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HomeMy WebLinkAbout020-1445-09-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division 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 Croix Custom Homes, Inc. Hudson, Town of SST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER w P P~--S"z.S~ CAPACITY Septic Dosing Aeration Holding TANK SET~A1d~ INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ / t ,SZ 9 Dosing P.eration Holding PUMP/~JPHON INFORMATION Manufacturer Demand GPM Model Numb TDH Lift tion Loss System Head TDH Ft Forcemain ength Dist. to well ~l)11_ ARSnRPTI(~N SYSTEM h ~\.11,.._. ,hQ1 i`-frea..c~ ELEVATION DATA county: St. Croix' Sanitary Permit No: 463435 0 State Plan ID No: Parcel Tax No: 020-1445-09-000 Section/Town/Range/Map No: 11.29.19.2830 STATION BS HI FS ELEV. Benchmark ~ I ~n I ' ~ • ~ i Alt. BM Bldg. Sewer 2. O 13• ~,/ f 1 /a SUHt Inlet t / 3 • s~ SUHt Outlet .~ ! ~ 3.3 ~' Dt Inlet Dt Bottom Header/Man. r Dist. Pipe Bot. System 12, g /a Final Gra 4 • ~ f St Cover , .l7 r~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ 3 ~ Z L Psc• SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufac~r~~~ INFORMATION CHAMBER OR • 1N~ Type Of System: t s ~ UNIT Model Number: IIISTRIRl1TiON SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Lengt Sp R(lll CCIVFR ., nre~~..re c..~•e...~ n..l.. vv IUnnnrl nr D4-rPAfIP SVC+PMR OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ` ;I No 1 Yes ' No C0 3 ~~T~V(~[ude co di ~epe cie ,persons present, etc.) Inspection #1: 6~~2 +/?.OOS Inspection #2: /_ Location: JNb66 LaBarge Road Hudson, WI 54016 (NW 1/4 SE 1/4 11 T29N R19W) Sunset Hills Lot 9 ~~ Parcel No: 11.29.19.2830 //r -.^_ _ i 'Yf 1.) Alt BM Description = ~ • ~-~"~ v _ I ~ ~' 2.) Bldg sewer length = (°` ' -amount of cover = *t $ p,l., t~s;,, I ~`,~,R~, .. ~ Od ' Use otherls de foruaddit onal ,n Yes "' o _,~ i _ - -- _-_- ------ _ -J formation. I__ _ -- -L--- - '' Date I p tor's Signature Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division Comity r 201 W. Washington Ave., P.O. Box 716 $t. CiO1X isconsin ~ Madison, WI 53707 - ~vE~ 6os sanitary Permit Number (to be fi~led;n by Co.) - Department of Commerce ~ - 05 Sanitary Permit ' pl~i ~ Plan LD. Number 6 2D a ht accord with Comm 83.21, Wis. Adm. Code, personal irrf 'on yot~~de f+ l be d f d P i L 15 Y jest Address (if different than mailing address) vacy aw, s may use or secon ary purposes r . xm UNS L Application Information -Please Print All Information S tiON~NG OFFIG 66 LaBarge Road Property ( 's Name Pazcel #: Lot # Block # C~~ ~ ` 020-1445-09-000 lot 9 Na CroixlHomes, Inc. .2$30 Property Owner's Mailing Address Property Location 707 Grandview Drive NW '/., SE '/., Section 11 City, State Zip Code Phone Number T 29 N; R 19 W Hudson, WI 54016 (715) 381-9896 IL Type of Building (check all that apply) . ~ ~ ~p, ~,,~ ~ ^XI or Z Family Dwelling - Number of Bedrooms 4 ~ S "''-' " - t Subdivision Name G~ei- ^ Public/Conmxrcial -Describe