWe Amount you owe. For details on how to pay see instructions. 44 45 Estimated tax penalty (see instructions). 45 Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer here (o~~an the taxpayer) is based on all information of which the preparer has any knowledge. Joint return? See instructions.' Keep a copy for Paid preparer's use only SMA 1040A2 Di~s('~j~0 Your occupation Daytime phone number ~$ ISABILITY ' f join rt th mu n. May the IRS discuss this return with Date /^ / Spouse's occupation the preparer shown P...rr. ~~ ._...!/~~ Z1~faZor,J7 URSES AIDE (seemstructions)1 ~yag ~ Preparer's signature ~ Firm's name (or yours' THELYN SCHONE if self-employed), 152 HWY 63 address, and ZIP code DEER PARK, WI O1 T0905 Software by Tax and Accounting Software Corp. Date Check ii self- Preparer's SSN or PTIN 02/02/2001 employed P00148222 Phone no. Form 1040A (2000) POWERS EX INC. 1969 185th AVE NEW RICHMOND, WI 54017 ST CROIX Voice: 715-246-5135 Fax: Duplicate Sold To: DENNIS LUTZ 2629 210 AVE CLEAR LAKE, WI 54005 Ship to: Customer ID ' Customer PO LUTZDE Sales Rep ID ~ Shipping Method i __ _ __ Courier Quantity Item ~ Description D 1SEPT 19 INSTALL HOLDING 'TANK 1.OOHOLDING TANKS `HOLDING TANK W/ PERMITS 48.OO~STYROFOM !STYROFOM 1 ,~ ^1~ \~ - 5 5~ D ~ ~ Q~ 5 .~ 1 L 4 C Check No: ~' Invoice Invoice Number: 5710 Invoice Date: Sep 30, 2001 Page: 1 Payment Terms Net 30 Days Ship Date ~ Due Date __ _ 10/30/01.. Unit Price Extension _. _ _ _ 2,900.00!. 2,900.00 2.00' 96.00 Subtotal Sales Tax Total Invoice Amount Payment Received TOTAL We will add finance charges on invoices more than 30 days overdue. 2,996.00 2,996.00 0.00 2,996.00 sin Department of Commerce PRIVATE SEWAGE SYSTEM 3nd~eikNngbtvision INSPECTION REPORT ERAL INFORMATION (ATTACH TO PERMIT) al information you provide may be used for secondary purposes [Privacy Law, s.15.t14 (1)(m)]. Holders Name: City Village X Township ker, Ronald Forest Townshi M Elev: Insp. BM Elev: BM Description: / I( tAICnRMATInN ~E MANUFACTURER CAPACITY 9 io ng Z bb O ~~ ecTt:eer_lu INFnRMAT10N K TO P/L WELL BLDG. Vent to Air Intake ROAD is ng ~tion ping tuto~ctal-tnN INFORMATION ORMATION Eder/Manifold ,gth/ Dia / )IL COVER th Ov rr cvATInN r1eT0 County' $t. CroiX Sanitary Permit No: 395262 State Plan ID No: Parcel Tax No: 014-1040-60-000 STATION BS HI FS ELEV. Benchmark , Z /, Z G /d jj ( Alt. BM -, / f /~ ~/ 1 Bldg. Sewer Z ~.; ~? 2 3 Q 3. 03 H nlet (b. 0 A / St/Ht Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover c// ~ 9 ' ~Q MENSIONS No. Of Pits !STREAM LEACHI CHA R OR ~~ UNIT cm ~ x Hole Size x Hole Spacing Vent to Air Intake Distribution / ~ Pipe(s) / ~ ~ - Length Dia Spacing x Pressure Systems Only xx MOUnO Vr Aiwraaa ~ya~an~a v~ ~ er Depth Over xx Depth of xx Seeded/Sod~ 1(french Center BedlTrench Edges ToP~I (] Yes [] No U Yes [] No ~MMENTS: (InGude code discrepancies, persons present, etc.) Inspection #1:~/~/~ Inspection #2: / / cation: 2629 210th Avenue Clear Lake, WI 5400f 5_(NE 1/4 NW 1/419 T31N R75W) NA Lot Parcel No://19.31.15.2936 I Alt BM Description = N ~(.~Y/l L ~ ~ >< 8h ~-y~ S~ .3 ~ i~/ot~[r ~C~rcr kl ~ /~ kt i k S Y~Q.f ltd Bldg sewer length = ~p' ~y fw~c riir rq ~1r amount of cover = ~ S ~ aa~ i~c u ~~cd `` `/ C~ dr+VCW4~ ~J~X~ u~i an revision Required? ~] Yes No ~ 2 t se other side for additional informati n. ~ '^ Date Inse ors Sign 3D-6710 (R.3/97) Cart No. AIL ABSORPTION SYSTEM /TRENCH Width Length No. Of Trenches JIENSIONS ~~ /~ ~-