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020-1415-10-000
Wisconsin Department of Cc~merc' PRIVATE SEWAGE SYSTEM Safety and Building Division ~ •NSPECTION 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 Sienna Cor Hudson Townshi CST BM Elev: Insp. BM Elev: O ~ BM Description: ~' / ~~ ~ / vU' . Jl 1 S ' TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic / ~ ~ ~ ' _ / (~ S~-I~ / Z~~ 6 Dosing Aeration Holding TANK SETBACK INFORMATION ~~-~ ~/J~' TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Q ~ ~~~ ' ~ p lS ~ Dosing L ~ Aeration Holding PUMP/SIPHON INFORMATION ? D / /~t~ ' /a7Q Manufacturer Dem. GPM Model Number Friction I[oss ISvstem HF~aa/ \ /, IZDW/° Ft Forcemain iLength SOIL ABSORPTION SYSTEM , ~ c,e~(~sJ ELEVATION DATA County: St. Croix Sanitary Permit No: 430328 0 State Plan ID No: Parcel Tax No: 020-1415-10-000 Section/Town/Range/Map No: 20.29.19.2619 STATION BS HI FS ELEV. Benchmark z UD, c~ Alt. BM G{1u.c~ii. Bldg. Sewer ((~~ gyp. (~ r SUHt Inlet r. -~ . ~~ 9' ~• ~~s SUHt Outlet 7~ q (7' Dt Inlet ~ ~_ Dt Bottom .--- ~- Header/Man. !d•r Dist. Pipe Bot. System n y~ Z N•"Z- lY. 3•f 3. +J Final Grade ./11.c i~t ~ . St Cover 3 , ~ 3 j ~~~, L BED/TRENCH Width Length ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ~ ~ ' SETBACK INFORMATION SYSTEM TO P/L LDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: L i ,~q.~ ~ T ! /'~LtJK ~ . Type Of System: rl.+a-l..t> c~~,~l,~; ~ O/ ~~ ~ / l~~ UNIT Model Number: - (~ ~I~ DISTRIBUTION SYSTEM ~ivv~ Header/Manifold f f/ ~ Distribution Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake Length ~ Dia Lengt Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Bed/Trench Center ~ ~ Depth Over Bed/Trench Ed es `~ , / xx Depth of To xx Seeded/Sodded xx Mulched ~ ~ g „ 7 /,~. ~ es i,I;No e COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~1 /~/~ GLlns Location: 742 Martin Av~enuey}Hudson, WI 54016 (NE 1/4 SW 1/4 20 T29N R19W) The Glen Lot 25 Parcel No: 20.29.19.2619 1.) Alt BM Description = ~'I-~ ~~ ff~ ~~11 j~ ~ ..-Q / 2.) Bldg sewer length = ~'') 7 ~l G~~ ~ t N / ~ - amount of cover ~ i.F-5 ' V ~ -' ~-,d~y~ ~(/~- ~~ --- - . ~ -- - - Plan revision Re uired? Yes Vo /~~"' Use other side for additional information. iyt(/~_U~1 7 I ` ~ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. '~ ~.vv~~ c arm ~ ,~ oT ~ S T~ ~ ~`,~.< e,v ~ ~ ~'~~ ~ ~ ~G"d~ZJ =y()~ ~/~/,veers-~// /~,~ ~/ Y Loy' Ll~~ ~~. ~ .~w ~M J~ a~ ~~ ~a Y ~~ ~~1 ~~~ ~~e~ ~,~I ~r~g ~ . 3~ ~~~-~ _ ~aaz ~~d ~ ~ y /~ _ _ _ ~~ ~~ ~ ~ Safety and Butidings [3ivisiun ~Ccunty _____ ~~~ ~ ~ 2?1 W. Washington Ave„ P.O. Box 7162 ~~ Ct~'d.