Loading...
HomeMy WebLinkAbout020-1370-39-000/* VWsoor>sirt pepartment of Cortxnerce Safes and g;r'Idings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) °~`y~Croix sa 38212 ~ ~~~ State Plan 10 No.: Parce Tax No.: 020-1370-39-000 Personal iMortrlaUon you provice maybe used for secondary purposes [Prrvacy t aw, s.15.oa (lxm)J. WI~SrtKl1 eS~llame: ^ City ~u~t~S90n~ Winship CST BMElev.:- / Insp. BM E ev.: BM Description: .ZD o bl IM. ~~ = Pr-~ TeNK INFORMATION TYPE MANUFACTURER CAPACITY septic M.~ . p .r. Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Airlntake ROAD Septic ~ ~ ~ 3 1 r NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION . Manufacturer TDH 1~ Friction ' S)rst~m ~ TDH~ Ft rcemain Length I Dist. To Well SOIL ABSORPTION SYSTEM ~~ ~~ BED /TRENCH Width ~ L n't}S I N Of Trenches PIT No.Of Pits Inside Oia. Liquid Depth 1 EN I N DIME I N Manua rer: SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING ~~', ~?~„ SETBACK CHAMBER a Num r: INFORMATION TYPe O n ~ „„ 1 --~ OR UNIT ` - System: l~W~• ';' DISTRIBUTION SYSTEM x Hole size x Hole Spacing Vent To Air Intake Header / Mani old ~ It Distribution Pipe(s) length Qp/ Dia. ength ia. SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Topsoil ^ Yes ^ No ^ Yes ^ No Bed /Trench Center Bed /Trench Edges spec Ion : 06 alto( Inspection #2:---T COI~1M NTS' (In"~l~de ode discrepancies, persons present, e~ . ~-L. WQSd( ~Sk•tic~ebt ~~s(ea,'o~^ d'~t, , Login: 90 Parkwiew Lane, Hudson, WI 54016 (NW 1/4 NW 1 4 16 T29N R19W~I 1629192205 Parkwood Meadows -Lot 39 ~ ~'~~•~-'~~-ber~ 1.) Alt BM Description = '~ 2.) Bldg sewer length = 34.0' ~ ~-~Q , w~ 1,~ a~ Z`~ ~ ~ ~,~•,~~'; -amount of cover = ' ~~,` I~ ,, ~~~ PI_afi revrslon r qulred . Yes~n O I ~ .S~-b Use other side for additional infor (~at_ion. Ob Z date Inspector s Signature Cert No SBO-6710 (R.3/97) ,n 1 4. LL01 ELEV/~TIUN u-Ea ~ A ~~' ~ " " " STATION BS HI FS ELEV. Benchmark ,(Q ~. ?.X~ It. BM .f.-o o _2 1 Bldg. Sewer Jam. ~,s o1e , a / St / Ht Inlet , ©( e . ~{ ~ St / Ht Outlet ~- 3 S I o . Sb l Dt Inlet --'~ Ot Bottom "'-- -^ Header /Man. I~~ a ~ o I gl I Dist. Pipe ~°'zp Iol.toS/ Bot. System ~;. ~ cro • 20 )oo . ~ Final Grade °~ ~ 2 O I o2 ~ bS~ e ~,~,~ ~~ ~~ l ~~ ~ , ~1 ~~ ~, •fi~ ~ •~b a2 ~ ,,,~f1 ~~ ,L ,~ < ~ b~ o ° 6 ~__f~ \ ~% •'~ v ~ ~\ q3~' ~~ 99 ~ P ~~ Sanitary Permit Application Safety & Buildings Division ~~ ~ `~ In accord with Comm 83.21, Wis. Adm. Code See reverse side for instructions for complef i5 appIi 201 W. Washington Ave. PO Box 7302 SCOnSIn Madison, WI 53707-7302 Department of Commerce Personal infon~nation you provide may be u fipr secondary purpo (Privacy Law, s. 15. (~)] ` (Submit completed form to county if not ,*.; ~,; state owned.) Attach complete plans (to the county copy only) forth system, pag~~diAless than 8 --1 x 11 inches in size. County r State Sam Permit Number ^ Che if revision p vious app~igation 44t~ 11 S to Plan I. D. Number ~. 