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Wisconsin epartment of Commerce PRIVATE SEWAGE SYSTEM
Safety an Building jlivision
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
Midwest E uities Hammond Townshi
CST BM Elev: f
O Insp. BM Elev~ BM Desaription:t J ~~
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TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
~~S
(~
Tian.
Hoto1 'IJr~
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic 2- t ~ 3 t Z f
Dosing
Aeration
Holdin
PUMP/SIPHON INFORMATION
Ma facturer Demand
M
Model tuber
TDH Li Friction Loss System Head TDH Ft
F remain Length Dist. to Well
SOIL ABSORPTION SYSTEM (I~-l r Ilre~.harc /-f-t~,~ r11,
ELEVATION DATA
county: St. Croix
Sanitary Permit No:
430641 0
State Plan ID No:
Parcel Tax No:
018-1094-11-000
Section/Town/Range/Map No:
17.29.17.751
STATION BS HI FS ELEV.
Benchmark
.(a,o
o9•b ~ /
w .fl
Alt. BM
Bldg. Sewer ~
0.4~ ~
8.x-3
SUHt fn(et ~ ~ ~ 1 ~ O ~ t
SUHt Outlet ' ~•~ ~~ . r
Dt Inlet
Dt Bottom
Header/Man.
13.06 /
`jb
Bist-Ptp y s 13.20
.~ IMP ~~ /
Bot. System t 20
I'"E'• Zo f
9 s. ~o
Final Grade
~o.~0 ~
9'q• 20
St Cover A ^
RENCH Width
f Length No. Of Trenches I PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~ f
8 2l
0.• /
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR ~
L
'1'Q
Type Of System:
t
~/- r
-] I
UNIT ,
u
.
Model Number:
t
DISTRIBUTION SYSTEM
Header/Manifold tt Distribution x Hole Size x Hole Spacing Vent to Air Intake
,
i
~ ~ }
l Pipes Z ~
~
Length
D
a Leng h Dia Spacing
SOIL COVER r Prpscurp Svd•pme Anly YY Mnund Dr At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
~l Yes [!, No
I 'I Yes ~' No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~~T/_~/ ~~
Location: 986 167th Street Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 11
1.) Alt BM Description =
r
2.) Bldg sewer length = ~j j
- amount of cover = >.~Z u so,;, ~ C,o•~~ ,
~. No ! ~ I
Plan revision Required? Yes [~ ~
Use othe (side fj r additio/{I 'nformation. _ , __ __L._.__ ~__- ________--_______.__.
SBD-6710 R.3/97 \ s~ e Insepctor's Signature
\ Q0.. .
Inspection #2:
Parcel No: 17.29.17.751
r-~--i -
Cert. No.
Safety and Buildin s '
,,, ~ 201 W. Washington A ., P.f~~oE
SCOO~f~O Madison, WI 5 07 - 7162
De artment of Commerce (b08) 266- 151
Sanitary Permit Application
In accord with Comm $3.21, Wis. Adm. Code, personal infotmadon yo prov~~ CROlX COt
may be used for secondary purposes Privacy Law, s15.1>4(1)(m ZONING OFF
I. Application Information -Please Print All Information
Property-Owner's Na me
Zip Code ~ Phone Numher
+' t )
II. Type of Building (check all that apply) St~~.i
~1 or 2 Family Dwelling -Number of Bedrooms _.S ~ s ' -
^ Public/Commercial -Describe Use
^ State Owned -Describe Use ~ ~ ~ l
TII. Type of Permit: (Check only one box on line A. Complete tin if applicable)
A' New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only
Sanitar Permit lumber (to filled in by Co.)
6
State Pl Y.D. Number
iT
dress (if different than mailing address)
Parcel N (Lot 11/~ ~ -13ieeirA~
UI1S ' 10'7 `t - I l -O'OO C• 'f`J l )
Property Locadon
~(~ ~.i,~~b6,Section ~_
,,~ (circ)e ~)
T N; R E r
Subdivision Name CS~hi-idmftliTCr.
I ; ~ _ 1i' ,
_^Vil~a~E-^`fownship of
^ Other Modification to Existing System
1 l;. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued
~ Before Expiration Plumber Owner
,~ _ ca... 1 l., „~w f ~~,~ ~e 'suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter
----__----- ~ - ----~ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter
_ _ ~~-~---tambe ^ D i Line ^ Gravel-les 'pe ^ O pia )
Dumber
D F~-- if Urtits
~~f I [~'-/- - ---
_~ 4~--- L '-!_i r ~ -
~ ~~ - ----
~~~
i 3 Zd some re
--~~--- - _ _ ~tre
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-- ~ : ,a, ~ - _ - -
- -,
Hilary Permit
~-~~ ~ ~~
11 ~ _
_ ~~
=~-- - rcharge Fee)
.
