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Washin P.O. Box , Madison, 153 266 - -Sanitary Permit Number (to be filled in by Co consin (60 [�! p k Department of Commerce Sanitary Permit Applica on ; S14 P lan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal info tion you provide ` maybe used for secondary purposes Privacy Law, sl 04(1 P P ject Address (if different than mailing address) J . i;KVIX C - L Application Information - Please Print All Information OFFICE t Property Owner's Name Parcel # Lot # Block # 1L # it Property Owner's Mailing Address Property at City State Zip Code Phone Number Y Section 6�6A A /_/ 55-0 trcle o e) T N; R�Et II. Ty a of Building (check all that apply) Subdivision Name CSM Number XD or 2 Family Dwelling - Number of Bedrooms I r ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use ❑City_ ❑V "Ilage ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A " New S stem y El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B, List Previous Permit Number and Date Issued ❑ Permit Renewal Permit Revision 11 Change of ❑Permit Transfer to New Before Expiration ` Plumber Owner ?6 / -7 y/ O IV. Type of POWTS System: Check all that appl ,&Von - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter 4 Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatm Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dispersal Area Proposed (sf) System Elevation z C-.1 sz 9 2, 9y. �s VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Sta tement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu 77 (MP4APRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Cod ) VIII. Count /De artment Use Onl pproved El Disapproved Sanitary Permit Fee (it udes Gr ndwater Date Issued Issuin Agent Signatu o Sta ps) Surcharge Fee) ❑ wn eason for 'al ��' Z - IX. Conditions eaNr► Attach complete plans (to the County only) for the system on paper not kss than 81/2 x 11 inches in size SBD -6398 (R. 01/03) A -goo z�- s 5 4 S X X3-3 XB -r ��Q aa.a3s7 �. w Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division < I INSPECTION REPORT Sanitary Permit No: 408261 0 GENERAL INFORMATION ` (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: McCabe Homes Inc. I Hudson Township 020- 1402 -11 -000 CST BM Elev: Insp. BM Elev: BM Description: /1' TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic I l,M Benchmark Q c • �l � O Dosing Alt. BM 6'L a3, Aeration Bldg. Sewer Holding St/Ht Inlet Ilt•30 . TANKS TBACK INFORMATION SUHt Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , 2�l Dt Bottom Dosing Header /Man. Aeration Dist. Pipe t k rs.�prj Holding Bot. System 14. Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift ction Loss System Head TDH Ft Forcemain ength Dia. Dist. to Well S ABS ORPTION SYSTE (� BED/TRENCH Width f Length No. Of Tr@nches PIT DIMENSIONS No. Of Pits Inside Die. Liquid Depth DIMENSIONS Z SETBACK SYSTEM TO P/L ELL LAKE /STREAM LEACHING Tumb del c�turer� INFORMATION Type Of System: 't } / CHAMBER O 4 V. [ . 1 " UNIT 11 O to { ki Mti�Y. DISTRIBUTION SYSTEM -(r- N'n Header /Manifold / K Distribution x Hole Size x Hole Spacing Vent to Air Intake �j�� Pipe( Length "" Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil —, ❑Yes �� No ❑ Yes ' No COMME (Inc e,sgcte discrepencies, persons present, etc.) Inspection #1:J Inspection #2: Location: 1025 Crescent Circle Hudson, WI 54016 (SE 1/4 SE 1/411 T29N R19W) Misty View Lot 11 t Parcel No: 11.29.19.2522 1.) Alt BM Description = l'-Iq 2 , S 2.) Bldg sewer length = S1,/sjj y b ynlZr� - amount of cover = Plan revision RequiredIn No Z tc ll Use other side for addi �_ Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) v, CD � re c -e we.cQ ql �rl aS' a a u. i CU �� � 1 2 Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 r n, WI 53707 -7162 Site Address Department of Commerce Sanitary Permit App 'ca sanrtary Permit