02.~~- , e 1; I. Application Information -Please Print all Information .,,~,~.`°; ti;. ~ cation: Property Owner Name ~ ,-. , 5~ ~rl ~ `~ _- ~ C~ p6F~' petty Location '~, ' M~' ~ ~ ~ (x(1/4 IUltll/4, S (,N, R (or ~. `~- ,- ~ ' Pro rty Owner's Mailing Address ~„ ~~ ~ r- ~ , Lot Number Block umber ~,.._.. ~ ~~ ; ~ Q .~r C1' ~~ ~. _.~_.~ City, State Zip Code Phone Number Subdivision Name or CSM Number II. Type of Buil ing: (check one) °~ ~ s ~ of Bedrooms :~ ~ ~~ Dwelling - No 1 or 2 Famil ^ City ^ Village . . y n of ~'Tow ^ Public/Commercial (describe use):_ . /~ L ^ State-Owned ~ Ne:lryst ad ' ~ (,2 3 r k `l 3 . ~-S'r - l.5 ~~/~ \-- ! ~' / [ /~ Parcel Tax Numbe s a - _ IIL Type of Permit: (Check only one box on line A. Check box on line B if applicable) ~ ) q , aacls- p) 1. New 2. ^ Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to System System Tank Only Existing System B) Permit Number Date Issued ^ A Sanitary Petmit was previously issued IV. Type of POWT System: (Check all that apply) 'Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At-grade ^ Aerobic Treatment Unit ~`~~^ Recirculating ^ Other: V. DispersaUTreatment Area Information: I. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade ~~~ Required ~-oc~ Proposed ~~y Rate (Gals./day/sq. ft.) a (Min./inch) ~ ~n~.3 Elevation v~ ~ . ~ VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks ` J ~~l,C.t.Piti_ ^ ^ ^ ^ ^ ^ ^ ^ ^ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS sho n the attached plans. Piu r' N e tin) Plumber's natu (nos MP RS No. Business Phone Number 1~ ~~~ ~~G7~ aa~ ~s ~ ~ s Plumber's Address (Street, City, State Zip Code) ' n ,^ c` </~' ' ~ CK f-O -L J 6 /~ IX. County/Department Use Only ^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued s ' g Agent Signa o stamps} Approved ^ Owner Given Initial Adverse ti D t i Surc arge Fee) ~ ?Z~ ~ ZOD ~ - na e erm on , t.Ma. X. Conditions of A proval /xe sons for 1vlsapproval: ~~ is ~-.e,ct~w••,/.E-cb~. SBD-6398 (R. 07/00) i ~a~ /~ f ~~ u ~o ~. ~~ .J~ ~~ ~~ ~~~~~~ Na~- U~-c.e~ s~ . 1 /; .~~ a - is~~~- ~`- ~ o s ' ~f -~a o ~,~-,~.~ ~ ``~v ~ ~ ~ ao T ~ ~ ~ ~ti~~~ ~° ~" I~ ~P as .5'u /c l,.3 /~ l ~~ ~` ~~ ~ 3~ , y- ,~~~~ N~ ~~ 5~ . 1 / 3 ~~~~ ld ~ a ~~. ~-~o s ~, UL ,~ = ~~~ T~ ~~ ~ ,~~. aao ~s7 Su 101,3 4-19-1995 6.35PM FROM P.1 .i -wrrscwr~n ueps~trrwns or ~nouacry. L.+bo- and FAwnen Rsledons Division of Safety d, Btildnps StJlL ANU :ii! C tVALUA I IVNI MC1~'VM 1 rye=,,,.a= ,.. ----. - ...... , -... .....- . ,.. .