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HomeMy WebLinkAbout014-1068-10-100Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ' INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. emtit Holder's Name: City Village X Township 5ina, Mathew Forest Townshi ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic // Z`g© Dosing c Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic l ~~ a' .J l ~ / 7 IV ~ V 9p i 1 ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION ELEVATION DATA county: St. Croix Sanitary Permit No: 453274 0 State Plan ID No: Parcel Tax No: 014-1068-10-100 Sectionfrown/Range/Map No: 32.31.15.497A10 STATION BS HI FS ELEV. Benchmark ~•~ 9Z Alt. BM iCi God ,r~ 0 "l ~~ /~ Bldg. Sewer SUHt Inlet -fir Sj . ~ ~~ ~5 SUHt Outlet ~ ~ . ~ Y Dt Inlet \ \ Dt Bottom Header/Man. c., t-SeB~ ' ~ . d . ~ Dist. Pipe Z y5.. Bot. System ~~- 7 . q 9a Final Grade 3 36 5Z St Cover ~ ~ ~ - ~~ G'c~ l.W t'i BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS N f Pits Insi Dia. Liqui epth DIMENSIONS ~] ~ _I ~ {e~~ ~. SETBACK SYSTEM TO P/L BLDG WELL LAK /STR AM LEACHING Manufacturer: INFORMATION CHAMBER OR ~ d ti Type Of System: /" it ` Z~ ~ 1 ~ J ~~~ ~ UNIT Model Number: l.r O~hJ ~ ~ b { 1 ~ ~ DISTRIBUTION SYSTEM Header/Manifol~ j~. Distributio ~ Pipe(s) ~ ~ ~ x Ho Size x Hol pacing V`ent/topA~Intake e r" Length Dia 11 Length \ Dia Spacing ` ~/ ~ ~ /~. SOIL COVER x PressuRe Systems Only xx Mound Or At-Grade Systems Onlv ~I b R~! Depth Over I Depth Over xx De of xx Seeded/ d Mulched Bed/Trench Center ~ ~ Bed/Trench Edg Topsoil s C No ~, [] Yes ® No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / tf3 /~~" Inspection #2: / / Location: 2793 C.T.Hwy 64 Emerald, WI 54013 ( E 1/4 NE 1/4 32 T31N R15W) NA Lot 1 ~ ~ Parcel No: 32.31.15.497A10 1.) Alt BM Description = ~e~"- GOUT-' ~ ° ( ~ l.r~CA,~+~ ~-- Lo~ G I~- 2.) Bldg sewer length = ~b -amount of cover = ~~j ~ ----~- ~ -- -~ r - - Plan revision Required? I :] Yes ' No ~ -'1! r~ O I I (~ -- ~-~ ~ ' - - ---- -- _ ---- ~ I -- - Use other side for additional informal n. ~ / ~°„J ~ L ~~± Date Inse ctor's S' lure Cert. No. SBD-6710 (R.3/97) SOIL ABSORPTION SYSTEM it~. U _ . , 1 ~1. ,.~ l Safety and Buildings Division 201 W W hi A P O B 62 County C ~ ~ . as ngton ve., . . ox 71 , , l SCOT t Sll t Madison, W 153707 - 7162 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (608) 2663151 ~ 3 ~~, Sanitar Per it A li ti State Plan L D. Number y m pp ca on In accord rural Comm 83.21, Wis. Adm. Code, personal information you provide , r /~' maybe used for secondary Purposes Privacy L.aw, s15.04(ixm) Project Add (if di erent than ff ma iling address) ____ __. W.. R / / ~ q ~ I. Application Infornation -Please Print All Information „~ _ ~ ~ f ~ (, - ~ • ~• LLB - _ _ Property s Name , ~, / ~ 4 + 1 ,~ ~ ~ ~ a 4 ' c;~~~ ~/ Parcel Block # Ptnperty 's Mailing Address S t . l R Ci I X L' 0 J N7'~ / "" LUNING OFFICE Property I.ot:a6on ~ ~ / ~ /~~f~ ~~ City State Zi ~ Section ~~~ . ~ p Phone Number ~ N E r II. Type of Building (check all that apply) _.,, ; 10 2 Family Dwelling - Number of Bedrooms _ ~~/zLt.LGf~~ ~~ 3/~sL/,~2.?/~ Subdivision Name CSM Number ~' ~ ~ ~ ~ " PublidCommercial -Describe Use ~ 7c~ S Stale Ownod - Descn'be Use D 1ST .