Use St12LSet Hi11S ^ State Owned -Describe Use ^City ^ Village ^XTownahip of HudSOn 1TL Type of Permit: (Check only one boa on line A. Complete line B if applicable) A' ^X New System ^ Replacement System ^ Treatment/Holding Tank. Replacanent Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Pemtit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T of POWTS stem: Check all that a ,S ^ XNon -Pressurised In-C»~ormd ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ A2-Grade ^ Single Pass Sand Fiber ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat FiNsr ^ Aerobic Treattnerrt Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. llhs rsaUTreatment Area Information: Twenty t;i t (28) Standard Bio-Difruser Chambers at 31.1 . ft. EISA/chamber = 870.80 . ft. ELSA Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) S Elevation 600 gpd 0.7 gpd sq. ft. 857.15 sq ft 870.80 sq ft EISA 105.0' upper trench 103.5' lower trench VL Tank Info Capacity in Total Number Mamrfacturer Prefab Site Steel Fiber Plastic trallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic orFIoldingTaok 1,2,50 - 1,250 1 Wieser Concrete X Aerobic Treatment Unit Dosing Chamber VIL Responsibility Statem nt- I, the e r instaDation of the POWTS shmm on the attached plans. Plumber's Narrie (Print) Pl s Signature MP/MPRS Number Business Phone Number James K. Thompson 5--- MPRS #30021 (715) 248-7767 Phmlber's Address (Street, City, ,Zip Code) 340 Paulson Lake Lan ,Osceola, WI 54020 VIIL Coun artment Use Onl Approved ^ ved Sanitary Permit Fee (includes Date Issned Issuing Signahtre (N } Groundw Surcharge Fee) ~ ^ eason for 'al IX. Conditions o Approv SYSTEM OWNER: 1 Septic tank, effluent #Ilt~r end dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances Attach wmplete plans (to the County only) for the system on paper not teas than 81lL z 11 inches in size o. ~I ~'~Sf+~^ ra de eje% =/o~„sm eiu~:. / ~~ ~~ ,~~ ,7 ti ~~ ~o- ~`~ / ^ e Sys~c,,., Crosss~cct7n-a ' ~rgde e~e~ _~oB,RS' ~-- 0.~ 5'O ~ ~. ='•a s ~o // y ,. ~ yo R d E, i ~ yue~c-~ o,~, %/oe5 in 2'~d-~a,.,.6e.-~~ /lr9~ ~pi~~5 i•~ /~~C~wMbCr oFeptl~ ~rencl,. Y~Su(. d0 P. /. c. bcu/olln r a~,~( wc.A jxst~-mQ Sep~:e~~K ~; ~f~ at out/.~~. n ~ ~ 0 5~ QjeQ ~i~~~ ~~ ~ ~~~ ,. ~! •P~~ -~ ~ ~~ (~ropost,o( di s~o4is~/ ce //, Two (z~ {r~nc-x+15 of 3'x 87S~w/ /S~ t ruc.~.. N ~~. D. P of y~ P,;oe. ~/4v~ = /0 3. SY,~ zi7.zs 3~ ~~,~ - ~~ .~~ b~` o`'~ Q~°e ~~~de a 0 ~Oi~ Qikt~GlQbOr) ~it ~0 iX Cus~Cw, ~m1ls, /_o~ 9 P/a-f Q ~' Su,.~s~ ,~//s ~u; //, ~-„ , off' ,c~,dro-,, 5t . ~ir Co., cJL P'~ a ~I 1n ' ~.ade eie~ 'i°1,1~ ~~ B q 510 \y ~c de ~yi5~.,~ rude= ~"~~shcd 2df~ ~, i~ ~8 S~ s ~a // y" ~`• yo R~/. E, i n/,yoec-t o,~,,I~%loes i.~ 2'~- tea,... ber• ~ /!/9~ ~i/AQS ir7 /3 `~CywmbC/ o~'eacl~ trencJt. I~ro~003~G (.Jics~~' CdrK1'¢~P w~P ~,xs~-mQ Se~e~aK a ~; /fW at ou-tl~~. b n o°~ ,~ '~ Y'su(. s/o o`''ff ~ ~ R/.c. pt~b~ata°~c~ $' ~ bu:/alin ~ ~~ ~ ~~,~ a ~ o ~~ ~° Q pr•pascd w weU i- d~ :~ c ~ ~roposc,d elis~oaiso/Ce/l.Two(z~ ~ib trtnchts of 3'x 87.S~w/ /S/ Qoy t rc.,c.ti . l6. ~. pof'Ysu~o.;oe. E/eve = io 3. ~,~ ___.