HomeMy WebLinkAbout020-1452-05-000Wisconsin 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
LaCasse Develo ment Hudson, Town of
CST BM Elev: Insp. BM Elev: BM Description:
/~ ~~'~ ~ C,5\
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic
~-^~ 2:
~ .
E-. \ ~ ~~
Aeration
Holding -
C...~..~.-„_...,., .. ,
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic ,~ ~ ~ , L^
J ~~i ~~ ~
Dosing
Aeration
Holding ..:. -
PUMP HON INFORMATION
~-
N
i
r ., ri4tfaeturer
,~ ,.,
,,~ Demand
GPM
Model Number .,:~:.;
TDH Lift Friction Loss ystem Head DH Ft
Forcemain Length Dia. Dist. to well
S(~11 ARS(~RPTI(~N SYSTEM
County.
St. Croix
Sanitary Permit No:
463390 0
State Plan ID No:
Parcel Tax No:
020-1452-05-000
Section/Town/Range/Map No:
13.29.19.2893
STATION BS HI FS ELEV.
Benchmark
103.
/ate
Alt. BM (~ -7
Bldg. Sewer ~
'' l
~~ ~ ~~
SUHt Inlet ~ 4 q~ y~
~7
SUHt Outlet $ Z ~•' c
~
.7
Dt Inlet ' ~
Dt Bottom
Header/Man. 7~ ~ q ~ ~ ~ G
Dist. Pipe ~' ~ 4 y , ~ S
Bot. System (~,
~~ ~ ~ 1 ~ 3 , Z~
Final Grade
S Z. q
! ~ ~5
St Cover ~ .~\
BED/TRENCH Width ~ Length No. Of Tre
n
ch
es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 ('ZI Z,
~'1 -
r-
-
Z ", ~p~ ~ ` ~.__ ice`. ~~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: r
~~
a
INFORMATION CHAMBER OR -/~dr~
~,TcZ
Type Of System ~/ ~~~ ~~
'~" UNIT Model Number: ,
. ,
C c, nv e~ ~ c~r~~
I~ISTRIgLJTION SYSTEM L. 5 ~r; .1,. Y (~ /tf-~_
Header/Manifold /~ DistribuFon
Pipe(s)
\ x Hole Size
~ x Hole Spacing
~ unt t~~ir Intake
'~. ,
.Length 5. 5 Dia ~ Spacing ~
Length Dia ~ ~~~.
SClll CC1bFR ., o.e~~..~e c.,~se.,,~ n.,i.. .... Mn~~nr! nr nt_r:rariw Svstams r7nly
Depth Over /
Bed/Trench Center ~ Cf Depth Over
Bed/Trench Edges xx Depth of
Topsoil xx Seeded/Sodded xx Mulch@d\
N
\Y
~
1 I \ ` Yes No o
es
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / !
Location: 937 Sadies Lane Hud n, WI 54016 (SW 1/4 NW 1/4 13 T29N R19W) Bluebird Meadows Lot 5
1.) Alt BM Description = ~J~~~~ ~~' ~o ~ ~~,~
2.) Bldg sewer length = ?) ~ r
- amount of cover = i t , : t
,..r ;~~
r
~~,~~ _. --- - /~
Plan revision Required? ,Yes I]~ ~ L-1 GS ,..~J'
Use other side for additional information. _(
Date
SBD-6710 (R.3/97)
Inspection #2: / /_
Parcel No: 13.29.19.2893
(~~ 3 ~Z 5
Cert No
Safety and Buildings Division County /~
` ~ m 201 W. Washington Ave., P.O. Box 7162 C/~, '
iseons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
De artment of Commerce
(608) 266-3151
3 ~ ~
Sanitary Permit Application State Plan LD. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s15.04(I xm) Project Address (if different than mailing address)
I. Application Information -Please Print All Information
Property Owner's Name /Faz 1 # ~ t # s $leele#.
,7 ` _ L
~M/1
operty Owner's Mailing Address Pro Location
- i~4.sa-as-acv
1 Y
L'
'~
City, S e ~ Zip Code Phone Number ., ~l
/,, Section
~ prp
T~~ N
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f B
k
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.
ype o
u
ng (c
ec
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at app
~
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~
~1 or 2 Family Dwelling - Number of Bedrooms
S Subdivision Name
^ PublidCommercial-Desaibe Use
^ State Owned -Describe Use ^City ^ Vil e ~1'ownship of
III. T ype of Permit: (Check only one boa on line A. Complete line B if applicable)
`~' ,~ New S stem
y ^ R lacement S stem
ep y
^ Treatment/Holding Tank Replacement Only
^ Other Modification to Existing System
B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. T of POWTS S stem: Check all that a 1 S 2
Non -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 edia Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain)
V. Dis rsal/I'reat ent Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
7~
~ ~
~~ s
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic
Gallons Gallons of Uni ~,.Z~0.~ ~). _ ~~ Concrete Constructed Glass
New Existing r/.~-.
