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HomeMy WebLinkAbout018-2011-78-000o d vi p N d p N N N fD ~, ~ 3 ~ ~' n n o cn Z D co D ~' n c ~ ~ Z O C h m a ~ m a N X ~ a, ._ ~ ~ a ~ S ~ C j~ (D N 7 v y N 0 7 fD fD d 7 f ~' N~ O D S O Q fD ~ fD ~ O Q O ~ ~ ~ 7 O ~~ ~ ~ ~ ~ N 4U m<~D~°c Z ~.~mom? ° Ul 7 ~' ~ f0 y Q ~ N N p S~ O `C - Cl (D ~ O 7 ~- 7 y N ~~ 7 ~ U! O Q O y N a y C ~ ~~~na ~ N r2 dC1~ N O ~ ~ N ~ m a ..: ~ _ a n ~ o ~ ~ ~ 0 m <n O o g o m o Q- f)cnp c °: ~ ~ ~ N ~ i <D it i+' O ~ ~ N T 0 7C N M QO a ° a a m N v O N O ~ ~ O ? A ~ m $000'-' y ~ ~ ~ ~vvoo ~v ~- o = m ~ ~; ~ ~_ ~ A 7 O e~ .. ~ Z OD Z D o ~ v ~ N N ~ c N~ ~ fD ~ ~ ~ ~ D n ~ ~ N fD d O '~ !~! Z N A ~ G T C 7 a ~ ~ O ~ A n ~ '~ ~ # = WO O N O fV t0 N O ~ 7 v ~ n ~ ~ o ~ f w °o ~ O O ~ O C 3 ~'• a .. ~ a~ ~ rn m d a m y y Q. I n -s -1 N A Z f~'f A Z ~ •• ~ 3 m N O (O Z CA ~yVC < G A GGGG Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal intorihation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township 3ast, Kernon Hammond, Town of ST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding ELEVATION DATA County: Sanitary Permit 46327 State Plan I o: Parcel Tax No. Section/Town/Range/Map No: 30.29.17. STATION BS HI FS ELEV. Benchmark .B Idg. e r Inle Ht Ou Dt nlet Dt Bottom Header/Ma Di ipe Bot. System Final Grade St Cover TANK SETBACK INFORMATION ' ' ' 1 TANK TO P/L Vent to Ai take AD Septic Dosing Aeration Holding PUMP/SIPHON INFO~ATION~ / Manufacturer errand GPM Model Number TDH Lift Friction Loss System He TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SC)II C(~VFR ., o~e~~~.~e e.,~*e.,,~ nni.. ..,. Mnnnri nr ef_[;ratla Svcfc±mc Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil I] Yes ~] No ~~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 780 154th Street Hammond, WI 54015 (NE 1/4 NW 1/4 30 T29N R17W) Emerald Acres 1st Addition Lot 78 Parcel No: 30.29.17. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = ~ -T----- Plan revision Required? 1_-] Yes [] No ~ i Use other side for additional information. i__ ~ I _ ~ I Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) ' O RECEIVED o, Q DEC `~ ~ 2004 GT, CROIX COUNTY" ~nNING OFFICE ~~ ~. ~i ~~ l __ Safety and Buildings on County ~(~ ~ i / L e ~ ~ 201 W. Washington Ave., P.O. Box 7082 ~ lJ ~ , ~ ,S~O~S,~ Madison, WI 53707 - 7082 Sanitary P it Numbs (to be filled is by Co.) Oe artment of Commerce (608) 261.6546 3 2~ Sanitary Permit Application State Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, persoaal information you provide ~ maybe used foc secondary Purposes Privacy Law, s 15.04(1 xm) Project Addreu (if different than mailing address) M• I. Appllcatioa Iafortnattoa -Please Print All Information --~pr ~ ~ c ( • 1 L Pro nu j Parcel M Lot S Black!{ i ~~ ~1~ ~1 CL1 ~ ~ Pr Owner': Mailing Address ~ Pro scion a " ~ ~a ~ ~ Ci ,State - Zip C e , Phone Number ~~ ~~ T ~ - ~ ~ (circle ~ . L 1 VIS...6"~.CJt 1 ~v`*-'" TZ~ N R~E o W~ )L Type of BuUding (check all that apply) ~ s ; . l or 2 Family Dwelling - Number of Bedrooms ~ (~S, Subdivision~Na /me CSM Numbs ~ ~ ~ licJC.otnmercial -Describe Use `~- ^ State Owned -Describe Use 'ty ^Village o i of III. T ype of Permit: (Cbeck only one box on Une A. Complete IIne B if applicable) A' New S em yu ^ Replacement System ^ TreatmentlHolding Tank Replacement Only ^ Other Modification to Existing System c B• ^ Permit Reaewal ^ Permit Revision e ^ Permit Transfer to New List Provious