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----
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~~ --
-_
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tuber.
3
~ ;ned
SBD-6398 (R. 01/03)
a Required (sf) Dispersal Area Proposed (sf) ystem Elevation
.~ ~2
Manufacturer Prefab Site Steel Fiber Plastic
Concrete Constructed Glass
,~ ,:
for ittstallation of the POWTS shown on the attached plans.
T MP/MPRS Number Business Phone Number
~cludes Groundwater Date Issued Is uin Al;ent Signatu (No Stamps)
~ ~
25~ - .o
~ ~- >~~ '~
~`~ ~ -~
(to the County only) for the system on paper not less than 81/2 z 11 Inches in
i
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Wisconsin Department of Commerce
Division of Safety and Buildings
SOIL EVALUATION REPORT
~ ~ ~
Page ~ of
County ~.
Cro
~c
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must .
i
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. a 'wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). .~ , p9
Property Owner Property Location
~~ ` Govt. Lot ,(jam 1 /4 ~ E 1 /4 S ~ ~ T Z ~ N R / ~ E (or~j
Property Owner's Mailing Address
' Lot # Block # Subd. Name or CSM#
ct ~ 4 ~ ~
S~• I
City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road
f-~ w-nno,na w I Y ors. (~~s) ~q~- Z~43 ~ur-•trno,~c~ /~.~'' ~~~ .
[~ New Construction Use: [~ Residential /Number of bedrooms 3 -y Code derived design flow rate h~.S`tt /G Qa GPD
^ Replacement ^ Public or commercial -Describe:
Parent material r .~I ~ Flood Plain elevation if applicable if// ~ ft.
General comments 5 Y S~{m Q ~~ ~ ~-G ~ ~,S G o Gow 1,~ Q S /G
and recommendations:
Borin # ^ Boring {.k;k' ~~ '
® Pit Ground surface elev. • /G ft. Depth to limiting factor in.
"
I ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bo 'any ' ~toc~ts . t GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
~ p-tS I ~ 3lL Sr I Zrnab mfr c-S I v-~ . 5 • $
~5 ~44 ~o r~tl ~f si I Z rr~b ~ c -- . 5 ~ $
~~-(.
.~
^
z Boring # ^ Boring
®Pit Ground surface elev. q a ft. Depth to limiting factor I C~~ 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
i o Zo I IZ - sr~ k m-~r cs Ivy . S • g
z :3y 1 5 ~ ~ n~ cs - . 5 _ S
3 4-/~ m5 1 - `- .7 1.2
•`f 92
* Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name Please Print) Signature CST Number
~~rr- ~i~rr~ker G~~~-----.~G.._-.- 1539
Address Date Evaluation Conducted Telephone Number
i 13 $0''~ .~ . CYyrner~, I,LJI 5~-EU25 /I -2~- o ~ ~~~~)2~ 7- ~1 g
~~~-~s.s~ tK~~~~~/
_~ ~ , r
Property Owner t"~.~Li Y~.InS
Parcel ID #
Page ~ of
Boring # I^t~~tt Boring
Ipt Pit Ground surface elev. dG • O 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
2 -y2 ----~ 5~~ t -~r- ~~ -- . 5
3 Z-~~ ~tl ~ os m l -- _ ~- 2
.Y ~
^ 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)
~ ~ ' .
