HomeMy WebLinkAbout020-1376-75-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
SafetX 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
Bast, Kernon Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description: ~~
/ ~
dv o z
TANK INFORMATION
' ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic
l~/ - ~
z o d
Dosing ~==j'
~~
Aeration
ding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic y ~
s
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Demand
to
Ft
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length
DIMENSIONS 3 ~ (J -~ ~~ ~
INFORMATION
DISTRIBUTION SYSTEM
G Manutanurar -
OR S
Model um r. ^ ~,
~ ~ o G{~ t=1"-~
p
~'fpl
Header/
M
d
a Distributi
n
o x Hole Size x Hole Spacing Vent to A' ke
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5 (
~
? --7
th Di
i
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L
S
Length Dia ng_
L
eng
a
pac
SOIL COVER v Prrassura Svs4pme []nlv YY Mnund 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
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~_/~/~~ Inspection #2: / /
Location: 964 Fraser Lane Hudjson, W(I 540116 (SW 1/4 NW 1/414 T29N 19W) Sweet Grass F//arm Lot 75 Parcel No: 14.29.19.2336
1.) Alt BM Description =~~ ~ ` ~ It erri t pOx 6~~ ~'~ ha S2 c ~ WC (I ~" Tt~r~r/
2J Bldg sewer length = ZS-~ ~i~S><4 ~~~~ ~ S,~ R~~1/ ~ fi(Yv~p/GTC ~ ~"/'"~I
- /amount of cover = >l~+" (~r r' ~C/ A /
3.~ Irp sGv v ~t~ a~.• J pc pr 5 r ~sfa //ear -~0 ~ lei Gt l^~C~`V~ ~ h ,lao~ ~G
~r, ~~ "'1 ~rr~,•. ~ ~ j r
Plan revises n Required. ?~~,: Yes i No I i
Use other side for additional information. L_ 1 D Z I~
~ Date f Insepctor's S' tune
SBD-6710 (R.3/97)
county: St. Croix
Sanitary Permit No:
399654 0
State Plan ID No:
Parcel Tax No:
020-1376-75-000
STATION BS HI FS ELEV.
Benchmark
Alt. BM _
~.~
Bldg. Sewer
~;' q
, ~
Ht Inlet
. ~
St/ t Outlet
t Inlet
Dt Bottom
Header/Man.
Dist. Pipe ~ ~%O /
v
~ ~ .s7
Bot. System ~- 9'• yP q S ~Z
Final Grade ®
St Cover ~ ~ S`" 3~
G Cert. No.
~l
~s
,~ Qt Ga- (,~/~ S~
Gt,S CST % ~c~ ~
1~3~
~, ~5 w. .., .- ~„
Safety and Buildings Division County Q
~ ~ 201 W. Washington Ave., P.O. Box 7162
,~'COn~,~ Madison, WI 53707 - 7162 to Address
Department of Commerce ~~~, ~,~; ~~? ~~ ~~
Sanitary Permit Applicat' $ ~ s,\ S~"ar'' 3 9 ~ ~ S~ ~
In accord with Comm 83.21, Wis. Adm. Code, personal info ou pro}~e ~ ~~
'a'" ~"`
Check if Revision
~~
ma be used for second u ses Privac Law, 1)(
I. Application Information -Please Print All Information
,..:; to Plan LD. Number
~~
Property Owner's Name --; ~E C `? i 2
~ '~.' ~; l Number ~ 3 3
~. 9. ~ 9- a
'~
`-
~~
~~ DOZE
D - ~
.$
Property Owner's Mailing Address ` - ~ ; ,; ~
n; operry Location
City, State Zip Code
~; ~ ;
Lot ~ Block Number
i~ t , / ~^
~
~~
y
- Subdivision Name CSM Number
t/~
l.~~ ~
,~ - v~ ~-~ ~~~
~s ~,
II, Type of Btulding (Check all that apply.) ~ ~ ~ S ""~ ^Ciry
1 or 2 Family Dwelling -Number of Bedrooms _~ O Village
O Public/Commercial -Describe Use ~IT
hi
^ State Owned Owns
./
1 ~~
/ Nearest R
oad
~~
-
f ~ ~
` ~ ~,
~~ ~~ nn ~
/l~L.
III. Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Compl ete line B, if applicable.)
A. 1 New
S stem
2 ^ Replacement System 3 0 Replacement of
Tank Onl 6 0 Addition to
Existin S stem
For County use
B' ^Check if Sanitary Permit Previously Issued Permit Number Date Issued
1V. Type of POWT System: (Check all that apply. Numbering is for internal use.)