Permit Number sad Date Issued ~ Before Expiration um ~ Owner IV. T e of POWTS S stem: Check all that a 1 Non -Preuuriud In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Co Wetland ^ Pressurized !a-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculatin S thede Media Fiher Leachin Chamber ^ Dri Line ^ Gravel-less Pi ^ Other (ex lain) V. DIs ersallI'reatment Area Iafor atIon: Design Flow (gpd) Design Soil Application Rate(gpdsf) Disper sal ea R equired (sf) Ar D Area P s t) System Elevation ~ ff ®CJ O / ~ ~ j f / J V VI. Task Info Capacity in Total Number Manufacturer Pre ab Site Stoe1 Fiber Pl tic Gallons Gallons oCUnits Concrete Conswcted Glass New Fxistiae Tanks Tanks `j Scptic or Fbktins Teak r , ~ I V•+ Aerobic Treauoeat Uait Dosin` Chamber VII. Res otuiblUty Statement- I, the and aed, assume respoasiblllty for Installation of the POWTS shown oa the attached plans. ber's N (Print) Plu s Si lure MP/MPRS Number Business Phone Numbcr ~'tx1, Addr trcet, i , Sta o. zip cod ~~ / /' ( ~ VIII. oua /De artment U C sse Onl Iq'Approved ' ~ Sanitary Permit Fee cludce Groundwater Date Ltsued Issui Agent Signs (No Stamps) Pl rven Reas~n,E'or Denial Surcharge Fee) '2~ ~ . Z~ IX. Coadltions of A prov VReasons fo~r~1(~s~ap~o-val 3, ~~~ '(S I~ S~ aka .~ e~ ~"~" `~ ~ „ '~~s ""~"_ t)~ . -L ~ a~cu`n ~e d~ , ~ f C ~ ,,, ~ r ~ ~ ~ ~ ~~~ ..sue. -~~ ~ s y q `~ ~,~~. a7 1 -%~ f3-3 t ~ ~`~ ,~- ~---- aR~ c ~aao3n l duo ~ ~~ /~ s- ~~~ z~-~ ~R ~qy ~ _ ao 7 ~,< .-~y T~--~. ~N ~n~ ~~ ~~ Sy~- G ..-~ :~ Wisconsin Department of Commerce SOIL EVALUATION REPORT Uivis'ron of Safety and Buikl6rgs in acxrordarrce wiUr Comm 05, Wis. Aron. Curie County Attacfr complete site plan tnt paper trot loss bran 0 1/2 x 11 it atairrs' an m t - 6rdude, hart not limited to: vertical and horizonta hrtli~~~~i fon an Parcel LU. percent ~ rope, scale or dirnonsions, north arrow, nd to rce to near l road. Please prfn[ al! br urrna[/on. 1 too' ed by Personel InrormeUon you provide maybe used for eeco dart' W~~o~ (P~aty L~ . 1 m)). \ er~(y f Properly ~Wnef tst pFFI ~av __ Property Owners Mailing Address Lot # !)luck bd (~5 3 ~vp-~4~ee~ . r -.-- ~~, I ----- City Slate IJp Ctx)e Phone Number ^ Cif ly LJ Villaye Pay©_ ~ of _~ . C ~~t, Uale 1/4 S ~ ~l~ 29 N 13 (7 E (or~ me urur csM# ~- ~~~ ~S D~ town Nearest Ruad ew Construciiar Use: esidential 1 Number of bedrooms ~~ Crxlo derived desiyn Iluw rate _ ~~ 1 lQ ~____ GPD ^ Replacement ^ Pubilc or cormnercial -Describe: _ ~-_- _ ---- - --- Parent rnateriel __ a __---__-_- Flood Plain elevation it apfdicabin ____. __~ T~' _ ______- R. '~-E-~---------- Y _ General co-nmerrts ~ ~ [e ~` ~ (~ ~ qz ~ (~ \ arrdreeornmendatiars: ~ 7 y[ C~ S~,tr,~~~.Qf see.~,~ rQ - ~-- Bunny `'a'y~ty~~v'.,~.~~ ~ . Boring # ~ -7 Pil Ground surface elev. ~ ~ ft. Deplir lu Ilndliny factor __ _l _____ in. __ _ __ _ Horizon UopUr Uominanl Color Redox Uescriplion Texture Structure Consistence Boundary in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. ~-. ~, z wc.ar~..c. -- _ _ _ Soil A I'rcalion Rate Rrx~ls GPU/lt' _ 'Elf#t 'Elf#2 2 I- Z i ~ 2mS~~ ~~ c 5 -- _~_ 3 ~-~ i g12 ~ 5 d ~1_ ~ ~ - _~_ ~ 4g 7j ca ~` -~~ ~,_ - ~ _~ ~ 7 caun . o. r., Z Boring # ~ Bonny y ~- Pit Ground surface elev. ~L~ it. Depth to IimiGng factor -! ~ - in. Sa8 Appl'rcatiorr Rate Horizon Deptlr Uaninarrt Color Redox Description Texture Struduie Consistence Boundary Roots GP D!(t= in. Munsell Qu. 5z. Cnrrt. Cobr Gr. Sz. Slr. 