Number f In accord with Comm 83.21, Wis. Adm. Code, personal info on EIV ED Check if 'Revision may be used for secondary purposes Privac Law, s 1 m I. Application Information - Please Print All Information Plan I.D. Number JUL 1 7 2002 Property Owner's N arcel Number o ZO — ST. CROIX COUNTY OFFICE Property Owner's Mailing Address Property Location 935 .5 lf %; Sl TV? N, R/ E City, State Zip Code Phone Number Lot Num / Per Block Number Subdivision Name CSM Number H. Building (check all that apply) V u Pnr 4w6" ❑city 1 or 2 Family Dwelling - Number of Bedrooms b. ❑Village ❑ Public/Commercial - Describe Use ownship ❑ State Owned C:Z) 3.K n 4;ZZ_L S / l�'o st Road ✓f� a0 7 /o g�A M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use S y I Tank Onl stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44on - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 Q Recii cula ' 00 ❑ Other V. Dispe rsaU'Treatment Area Information: 0 - Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate 'i eSystent Elevation Final Grade R_eeS iEed Proposed Rate( Gals. /Days/Sq.Ft.) (Min. /Inch) Elevation 600 . �# P ID 0 .. VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing • Tanks Tanks Septic or Holding Tank Dosing Chamber VII. Responsibility Statement - I, the undersigned, assume responsibility for tion of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' S' lure MP RS Number Business Phone Number Plumber's Address (street, city, state, iZCod ) D / � xv_ Vift Coun /De artment Use Onl KApproved ❑ Disapproved Sanitary Permit Fee (includes Groundwater f5ate Issued Issuing Agent Signature (No Stamps) Surcharge F Cjp ❑ Owner Given Initial Adverse !ti9_1 ^ Determination _ IX. Conditions of Q,PProval/Reasons for isapproval � � �'� N/�cl,t. M ld �•W• L' o<Aaa s^ 9L^ ty`aa', MW ply SBD2080 O 5 Ul�s j : !i/Y' _4 NHS ��.7 30 r f ` 0 t / / llll-�l 5 5� 973o r F 1��2�ibI t+— _UZg wisconsin pe;amrnerit of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings • in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must t 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 R by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ( ; Property Owner Property Location 2 * t&, ,004 Govt. Lot ,S 15 1/4 1/4 S// T29' N R/ 9 E (or) G Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 135 e Tra l ! City State Zip Code Phone Number ❑ Ciiy ❑ Village [Tow Nearest Road [�g New Constriction Use: E�F Residential I Number of bedrooms Code derived design flow rate d Q GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material �t1 °�- e v Flood Plain elevation if applicable ft General comments $ ,S-kc rr\ t 1/ Q 3 d and recommendations: y A4.4 ek -V. 1-7- 30 N �T 1��� 9 � l 5] Boring # ❑Boring *.t 1`, G� 3° V] Pit Ground surface elev. / 6 • � U fL Depth to limiting fador it mil . ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bo i Roots in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. t , ' !` ' > , " *Etf#2 6 -iz 16 o f z — 2mnhk m es Z 12 �} y �S 19 -11Co 1 6y Nko m S S M I 'r, a� 4 9Y Boring # O Boring ® Pit Ground surface elev. /Oa• 5a fL Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efr#2 I 0-9 ho 3/Z s; k c ( V-� .5 8 2 9 - 10 X 9 3 5t 1 2-wiahk ayCr c 5 - 5 . 19 -10$ lD r 4 o — m .5 0S rn I - C44 Ct .� Y * Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sngnatu CST Number Address Date Evaluation Conducted Telephone Number 211 SOb Sys l �`7-G/ C�15)24� -yov8 cI 3 Property Owner Parcel ID # Page Z of Boring # ❑ Boring a ® Pit Ground surface elev. 0 ' 9 ft Depth to limiting factor � � � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfF in. Munsell Qu. Sz- Cont Color Gr. Sz. Sh. i 'Eff#1 *Efr#2 0-1Z / 14r ,317- s/ Z,►- �k I v-C 5 2 12- q1 3 rn c — 5 F-1 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 GPDff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Ong # ❑ Boring 1:1 Pit Ground