~. ......... Attach complete sRe plan on paper not lase than 81/2 X 11 inches in slie '~lan must "tnduds but lJ St. C~O1R , . net limited to v®rtical and horizontal -eferenae point (i}M), direcpon end 96 of slope, scale or PARCEL I.D, s dimen~oned, nosh arrow, and loeation and dixlanc® to nearest road, 20-1028-90 APPLIC4NT INFORMATION-PLEASE PRINT All INFORMATfON R EW D DATE 2e~o 1 PROPERTY OHINEl4= PROPERTY LOCATIQN IstCdBSe t~t'GZiI FMS i Tnr~, GOVT. LOT Nli' 1/4 1VW 1l4,s 16 T 29 ,N,R 19 , S(ar) w PRQF'ERTyOWNER':S MAILING ADDRESS 521 McCutcitreart Ad. L4'r a 39 HLOCKe tta SUBO. NAME QR CSM#~ Pa>:kwood 1~leadows Fi~si; ,Adds,. GTY, STATE ZIP CObCe PlipN NUMBER OG~ VILLAGE N NEAREST ROAD Hudson,. WZ. 54016 ('71$ 381-5405 I ~ ~- Construction Use ~ j Residential / Number of bedrooms a [ J Addition tp existing building j) Replacement [ ] Public a oorrmterfdal describe Gade derived deuly slow ~- gpd ~ Recommended design boding rate . 7 bed, gpolft2 .8 bench, gpdr'ft2 Absorption area required 858 bed, ft2 75p trendy, tt2 Maximum design loading rate .7 tied, gpd/lt2 .8 trench, gp~f t2 Recommended infiltration surface elevation(sj a*ea A=101.3/,~,aQ0.4 ft jas relrirred b site plan benchmark) Addiponal design / sfle cortaiderations ~„_,~ Parent material outrtta~h Flood plain elevation, if applicable na ft 5 = Suitable For System CONW~VTIONAL u = urrsuirable for bVn ®5 D u MOUND ~ ~ s C] u IN-GROUND PR@SSURE ~ s D u AT-GRADE ~ 5 ^ u SYSTE41 IN Fill ®S ^ u HOl,DM10 TANK C] s t$u SOIL DESCRIPTION REPORT Boring # ........ 1 Ground elev, lII3_4t• Deplh to limiting factor +g0^ Boring # 2 :. Ground elev. .. 1Q3_0.~ Depot to limiting t8ctor ~, Horizon Depth in. Dominant Color Munsell Mottles Ciu. Sz. Cont. Color Texture Structure Gr. Sz. 5h. CorfsisAenoe ~ Bla~y Roots ~ GPD~t g~ 1 ~ 0-I1 1 x3/3 none 1 2tns]olc dsh gv 2f .5 ,6 2 11-28 10yr4/4 none siI 2msbk dsh gv if .5 .6 3 28-90 'i . 5yr4/4 nom cos Oag tn]. na na . 7 .8 Remarks: 1 0-9 10yr3/3 n~ 1 2msbk dsh g1r 2f .5 .6 2 9-29 10y=4/4 none sil 2csbic dsh gw if ,5 ~ .6 3 7.5yr4/6 none cos Osg ml na na •.7 .8 -,i'?~! 7 ~,,Z 7 r p Remarks: ~`~ '~15-24g-62pp 5ignstnrc: ~~ (.i' LjY_ _ .. ~f _,[l (Tl1A~~ Due: ~30-99 CST Number: enO1Z98 Wisconsin Department of Industry, SOIL AND SITE EVALUATION R E P O R T Labor and Hur~ n Relations rlivicir~fRaf~iRRnilrfinns ____~...~.~~~~~........~...•_ wr-_~"'r._~:'~. Page 1 of 3 i~ - 111 QVVV~V •. ~.~i ~V,„~ VV.VV, •IJ•.+~V~~~•-. COUNTY '` St. Croix Plan must include -btdt lan on a er not less than 8 1/2 x 11 inches in size Attach com l t it p p . p e e s e p not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or ~~~; PARCEL LD. # ,.. dimensioned, north arrow, and location and distance to nearest road -•-'' 020-1028-90 , APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION- y •-,~~ EyVEDBY DATE S PROPERTY OWNER: N PROP~, LaCasse Custom Homes, Inc. ~~~ GOVT. LC1"~'~G:~ a 4 NW "v4;5 16 T 29 ,N,R 19 f(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUQD: NAME OR CSM # 521 McCutcheon Rd. ~9,: na `.,Par-kwood Meadows First Addn. CITY, STATE ZIP CODE PHONE NUMBER ^CITY -LAGE° OWN NEAREST ROAD Hudson, WI. 54016 (71~ 381-5405 [~ New