_d ' l
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Res onsibility Statement- I, the undersigned, ssume responsibility for installation of the POWYS shown on the attached plans.
Plumber' N e (Prigt) Plum er's S~ ~ MP/MPRS Number Business Phone Number
j ~
lumber's Ad s (Street, City, S , Zi od
~ ~- /~/ ~~
~--~ ~' ,
VIII. Coun /De artment Use Ool
Approved ^ Disa roved Sanitary Permit Fee (includes Groundwater Date Issued Issuin Agent Sign (No Stamps)
^ Surcharge Fee)
~ 3~
S ~
n e r Denial ~
IX. Conditions pprov U ~\ I i0 ~~- tr
1 dZ~
l
8YSTEM OWNER: J ~ S
--
„n
1 Septic tank, effluent filter and %-
dispersal cell must all be serviced !maintained .2 A~,Q,v1~Q.~ D~~ S c~'-~
as per management plan provided by plumber. `._
r
2, All setback requirements must be maintained ('
as per applicable code/ordinances. d-~^^¢"(~~" .
.a~acu wm yu,e pmua tso me a.omry onry) for me system m paper nor seas man al/L i l r Incues to size
SBD-6398 (R. 01/03)
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Wisconsin Department of Commerce
rlivicinn of Safaty and Ruildinas
SOIL EVALUATION REPORT
_-J........ ...ati ~,......, Q~ ~ni~~ erlm r~rlo
1485
Page 1 of 3
Steel's Soil Service, Inc.
-~- ------- -- - - County
Attach complete sfte plan on paper not less than 8'/: x 11 inches in size. Plan must St. Croix
include, but not IimKed to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.
pending
Please print all information iewed By
~ Date
~
Personal information you provide maybe used forsecondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ , ~
Property Owner Property Location
LaCasse Development , Ina. Govt. Lot na SW 1/4 NW1/4 S 13 T 29 N R 19 W
Property Owner's Mailing Addre>~s Lot # Block # Subd. Name or CSM#
'' ~
573 Cry Rd " A" ~..~.... ~.., _..._,. 5 na Bluebird Meadow
_
City State Zip Code Phone Number ~ City J Village yJ Town Nearest Road
Hudson ~ WI ~ 54016 715-381-5405 Hudson McCutcheon Rd
/J' New Construction Use: ~ Residential / Number of bedrooms
Replacement ~ Public or commercial -Describe:
Parent material Sream terraces and pitted outwash plains
General comments
and recommendations: Conventional system, system elevation 94 4 Code derived design flow rate 6UU ~r~
Flood plain elevation, if applicable na
5ft. Trenches spaced and depth to code 5.25tt elow grace.
~~ v~
Boring # ~ Boring
Pit Ground Surface elev. 99.40 ft
. Depth to limiting factor 120 in.
Soii Application Rate
i
ti
R
d
D Texture Structure Consistence Boundary Roots P D~
Horizon Depth
in. Dominant Color
Munsell escr
p
on
ox
e
Qu. Sz. Cont. Cdor
Gr. Sz. Sh. *Eff#1 Eff#2
1 0-24 10yr3/1 none sil 2msbk mfr cs 1f .6 .8
2 24-54 10yr4/4 none sicl 2msbk mfr cs na .4 .6
3 54-80
.---- 7.5yr4/4 none ms/Is osg ml cs na .7 1.6
4 80-120 7.5yr4/6 none cos osg ml na na .7 1.6
~ 9 . ~S"'
!~3
a
Boring # -.~ Boring
Pit Ground Surtace elev. 99.40 ft. Depth to limiting factor 120 in. Soil Application Rate
ri
ti
D
R
d Texture Structure Consistence Boundary Roots GP D/ftZ
Horizon Depth
in. Dominant Color
Munsell p
on
ox
esc
e
Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-11 10yr3/1 none sit 2msbk mfr cs 1f .6 .8
2 11-22 10yr4/4 none sicl 2msbk mfr cs na .4 .6
3 22-60 7.5yr4/4 none ms osg ml gw na .7 1.6
4 60-120 7.5yr4/6 none ms osg ml na na .7 1.6
• Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mglL * Effluent #2 = BODS < 30 mg/L ana i ss < su mgrs
CST Name (Please Print) ignature: CST Number
David J. Steel ~ ~ 248956
Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number
994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680
/1 ~' ~ ~ f X I ~ ~ <Y-
POWTS OWNER'S MANUAL & MANAGEMENT PLAN,..,.,. Page~of~
Flf_E INFORMATION
Owner C
Permit ~ ~ ? ~c~.0 _
ncetr=lu pARAMFTFRS
Number of Bedrooms Q NA
Number of Public Facility Units ;(ANA
Estimated flow (average) ~5 al/da
Design flow (peak), (Estimated x 1.51 al/da
Soil Application Rate 7 al/da /ft~
Standard Influent/Effluent Quality Monthly average *
Fats, Oil & Grease (FOGI 530 mg/L
Biochemical Oxygen Demand (BODE) 5220 mg/L 1~NA
Total Suspended Solids {TSS) 5150 mg/L
Pretreated Effluent Quality Monthly average
Biochemical Oxygen Demand (BODE) 530 mg/L
Total Suspended Solids (TSS1 530 mg/L ^ NA
Fecal Caliform (geometric mean) 510' cfu/100m1
Maximum Effluent Particle Size Ye in die. O NA
Other; ^ NA
*Values typical for domestic wastewater and septic tank effluent.