surface elev. fL Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 " Effluent #1 = BOD > W 220 mgr& and TSS >,V 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg1L 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) Property Owner Panes ID # Page Z of 3 ❑ erg a Boring # ® Pit Found surface elev. 00 ' 5 fL Depth to limiting factor � >' o in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure C.onsisterm Boundary Roots GPD/fy in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 o -iz I 3 2 s; I Zryr,.l k ( v-C 5 S 2 12- q/3 - 5./ 2rr,Gb m i5 3 � Ig p -4 - m 5 �S m f - /. z F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Efl#2 Bori I # °Bo ring ❑ Pit Ground surface elev. R Depth to limiting factor in. F Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg& and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 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 TI'Y 608 -264 -8777. SBD4330 (R.07M) w PAGE �5 OF�_ NAME .56 u TOT# 1 / LEGAL DESCRIPTION S E %.SE i4 ,S /I.. T Z - y ,N,R, / i E(orco ✓ SCALE: I"= BM I ELEVATION 0 BM I DESCRIPTION b P a -. w{ Z '' f .� IN BM 2 ELEVATION `J 9 BM 2 DESCRIPTION k, e a L I c ,-E-G. Z '` U,l S c SYSTEM ELEVATION :7-,3 v 1 ALTERNATE ELEVATION Q ?-, 3 CONTOUR ELEVATION nu 51u j2 t x ao ■ J 8 ■ d--I � SG SIGNATURE ,� % DATE POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner C,� Septic Tank Capacity Q al ❑ NA Permit # / Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 77 ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units IXNA Pump Tank Capacity a l 'KNA Estimated flow (average) O gal/day Pump Tank Manufacturer IKNA Design flow (peak), (Estimated x 1.5) 4 al /day Pump Manufacturer 1-NA Soil Application Rate a gal /day /ft2 Pump Model ITNA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit P�NA Fats, Oil & Grease (FOG) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD <220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD <_30 mg /L In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) <10' cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ ear( month(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: e mon th(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: Z �rea r(s) ❑ m l ❑ NA r(s) Inspect pump, pump controls & alarm At least once every: 0 y ❑ NA Flush laterals and pressure test At least once eve ❑ month(s) year(s) ❑ NA P every: ❑ years) Other: At least once ever ❑ month(s) ❑ NA y: ❑ year(s) 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 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 (Y 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 of START UP AND OPERATION For.new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals .that may impede the treatment process and /or damage the dispersal cell(s). 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 cell(s) in one large dose, overloading the cell(s) 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 p rovide 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. ❑ 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 tank 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. 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 INSTALLEft POWTS MAINTAINER Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name j cx_k 'C. Q Phone Phone 71 S - _' ® This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MARUBNANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnedBuyer z . Mailing Address Property Address X X G 4e r' e� (Verification required from Planning Department for new comstcmction) ( ity/State 7yO � -t Parcel Identification Number .;'� - /Dl3 — 30 - 00 t 1�AL DESCRIP7ZON Property Location _.f y, 5 5 %, Sec. �, T N �w' Town of Subdivision &Z23 �Aaa Certified Survey Map # , Volume _, . Page # W nwity Deed # �. r . Volume o Page # Spec house ❑ yes, no Lot lines identmabl�es ❑ no SYS'YT -M MAINTENANCE prema