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HomeMy WebLinkAbout020-1452-09-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Divisi9n y 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 Townshi CST BM Elev: Insp. BM Elev: BM Descri on: ~oU•0 /p(7. O ~~ ~( TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ Dosing ~ ~/ 6 ~/~ Aeration Holding TANK SETBACK INFORMATION TANK TO ~ WELL BLDG. Vent to Air Intake ROAD Septic 7 ~ i \ ~/,l ! V Dosing Aeration Holding PUMP/SIPHON INFORMATION l~f ~ll(;t-~~L Manufacturer Demand GPM Model Number TDH Lift Friction System Head TDH Ft Forcemain Length Dia. Dist. o ell 501E ABSORPTION SYSTEM /" t~QJ(_(/ ELEVATION DATA county: St. Croix Sanitary Permit No: 463178 0 State Plan ID No: Parcel Tax No: oza-/ ~-0 -acv Sectionlrown/Range/Map No: 13.29.19. STATION BS HI FS ELEV. Benchmark Z U~• ~ O 7~ - l7 Alt. BM IN/1~t d~ sd((~ v 3.3 ~o~ Bldg. Sewer 3a~~ ~'. ~~ ~ y S t Inlet 9s ~--~ S t Outlet O.'Z ~~- ~ pt Inlet l' / Dt Bottom ~ ~~ I,~ader/Man. p /~y Dist. 1?ioe ~ /~ ~ u / t-/1 '(~ ~/ 3 • 0 Bot . System 2 .S~b y ~` 76 ~/ Final r /.{ ~~ a S j ` / 15 . ^] ~ q ,7 / 6' St Cover / ~. ~ ~I•~ a~ 3.~f ioi.~7 C BEDITRENCH DIMENSIONS Width ~ ~ Length ~ No. Of Tren hes ^1 Y' PIT DIMENSI S No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREA LEACHING / „ Man aver INFORMATION CHAMBER O , ~ _ ~ ??~T~ Typ System: ~ ~~/ > ~ ~ ~ UNI Model Number. DISTRIBUTION SYSTEM Head anifo7d y ~{ h Length~l~ Dia / Distribution Pipe(s) r y ~ Length Dia Spacing 3 x Hole Size x Hole Spacing ~. /~ 1 ~ tv SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 0~ u'`~~~ Depth Over ,r ~, a Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~ Bed/Trench Edges Topsoil '~ Yes ~ °~ No [° ~ Yes J No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ ~ / Inspection #2: / / Location: 817 Dove Court Hudson, WI 54016 (SW 1/4 NW 1/4 13 T29N R19W) Bluebird Meadows Lotl9 Parcet No: 13.29.19. 1.) Alt BM Description = W~ ~'1drl1~/ Si ~~G~ ~~--U~ 2J Bldg sewer length = LjG(' "~~ /~~ [/ ,~JG,W_W 32- ~1t'L~'1~x~ i -amount of cover = ~ 3 I -S"i't-~X 7 ~~p G~GI~~'n~Yh, `~~~ Use otherlside for additional informatio~o ~`~~ ~ I Q~j ~~ ~~~2 _-_.__ __ .__--- --- .,I r~~~~___.._, --~ _ ~ _ .. _- --- -- - --- - . L- _.J--L! __~----J SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No. ~ ~'llYrt Vent t it Intake ~ C ` Safety and Buildings Division County 201 W. Washington Ave., P.O x 7162 ' ` m s /~M SCV/ISIII Madison, WI 53707 - 162 (608) 266-3151 R~ + Sanitary PermitNumber ( e filled in by Co.) ! - De artment of Commerce . G ~ / 7 Sanitary Permit Application /T O` I 1 LD. 'umber In accord with Comm 83.21, Wis. Adm. Code, personal information you p vide 2 may be used for secondary purposes Privacy Law, s15.04( m) Sl C Addr s (if dill t thanling address) R I. Application Information -Please Priat All Information d /~/G O ~/~ (JNrr F CE ~ Property Owner's Name Lot # BI # ~ ~ .. ~ t s - Property Owner's Mailing Address Y S i 3 ~ ~~ City S ~ Zi Cod Ph N b .' ect on °' ,=: vv / , p e one um er ~ ~ / (circle T~~ N R~E II T f B il i h k l ; ype o . u d ng {c ec al that apply) r/ ~ ~~ 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name ~'"- ^ Public/Commercial -Describe Use ^ State Owned -Describe Use ~/'~ ,Q`C.f~ ^City ^ Vill ,~rownship of III. T ype of Permit: (Check only one box 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: Cheek all that a 1 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 Media Filter Leaching Chamber ^ Drip Line ^ Grav -less Pipe ^ Other lain) V. Dis rsaUTreatment Area In ormation: h ~ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Propos sf1 System Elevation l/ . Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Units -Concrete Conshucted Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Respo sibility Statement- I, the undersigned, a me responsibility for installation of the POWTS shown on the attached plans. Plumb 's ame Pri t) t~ Plumber' Sign MP/IvIPRS Number Business Phone Number - _ P tier's Address (Street, City, S ,Zip Code ~'.' i ~ VIII. n /De artment Use On pproved ^ Disapproved .Sanitary Permit Fee (includes Groundwater Dat Issued uing Agen Si at Stamps) ^ Owner Given Reason for Denial Surcharge Fee) 2.~ ~ ! f` ' ' A proval/Reasons for DisapprovaL2LTif.~CLi/ ~ ~ ~ ~~ / SYSTEM OWNER: ~~Ykl w~~ 7 Se ti uent filter and • dispersal cell must all be service /maintained as um 2 All setback requiremen us a maintained as per applicable code/ordinances. naaca comp~ece pros tro me couuryonryl for me system on paper not teas than strz z 11 inches in sin ~. ~~ SBD-6398 (R. 01/03) ~~r~ss.E' _~7Jc'.G~.~~b' ~ G _ _ _..syJ~~-/~~+li~ to /3- T~1~1 ~Jf N1 _ _ - - _ __ _ _ _ aos4nJ __~l__s`~/~ _ a ___ _ _ _ _ /'~ ~'o'sc~/,~ ~4 3~~ ~~ ~ -_ ---- - -_ ~ o}-,~S tb DJ~ G'~RT ~~~~~ ~J~~~~~fi T ~o ~~. ~~ ~,~ -~ <,,~„ f '~ ,~,~ ~, __ ~~t,,~~ ~~ lot/,,J,~S sv/~-~~/'/ .~e /.3' T~iy ~/g1~ ut~sor/ n ~ ,~B,gJe r ~/.}~Il~~- .4f~ ai' % `/~c ~i OR = t~ 99~ ' a ~ l ~~,~y s ~s~~y ~~~ 4 a~~~~ ~~~°~~~ o -~~ ~ a~~3 p 6J~ ~ C~~QT ~ ' Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in accordance with Comm 85. Wis. Adm. Code 1489 Page 1 of 3 Steel's Soil Service, Inc. County Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and twrizotdal reference point (BM), direction and and location and distance to nearest road. north arrow scale or dimensions percent slope Parcel I.D. , , , Pending PL~as~e p»ntall..iafalc-171t _ __ ~ view Date Personal information yo~ provide may fle used7or 9AC~fliBr~purpa~ (Priv Law, s. 15.0411) (m)). ' 3 Property Owner ' Property Location , Inc., i;~~. # LaCasseDevelopmen Govt. Lot na SW 1/4 NW1f4 S 13 T 29 NR 19 W Property Owner's Mailing ddreiss Lot # Block # Subd. Name or CSM# __~ ""~~ 573 Cty Rd " A" ; ,? ~ 9 na Bluebird Meadow -~ ~1L~G/ City ~ °StAtE"~~~f+ilgn~ _J City ~ Village ~ Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd ~"{ New Construction Use: ,~ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement J Public or commercial -Describe: Parent material Stream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional systems, system elevation 94.70ft. Trenches spaced and depth to code 4.OOft below grade. Boring # ._~ Boring Pit Ground Surface elev. 96.10 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GP "Eff#1 D/ftz *Eff#2 1 0-17 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 17-37 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3T 37-52 7.5yr4/4 none ms/cos osg ml cs na .7 1.6 4 52-120 7.5yr4/4 none Is osg mvfr na na .7 1.6 Boring # J Boring Pit Ground Surface elev. 96.10 ft. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GP *Eff#1 D/ftY *Eff#2 1 0-11 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 11- 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 22-120 7.5yr4/4 none ms osg ml na na .7 1.6 * Effluent #1 = BODS> 30 <_ 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and T55 <su mgiL CST Name (Please Print) 'nature: 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 Property Owner L-eCasSe Development , Inc. Parc81 ID # Pending Page 2 of 3 Boring # ~ Boring i~ Pit Ground Surface elev. 98.70 ft. Depth to limiting factor 120 in. Soti Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 9-2 10yr4/4 none sl 2msbk dfr cs na .6 1.0 22-120 7.5yr4/4 none ms osg ml na na .7 1.6 / `~ y ,. ^ Boring # _~ Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ~ Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. CoM. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 ~ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODs < 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 TTY 608-264-8777. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200x` St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 L1C. #248956 SWl/4,NW1/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 9 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 Top of 3/4" gvc pipe • =Alt Benchmark Ele. 99.25Ft Top of 3/4" pvc pipe ~ ^ =Borings Boring Elevations B 1 = 96.lOFt B2 = 96.lOFt B3 = 98.70Ft ^^~ ~ B4 = OO.OOFt ~~ ~,, e ~ ~~~~ ~D sr~ ~~4.5~~~ e. ~~ -.~ ~, -~,~ s ~ 9~'~'~ .,~~~ uyUi d`V~ T ~~ X Y '-. POWTS OWNER'S MANUAL & MANAGEMENT PLAN.., , FILE INFORMATION ` Owner -p ~ Permit +~ ~~/~ ~ ~ ~ /1 ---- rve-n~nu BAb A~AC7CDC Number of Bedrooms ~ j DNA Number of Public Facility Units ,j~ NA Estimated flow (average- ~ allda Design flow Ipeakl, (Estimated x 1.5) al/da Soil Application Rate ai/da /ft2 Standard Influent/Effluent Quality Monthly ave rage' Fats, Oil & Grease (FOG) s30 mg/L Biochemical Oxygen Demand (BOD61 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mglL Pretreated Effluent Quality Monthly ave rage Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) S30 mg/L ~NA Fecal Coliform (geometric mean! S10' ctu/t00rt~1 ^Maximum Effluent Particle Size Ye in die. ^ NA Other: DNA *Values typical for domestic wastewater and septic tank effluent. Page ~ o(~ SYSTEM SPtutrw~ i was J Septic Tank Capacity ) al O Nl~ -- Septic Tahk Manufacturer- :,. ^ N; Effluent Filter Manufacturer ° `~ ^ N" Effluent Filter Modal _ ^ NA Pump Tank Capacity al '~ ~"' 4 ' f ~-fJt. Pump Tank Manufacturer Pump Manufacturer -~ NA Pump Model ~ N/'' Pretreatment Unit ~-NF' ~ Sand/Gravel Filter O Peat Filter O Mechanical Aeration O Wetland O Disinfection D Other: Dispersal Ce(lls) ^ N'~ '~ In-Ground !gravity! O In-Ground )pressurized! O At-Grade (~ Mound O Orip•Lina D Other; Other: ^ Nf+ Other: DNA Other: ^ NA MAINTENANCE 5crteuu~.t: Service Event Service Frequency Inspect condition of tank(sl At least once every: © monthls! '` i;Maximu.m 3 years} {~ ear(sl„ ,:- ^ NA Pump out contents of tankls- Whan combined sludg e and scum equals one-third (Ysi of tank volume ^ N~+ inspect dispersal celf(sl At least once every: ^ monthls) " ` (Maximum 3 years) yaarls) ^ Nh _ ^ monthls! . ^ Nt., Clean effluent filter ~ t least once every: ~-yearlsl _~ ^ month(s) ~Nf. Inspect pump, pump controls & alarm At least once every: Q ear(s) _ ^ monthls)- r. , ~ Nk Flush laterals and pressure test At least once every: O earls) Other. At Ioast once every: ^ month(s) O ear(sl p NA Othor: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shalt be made by an individual carrying