44 C~Non -Pressurized In-Ground 21 O Mound 47 D Sand Filter 50 O Constructed Wetland
22 O Pressurized In-Ground 41 O Holding Tank 48 O Single Pass 51 ^ Drip Line
45 O At-Grade 46 ^Aerobic Treatment Unit 49 ^ Recir ulating 30 OOthe
~
V. Dis rsaUTreatment Area Informat ion: ~ -/S x
Design Flow (gpd) Dispersal Area Dispe al Area Soil Application Percolation Rate tem Elevation teal Grade
Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation
/~ / ___
VI. Tank Info Capacity in Total Number ufacturt:r Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank _~ / , Q t
/
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for ' lion of the POWTS shown on We attached plans.
Plumber's Name (Print)
Plumber's Si tore P/ PRS Number Business Phone Number
~
~/ Vr C
~ ~ ~ ~7~ ~ f
l ~ ~ ~~ ~ - (SJ ~~
Plumber's Address (Street, City State, Zip Code)
VIII. Count /De ent Use Onl
Approved Disapproved
^ Owner Given Initial Adverse
Sanitary Permit Fe (includes Groundwater Date Issued Issuing A ent Signatttre o Stamps)
, Determination Surcharge Fee) 2S- ~ 0~
IX. Conditio"q~ of Approval/Re ons for Disap~ro al
o~-~m~i~ta~.t'.~
q-t.( s2SQ~a.t.~s -~ ~naiw °'~
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'EWiscons'iFi Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings _ ., Page ' of
Bureau of Integrated Services In accordance w,itfi Comm, $3:09, Wis. Adm. Code
,: = t. .,
Attach complete site plan on paper not less than 8 1/2 x 11 inche$ m~sze Plan rr#i~st County ,
include, but not limited to: vertical and horizontal reference point (BM), direcHOri and' ~ C®~ /
percent slope, scale or dimensions, north arrow, and location a+id distance to nearest road. Parcel LD. #
F' ,- _ e
APPLICANT INFORMATION -Please print all information. Re iewed by ate
Personal information you provide may be used for secondary purposes (Pri4acy Law, s. 1 S_t]d',(1~ (m)). ~ ~ ~ 3
Property Owner -(~~/ ~~,( I roperty Location,
t ~ ~~ 1'c..t ~ (~T Govt. Lot ~ ~ j 1/4 ,~(.~JI/4,S /~~ T 2 ,N,R ~ C~ E (°r~
Property Owner's Mailing Address ~ `-~ ~ Lqt # ~.,~~ ock# Subd. Name or CSM#
353 ~~~-~i key ~~ ~ ~~ r- ~~e-+ C.-trays
City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road
l-S,vtc1 l~Ji vC~ (~-~ )~y~-~"?3I Aso %ra~-ems lG,~
[~ New Construction Use: ~ Residential /Number of bedrooms 3 - y Addition to existing building
^ Replacement ^ Public or commercial -Describe:
Code derived daily flow (~ U y gpd Recommended design loading rate - ~ bed, gpd/ft2 ~ ~ trench, gpd/ft2
Absorption area required ~S~ bed, ft2 7 SQ trench, ft2 Maximum design loading rate bed, gpd/ft2 ~ trench, gpd/ft2
Recommended infiltration surface elevation(s) ~ `S• ~ S ft (as referred to site plan benchmark)
Additional design/site considerations 7 ~• y~
Parent material r) U•'~C.~ ~ ~ ~ Flood plain elevation, if applicable .~~ ~ ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
u = unsuitable for system [~ S ^ u ~ S ^ u ~ S ^ u l~ S ^ u ,^~f1S ~®U !t ^ S ~ u
cnu necro~nTinr~ QCD~IRT 1 \_. • /'_.nn : F-i{e~.:e_ ~i~. I t ~-~ '~
Boring #
tl
Ground
ev.
d~.zsft.
Depth to
limiting
factor
IDS in.
Boring #
.. 2
Ground
elev.
q~ •~i~Zft.
Depth to
limiting
factor
//[~ in
Horizon Depth Dominant Color Mottles Structure B
d R
t GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence oun
ary oo
s Bed ,Trench
I b-IZ 1U r~~2 .l mfr Cs Iu~' ~ S ' ~~
Z IZ-`1 !D ~r~~~ 5~1 -~ cS - •~ ;.(~
Remarks:
1 b-II I[~ ~3~Z r ~ ~ vbk ~r C-5 l ~ • ~ '- (p
R~ 8S'~ '
Ramarkc~
CST Name (Please Print) S' lure ~ Telephone No. // p-
Address Date CST Number
Z/~3 a *~- ~ .~.~.e~se f Gv ( S` Oz S' ~/-y act z.s 33 ~
PROPERTY OWNER ~ ~~ ~ SOIL DESCRIPTION REPORT
PARCEL I.D.#
Boring #
3
Ground
elev.