-- ~..i7.2s ~~~~.2 ~ ~a~/ 2Na/ua~o~ Pit ~o;X Costa., ~m~s, /_o~ 9 P/af Q ~' S«..~5~ ,'~"//.s sec //, r., . oc ~dto+--. Sf . Cro.,r ~o., cJ/ eau/: = /~ .~--'~ wis~o~in Departrnern ~ SOIL ALUATION REPORT 0" of s°f~y~,d Bins .JAN 0 4 ~n n~ ~ / ~ 3 Roi X Attach complete s8e ~, «. ~ ~ , $' ~ Plan must . ~. but not limited to: vertical ~ .~ int ~B ~• dire ction and Parcel t.D. o ~. o • /0/3 • s0 • ~ percent slope. scale or dimensl lance to nearest Head. Please print all lnformatfon. Re ' by Date Paso~W hiwmr+don Ya+ P~de ~Y ~ ~d for sacaWSrY O~+P~~ t~~Y law. s. 75.04 (1) (m)). ~~~j~'V ? ~f~i/ /I'~D~tI T~/f~~f~N~ s~ 2 ~ `~ ~~ _ va s N R cwt. eoc tta r s ~o~ w Property Owners Mailing Address /D g(o s o a ¢"t" ~l~ ' Lot # Block # Subd. Name a CSM# s v~St '~'- ~i l/S aty sure zp code Phone Number ~~oso~ ~~. s ya/~ ~ ~~5, 38~ •~yoz o (~+ ^ Y,tlage Q town Nearest Road ~Uoso~ T,~,~,~~~ ~,~ . ter New C.oton Use: (8 Residential / Number of bedrooms 3 ` code delved design flow rate yJ~b - t'o d O GPD ^ R~ ^ Pubtic or oonunerac~-ai~~/- Descx~e• _ Parent material 5 A'itl,Q~ D{1 T Gtr} rrlit> Flood Plain elevation if applicable ~N~~ tt. General oomnents and ~ ~.R~~, ~'ST~O !S SUeT~'~G~' ~o/~' r1•l~ /N(rtiQOU.v1J Cl9.(~Ut:~IJ.T. lD.~J~} L ~. D .W . T' S , LCI F'li wawn.u aw.awwcr. ~a. ue~n~1 w mr~mm Cauca - ^1. ~ Rata Morison Depth Dorfiktarn Relax Description 7exdse struckxe Corrsistenoe Bourdery Roos GP DVft in. Mussel Gltr. Sz C;orrt. Color Cit. Sz. Sh. 'E1fg1 'EtF~2 o- 9 /o y/2 3~ L afsh~ Sti w 3 . s Z • ZO / S ,s/L / f ~ - 2 3 D 7•s ,Q S S o, s ae. -~ cs - ~ t• Z ,_-- 5 p a2.Q_ ~ ~- -as o ~ -g 0~ z sorirg # ~ pit Ground surfaoe~lev. /D~ • tt. Deptn to factor 7 ~l" in. . sot Rabe Horizon Depth Dorf~t Redouc Description Texture Structure Consistence Barndary Roofs GP O,IfP in. tNunsel (lu. Sz Corn. Cobr Gr. Sz Sh. 'Eff#1 'Efi#2 o• Z~ /o R G zfsh sit w 3-~ . S •' $ ~ SiL fs ti _. .z • 3 •S s D . s .e c - • ~ i'- /4 7 --- S O cQ,P • l3luern #1 = BOD_ > ~ < 220 moll and Tss >30 < 1 50 mofL • Effluent u2 = BOD _ < ~ mdl and rss < 3o moll. . CST Name~Please ~ ,T 7tG~~/ GGlT" ~ 2 ~.o~ 5 Address ~7 ~ ~ Date Evaluation Teleptiorte Number ~~• ~ - ~.o 0 3 -7~s • ~ 7a • ,3 yyZ. Ulbricht ~ Associates Private Sewage Consultants 2812 1 C`-~1~ Ave. ~ q Spring Valley, WI 54767 ~"~ ~~ ~ ~ FA~~ ~ ~ ~ r ~~ ~S ~~ ,~ )• ~; S vuSE~ }~'~i~/S ~ , ~. N1DN T,~3~Pi~t~V j> o a p . io~3 • so • oua ~ P~rtn~ GD ~- 7~f- 1r Z ~ ~~ n= 3 ~ ~ p ~ ~~;~ s~~~ /o ~ ~ ~- ~ tam ~~ ~' Ram t ka. Daunt AAunsetE Rsdox Desaa tom. 5z Cont. Cotar ~ s C,r Sz Sh. ~ Botxadary Roots C,P i~lE / o • /D 2 3 LS /.~ cs~ ~~ - 7 r • Z. Z - ~~ . Z. 3 7 Z # ~ _ Pit Gtocasd s~tace elev R to ~rrtiting factor in• Sod Rate tfcxizflra i)osrunar-t Redox Desaip~a Textwe 5t~xs CakspsE~ce 6otaadary .Routs Gl' QIEtT ~- ~ t1u. Sz. Coact. Cator fa'r. Sz Sh. 