PAGE 3 OF 3
NAME ~ ~S ~; n S LOT# ~ ~ LEGAL DESCRIPTIONN~/ ~~V~ ~.S ~ ~' T Z~f ,N.R l~- E(orY~1
SCALE: 1"= G/4
BM 1 ELEVATION ~(~ ~ 6
BM 1 DESCRIPTION~o p a-~- ~ ~ •1 ~ ac P ,'~ :¢
BM 2 ELEVATION q 9. ~ O
BM 2 DESCRIPTION ~op a ~ ~~ ~~ flTTo-e
SYSTEM ELEVATION ao p 9s Go LG W ~r qS, /6
ALTERNATE ELEVATION~oP cI(ol(~ Lewer9S• So
CONTOUR ELEVATION 9~j'po ~. ~pQ.Od
N
®I
S,eG , (~-
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boo
SIGNATURE
DATE / 2 -/2 -a /
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Paga,~ot~
FILE INFORMATION
Owner , ,~
Permit # 3t~f%o
DESIGN PARAMETERS
Number of Bedrooms ^ NA
Number of Public Facility Units f~NA
Estimated flow (average) ~' ai/da
Design flow Ipeakl, (Estimated x 1.5) al/da
Soil Application Rate al/da /ftx
Standard Influent/Effluent Quality Monthly average"
Fats, OII & Grease (FOG) 530 mg/L
Biochemical Oxygen Demand (BODE) 5220 mg/L O NA
Total Suspended Solids (TSSi 5150 mg/L
Pretreated Effluent Quality Monthly average
Biochemical Oxygen Demand (BODE) 530 mg/L
Total Suspended Solids (TSSi 530 mg/L ^ NA
Fecal Coliform (geometric mean! 510° cfu/100m1
Maximum Effluent Particle Size Ya in dia. ^ NA
Other; ^ NA
"Values typical for domestic wastewater and septic tank effluent.
nnewrcuewrc crNCnirr G
SYSTEM SPECIFICATIONS
Septic Tank Capacity al ^ NA
Septic Tank Manufacturer O NA
Effluent Filter Manufacturer O 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: ANA
Dispersal Cell(s)
k~ln-Ground (gravity)
^ At-Grade
^ Drip-Line O NA
^ In-Ground (pressurized)
^ Mound
^ Other:
Other; ^ NA
Other; ^ NA
Other: ^ NA
Service Event Service Frequency
Inspect condition of tankls) At least once eve
'~'~ ^ month(s) (Maximum 3 years)
ear(s) ^ NA
PurTip out contents of tankls) When combined sludge and scum equals one-third (Y,1 of tank volume ^ NA
Inspect dispersal cell(s) At least once every: ^monthls) (Maximum 3 years)
!~ earls) ^ NA
Clean effluent filter At least once every: -> ^monthls)
~ ear(sl ^ NA
Inspect pump, pump controls & alarm At least once every: ^ earl lls) ~ NA
I Flush laterals and pressure test
At least once every: ^monthls)
^ earls) .ANA
Other; At least once every: ~ ea~ls-lsl ^ 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 cell(s) 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 tho
immediate notification of the loos) regulatory authority.
When the combined accumulation o} sludge and scum In any tank equals ono•third IY~1 or more of the tank volume, the entiro
contonte of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with chapter NR 113,
Wisconsin Administrative Code.
Ali 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.
OMW (41011
Paga~ of
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 damago the dispersal cell(s-. If liiph concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power la restored the exoes• wastewater will be
discharged to the dispersal cell(s) In one large dose, overloading the De(lls) and may result In the backup or surfao~ dlsoharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
Dower to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
-store normal levels within the pump tank.
.~o 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 (sump 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 bo removed and properly disposod of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or thoir covers removed and the void space filled with
soil, gravel or anothor inert solid material.
CONTINQENCY PLAN
if the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
roplacement system: •
,~ A suitable replacement area has been evaluated anal 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.
^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tan(.
may be installed as a last resort to replace the failed POWTS.
^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconatructlons of such systems must comply with the rules In effect at that tfine.
< WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL QASSES ANDIOR INSUFFICIENT OXYGEN. DO N07
:LATER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
'ERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
~DITIONAL COMMENTS
~~
?OWTS INSTALLER ~ POWTS MAINTAINER
Name ) ,,, Name
Phone - - -~ Phone
SEPTAQE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
t
Phone
Name , ~ r
Phone f -- _
~~~~ documont wee drafted In oompllence with chapter Comm 83.22(211b11111d-&If) and 83.64111, (21 & (31, Wleconsln Administratlve Codo,
ST CIrOT.X: CCg.TN'i"Y
SL~PTIG TANK MAINTI~NANGL' AGRi:1;M~NT
-AND
~wtler/£iuyer
Mailing Addr~
Proporly Address
(Vcriticatian required fram Planning Departzncnt for new
City/State,j; ~-~~1/~ ~2 _4~ ~ lxareel Ideciti~cation Number
S'~oa d-
oIS r Id`1~f -1 I - ~o+n C ~I~
~rGAZ, DrscR~PT~c~N
Property Location .._,'/a, _ h/~' `/,, Sec. _,/~~ T ~ N-R...L~-w, Town of „~ iy ~~'Z,~%~~
Subdivision ~.,~.~=.~C.~,-per 1~--e-~2 ,Lot ##,_Y ~ ____.