Construction Use (x] Residential / Number of bedrooms 4 [ ]Addition to existing building j ]Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) area A=101.3/B=100.4 ft (as referred to site plan benchmark) Additional design !site considerations na Parent material outwash Flood plain elevation, if applicable na ft S =Suitable for system CONVENTIONAL ®S ^ U MOUND ®S ^ U 1N-GROUND PRESSURE ®S ^ U AT-GRADE C~ S ^ U SYSTEM IN FILL ®S ^ U HOLDING TANK ^ S L~U U =Unsuitable fors stem SOIL DESCRIPTION REPORT Boring # .................. ................. .................. ................. .................. ................. ~1 Ground elev. 1t13~4t• Depth to limiting factor +90" Boring # I 2 ................. Ground elev. lOR.O ft. Depth to limiting factor 11 Depth Dominant Color Mottles Texture Structure Consistence Botr~ Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. y Bed Trerxh 1 0-11 10yr3/3 none 1 2msbk .dsh gw 2f .5 ~ .6 2 11-2$ 10yr4/4 none sil 2msbk dsh gw if .5 .6 3 28-90 7.5yr4/4 none o Osg ml na na .7 .8 o ~ ~~ t Y~"' Remarks: 1 0-9 10yr3/3 none 1 2msbk dsh yw 2f .5 .6 2 9-29 10yr4/4 none sil 2csbk dsh gw if .5 .6 3 29-90 7.5yr4/6 none cos Osg ml na na .7 .8 Remarks: PROPERTY OWNER LaCasse Custom Homes SOIL DESCRIPTION REPORT PARCEL I.D. # 020-1028-90 Boring # 3 Ground elev. 104.8 ft. Depth to limiting factor ~~ Boring # Ground elev. 105..,~t. Depth to limiting factor ~~ Boring # 5 Ground elev. 104.8t. Depth to limiting factor +90" Boring # .................. Ground elev. ft. Depth to limiting factor Pag~ 2_ of ~ , Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou,dary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer~ 1 0-11 l0 r3 3 none 1 2msbk dsh gw 2f .5 .6 2 11-22 10yr4/4 none sil 2csbk dsh gw if .5 .6 3 22-90 7.5yr4/6 none cos Osg ml na na .7 .8 at /o!• 3 ~Z~~ Remarks: 1 0-8 10yr3/3 none 1 2msbk dsh gw 2f .5 ~ .6 2 8-28 10yr4/4 none sil 2csbk dsh gw if .5 .6 3 28-JO 7.5yr4/6 none ,~a.._s Osg ml na na .7 .8 51.6 ~. ~ Remarks: 1 0-10 10yr3/3 none 1 2msbk dsh yw 2f .5 .6' 2 10-34 10yr4/4 none sil 2csbk dsh gw if .5 .6 3 34-90 7.5yr4/6 none cos Osg ml na na .7 .8 ~21~$ Remarks: Remarks: SBD-8330(8.05/92) s' Y . STEEL'S SOIL SERVICE Gary L. Steel LaCAsse Custom Homes, Inc. 1554 200th Ave. CSTM2298 NWgNW4 sib-T29N-R19w New Richmond, WI 54017 MPRSW-3254 town of Hudson : (715) 246-6200 lot #39-Parkwood Meadows First Addn. This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted.. N 1,.=48' iH<n.= top of 1" pvc pipe C el. 100.00' /Alt. BM.= top of 1" pvc pipe C el. 97.20' ~~ ~ Vv ~~ 1~~ 1^ ~ `i ~1' 2-`~~ t loa' ~6 ~ R. ~~ , 3 ~~ r. ` ~~ Gary L. Steel t'~30-99 ~~ d.