't:#t#'E 'Eti#2 Pit Groucad sasf~e dev, ff. to ' fat~or tca. ~ ~ , Sa't Rate tiort~on tlspTft t7ar~ant Cotor Redox Qem~on- Tsxiure Ca-sistenre @oemdaRy Rocs ! en. Mt.aase~ Qu, Sz. Cont. Cotor . S`t Sh. 1 'Etf#2 ~ ..c Ptt C,sound sa>fface stew. #t. Dept b 9 fadar a~. ~ ~ Sexy horaaan t7etma [lantnanat Redax Texlc>fe Struchare ~ 6oaRaciery Roo1a t iia. t;+Eunae~ Qu. Sz. t~lor Gr. Sz. Sh. 'Ef~fEi " Ettkeailt #'1 = 90U6 > 3t) < ?.~f3 n'K~I_ and T$S >30 < 150 angtL ~ Etfltaeart t32 = ~Qp6 < 30 atK3A. 2nd TES < 3f1 R1g-L. . y ", . ~ _ LoT ~ ~ y .r r / Tb~' ~~ ~ ,DhiO ~•~ p ~1L /r ~~ ~3 ,o • ~, /1 y/i ~' 3.j` " ~- . ~ -~" 5 , S G~4~t "O,v Gi,v~ ~n~ ~~ ld~ -t'a P a ~ ~a, ~+ 5~ p~~` I a3. ~ ~ ~.,.. ~ 0~,0 A ~ g ~o ,b y, o d • = j3~4.c,~~,.e 4,~ rc BioDiffuserTM Standard & High Capacity Chamber Specifications 76" oooG-moo r~o 00 Q o0 0 oao 0 00 0 00 00 0 c=ooooo ~~ °oo 00 0 c~ 00 a coo 0 0 0 oo ao c~ o ~'~o 0o coo °G~ o a a~ 00 00 All three BioDiffuser sizes can withstand H-10 loads when installed with properly graded and compacted soils. A mini- mum of 12" of cover is required for H-10 loads. The 14" High Capacity BioDiffuser is designed for H-20 loads. A minimum of 18" of cover is required for H-20 loads. Available Sizes 11" Chambers Standard H-10 " Knockout Chamber Heilght Chamber Height 14" High 16" High Capacity Capacity H-20 H-10 ADS Prod # 1100BD 1400BD 1600BD Length 76" 76" 76" Width 34" 34" 34" Invert 6.5" 9" 11.3" Units /Pallet 51 38 45 Units / TL 1071 798 945 ADS / PSA BioDiffuser Chambers can be ordered in pallet quantities. Contact your ADS Customer Service for ordering details - 1-800-821-6710 Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shad be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.O1/O1). All local and/or state rules pertaining to system maintenance anal maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics imply with Comm. 83.54(lxe). Septic tank to be located within 150' of service pad, with bottom of tank to be 5 i5' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 113 the liquid volume of the tank. The amtents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 113 scum and sludge aceumuiation in the tank. The outlet filter shall be cleaned as necessaryy to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. if the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diam~er shall be secured by an effective kx~cing device to prevent accidental or uosuthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases maybe present that oouid cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division Soil Absorption Cdf Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg1L 8OD5, 150 MG/L TSS, and 30 mg/i, FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule lay use of a diversion valve. valve to be switched diverting effiuent from dispersal cell currently in use to resting cell on a two-year cycle coinciding with septic tank inspection and maintenance. Continnencv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St Croix County Zoning Department at (715) 386-4680. ' ' ~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/lamer C~ -d i,~' /~eS ~i~C Mailing Address 70 7 6~a•~dv~ e.c,J ,Qr'i de / Property Address City/State Parcel Identification Number O~ ' /~~ 09-~~ ~. 