Certified Survey Main #
_ v~tttt„~
Page ##
Warranty Deed # 7~-~yS/ . Vc~lume~~r-~ ,Page #
Spec house ^ yes no
I.at lines idet~tifiabie yes ^ no
t~YS'TI;M MA,ZNTENANCIC
Improper use and maintcnanceof your septic sysicnx could result in its premature failure tv Handle wastes. Propertnaintenance
cvtisists of pumping out the septic ta~ilc every three years or sooner, if deeded by a licensed pwnpcr. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal systctn.
The property owner agrees to subuut to St. Croix Zoni,tg Dcparunetat a ccrtific:ation farm, signed by the owner and by a
noa$t~rplumber, journeyman plumber, restrictcdplumber or a ticettsed pvmperverifyiUg that (1) the on-site wastewaterdispvsal system
is in proper operating condition and/or (2) after inspection and putnping (if necessary), the septic tank is less than 1/3 fvl[ of sludge.
Uwe, the undersigned have read the above requiretnettts and agree to maintain the pzivate sewage disposal system with the standards
set forilz, herein, as set by the De~arUncnt of Conttnercc and the lleparluteni of Natural Resources, State of Wisconsizt_ Certification
stating that your septic systezu has been maiutaiued uwst be con~pletcd and returned to ilic Si. Croix County Zoning Offxcc witLin 30
days o~lzc three year cxpi.ration date.
/ ~ ~;'~
APPLI ANT ;
DAT>;
UWlVLI.t C;151C1a.l.~a.l.Al1V1Y
I (we) certify chat all statements on this form arc trzze ro the best of any (our) knowledge. I (we) aui (arc) the ownec{s) of
the pto y described above, by virtue of a warranty decd recorded iti Register of I)ecds Office.
r1ATV or Arr1.lcArrr DATE
Any infonnation that is mis-represented znay resutt in the sanitary permit being revoked by the Zoning Depaztmcnt. ~"`***~
rttarr•
** Include with lh[s applicat[on: a staznpcd warranty decd from the Itegisicr of Deeds office
n copy of tlzc ecrtit3cd survey zzzap if refcrazicc is made in the warranty deed
QWNrRSIiIP CI?RTIFICATION FORM
J 2252P 3y0 ~~
7 2 2 7 5 1
DOCUMENT NUMBER
Wl-RRAIiTY aEED
William E. Hawkins, Grantor, conveys and warrants to Midwest Equities,
LLC, Grantee, the following described real estate in St. Croix County,
State of Wisconsin:
Lots Y, 3,' 6, 10 11, 12, 13, 17, 18, 19, 22, 27, 30, 35, lA and 3A,
Prairie Run, Town o ond.
This is not homestead property.
Exception to warranties:
All easements, restrictions and rights-of-way of record, if any.
Dated this S 3 day of May, 2003.
(SEAL)
William E. Hawkins
(SEAL)
AVTAENTICATION
Signature(s)
authenticated this day of 2003
(Signature)
(Name Pzinted oz Twed)
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by 5706.06, Wis. Stats.)
THI9 INSTRi714$NT i7A3 DRAFTED BY:
Leo A. Beskar
Rodli, Beskar, Boles & Krueger, S.C.
P.O. Box 138
River Falls, WZ 54022
KATHLEEN H. MALSH
REGISTER OF DEEDS
ST. CROIR CO. , MI
RECEIVED FOR RECORD
05/23/2003 02:20PM
MARRAHTY DEED
EXEP~'1 ~
REC FEE: 11.00
TRANS FEE: 594.00
COPY FEE:
CC FEE:
PAGES: 1
N~E FiND RET~R ~SS
s i +GS~~r'
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18-1037-10-000; 18-1036-90-000
18-1036-80-000; 18-1036-70-050
Parcel Identification Number
ACIQTOiQLEDGMENT
(SEAL)
(SEAL)
STATE OF WISCONSIN )
ss.
COUNTY ) ` `1~ o' •~1 J ,
~~}}~~ V .
Personally came before me thisQLJ ` ;8ay1i2'~Fl~y, 3,p03
the above named William E. Hawkins ' •'' ro
to me known to be the persons(s) whO.•e~~u the +.
foreg~i~n(Jq/'/~instrum t and acknowledcle ~kha.,s~Q~ u'.
ry~ 7 v Si nature
* ~' ~ 1 ~~ ~•. N e r' or T ed
Notary Public ~o~in-ty, ~wis.
My commission is permanent. (If not, expiration date:)
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