~"Z, City_ Vdlage~owrtship of IIL T ype of Permit: {(deck only one boz on line A. Complete line B if applicable) A' New System Replacement System Treahrtent/Holding Tank Replaoemertt Only Odtex Modification ~ Existing System B • Permit Renewal Permit Revision t3range of Permit Transfer to New Last Provtous Permit Number and Date Isstted Before Expiration Plumber Owner IV. T of POWTS S stem: (Check all that a 1) oA -Pmssariud In-Ground Mound ~ 24 in of suitable soil Mound < 24 in of suitable soil At-Grade Single Pass Sand Filter Conctnrued Wedand Pressurized In-Ground Holding Tank Peat Filter Aerobic Treatrnent Unit Recirwlating S~nd Filter Recirculating Synthetic Media Filter " g Chamber Drip Lute Gravel-less Pi (ezphtin) , J~ V. Di ecsaVit'reatment Area I ormation: ! U F(./ S /Z ow (gpd) gn Design S oi l Application Rate(gpdst) Dispersal Area Regairod (st) 's roposed (st) P System F1ev ~ "' ~ " ] , VI. Tank Info Capacity in Total Number Manafactnrer Prefab Site S Fiber Plastic Gallons Gallotu of Units Concrete Coastmtxed Glass Ncw Existing Tanks Tanks Seplicor Holding Tank ~~ ' Aerobic Treatment Unit IN DosiAg Chernbrt VII. Res oasibility Statement- I, the and ed, a asibility for hutallatioa of the POWTS shown on the attached plans. P1u s Name (Print) ~ Plumber's S' MPIMPRS Number Busine~ss-Phone/Nu ~ , eta ~~~ "-~ ~</ r®` ., Plumber's Address (Street, City, State, Zip ~ ~j ~ ~` f J G `~? . vc VIII. Coon /De artment Use Onl Approved Disapproved Sanitary Permit Fee ('includes Groun awa~r surcharge Fee, ~- Z~ `_. Date Issued ~~ g t Si store ) Owner Given Reason for Denial .~ 4 IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: p ~~~ ~2'~d eptic tank, effluent i t nd ~ 0 3 ~SZ l d / i t i d ll t ll b d i ispersa n ne ce mus ma a a e serv ce as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. iv Attach complete plans (to the County only) [or the system on paper not less than Stf2 x tl inches in sine PROJECT Mdtthew Sina e~DRESS 1885 Ctv Rd D Emerald WI 54012 NE 1 /a NE i /4S 32 /T 31 /R 15 w TOwN Forest COUNTY ST. CROIX 5/27/04 BEDROOM 4 MPRS Shaun Bird 226900 DATE CONVENTIONAL X~ IN-GROUN PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TAN E HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambe ~ 28 ,BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION 100° Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 90.9/89.8 4.5' below grade Alt. BM Base of 2" Pipe @ 98.5' 350' 600' Well is to meet all setbacks required by WDNR 30 way 64 Plans Designed Using Conventional Powts Manual Version 2.0 V B-2 10' I Pry 3 Bedlroom Trailer I 25' i~ B-3 Line J ~ `_ Please note: 3 Bedroom Trailer is to someday be removed and replaced with a 4 bedroom house ^ r~ 15' (~` 70' 15' -3' X 8$' cells with 5 1 Vent >6" of Cover 11" 6' Long Grade 34" 0' 4 'Spacing B-1 ~~ 12% Slope Standard Biodiffuser Leaching Chamber with 31.1 ft2 of Area at System Elevation PROJECT Matthew Sina DRESS 1885 Ctv Rd D Emerald Wi 54012 NE 1/4 NE 1/4S 32 /T 31 /R 15 w TOWN Forest COUNTY ST.CROIX 5/27/04 BEDROOM 4 MPRS Shaun Bird 226900 DATE CONVENTIONAL )OCX IN-GROUN PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TAN E HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambe ~ 28 ,BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 90.9/89.8 4.5' below grade Alt. BM Base of 2" Pipe @ 98.5' 350' Fro e Line Pro 3 Bedroom Trailer 600' Well is to meet all 25' setbacks required by Please note: 3 WDNR Bedroom Trailer is to S someday be removed ~ and replaced with a 4 ~ bedroom house B-3 15' 70~ V ~vay 64 3 B-2 Plans Designed Using 10, 15' 2-3' X 88' cells with ' Conventional Powts Spacing 50' 40' 3 Manual Version 2.0 B-1 12°Io Slope Vent ~6„ Standard Biodiffuser of Cover Leaching Chamber with 31.1 ft2 of Area 6' Long 11 " Grade at System Elevation „.„ ~ i R Wisconsin Department of Commerce Divis9i5n of Safety and Buildings SOIL EVALUATION REPORT Page ( of~ -~'S^°~ ` r' it ~ ~ f- ~~ ~.