99~ y5 tt.
i Depth to
limiting
fact r
/n ~ in.
Boring #
Ground
elev.
/0~ • Z~ft.
Depth to
limiting
factorF
lv in.
Boring #
Ground
elev.
~• `f -ft.
Depth to
limiting
factor
/1 in.
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
J ~ ~ ~.
Page L of
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
~ -~d r3~Z ~/ Z bl~ ~ ~v-~ ~5 ~ ~ ~
Z ~o ~ ~D r yly ~ l 2rv~bk m~ ~ c . 5 ; ~ ~
i
9r• ~ s
.Z ;
Remarks:
I o-jl ~ , /Z ~~ i 2 bk ~ -~-- c I v~
2 ~1-3~ /D r ~4 Sr 1 ~ rY~~ c - . ~ ' . ~
3 -~ id `~ r» os l ~s .~~.g
2.8 8$•
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/tt2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
Z iz- Z tv r~tly ~ s~ l Z k ~~ ~ c~s ; . h
3 ~lz-H 1 r y ~ ~ < <5 - . ~ ' . 8
Remarks:
'n' Remarks:
SBD-8330 (R.9/98)
PAGE~OF~
NAME S7cv '~- LOT# 7.~LEGAL DESCRIPTIONSw '/4 NW Y4,S I ~/ TZ~f ,N,R /Q E (or~
SCALE: I"= ~(~(~ ~
BM I ELEVATION (yU. O
BM I DESCRIPTION-}r,D~a~ (~ p,k ~(.Fe laf(,,y/Fbv
BM 2 ELEVATION (OCR. O
BM 2 DESCRIPTION -~opo~'. ~ ~ ~/c ~~~}Q. ~(~~F~
SYSTEM ELEVATION 9S. `~ ~
ALTERNATE ELEVATION `I S , N ~
CONTOUR ELEVATION 4~~
~~
DATE ~'-' `~' o ~
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION
Owner
Permit # Gi
DESIGN PARAMETERS
Number of Bedrooms ^ NA
Number of Public Facility Units ---- r ^ NA
Estimated flow (average) Q ~ gal/day
Design flow (peak-, (Estimated x 1.5) (`~ gal/day
Soil Application Rate , 7 al/day/ft2
Standard Influent/Effluent Quality Monthly aver age*
Fats, Oil & Grease (FOG) 530 mg/L
Biochemical Oxygen Demand (BOD5) 5220 mg/L ^ NA
Total Suspended Solids (TSS) <_150 mg/L
Pretreated Effluent Quality Monthly aver age
Biochemical Oxygen Demand IBOD51 <_30 mg/L
Total Suspended Solids (TSS) 530 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.
SYSTEM SPECIFICATIONS
Septic Tank Capacity 1 ~ al ^ NA
Septic Tank Manufacturer ~ ^ NA
Effluent Filter Manufacturer ,,~ ^ NA
Effluent Filter Model _ ~~ ^ NA
Pump Tank Capacity .---~'--~- al ^ NA
Pump Tank Manufacturer ~--~ ^ NA
Pump Manufacturer .-_---. ^ NA
Pump Model ~ ,------ ^ NA
Pretreatment Unit
^ Sand/Gravel Filter
^ Mechanical Aeration
^ Disinfection
^ Peat Filter
^ Wetland
^ Other: ^ NA
Dispersal Celllsl
I~In-Ground (gravity)
^ At-Grade
^ Drip-Line ^ NA
^ In-Ground (pressurized)
^ Mound
^ Other:
Other: ~NA
Other. f~NA
Other: ~A
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tankls) At least once every: ~ yearl 1(s) (Maximum 3 years) ^ NA
Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA
Inspect dispersal cellls) At least once every: ^ monthls) (Maximum 3 years)
.~( yearls) ^ NA
Clean effluent filter
At least once every: ^ month(s)
~ ,~( yearls) ^ NA
Ins ect um pum controls & alarm
P P P. P At least once ever •--
Y' ~t ^monthls)
^yearls) NA
~ ^monthls) ANA
Flush laterals and ressure test
P At least once eve
ry~ ^ yearls-
Other:
At least once every: ^monthls)
^yearls) NA
~
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 tankls) 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 cellls) 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 tankls) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cellls-. If high concentrations are detected have the contents
of the tankls) 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 cellls) in one large dose, overloading the cellls) 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 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.
