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Home My WebLink About020-1452-06-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TQ 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 Development Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: °~'6 •qS' y~ •4S"' ash. «~" B3 rn~r~ r~irnoeenrrnsi CI CVATI(1A1 neTe TYPE ~ NUFACTURER pLS-ZS-'E~.. ~I CAPACITY Septic w S 121~e Dosing Aeration Holding TANK SETBACK INFORMATION . en o rr na e ep rc ~ r ~ "~ ~ Q ~ l -h osrng era ion o mg PUMP/SIPHON INFORMATION GPM n /~ county: St. Croix Sanitary Permit No: 488283 0 State Plan ID No: Parcel Tax No 020-1452-06-000 Section/TownlRange/Map No: 13.29.19.2894 STATION BS HI FS ELEV. Benchmark rte- ~ '43 ~r ~ ~ !~3 • 9~ • Qb~ qp BI .Sewer t net ~Z • l,2„ ~l• ~ 3 ~ t t utet ~2.~f3 q •S2` net / 0 om ea er an. !3• q'i ~Jo .zS ina r e o !~ ? iJ"~~ °~ 1 DIM S r 3 ~ 9D ~.. z J INFORMATION CHAMBER OR UNIT v. ~ !S , 3n ~ /' mac..- 3 u~crov r rvr~ v tiv r ~.~^~ i ~ .r.e c-,^s iii ~ a~g Length ~ Dia ! Pip Length Dia Spacing e ~ ~ ~ wig vvv ~n x rressure avsierns vnrv nx nwunu •+~ .,,.-..~a.... ~~~•~•••° -•••~ BedlTrench Center Bed/Trench Edges Topsoil Yes °' No _. ', 'i Yes ~ '' No GOM t 15' (Include code discriipencies, person~npresent, etc.) Inspecnon ~r.~ • ~7.w1~' ~~~~N~~~~~~~'r~• ~ ~ - Location: 933 Sadies Lane Hudson, WI 54 16 (SW 1/ NE 1/4 13 T29N R19W) Bluebird Mead ws L t 6 ~~--" Parcel No: 13.29.19.2894 i i n = ~ ~ D 1Y^" ` 1.) Alt BM Descr pt o ~ ll ' ~p f / 2. Bld sewer len th - GQ 9 9 ~ 1~ .~ "~.~- tr0.11h -amount of cover = 1$ f t~ ~' ~ 1 ~ 3~ w ! u~' ~~~~ ~' ~ t•~~ Se~i-Q '~°~'- s' C.. ~ ~_ ~ --- Use otherrs de foruadditional reformation. No , i ~ ~ - - - BateV- Srgna re- _ ~ --- -Eert` SBD-6710 (R.3/97) Safety and Buildings Division 201 W W h County ~ '' s ~ . as ington Ave., P.O. Box 7162 ~seons~n Madison, WI 53707 - 7162 Sanitary P ~ Number be filled in by Co.) De artment of Commerce (608) 266-3151 Sanitary Permit Application state Plan LD. Nutgber ~ In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ~"~~~/p'/ 1 may be used for secondary purposes ~ s I V E D Project Address (if different than mailing address) I. Application Information - Please Priat All Informati n / Prope~ Overt 'Name arcel # Lot # ' ST. CROIX COUNTY Prope er's Mailing Address property Location tY Zi Cod Ph , p e one Number ~ circle qqe) ~ ~ r~ T f B ildi h k T N; R E ot~ . ype o u ng (c ec all that apply) ,~ 1 or 2 Family Dwelling - Number of Bedrooms ~N,t, l.'~ Subdivision Name -C61•¢.pittmber ^ Public/Commercial - Descnbe Use S . ^ State Owned - Descnbe Use ^City illage,~Township of III. Type of Permit: (Check only one boa on line A. Complete line B if applicable) ~ Z0 _ ~ 5-2 _ ~ (o _ tj~ ~ oZ A. ~{ New S stem t~+ Y ^ Replacement System ^ Treattnent/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New ~~ Previous Permit Number and Date Issued Before Expiration Plumber Owner N. T of POWTS S stem: Check all that a 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 ^ Rxirculating Sand Filter ^ Recirculating Synthetic Media Filter ~Leachin Chamber ^ D 'p Line ^ Gravel-less Pipe ^ (e lain V. Dis