2~3 0 LEGAL DESCRIPTION ~ ~ ~~ Property Location /7 W '/4 , ~ Ems'/< ,Sec. /~ , T ~-9 N R /9 W, Town of ~f'r.~'~~~'1 Subdivision Su-/15~~ hfi'~~s ,Lot # ~. Certified Survey Map # -~ ,Volume - ,Page # - Warranty Deed # ~~.,?~~~ ,Volume ~7~ ,Page # 7(0 Spec house ^ yes 1~1'no Lot lines identifiable ~d'yes ^ 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 function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 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 system has been maintained must be completed and returned to the St. Croix County Zoning Department within 30 days of th three year expiration date. ~-- SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property d ribed above, by virtue o a warranty deed recorded in Register of Deeds Office. ~/Zsids- GNATURE OF APPLICANT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** (Verification rewired from Planning Department for new construction.) Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. Document Number Document Name THIS DEED, made between Daniel P. Montbriand. ("Grantor," whether one or more), and Croix Custom Homes Inc ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is please attach addendum): Lots 9 nd 10, Plat of Sunset Hills in the Town of Hudson, St. Croix County, tsconsin. -" 7671+41 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO.. WI RECEIVED FOR RECORD 02/14/2005 01:00PK WARRANTY DEED EREidf~T I REC FEE: 11.08 TRANS FEE: 570.80 COPY FEE: CC FEE PAGES: 1 Recording Area Name and Return Addn:ss E~-y/,~ v~.tL~ ~. tt 020-1013-50-000 Parcel Identification Number (PII~ This is not homestead property. (is) (is not) Exceptionsto warranties: Easements, restrictions and rights-ot way of record, ifany. Dated `~ / '~ /~~ '' --- - - ~i r"i-~. P. Montbriand (SEAL) (SEAL) Signature(s) _, authenticated on TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Attorney Kristine Oglan Hudson. WI 54016 ACKNOWLEDGMENT STATE OF lS-~_`X'~~5~' ~ ) ss. ~~ . ~j ~ (X COUNTY ) Personally came before me on ~'I ~7 ~c30~ 5~ , the above-named Daniel P. Montbriand. to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. * Ll r,~-~' ~L~`rZ- zfl Notary Public, State of t.~l ~Gbn~l ~ My Commission (is permanent) (expires: d (Signatures may be authenticated or acknowledged. Both arc not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ®2003 STATE BAR OF WISCONSIN FORM N0.2-2003 AUTHENTICATION U: 2?y9P 0?6 State Bar of Wisconsin Form 2-2403 WARRANTY DEED * Type name below signatures. INFO-PROT'" Legal Forms.- 800-655-2021 www.infoproforrns.com ~ `1~ ~ i Y1 t.,. I ~i ~~ ( ~ t ~- ~` r. • 1~~ . ,64'StS 3.9~,9£.t :. t ~. ~ ~: ~ _ _-----------_..~._._.- ---._ _._ _. a ~•- a ~~N . ~ ~ ~ NQ~ ~~.~ . ~. 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