~ ~~ l Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number Z Number of Bedrooms Design Flow -Peak (gpd) ~.? Estimated Flow -Average (gpd) Z, Septic Tank Capacity (gal) ~ Soil Absorption Component Size (ftz) .S ~ Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary 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 ~ ~'~ Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole 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 diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years: The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 ti , Management Plan for a Septic Tank and Soil Absorption Component ~~ Y Plantings of deep-rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. o.,_,.~ a.a~ s.k~.,.,_ A,e~.,.,e~. s~.° v-~ a- a ~~~ Nom- ~ ~~ a~ C7i5) 3g6-y~g~ sr, ~. z~ 3 MAY 29'01 13:23 FR PRUDENTIAL SECURITIES 12 340 4580 TO 917153816541 P.02i02 d5/29/7~001 b3: a6 %153ti165a1 L~LWS~ uua~uri riur~~ rHUC ut. . $'~ CIZOI~ COUNTY SEPTIC TANK MAY)!TCENANCB A(}RESMBNT • AND . py~'g~~Ip C$R.'Y"tFICATION FARM ,~ OwnorlAuyo[ ' '~ n Mailing Address Property Address (Veriticaitoti ttquired from 1'lanntrig Uepe~unem ~~+. •~~~ :r .. +: j, . ~. -~ ~. . ., Parcel ldentirication Number ~d ~ ~ ` ~~0 ~` City/State • ~G_AI~~_TSCRXPT~ ~ ~ ~ ~/,, Sec. ~ T~~-R,.~.W+ Town of property LOCatioa Gt) /~, ~, Lot # Subdivision ---- , Volurtte ~ Page # ..- Cet'tltied Surveq Map # (~ ~ ~,l, Volume ~ Page # Warrattty Yleed # Spec house C] ye9 Q'uo Lot lines iclentifiablo +ll"yes ^ no SYST T Ate [ptproper use and anainte0artce of your atptie system could result in ila preraalure rillut+e ko handle wastes. Proper malutenasice ~~~ °f p~p~g owt ~ sepde tank every tlueo yoata or soa°cr, it nocdcd by a liceoaed pumper- What you put inW the ryctem can affect the iwxction Of the septic tank as a treatment stage in the wade d(eposKl rystem. 'I'hn property onvnor agrees to subinlt to St. Croix 7.ooiag Depaztment * certifieruon f°'rn~, ~~+Gd bl- rho owndc amd `~ resta~ctedpiumber or a licensed pumper verifyittg drat (1) dxe ot~ite wastowaterdiepotrt y m~-sterplumber, journcytnaitplumboc, tha eepeic uok is loss thaw 1/3 11tt1 of sludge. is improper operating canditiorl a,odldr (2) after lnspectiou~ and pumping (if nece9sary). flank rho yuulnisigmat have read the above tcgnitetneals and agree tb maintain the private eawage diepoea[ t'yaeem'aritb tlue et~dat~ds sot forth, herein, is set by the Depatlatenn O nC cmd must be ompleted emend re°tutpodt to the S Croix County Zoul~ O~G~ ~ ~ atallag dtaC yo eepHc aysterA has been ,~ year expiradca date, _~~~~.~ . ~~ DATE SC A APPLICAN'C OV~IVER CI` FI~O-~ o~ lonowledga. i (we) am (arc) tha owuot(s) Qf I (we) fy tlu-t atl atatCmenl9 os- this form a[t true to the beat of 111y the p d c 'bed above, by virtue of a warranty deed recorded in Register of Deeds OiTca, i NA APPLICANT M"~c"",I "+••+'~ Any informatics that ie m+s-represonttd may result wn tl,e sanitary ncanit being rcvokad by the Zoning Deparanenc. "• tndndE with tlda appllcatlvn: a copypof the ceri fi d un~ey tirnp ifs oifercncoDisemadef in 11in ~"rstsanh' deed