ersal/1'reatment Area Information: C 2. r Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requi~ {sf) Dispersal Area Proposed (sf) Sy Elevation `~ ~ mss' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fiber plastic Gallons Gallons of Units W/p Q,,,~~ ~,~~' E~ , Concrete Conshucted Glass ~~ 7 __ ) New Existing ,~ f~ Tanks Tanks Septic or Holding Tank Aerobic Trearmentt Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, a me responsibility for installation of the POWTS shown on the attached plans. Plumber's ame Print , J Plum s Si ~ MP/MPRS Number Business Phone Number ~ ~ ~~= Plumber's Address (Street, City, State, Zip Code) ,s'~o ~rs l VIII. Coon /De artment Use Onl Approved ^ Disapp Sanitary Permit Fee (i lodes Groundwater Date Issued Issui Ag Signature Stamps) ^ Surcharge Fee) ~ ~ ~ en Reason for ial IX. Conditions pprov 3l~E~U IO _~~ SYSTE NER: /CZ.t.,lt. 9 Septic tank, effluent filter and 11 _~r,~~~ ~~ _ / _ ~ ~ -- dispersal cell mu t~9-W`u `TZ' t ll b -'~^^t` s a e serviced/maintained as per management plan provided by plumber. 2. All setback requirements must be maintained ~ as per applicable codeJordinances. ' Attach complete plans (to the Comty only),for the system oo papv not kss than gl/2 z 11 inches is sine SBD-6398 (R. 01/03) o~~~~.-~ ,~~r~.~~~~a~ ~~. ~~v~j - ~~~,~ i~ .sic ~~ - ~~ir/- ~LJ /J~l,t~.SO.+J 6~1J-Y ~7l~l~ 1~~~~""" AAA j ' (}r ' 1 ~ I I - ~~ y~ n ,~ ~ ~ ~~ ,~ ~ i ~ ~ j I L (~ ~~k~P ~ i ~ ~ '~ ~~ Nay' 1 ~, 1 ~,f1~6,~ ~ ~ - ,~ ~ ! ~~,~~.~ ~~ ~ w ~' ~~~~ ;~~ ~ .-,~ ~~~1 ~+~t ~~~ - - ~~ ~.8i~s -~,fU~ at T ~~- - , r.__- ~~~~~ ,~v.~~~EaT ~~ ~~'y-~w~y- see ~~ - 7~//- ~ ~7'iJ 3 ~ y~.l ~ _ ~ ~ ~zr~sohJ _ / / ~`~'~losv~J ~tJ.6 ~~4/~ i i- - ~ ~ - ~- ~ ~~~~ ~ ~- , ~ , -- _ ~R~a l =-~ ~° -- ~s _ _ _ ~.~6~ a 1 _ ~/ r -- - -- ___ __ ___ w` __ _ __ -~ ~~f~l ~~t ~~~ T ~~ __ ;_ i I ~ ) I -±---~--~---4--+- i -SA~~s ~.~JE _'_ ~ WisconsiFl Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT ,n .~nnn.rl~nrn ui,#h (`nmm AF 1A/ic Aram (:rv1a 1486 Page 1 of 3 Steel's Soil Service, Inc. County Attach complete site plan on paper not less than 8'/: x 11 inches in s¢e. Plan must St. Croix include, but cwt limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent sbpe, scale or dimensions, north anow, and kxatan and distance to nearest road. - . . Pendin ,..._.._ .--.- ~ g P/ea~`"pr~p#~al~t$tr. iewed OY Date Personal irdomration you prov~ie may be used for secondary purposes (Priv Law, s. 15.04 (t) (m)). ~ Cj/0 Property Owner e ; ~.:~ ~ ~ ~~~ Properly Location ~ ~ ~ t ` LaCasse Development , In . ~' `'"~` Govt. Lot na SW 1 /4 NW 1l4 S 13 T 29 N R 19 W Property Owner's Mailing Addr Lot # Block # Subd. Name or CSM# 573 Cty Rd "A" ~::= 6 na Bluebird Meadow Ciiy ` e Phone Number City ~ Village t/ Town Nearest R Hudson ~ WI 54016 715-381-5405 Hudson _ _ _ -1afc~utcheonRB------- New Construction Use: ~/ Residential / Number of bedrooms 4 ~2Sde derived design flow rate 600 GPD' J Replacement J Public or commercial -Describe: 4- Parent material Sream terraces and pitted outwash plains Flood plain elevation, 'rf applicable na General comments and recommendations: Conventional system, system