SYSTEM SPeclrwA t tuna
y
Septic Tank Capacity ~ ~
al O Nl•
Septic Tank Manufacturer ~~' ~ ~ ~~ ` ~ ` ~ N'
Effluent Filter Manufacturer ' • ~ ^ N~•~ j
Effluent Filter Modal , ^ N!;
Pump Tank Capacity al ~ NA
~'ff~'
Pump Tank Manufacturer
Pump Manufacturef ~NA
Pump Model • }~ NA
Pretreatment Unit NH.
^ Sand/Gravel Filter ^ Peat Filter
^ Mechanical Aeration O Wetland
^ Disinfection O Other:
Dispersal Cell(s- ~ N< 1
~In-Ground (gravity) O ln-Ground (pressurized!
At•Grade D Mound
p Drip•Linu ~ Other:
Other: ^ N/.
Other. ^ NA
I
Other: ^ Nti
MAINTENANCE sctlE~ut.e
Service Event Service Frequency
Inspect condition of tank(s)
At {east once every: ^ monthls} '' (Maximum 3 years)
'~ ear(s) ,, , ^ NA
Pump out contents of tank(s) Whan combined sludg e and scum equals one-third .(Yi1 of tank volume- ^ NA
Inspect dispersal cell(s)
At least once every: ^ month(s) "' ` (Maximum 8 years)
year(s) Q NA
_
monthls- . p Nf..
Clean effluent filter
At least once every:
year(s) ~
^ month(s) -1:~Nf.
Inspect pump, pump controls & alarm At (vast once every: ^ ear(s)
^ month{s}- r,:. _, 1~7`Nk
Flush laterals and pressure test At feast once every: ^ earlsi
other.
At (vast once every: O monthls)
Q ear(s) DNA
Othor; Q 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 crooks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent an the ground surfacE.
~ he dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to cheok -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 loos) regulatory authority.
When the combined accumulation of sludgy and scum in any tank equals one-third IY3} 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 t%hapter NR 113,
j =
Wisconsin Administrative Coda. "
All other services, including but not limited to the servicing of effluent filters, mechanics) or pressurized compon~9nts, 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 ofi any service avant.
onnw (ago i
ty~,,•~. Page ~_of
START UP AND OPERATION '
For. new construction, prior to use of the POWTS check treatment tank(s) 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 highwatar levels. When power is restored the exceps wastewater will be
discfiarged to the dispersal cellls) In one large dose, overlaadinp the Doll(s) and may result ln•ttN beakup o~ wrtao~ discharge vl
effluent. To avoid this situation have the oonterns of the pump tank removed by a Septa@a Servioin@ Operator prlorao restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually'ope~ating the pump' controls to
,.
restore normal levels within the pump tank.
t)o not drive or park vehicles over tanks and dispersal cells, Do not drive or park over, or otherwise. disturb or compact, the aria
within 15 feet down slope of any mound or at-grade soli absorption area,
Reduction or elimination of the ,following from the wastewater stream may improve the performance and prolong the fife 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; herbicidas;;;meat;scraps;-.medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When-the POWTS fails and/or is permanently taken ou[ of service the following steps shalt be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Coda:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings eealed.
....;.r; r,.r,
• The contents of all tanks and pits shall be removed and properly disposed of by a septage .Servicing Operator.