'Elf#1 'Elf#2 _ 2 ~4 ~ t~~r-~-lam --~ S i c.l Zf-n~b~ ~ c 5 -- _. `-( -~ ~~ _ l ~s12 v-~~ p ,m 1 ~ 5 _ : ~-I 4 l~ g ~L- S ~ m n~-~1 -" -" . ~ . ~o Effluent M1 =GODS > 3U <_ 22Q mg/L arni TSS >3U < 1 ~ my/L ' ERluent #2 = SOUS < 3Q my/L and TSS < 3U my/L CST Narne (Please Print) cure j "' CST Number _~~_~ Address Dale Evaluation Conducted Telephony Nwnber ~ ---- - ---____~71~ -- - 7 i f~, ~/~~~ ` 1"~k , ~p~~ ~,~ . ~~„~ r it tr ~~y"r ~C,~°' ,- Properly Owner ~~ -- Parcel IU I! ~~ ~_~_~ Paye ~-- °f ~-- ~ . f U Boring ~ ~ L BO1°'g # - 10~~C10 tt Pit Ground swtace elev. . De Ui W GntiGn t P g aclur in. Sol n r icatiott Rate e t T Strudme Consistence Buundary (toots GPDIfF Ilorizon Deput in. Dominant Color Murrsell RedoxDesctiiplion Qu. Sz. CrnrL Cubr ur ex - Gr Sz. Sh. .Ett# Eg#2 ~ 1 _ ~ o-l 2 ~" ~s-?9 l ~ Z '~ -~ - ~~s s ~ ~ ~_ ~_ r ~t ~ 5 ~ ~ ~-~ ~ 5 ~-( _. 7" ~- --- Bmin,g Boring'# - ^ Pit Ground swtace elev. . __ it. Depth to limitiny factor _______ in. Sal n licauort Rate d Ro ls GPDIfF I Iorizat Deput in. Dominant Cokx Munscll Redox Description (lu. Sz. Cont. Cobr .Texture SUudme Gr. Sz. Sh. Consislerrce ary Boun v •Ett#1 •E(TN2 U Bodny Boling # Ground surface elev. __~__~ it. Depth to limiliny factor ____ in. __ ^ pit _ 501 /1 licauort Rale Horizon Deptlt in. Dominant Color Munsell RedoxDespiption Qu. Sz. Cont. Cobr Texture SWdure Gr. Sz. Sir. Cvnsistvnce Boundary __ Rcwts GPDRF •Ett#1 'Elf#2 • Effluent #1 =130D5 > 30 < Z20 tny1L and TS5 >30 < 15(1 my1L ' Ettluent it2 = BODS < 30 my/L and l SS < 30 nry1L 'h6e Ueparttttertt of Cotntnerce is an equal npportut-ity service provider and cu-plvyer. if you aced assistance to access services or need material in art alternate Corntat, picase contact the depatttncnt at GU8-2GG-3151 or '1"I'Y GO8-2G4-8777. sno-ruwrrt.otronr a -.u~rrl-7 l.r•.c~n-. -~es~,-t-1`~rl~~t,: ii-i u~i,`, r r,,lit7_r<<,- v~ _ _ ---- - - -- -- SCALb: t „--- _ - ~ - - _- _- _ - - __ _ _ J ~ __ ;, L3mE GLLVA"I~ION:__-Jov_-_..G _ _ __- -. _ h /\ -- DCvt 1 DL•SCItIPiiOht:-_-(U-~_a_-±-.-~ ~sC.~`~Ie..-___. - ~~0.~ EiM 2 GLGVA"I IUN:_._ _-~q~ ~Sd ----.-----__ I ~C-~a --- ----- - [3M 2 DLSCRII` 1'I(~1~1: }op~__~-,~P J c.--(~-F-~---- SYS"I'L'ivl L'LLVn'1'(U11:__~-Qd - _- -__ _ - _ _ SYS'I'LM'1'YI'i;:-___-_(~iqs-e,~,-~L2sY~o~l __ __ _- _fi . ---- -- _-__ - ~I ~- POWTS OWNER'S MANUAL & MANAVtmtn 1 rLN-n Page ~ of FILE INFORMATION Owner Permit ~ ~ 3 Zoo DESIQN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units - ^ NA Estimated fbw (average) ~® al/da Design flow (peak), (Estimated x 1.51 (o (~ ~ aUda Soil Application Rate ~ al/da /ft~ Standard Influent/Effluent Quality Month y average • Fats, Oil & Grease (FOG) 530 mg/L &ochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids IT$$1 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) 510` cfu/100m1 Max'urwm Effluent Particle Size Ye in dia. ^ NA Other ^ NA Values typical for domestic wastewater and septic tank effluent. sySTEM SPECIFICATIONS Septic Tank Capacity Q al ^ NA Septic Tank Manufacturer ll~.~-,~- O NA Effluent Filter Manufacturer O NA Effluent Rater Model ~^ ~ O O 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: ^ NA Dispersal Cell(s) In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressuraedl ^ Mound ^ Other: Other: ^ NA Other. ^ NA Other. ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ~ ^ ear( ,Is) !Maximum 3 years) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY91 of tank volume ^ NA Inspect dispersal ceiilsl At least once every: ^ year(ths11s1 (Maximum 3 years) ^ NA ^ monthlsl ^ NA Clean effluent filter At least once every: ( yearls! ^ monthlsl ^ NA Inspect pump, pump controls & alarm At least once every: ^ yearls! ' ^ monthlsl ^ NA Flush laterals and pressure test At least once every: ^yearls) Other: At least once every: ~ yea f~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 certificatwns: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) 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 the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IYa) 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 I'unlted 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 Z or Z START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high 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 is restored the excess wastewater will be discharged to the dispersal celllsl in one large dose, overloading the celllsl 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 (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 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. Barmng advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ T a o Ong jank alua ' 't~RDf-l18 ffED. ~1~ /~/ ~'ONS77211~'lDN b e a~ ^ 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 Phone ~ - ~ - ~ "-"` POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name °`~""_ gam:; ~ .~ _ ~ ~ , Phone ~~ This document was draped in compliance with chapter Comm 83.22(21(blltlldl&Ifl and 83.b4111, 12! & 131, Wisconsin Administrative Code. u~: 4 ip ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C.~RTIFICATION FORM OwnerBuyer ~~ ~T Mailing Address Property Address C~ ~" ~~ .~~~, (Veriftcatioa reguind from Planning Depamnent for new p. i City/State Parcel Identification Number LEGAL DESCRIPTION Property Location /V ~=%, ~ ~I., Sec. ~~, T~N-R~W, Town of Subdivision ~!~t~f~~~ ~~t~ /S~iy~O/77~/ Lot # ~ . Certified Survey Map # .Volume .Page # Warranty Deed # ~ L~ (~ Q `~ ~ _ Volume _~~~~ ~ .Page # ~,~? ~Q' ._ Spec house p ao Lot lines identifiable D no SYSTEM ANCE impropernse and maionteaazsce of yon septic system could malt in its prematac+cfar~e m handle wastes. Propermaiatemncc co~osists of pumping out the septic tank every three years or sooner, if needed by a licensed paiaapet What yon pat into tine system can affect the Enaction of the septic tank as a hutment stage is the waste disposal system. The property owner agrees to submit m St. Croix Depattmcat a certi6catioa fiorm, signed by the owner and by a master pltmnber, jauaeymaapltmaber, restirictedplumber or a liceasedgtvoaper verifying that (I) the oa-site wasoe~vatardisposal system is is proper operating coition aaci/or (2) aRer inspection and pumping (if necessary), the septa tank is less than I/3 full of sludge. Uwe, the undersigned have read the above requirements and agree w maintain the private sewage disposal system with tlne ~++ 4}7~~ set forth, hereiq as set by the DepatttneflR of Commerce and the IJepartment of Nattual Resomres, State of Wt*~ Cectificatioa stating that your septic system has bees maintained must be completed and reoataed to the SC Croix County Zaaiag Oi~tx within 30 days of the three year expiration date. ik~i.,. fl J/Z/ OY SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I {we) certify that all statements oa this form arc true to the best of mry (our) knowledge. I (we} am (ace) the owne:(s} of tine property described