elevation 94. e 4.OOft_bel 15. renches spaced and depth to cod - grade. _ `tom e -Q... ~+ Boring ~ ~ ~ ^ Boring # ` 120 i n. ~J Pit Ground Surface elev. 98.15 ft. Depth to limiting factor Sot Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-23 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 23-40 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 40-86 _ 7.5yr4/4 none Is/cos osg mvfr gw na .7 1.6 4 86-120 7.5yr4/6 none cos osg ml na na .7 1.6 i `lZ. 6 - ~. Boring # ~ Boring Pit Ground Surface elev. 98.15 ft. Depth to limiting factor 120 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft= in. Munsell llu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 12-29 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 29-87 7.5yr4/4 none os ml gw na ~ 1.6 4 87-120 7.5yr4/6 none cos osg ml na na .7 1.6 * Effluent #1 = BODS> 30 <_ 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and T55 < 30 mg/L CST Name (Please Print) ignature: CST Number David J. Steel ~ ~ ~~ 248956 Address Steel's Soil Service, I Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680 _~ ~-- • ~~ Property Owner LaCasse Development , Inc. parcel ID # Pending Page 2 of 3 I__.-J Boring # ~ Boring ITt iI Pit Ground Surface elev. 96.95 ft• Depth to limiting factor 120 in• Sod Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Stricture Gr. Sz. Sh. Consistence Boundary Roots D *Etf#1 *Eff#2 1 0-13 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 13-29 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 29-40 7.5yr4/4 none sl 2msbk mfr gw na .6 1.0 4 40-120 7.5yr4/4 none cos osg ml na na .7 1.6 a~" 0. Sit ^ Boring # --~ Boring Pit Ground Surface elev. fl. Depth to limiting factor in. Sod Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots P *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 Rools in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/Land TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employee 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. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200' St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 Lic. #248956 SW1/4,NW1/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 6 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. Legend ~~ 1" = 40' (.Benchmark Ele. 100.00Ft `fl`op of 3/4" pvc pipe ~- ~_~ Alt Benchmark Ele. 99.80Ft op of 3/4" pvc pipe ~ ^ =Borings Boring Elevations B 1 = 98.15Ft B2 = 98.15Ft B3 = 94~9~Ft ~~~ ~ B4 = OO.OOFt ~ i ~~ ~. ~~ 33 <fE ~ I .. 2-_.~ ~~ ~ r r m -- y I ~ • x . ~ .Z61- N cv W a O I ( ~ r i ~• ~ ~ ~ ~ o jw x ~ ~~ . x ~ as x ~ cn I t0 N ~ ~ N 0~ V ~ ~~yy.~~ • .r~ 1N~N~VBN v rl 3'lriNlVtlO ~ v ' w 3t11M DOE v' XN r~ (~.~, x ~ ~ ~ OND ~ O I ~o cNO ~ rn I o ~ ~ n n o, V / l x ~ ~ . ~ .et. /~ c `~ ~' ~~ ~ r x ~ i w r~. y a ~ •~ ~ ~X ~~ ~ .. ,^,,, i,w ~ ~o •~ -. ~ .~ ~_ N ~ p~ ~ \ v N . , X N ( n V ~~ ~ ~ ~ ~ ~- x .,, wx w ~~~ e ~. ... ~• ` n ~ a X °' 1 ~_~1. :' .~ _ ~' ~ ~~~~ s~ ~ ~ _ ~po ~ ~ mA l ~ N ~ "; cn n 4 ~ I .