~r]I'11TIr1N~l CAMMENTS
POWTS INSTALLER
Name ~"~
Phone _ _ ~j ~ S
POWTS MAINTAINER
Name
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
Phone
Name ~,
~~, ~%Ltrx-
Phone /
/
~ ~ ~ .j U w .-- b Q
This document was drafted in compliance with chapter Comm 83.2212-Ib-1111d)&(f) and 83.54111, (2) & 13-, Wisconsin Administrative Code.
ST CROIX COUN'T`Y
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ~~,~o~ ~~'~
Mailing Address ~~ L~~i~G~ ~ ,S/!/~~~ i/1 ~ ~0/~
Pro Address Goy' 7~ ~'~~~~~~~ ~%''~~ ~~ ~~ ~~~`~9~~~
Pe~Y
(Verification required from Planning Department for new construction) =,~C7~
City/State ~lyo~~/ ~ ~1 Parcel Identification Number ~d ~ + 1 ~ 7 ~ - ~-5 " ~~Q
LEGAL DESCRIPTION
property Location ~ ~ 1/<, ~ I/., Sec. ~ T~N-R W, Town of H~/OSc9/
Subdivision ,,5~/E~%~'E.~s ~~~ .Lot # ~ .
Certified Sarvey Map # ,Volume / ~ _, .Page #
Warranty Deed # ~ 5 7 ~~ ~ .Volume ~ ~°~ `~ .Page # ~ ~~
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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mas6Cr Plumber, journeyman plumber, restricted plumber or a licensedpumper verify1ng that (1) the on site wastewaterdisposal 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
days of the three year expiration date.
/zi~i o/
GNATURE 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 property descn'bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
/2,~ lo/
GNATURE APPLICANT DATE
****** rmit being revoked by the Zoning Department.'`«****
Any information that is nus-represented may result in the sanitary pe
«* Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if refercace is made in the waaanty deed
172~~~~ 218
STATE BAR OF WISCONSIN FORM 2 - 1998 657335
WARRANTY DEED _ ~: H. wi1LSi~
Docum2^t Number '. .. ::.ih:.?. ~.,;J., wl
'
~ M1~:.~l VED FOR iiECUk-
This Deed, made between
'
--
' -----
R~
run~ n em nrim ~»d
-
dAF~~T B
SI'E1G1~' ~ .i-c;;-;:OOi 9:2~~ pn
,
_h.usband--and-w --
.
-,
ife, - -_ _ ppKRRH7Y DEED
' - -- ._.___, Grantor, .:(~yiPT ii
ar -~.CERNOAl--.I~ nc~~_~.,c3-ppNA~,nn~_?._eDa~u_na__.,.-.eT
_ ~.
:::
n Is ~
ife, _ ;
-S;;riSfkR~FEF.: 62?.3D
- ::h:a::i =Eu 1L00
_
-------- --- _
--- Grantee. .~'nv~ti: 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate In St _ Crni x County, State of Wisconsin:
Lot 75 76, 77 and 78, Plat of Sweet Grass '~°` "`' ~ "''
Farm, own of Hudson, St. Croix COUnty, Namo and Return Address
Wi$consin.
!~ F~-`-
020-1376-75-000
020-1376-76-000
P I if it rx I
T~ii20-1 376-78m000d property.
(is (is not
Excepuonscowarranties: easements, restrictions, rights-of-way and covenants
of record.
Dated this (~21 st day of $P~tQmhE?r 2001
~lJ'h9.~.,~t ~C~ C~ (SEAL) ^ '~-~ ~_~CL~~'~ -_._. (SEAL)
Richard O Stout. Janet P. Stout
(SEAL)
AU`TI3ENTICATION
Signature(s) _,_
authenticated this
day of
TffLE: MEMBER STATE BAR OE WISCONSIN
([f not, _
authorized by §706.06. Wis. Stats~
TRIS INSTRUMENT WAS DRAFTED DV
Janet P. Stout
Hudson, WI 54016
ACKNOWLEDGMENT
(SEAL)
Slate of Wisconsin,
St. Cro1X County. ss
Personally came before me this - 21 ,~~___ day of
S~ntember 2001 ,the above named
--Richard- Stntrt and Janet P-.__
Stout .T^_---------.....
~`- to
~• • • ~ ~'.'~ me known to be the person ~-,__ who executed the foregoing
a qM ~~ ~ instrurnen and - nowledge t carne.
~FFF ll~Y7~.
~ 6 ~~~
Notary Public, State of Wisconsin
My commission is permanent. ([f not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not ~ 3d ,~_~ J
necessary)
Names of persure sl~ring in any capacity muse be typed or printed below their slgnauve.
STATE 8AR OF WISCONSIN Wisconsin Legai BWr+k Co., InC.
WARRANTY DEED FORM No. 2 - 1998 Mdwaukaa. ww.
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aIATCH LINE SEE
SHEET 2 OF 5
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