~ ~s ~/q 111 PVWI4OIIVG YYILII VV Attach complete site plan on paper not less than 8 1/2 x 11 ' II ~Y~IJt Y\l~lly. VVO~G \ - ~ '- e .iii is ze.. Plyy~~n must C ~t County ~.J ~ r '0 ~~,/~. include, but not limited to: vertical and horizontal referenc l l i i rth BM), ~p1 ~a ~~~ - Parcel LD. / ~` ~d - /U~ ~ ~y"` D~ percent s e or d mens ons, no arrow, and to n ope, sca d dista st road. O - / Please print all informa i rr ~ RJR nevi e b Date Personal information you provide may be used for secondary p pos s ~F ?~r.... J, (Privacy Laws. T5.~ik jm)). , ?~ O Property Owner ~ --~" ~ ~p~rty Location J _ ~ ,~- ~~ mot ~ 1/4 ~1/4 Sj ~ T J N R ~ E (or) Property Owner's Mailing Address - ~ '~D ~ , + „Lot # ~ l Block # -- Subd. Name o SM# ~~z ~ ~- /~- ~ ~ ~o s City ate Zip Code Phone Number ^ City ^ Village °~Town Nearest Road /~ ~^ ~-' New Construction Use Residential /Number of bedrooms Code derived design flow rate GPD ^ Replacement ,~ ~ ~_ ~ ^ Pub/l~'c or commercial -Describe: /~ Parent material //~~,G~"G(icy~/ FloodpPlai~n elevation if applicable Jil ft. General comments sL'~,~ ~[ iQ,Gh~~t.[NDa - Q D l and recommendations: ~ s . ,5 `r / Boring # ^ Boring ~ ~ ~~~ Pit Ground surface elev.E[12~- ft. Depth to limiting factor / in. - ! Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. M u nsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 / ~~ ~/ Boring # ^ Boring ~~ Pit Ground surface elev ~ ft. Depth to limiting factor ~~-~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EfF#1 *Eff#2 ~ ~~/L l 3/z S" C ~ , S - trrwem ~ i = esw5 ~ su < «u mgiu ana i as Hsu ~ i 5u mgiL _ tmuem ~z = rsuu5 ~ su mgrL ano i ~s ~ su mgru CST Name lease Print) r, n e ~ST Number Address ate Evaluation Conducted Telephone Number ~1 ~~ ~ ~ / -nTX ~i~~/t/~~i <~~C~I~r ~A~l ~ ~lJ~ % /~~~~'U ~ ~J.3'o71~v1 ruovnm .1 Property Owner Parcel ID # Page of 3 Boring # ^ Boring ~ ~ Pit Ground surface elev. J 1 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ~---~ s~ s ,~/ d,/1 - 7 ~ ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * 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 (R.07/00) V Project Name Matthew Sina Address 1885 County Rd D Emerald Wi 54012 Lot Subdivision NE 1/4 NE 1/4S 32 T 31 Soil Test Plot Plan Shaun N/R 15 H- Boring 0 Well PL Property Line BM or VRP Assume Elevation 100 ft. C~S~'~I #226900 Date 1 /11 /02 Township Forest County ST. CROIX Top of 2" Pipe System Elevation 90.0/87.9 *HRpSame as Benchmark Alt. BM Base of 2" Pipe @ 98.5' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~' FILE INFORMATION Owner ~ Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~(J D al/da Design flow (peak-, (Estimated x 1.5) (~ gal/day Soil Application Rate Q. ~ gal/da /ftZ Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L [~' NA / Fecal Coliform (geometric mean) 5 " I Maximum Effluent Particle Size Ye in dia. ^ NA Other: ^ NA 'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity S al ^ NA Septic Tank Manufacturer /Z ~ (~ ^ NA Effluent Filter Manufacturer ~~~ ~~ ^ NA Effluent Filter Model -~` (~ ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: D(i'spersal Cell(s) C~In-Ground (gravity) /^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tankls- At least once every: 2 _3 ^monthlsl (Maximum 3 years) earls) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cellls) At least once every: 2 3 ^monthlsl (Maximum 3 years) ear(s) ^ NA Clean effluent filter At least once every: onth(sl yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ^ monthls) ^yearls) ^ NA Flush laterals and ressure test P At least once eve rY~ ~ ^monthls) ^ year(s1 ^ NA Other: At least once every: ~ yea~Is)(s) ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page 2 of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellis-. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal celllsl in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain Isump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T ~~ alua ' a o ing tank b e aie ~>QD~ittBTfF~ ~i2/~/$ln/ ('-DNS"T7elJ~DnJ ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~ ~2 ~ ~ l1'I. Phone ~ "7l~ ~ C~ - ~l POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name s^'r', ~ l bV N ~~~~ Phone ~/S- 3~(p_ (O e] This document was drafted in compliance with chapter Comm 83.221211b11111d1&Ifl and 83.54111, 121 & (31, Wisconsin Administrative Code. • SAC T~ MAIIV'TB~IANCB AC3RBSAlii3N'i' . AI1I) OWN~It~I~' C~R'I'IFIC.1-'£It1N FG1RM /Buyear Malit~ A Frapetty AcCSs ~D T ---~ -_- ~ (veas~cat reed, . P ctn fttc tta+v P`~rcxl Id~rtificaton Nutnb~ ~_.~,~'~ ~' a ~~ ~ ~,CAt ~C~.~7~4N pity Location ...,~.~, `fM SoC• .~ TAN ~~~ own of ,~~ re ~±____ . ,~- Suixivsion Lot # ~ ~ 9 ~ ~ ~ t0 Volute ~~ • Page # 3 +C~ ~trY~y ~~ ~ ~ C> ~ ~ ~ ~ .Volume ~~ ~ Page ~ -~ ^ ^ no Lot lines deatif~able ^ yes ^ ~xo i {we) ~Y ghat all tits oa thus form are true to ~ bcst of my (tax} lctzowl+cdgc. i (we} am {are) tho or~rt>~(sl of pcoperey d above, by vrc~e of a warty deal roearded ~ Register of Dceda ('~"icc. SI TURF QF PLIGt1` DATE 't rovokod b the ~s*s~s s~stts luny infortnat~~ that is miss-rdgrestated tray result in tho saaal~tty pcraru beua8 Y ~$ '* Indt~o trfth tbsls agpiieatlua: a warrat-ty doed &tam tha Ragister of Duds o~ a copy of the c~t~iad atsvcy ~ if rotbreta~so tc maclso iaa tlks wasraaty good U 2125P 303 STATE BAR OF WISCONSIN FORM 7 - 2000 TRUSTEE'S DEED Document Number Gary W. Heinbuch and Frances M. Heinbuch as Trustee of The Garv W. Heinbuch and Frances M. Heinbuch' Revocable Trust for a valuable consideration conveys without warranty to Matthew D. Sina and Ste hanie J. Sina husband and wife as survivorship marital property Grantee, the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Lot 1 of Certified Survey Map recorded in Volume 17 on page 4443 as Document No. 705876, being a part of the Northeast Quarter of the Northeast Quarter (NE'ri of NE%s), and the Southeast Quarter of the Northeast Quarter (SE's of NE's), Section 32, Township 31 North, Range 15 West, Town of Forest / 7Qi75£36 KATHLEEN H. IiALSH REGISTER OF DEEDS ST. CROIX CO. , )iI RECEIVED FOR RECORD 01/30/2003 09;20A?! EXEp9pT # REC FEE: 11.80 TRANS FEE: 59.18 COPY FEE: CERT COPY FEE: PAGES: i Recording Area Name and Retum Address Title One Premier Group, Inc. 706 19th Street South Hudson, Wisconsin 54016 part of 014-1068-10 Identification Number (PII~ Da this ~~oZ ~~ -dajc of Janura , 2003 ~a~ "~ ~,l~C.( *Garv W. Heinbuch Trustee AUTHENTICATION ~~.~~~~ ~ *Frances M. Heinbuch Trustee Signature(s) authenticated this day of \\\\°`°`n~~~"////je TITLE: MEMBER STATE BAR OF WISCONSIN °' , . ;~. ~~G : ~ ®, (If not, '- ;• authorized by § 706.06 Wis. Stats.) '• ~"' • • "' (•,0~~~ ~~ %~ \ ~~~/~//f/~ !If 11111U \\\\~\\\ THIS INSTRUMENT WAS DRAFTED BY Michael H. Foreeki, Attorney Eau Claire, Wisconsin (Signatures may be authenticated or acknowledged. Both are not necessary.) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. Dunn County. ) Personally came before me this ~ / day of January , 2003 the above named #~ 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. (If not, state expiration date) *Names of persons signing in any capacity must be typed or printed below their signature. TRUSTEE'S DEED STATE BAR OF WISCONSIN FORM No. 7-2000 Attorney Michael H Forecki 1830 Brackett Ave, Eau Claire WI 54701-4627 Phone: (715) 835-3029 Fax: (715) 835-4112 Michael H. Forecki Produced with ZipFormTM by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 3939805 T6438805.ZFX !~'1 ~/ ~l e ~ w-~ ~ ~~~ v ~ v 3 -~ S~ - ~ o ~ _o ~~ ~ ,~ Q x ~~~ ~~ ~ ~ ~ ~.~ ~' ~ ~~ ~3 ~ - o ~. ~ v ~-~;+~~ ~ °~ ~ o ~J s ~QQ ~ ~- ~. 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