above by virtue of a warranty dad rccorded is Register of Deeds Office_ '~'~` /! //z-/ Ofd GNATURE OF APPLICANT DATE ~•`«•* Any information that is rots-represented may result is the sanitary pemtit being revofced by the Zoning Depacomieat. s.ssss •• Include with this app[ieation: a stamped warranty deed from the Register of Deeds oflice a copy of the tertifcd stuvcy map if rcfett~ce is tnade is the warranty deed •~ ~~9~ P 300 • "' ~ STATE BAR OF WISCONSIN FORM 2 - 1999 • Document Number WARRANTY DEED This Deed, made between Gillis Farnts Inc Grantor, and Kernoil J. Bast and hard O. Stout, tenants fn comraQn~to li4 interest each Grantee. Grantor, for a valuable consideration, conveys and wazrants to Grantee the following described real estate in St. Crouc County, State of Wisconsin (if more space is needed, please attach addendum): NW '/~NW '/,, Except Certified Survey Map Vol. 14, page 3829 and also except Certified Survey Map Vol. 14, page 3829 and also except Certifies Survey Map Vol. 14, page 3967; NW1/. NEL/., NE ll. NW 1/., All in Sec. 30-T29N-R17W. St. Croix County, Wisconsin. ?6E,Qr'92 KATHLEEN }l. YALSH REGISTER [iF DEEDS ST, cROIx ca. , liI RECEIVED F'OR REGARD 06/16/2@@4 @1 :2@Pl! IiARRANTY DEED EXEIIf+T ~ REC FEE: 11.00 TRANS FEI;: 33(D0, p~ COPY FEE: CC FEE: PAGES: 1 Recording Area RETURN T0: METRO LEGAL SEIIVICCE3, INC. M NNEAPOtlS, MN 55401-241258 Natne and Return A~ictress - ~~ ~~~ s~ ,Vpts. _~ ~ ~~ ;14etro Legal Services 1 '+~" -t ,2 ~ ~~-- t fiDIRF:'I' 433921 a 371)744 ~~'D '90246 1&]066-60-000:18-1066-90-000:IS-1067-00-000 y Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties; Easements, restrictions and rights-of--way of record, if any. Dated this i * * day of June , 2004 AUTHENTICATION Signatures} Gillis Farms, Inc. sy: authenticated this f ~ day of June , 2004 * Kristine Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) Gil ' Farms Inc. >< ~G.r-.A Wj. By: * ~ -- ~ Y~ .~ ~ ---. ____-- * STATE OF County ACKNOWLEDGMENT ss. 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. .~__.____. ,_1 Notary Public, State of _ __ _ _ _ ___ __ My Commission is permanent. (If not, state expiration date: •) ~'' I~ * Names of persons signing in any capacity must be typed or printed below their signature. lnfocmation Professiorceis Co., Fond du La , WI STATE BAR OF WLSCONSLV 800-65502 ~ WARRANTY DEED FORM No. 2 -1999 / . , I ¢I z ~ O '• ~ _ QI I LOT' 48 ~ QZ . • ~ ~ LOT 47 I I E A . • - ' • ~ 96 ACRES I 1 I FT. j SG1 g4,752 i LOT ~ ~ " 91,138 SD. FT. I I ! O ~ 2"01 ACRES ~15 ~ I 87,527 SD. FT" 15 --~ . . .... . . .......... I . I I • ................. ............... .. . I ............ ..... I I al j i I $ I ~ ~ I - __ -- - t <~ -J _ __ __ '- -- 21~~a' ~ _.-- -- - ._ __ -- --~2 or -- -- -- -- x.03'_ _ Neg°45'02"E 723.42' -- - -_- c~+ -_-____ _ {-~--"- I --- ------._---- __ ____ ~ _ 1._4T._- -- -~ I 1..4T ----- - _211.4T __._- - ----- - - -- -- j I I 33' ~ I ~' ~ I ..... ......... . ....,... ...... •• .. ........................ . I ...... ......: ~i I I ~ N LOT 80 $ LOT 79 $ N LOT 78 ~ S` 2,00 $ N OQZ ~ $ N 2,00 ACRES ~ 2"00 ACRES 125 SD. FT" 87 ~ ~ 87,125 SQ. FT. i , w ~ ~ y ~. ~ 87,125 SQ. FT" ~ ~ , ~ ; ~ ~ ~ ' Z 100 i : j i i ~ sls' I - ` - EASEME DRAINAGE NT _____--- 211.4T 125.45' 86'07 - ' --- ~ --~ :------, 211.4T i j sear 2114T 45.06' 33' 33' N 9°48'02"E 2877.35' I I p i I I I I d04 9 ~ o• I d04 ~ ~ I I -- ~; I ~do~a~Q~~ I I ~~ ~~ I ~ I I s 8' :ETS I ~~`-_ w.~::..