~ ~ i X to ~P x W /Q a c Y POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of FILE INFORMATION Owner Permit DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~ NA Estimated flow (average) gal/day Design flow (peak-, (Estimated x 1.51 gal/day Soil Application Rate al/day/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) <30 mg/L Biochemical Oxygen Demand (BODS) <220 mg/L ^ NA Total Suspended Solids (TSS) <150 mg/L Pretreated Effluent Quality Monthly .average Biochemical Oxygen Demand (BOD5) <30 mg/L Total Suspended Solids (TSS) <30 mg/L ~ NA Fecal Coliform (geometric mean) <10° cfu/100m1 Maximum Effluent Particle Size Ys in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity gal ^ NA Septic Tank Manufacturer ~ - ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model .^ ^ NA Pump Tank Capacity al d~ NA Pump Tank Manufacturer ~-NA Pump. Manufacturer -~ NA Pump Model I~ 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 (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tanklsl At least once every: ^ monthls) (Maximum 3 years) ~ earls) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^monthls) (Maximum 3 years) year(s) ^ NA Clean effluent filter At least once every: ^ month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ~ NA Flush Eaterals and pressure test At least once every: ^monthls) ^ yearlsl -ANA ~t-e;: At least once every: ^ month(s) ^ year(s) ~N'~ 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 IY31 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 <_12 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 tank(s) for the presence of painting products or oth$r 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 wilt 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 Isump 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. 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 INSTALL R Name Phone POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~' Phone Phone _ , _ This document was drafted ~~ compliance with chapter Comm 83.22(21(b111)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE A~ AND OWNERSHIP CERTIFICATION FORM Owner/Buyer RECEIVED JUL 1 7 2006 ST. CROIX COUNTY Mailing Address b'73 ear-.tom l~" ~~d,5~9 ~ Property Address erification required from Planning & Zoning Department for new construction.) City/State ~.~~~_~~ . t ~~~ Parcel Identification Number 4~- (~2 -p{o.~~ ~• LEGAL DESCRIPTION Property Location ~atS'/4 , ~'/4 ,Sec. ~, T 2 ~j N R~W, Town of ~~ ~~,u•.-- Subdivision >~~1~r~ ~ ~,.-~ Y~ e~ cal, ~ ,Lot # ~_ Certified Survey Map # ~^ ,Volume- ~ ,Page # Warranty Deed # ~ ,Volume ~_, Page # ~_ Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning- & 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. I/we, 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 Deparhnent of Natural Resources, State of Wisconsin. Certification stating that your sepfic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms IGNA F APPLICANT(S) /~./~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/OS) 'J 26`I1 ~ 399 STATE BAR OF WISCONSIN FORM I - 2000 WARRANTY DEED Document Number This Deed, made between Roaald G. Raymond, Loretta B. Raymond, husband and wife Grantor, and LaCasae Development, Inc a wisconain corpora oa Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St . Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): Southwest iJ4 of Northwest 1/4 of Section 13, Towaship 29 North, Raage 19 Weat, St. Croix County, ial Recording Area Name and ? 72236 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 08/20/2004 11:SSAIt MARRANTY DEED EXEMPT ~ REC FEE: 11.00 TRAIiS FEfi: 2250.00 COPY FEE: CC FEE: PAGES: 1 54016 Together with all appurtenant rights, title and interests. 020-1017-30-000 Parcel Identification Number (PIN) This not 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 encumbraacea of record 1 Dated this da of Au s t 2 0 0 4. *Roaald G. Ra AUTHENTICATION c L. Turner Signature(s) Tra Y p otar~l -;~ 1 authenticated this day of O TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Redman Law Chartered (Richard Lau) 2217 Vine St., Suite 204, Hudson, NI v-t..e.ft~ ~ r`-~ /C~- m r~xd *Loretta 8. Ra nd ACKNOWLEDGMENT STA F WISCONSIN ) ) SS county. Personally came before me this day of August 2004 the above named Roaald G. Ravmoad___ and Loretta B. Raymond h an n w'f to wn to be e n who executed th o i ' s wledged the same. Cl f di'L~l Notary Public, State of Wisconsin My Commission iJ,_permanent. (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 ~~ Redman Law 2217 Vine St Ste 204, Hudson WI 54016-5864 Phone: (7t5) 386-0100 Fax: (715) 386-0700 Redman I.aw Chartered T4926305.ZFX Produced with 21pFOrrnTM by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800)383-9805 www.aofonn.com a ~4f~D ~[~1D~ I ----------------------- ~----------------- I McCutcheon R __ oad NoRTN ~_ ~ ------------- sw1i4 ~ :,, , N.w.L. • 128.0 . ~i~+ ~ '~0 O~~fOF n o ~~ y~~ ~SEM~ i .........:~............~2i9~ .. .. s8r•ss'~e`~~`rsa~a~'e ~'" LOT 3 1 2.83 AC. 123,209 SQ. FT. ~ L.s,o. =930.0 of _.._.._.._.._.._ ~I i .-..-..-.._.._ .~ i 30' WIDE . ~6 r• DRAINAGE • icy fp6 EASEMENT 5g6 g6' 281.58' ee ~ M \ / /~ N , ~'o ~w. ~56'13~ ~ \~ .. i 1 LOT 2 ~ I 3.42 AC. ~° ~0 148,987 SQ. FT. DRAINAGE EASEMENT A C L.B.O. = 930A ~ i ~''~ ~s ( N.w.L. = sz8.o ~; 199.80' _ _ 198.83' 270.T0`~ . ~ . . 589°48'08'1 N y .r~~. t~~ • ~. O\ ~~ ~ •00~ 42" S Ne 47.87. LOT 5 I .OT 4 ~ 2.25 AC. ~ .25 AC. ~ 98,034 SQ. FT. 16 SQ. FT. ~ I ~ L.B.O. = 930A ~ ~I ~I u: "i ss-- I 122.83' I 384.97 - 188 N ~ 703.34' ' ~. ~~ w ~~? '~ C. ~ 1 ~. o ~., 0 N.M • .~ O w fA ~! N8a•ay' oa~ ~ J ~ r.. ~s2-Be~-. LOT 6 V ~ 2.26 AC. 98,598 SQ. FT. ' LBO -930A 1 3n.7s 0 BENCH MARK: TOP OF 1' IRON PIPE ELEVATION 933.17 L07 2.67 , i 16,214 LOT 7 ' 2.17 AC. i ... - ~ 94,547 SQ. FT. °, I~ ~~ ~ ~ ~~ ~~~ I iav ~ I ~ ~~~ i ~ -a~- -~__ I ~ GOJ~-_ ~i e N88°44'43"W 508.81 / O~ •~~~ ,, ~~ -SADIE'S LAME - - ~ ~ •,,,~ O .~ ..... 14 f. 77 57'.02' 58.55' 113.03' ~sP` ~ '~. - ~ . ~P ~ ~ M (~T) J) ( ]MCI) W ~' ' N N ~ O ~~ J ~~ ~ ~~ ~ V r O ~~ N ~ ~ ~,~ O ~~ . f~ ~~ M\ .. ~MM r ` W -~ N -- :.~, ,.a._. _ . .._. ,_ .. _.. .~:~ c~ M ~ 00 ~ ~ L~ 00 r- ~ N ~ W cry Z c°n ° ~ ~ d~ `~ rn ° " 00 ~ =y N ~ z v m i ~ 0 O~ W w~2' N } ~ ~ ~ W WIL tn= J O 0 ~ a~z ~ W ¢ > OU Nw> W ~Jln W ~ ~ Y=~wY FHapQO ~~~~ 4 ~ J ~ N ~O~wa ww~a~ >~=wd NO=~U cn~Wz W Z w 3 Q W U W ~ W~ LL OQOU,Z~ ~a¢ozo Q~~aoo z ui w ~~ac~am awwLLUi~ LL J ~~FOwm