Improper use andmaintenammof your septic systemcouldresultisits prema rote the consists of pumping out the septic tank every three years or sooner, if needed by a licensed per. ,fit you Per system can affect the function of the septic tank as a treatment stage in the waste disposal system The property owner agrees to submit to St. Croix Zoning Department a ctrisficatton form, signed by the owner and by a t plumbw, journeymanpinmber, restrictedplumber or a licensedptmaper verifying ibat (1) the on -site wastewaterdisposal. system ism proper operating condition and/or (Z) after inspection and pumping (if necessar the septic tank is less than 113 fill of sludge. Yve, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with die standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and rehnmd to the St. Croix County Zoning Office withim 30 days of die year exp" 'on date. / /Dv SIt3NATEME OF APPLICANT DATE OWNER knowledge. I (we.) am (are} the owners) of I (we) certify that all statements on this form are true to the best of my (our) the p bed above, by virtue of a warranty deed recorded in Register of Deeds Office. OF APPLICANT DATE «« « « «« Any information that is mis- represented may result is the sanitary permit being revoked by the Zoning Department- * « * * *« •« Include with this appllcatlon: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if referaaee is made in the warranty decd U 1892P o01 STATE BAR OF WISCONSIN FORM 2 - 1998 � WARRANTY DEED 6 � 3 1 `} 9 KATHLEEN H. YALSH REGISTER OF DEEDS - Documeri Number ST. CROIX Co. MI RECEIVED FOR RECORD This Deed, made between RLCIiARD__O- 05- 16-2002 8:30 AN husband-- anc�wi e, T ,-- -- NARfZAM DEED EXDPT # and . -- MC CARE. HOMES , TNC -- REC FEE: 11.80 - -- —_ TRANS FEE: 185.70 _ COPY FEE: CERT COPY FEE; - - - - -- Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Crantee the following described real estate in ct Croix County. State of Wisconsin: Lot 11 Plat of Mist View, w, Town of Hudson, $ Croi y, iscons x Count Name and Return Address f= F L C_ 020 - 1013 -30 -000 020- 1014 -10 -000 Parcel Identification Nurnbw (PIN) This is not homestead property. (is) (is not) _ t Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this �11_t�h —_ of May 002 (SEAL) & ..e.� , � /" t � '` (SEAL) Richard 0. Stout Janet P. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, St. Croix County. authenticated this __ day of Personally came before me this 1 5ttl day of May _, 2002 , the above named TITLE: MEMBER STATE BAR OF WISCONSIN '� ��� _ to (If not, _.. me known to be Piii -S: hH-4xecuted the foregoing authorized by 4706.06, Wis. Stars.) instrument an814 QF,AA=0NSIN KERNON J. BAST THIS INSTRUNILNT WAS DRAFTED BY _ Janet P. Stout - 1353 Awatukee Tr. Hudson, T.1tI 54016 Notary ublic, State of � onsin -_ —_ My c mmission is rpermanent. if not, state expiration date: (Signatures tnay be authenticated or acknowledged. Both are not necessary.) -' — 'Name, of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEEP STATE BAR OF WISCONSIN Wisconsin t e9 ai Blank Co., Inc. FORM No. Z - 1998 Milwaukee, Wes . "° ..... . 87,120 SQ FT -�� 1 ^ @ ' L � J I l O o ro LOT 1 1 2.000 ACR S `\ 87,134 Sq FT 1 �' �I o \ � I • H 1 � /• �I �I �! / o N 15 ORES 30 FT IIN. FLOOR LEVATION -- - - - - -- F 913.00 I 283.65' ��` ---- - - - - -- /•• / ^� V v ms s, � .• LOT 11 / 2.000 ACRES f y� S a . O- ,S TER. 7 120 FT S h • / f T CROIX C� r �' S / / ^ G � a �b . MIN. FLOOR `� moved forRm �0► ,� .� / ELEVATION OF of 914.50 i - ft 'cl. / 388 °29'13 "E 472.36' ; r o @ @ ?p�` / MIN. FLOOR LOT 10 ELEVATION OF 2.000 ACRES ��,,, 914.50 OO 87,120 8Q FT \� 3 1 . � \ coo N87°4 2'17 "E 425.96' O 1 W oa LOT 9 - � ----o 1 .gQ C 5� 1 2.000 ACRES O Di p 87,120 SQ FT (11' Z • 1 �Zm� 1 .a o Lk S86 023'04 "E 377.98' i ci LOT 4 !.001 ACRES 17,143 SO FT 1�7 Q 1 Q 1 1 LOT 8 1 1 1 1 2.000 ACRES & 97,121 80 FT