Rcn4 MAY 29 '01 09:51 71538]6541 PAGE.002 *~ TOTAL PAGE.002 ** ~ ~.ll),3fAGE O1 6+4 X666 STATE [iAR OF WISCONSIN FORM 2 • 1999 Y,i1TH1.EGN H. WALSH WARRANTY DEED kEGiSTGk OF DEEDS Document Number $T. !'RhSX GO., WI This Deed, made between LaCasa Cum stem Homes Inc. RECEIVED FOR RECORD a W' a-- r'oroor9rion 0~-!6-001 1:50 ph Grantor, YARRANTY DEED EXE!!pT N and Russell F. and Maureen E. Lewis CERF COPT FEfs Husband and Wife COPY FEE: TkANSFER FEE: 209.70 Grantee RECORDING FEE: 10.00 . PAGES( - 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: (if more space is needed, please attach addendum): Recording Area Name and Retum Address The Rivos Bank X880 6th Street North Hudson, WI 54016 lions to warranties: Protective Covenants 020-1370-39-000 Dated this 16th day of March , 2001 ParcelldentificationNumber(PIN) This is not homestead property. (is) (is not) LaCass//e C~ om H~om s Inc. r-u--.~1' Ft~ A' <1 ~ # 'rRichard W. LaCass President r AUTHENTICATION Signature(s) authenticated this 'day of ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St Croix County. ) Personally came before me this 16th day of tir3rch _ , 2001 the above named LaCasse ~ 9tom Homes Inc. a Wis onain Co at on b La TITLE: MEMBER STATE BAR OF WIS ~ ' ' • , O~ ~O •• TAn authorized by § 706.06, Wis. Stat~Q~~ .*. ' THIS INSTRUMENT WAS DRAF~~Y AvB~\G ,'r J~ ~ Richard W LaCasse ~~~~~F,QFIWI[1G~s La as Q r'+;atom Homes Inc. (Signatures may be authenticated or acknowledged. Both are not necessary) ~~ to me known to be the person who executed G: * ~ the foregoing instrument and acknowle ged the same. z a. ~ ~: + •, ,~~ Notary Pub [c, State of W' cousin My Col~imission is permanent (If not, state expiration date) Names of persona signing in any capacity mus[ be typed or printed below thou signature. STATFORM No.2 1~9 NSIN WARRANTY DEED aCasse Homes Realty 573 County Road A, Hudson WI 54016.70(17 Phone:(715) 381.5405 Fax: (715) 381-6541 Jacque Howard prpk~tl wMh ::pFam^' M RE FomirNK LLC 16025 Fneen MiM Rae4, CIMOn Townrnp, Mkliiaan 46035, (a0013B3'~ T6267181.ZFX I ~ p~``--`._.. ` V ~ ~x m ~ C` m ` ~ X ~; tV ~ 9 9 1. ~ ~ ss,~ I ~~ j m ~ N~ `.dc~~~ ~ ~ i Ob x ~j: m m ~ ! lP ~~. ~' oa, ~ - J, ~. ~ , _ ~ Gino ~o N3 „ ~ l 6 °' x ~----- -- - ~ ~,~ x 0'80+ L old ~--_ / ~ ~ o ('~ ~ °~. /89 ~' " ~ ~ ~_ ~ x I ~ ~. D O - - ..._ ~,,.._ ~ a, °0 i ~ -. ~ , „9t- ,9l 068 N ~` m , 00 5= S< ~ o . ~....~ ... J~aM nl~. t~q~ ...... 3sv ,~ ~ 00'96 ~ ~ Q _/,i~0'099 ~ ~ 9 0 ~` i . Q~ ~ ~ O °~'9C ~ ~ _ x ~: rn ~ /' S , ~ ao .~ ~ W = M ~ Z ~ x n ~ . e} x~. ~ ~ / ~ ~ J X O A h '~ 7~~ M ~~ l 1 rnW ~ --,.~~ ~7 x _ Z ~ N ~,~, ~ ~ Z ~ ~ 1 m m ~ ~ O z~~-T x^ ~~~x ~ ~~~ ~ 6't~ ~ ~ ~~ w' °~-~-~p° M ,0 ,9i~o B 6~ NC „00 ,9068 N ~~-- ~ _.,~ ~.--~. - -°=-~ o ~ ~ ~ ~' 1 x ~ ,~ ~ 9~ ~ _ 9 ~ ~ ~ ''' 8 - \ j / -----!cl----~ 1 / ~ Q ----- 0 1 '9 a. ° ~--~ x x 3, o s os s ° x ~ `~- ~ ~/1 ~~ ~ ~