one of the following liaensea or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Serviaing 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 b.aok up or pondine of effluent on the ground surfacE. ~'he dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondin~ 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 !coal regulatory authority• When the combined accumulation of sludge and scum in any tank equals one-third lY,l 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 pressur(zed 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. RMW 14Iq 1 ,.kc~.. Page, of ,.L~ START UP AND OPERATION ' For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products os other chemicals that may impede the treatment process and/or damage the dispersal cell(si. If high concentrations era detested 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 by discharged to the dispersal cell(s) In one large dose, overloading the oeliisl and may result ln~tlt~ bavkup olr surf+lws discharge of effluent. To avoid this situation have the oontenta of the pump tank removed by a Saptapa SorvioinQ Oporator prior-to rottoring 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; denim floss; diapers; disinfectants; tat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicide8;;: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 followiny steps shall 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 >;ealad,. 3 ; r,.r, • The contents of all tanks and pica shall be removed and properly disposed at by a Septags .Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed attd the Void space filled with soil, gravel or another inert solid rnatvrial. CONTINC3ENCY PLAN If the POWTS fails and cannot by repaired the followiny moasures have been, or must be taken, :.to provide. a codq compliant replacement system: ;~.~ :.:~,:, ,,, ; A suitable replacement area has been evaluated and may be utilized for the location of a replacement soli 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 situ evaluation to establish a suitably replacement area.- Replacement systems musi comply with the rules in affect at that time. D A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS t chnology a holding tank may be Installed as a last resort to replace the failed POWTS.-~~:~•z=~~- • --=-" ~- :~~ •- . T site not be evaluat identify a it le replac t area. po oft a soil and silo ,I uatio m st be er rme to loc to a su' able re ace nt era o replacement area is available a holding k a by i stall d a las r ort to rep ce a failed PO TS. C1 Mound and at-grads soil absorption systems may be reconstructed in place fo(ioWinp removal of the 6iomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect 8t that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYQEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES, pEATH MAYAESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALL R POWTS MAINTAINER Name f / Name . k Phone ~ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AU ORITY Name Phone Name °~ 't , Phone ~~~. , ;;:; ,: ~ ,.~, .t.,,. his aocument was drafted in compliance with chapter Comm 83.22(2)Ib)(1)id)&!f) and 83.64(1), (2) & (3), Wisoonsin AdmlMstrative Cody. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer l..,a C ~~~~ J..ey ~ . t~.,P.,,,,.._4 ~ ~v Mailing Address Property Address g l `Z r (Verification required from Planning Department for new construction.) City/State ~,`~ t,~ 5c/Yt _~,~_S- Parcel Identification Number LEGAL DESCRIPTION Property Location _~'/< , ~'/4 ,Sec. l 3 , T ~~ N R~Q_W, Town of Subdivision Lot # 9 . Certified Survey Map # ~~~~ ~~~ ,Volume ,Page # Warranty Deed # ~ ~ ~ ~, ;~ ~ ,Volume ~~ `~t / ,Page # 3 Spec house yes no Lot lines identifiable es 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. 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 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 disposai 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 standazds 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 ys of the three year expiration date. 1C3 /ale SIG ATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe amaze the owner(s) of the e described ove, b irtue of a warranty deed recorded in Register of Deeds Office /U / Z~/ o ~ S ATURE OF APPL DATE ****** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. f . Document Number .~ . 26y1 ~' 399 STATE BAR OF W ISCONSIN FORM l - 2000 WARRANTY DEED This Deed, made between Ronald G. Raymond, Loretta 8. Raymond, husband and wife Grantor, and LaCasse Development, Inc , a Wiaconsia cozpozatiaa 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 1/4 of Northwest 1/4 of Section 13, Township 29 North, Rt+.nge 19 West, 3t. Croix County, All ?7236 KATHLEEN H. MALSH R£CIST£R nF DEEDS sT. cROix Co. , K~ RECEIt/ED FOR RECORD 09(28/2884 11:SSAlS i~ARRAII C`Y DBED ElIl~T # RfiC FEE: 11.08 TRA}1S FEE: 2250.8Q1 CQPY FEE: CC FSE: PAGES:- i Recording Area Name and Retu ress 3 C ty Ro Ku or3-)r-~4I 54016 a2a-lol~-so-ooa Fazce! Identification Number (FIN) Together with all appurtenant rights, title and interests. 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 encumbrances of recoacd Dated this da of Au st 2004 . *Ronald G. Raym AUTHENTICATION Signature(s) TCacY ~-• ~turper p~otary authenticated this day of ~i ~~, _ ~f,~~0~'~1 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706:Ob, Wis. Stets.) 'PHIS INSTRUMENT WAS DRAFTED BY Redmon Law Chartered (Richard Lau) 2217 visa 3t., suite 204, Hudson, WI (Signatures may be authenticated or aelrnowledged. $oth are not necessary.) v-t-2~cL ~ r`-e.. /Ca- m rrr~ d *Losetta B. Ra and ACKNOVYLEDGNiENT STA F WISCONSIN ) c ) ss U ~ County. Personally came before me this day of August 2 0 a4 the above named gQnald G. Raymond _ and Loz'etta B. Raymond hu n n f to wn to he e n who executed th o wIedged the same. Cu _ ,!!/vfll/1 Notary Public, State of Wisconsin My Commission i~ermaaent. (If not, state expiration date: *Names of persons signing in any capacity must he 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 W154016-5854 Phone: (715) 386-0100 Fax: (715),386-0700 Redmon Law Chartered TQ926305.ZFX Produced with Z1pFOrmTM by RE FormsNek LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800)383-8805 wrvw,ziofom~.com 10/29f2004 13:01 7153816541 LACASSE CUSTOM HOMES PAGE 01/01 . , • ~ , ~~iAS~ir~NE OF ev ~w+la o~'n; wt~~ ~ x . x ~ •~ ~ x_. . x +~ x ' r,^ ,~ x ~ E{~ ~ ~ 1 lit J .~ ~ ~ ~ • ~ ~ ~ 1 r _. fA ~ ~. •,: ~~ ~` ..~, s b:• ~i ~ o W `~: QS ~ ~ x ,~ x ~~ ~ ~- ~ ~ ~ ~ ~ ~ x rn ~ ^ l ~ ~\ ~~ X ~ ~~~ ,, c./ ~.. ~ ®, ~ _ ~ ~ 87` .ai . ~ ~ ~ x ~ ~~ u ,~ ~ ~ ~ _ ~ • 4i ~ ~ a ~ tit '~ ' ' ~' i ~, ~ a' I :~ ~y T- °'~ ~' x i ~ ~ ~ o x ~ ~ ~~ r~ ~i 1 ~ ~' ~ ~, aa• wi~~ w.. M ! '' ~ a~E ~ ~ ~ ~ O! "!' ~ G~V N a~ifJl~G1Y413~+~T ~~ ~ ~ X~ ~ 00 N I ~ ate.