• After pumping, all tanks grid pits shall be excavated and removed or their covers remgyed. and the Void space filled with
soil, gravel or anothor 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
replace ent system: ,;.:~:~ .~ :~,:. ,; ,~, :. .
j~ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
J ~ 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 musi
comply with the rules in effect at that time. •
D A suitable replacement area is not available due to .setback andlor soil limitations, Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.-~~-r-~~~•'• - ~~"-
O 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. ......::...~__ , ,,_., _.~
CI Mound and at-grade soil absorption systems may be reconstructed in place fopowinp removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
{".2":ink .e iS `R /
< < WARNINQ > >
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, ~ DEATM MAY RE$ULT, RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL GOMMENTS
... . <«~.ta. :;frtr
JTS INSTALLS / ~-, _~l~ POWTS MAINTAINER
Name ~ r/ Name
Phone ~ ~ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULA70RY AUTHORITY ._
Name Name
.,..
Phone Phone .~ , ,...g, ~,. ,f ,; ~ ,.:,.. „
_ ~ ,. r-
+'hIS document wes drafted in compNance with chapter Comm 133.2212)Ibittlld)&lf) and 83.64111, (21 & 131, Wlsoonsin AdmiNstratlve Gode.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ~ A ~A~~ 17.e/.U~e~y....c."~
Mailing Address ,~ ?3
Property Address
S1o/6
(Verification required from Planning Department for new
City/State ~~ b~~ Parcel Identification Number ~s~,~ ))
~-- 020 - ~D t~ - 3a -~'J
LEGAL DESCRIPTION P
Property Location !~t _ '/., .~t~'/., Sec. t d , T~N-R~_W, Town of
r
Subdivision -» _ b~ y~_'~g,Q ~ct s .Lot # S
Certified Survey Map # .Volume ~ ,Page #
Warranty Deed # ~~" 2'~3~ .Volume 76 `fl ,Page # 3 9
Spec house ~ yes ^ no
Lot lines identifiable ~ 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 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 Office within 30
da a three year expiration date.
IL~IaS'
GNA APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the roperty describ above, by virtue of a warranty deed recorded in Register of Deeds Office.
Y/3/G~
S GNATURE PLICANT DATE
****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ******
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
.1.26y1~ 399
STATE BAR QF WISCONSIN FARM I - 2000 ~
WARRANTY DEED
Document Number
This Deed, made between Ronald G. Raymond, Lozetta s.
Raymond, husband and arife
Grantor,
and LaCasaa DevalogmentLlnc a Wiacoasin
cor~ozatiaa
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the following
described real estate in st . Croix. County, State of
Wisconsin (ttte "Property") (if more space is needed, please attach addendtunj:
Southwest 1/4 of Northwest 1/4 of Section 13,
Towaship 29 North, Range 19 V~eat, St. Croix Couaty,
WI Recording Area
Name and
77~23Es
KA1'RLEEN H. MALSH
REGISTER aF DEEDs
sr. cRaix cu.. w~
RECEI'dED FOR RECORD
08/28/2884 11:55AIS
iIARRAN'CY DEED
EXE>~T ~
RBC FEE: 11.0@
TRA1i5 FEE: 2258.00
CAPY FEE
CC FEE;
PAGES: 1
4D16
Together with all appurtenant rights, title and interests.
020-1017-30-000
Parcel Identification Number (PIN)
This sot homestead property.
(is) (is not}
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
enctuabrances of record
Dated this da of August 2 D 04 ,
*Ronald G. Raym
AUTHENTICATION
Signature(s) TCacy ~'. burner
Notary
authenticated this day of ~~£~0~~~
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stets.)
THIS INSTRUMENT WAS DRAFTED BY
Rsdmoa Law Chartered (Richard Lau)
2217 Vine 3t., Suite 2D4, Hudson, API
fSianat~eres may be authenticated or acknowledced. Both ere not necessary.)
*Loretta 8. Ra and
ACKNOWLEDGMENT
STA F WISCONSIN )
c ) ss
V County---~r~~--1-
Personaliy came before me this day of
August 2064 the above named
Ronald G. Ra;Lmond and
S~orett~ B. ~~ygtg~
hu n n wif
to wn to be e n who executed
th o wledged the same.
/v~_~
Notary Public, State of Wisconsin
My Comrnission i~ermauent. (If not, state expiration date:
'Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 1-2000
l~
Redmon Law 2217 Vine St Ste 204, Hudson Wl 54016-5864
Phone: (715) 386-0100 Fax: (715),386-0700 Redmon Law Chartered T4926305.ZFX
Produced with Z1pPOtmTM by RE FormsNet, L1.C 18025 Fifteen Mite Road, Clinton 7ownshlp, Michigan 48035, (800)383-68D5 www,zioform.com
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