` X. ~~~ ~ Madison, VVI 537Q7 - 7162 San~tar Permit Number (to filled in by Ca.) Department of Commerce (b08) 266.3151 ~~ ~ ~ Zri r State Plan I.D. Number -~ Sanitary Permit Application ~~"/ ~ ; ~ in accord with Comm 83.21, Wis. Adm. Coda, personal irfformatlon you provide y __ ~,~ racy be used for secondary purposes Privacy L w, s Pra}ect Address (if dfferent than maBin address) _ ~~ ~lVl~ i. Application InPornaatian - Pkaae lo',rint All lnfotmatian 7 ~ `~ y ,, Property Owner's Na the _ Parcel N / /S--Lo~+VC` D ~ ~ Htock A' I .~/~,,rJ.~Ct ~ ©~ ~ S7. Ch~IX COUNT~~~ 6JS Property Owner's M ailing Address ~ Property Location S ~ ~,4,~~,Section ~Zd City, State Zip Code Phone Number ~, ` ~1.~ 5 ~~1~~ 3S = •~ ~tT2~ {circle ) II. Type oP Bt~lIding (check sill that apply}» r ~~ N; R~B or V~ ~ ~1 or 2 Family Dwelling -Number of Bedrooms ,__~_~j _ ~ Subdiv/salon NameQ,/ CSM Numbe~ ^ PubliciCOmmercial -Describe Use _ _V~ ( ~/t ~ ~/~~.tJ State Uwned -Describe llse ~ S 22 ~' ~ ! ^City_I~'Viltage,~ownship of ~. SQ./ ------ f III. Type of Permit: (Check only one box on Ilse A. Complete line B if applicable) - ~~}, ~g , ! ~, ~ ~ ~j 1 A' New System ~ Replacemcnt System v Treatmentllxoiding Tank Replacement Only ~ ^ Other Modification to Existing System ~ B. ^ Pcrmit Renewal Permit Revision ^ C'hangc of C Hermit Transfer to Naw I List Previous Permit Number and Date Isc d { F3efore Expiration - ;Plumber i Owner I. / / ~ /1 ~ ~ Q_ Y~Zy /6 ~ 1Non Presaurixed In-Ground+„ ^ ,Mound >u24`in. of suitable soil ^ Mound < 2~3 in. a suitable soil f7. At•Grede n Single Pass Sand Pilter ff ,- ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding "faro C Peat Filter r Aerobic Treatment Unir ^ Recirculating Sand Filter ^ Recirculatia S athettic Media Filter Leaching amber L_1.21i~ ins ~ Gravel-less Pi ^ Other (ex lain) _ V, Dfs rsal/Treatment Area Info an: ~__„~ __._ _ , ~' Assign Flow (8Pd} Design Soil Application 2 fj r Requtral (afl Dis sal Arta Pro aed (sf) Systern Elevation ~ QS~~ I g`71 ~ ~L/ ©O 7i VI. Tank Info Ca alit m Total Number C/ Manufacturer Prefab Site l Stcel I Faber Plastic I Gallons Gallons ~ of CJetiu ~ ~ Concrete Constructed ~ Glass aetx~c or rtototag rantG ~ X d / .r~SNy ACrabk Trcatmoat l3tfit ~ f ~ na.;n~ t:i,an,l>c~~x AGO 1 ~v_," ss ~ __.~_ - `'II. Responsibiltty Statement- I, ilt$ undecslEned, asstttne respousibtlity for is Ilation of the POWTS shown an the attachedLana. _ Plumber's Na trn (Print} Plumber's 5i gnamre F PRS Number j Business Phone Number f rJr.(Gs~ S"c 1zr.~ n~G~Ye,~ ~/ ...•~~ ~? S%%'~J ~7/S- 3~''6 3/~ Plurubcr's Atldre u (Street. City. State. Zio ccYiel _____ ~Apprav~Disapproved Sanitary Parmit Pee (includes Groundwaux~ Hate ssu ! I 'ing t Sig lure tamps) j Surcharge Fee) ~ ~~ ~ ~ 3 6 ^ Owner Given Reason far Aenial ~ l iX. Co~tclitiol>s of App_r/©vald ar p-//p'roval / _ . , ..- ___ 1~ __._._____. I r lit. :T~~ ,YL~~ Y~u~J' ~ ~ G~4GUI a _ s a-~ d -~~~ o ~ ~ ~/3 ~a y ~-ed oh. a-c.~ ~ ~ ~ ~ ~y f .~ c~ ~ ~ ~%SZ l ~ Attsctt total (to tlta cannty o y) for the ay~tsm en poi goo loos sgaa 81/2 x 1 }ea Iq ~yy,, ~ _ ~R~(R flt/ '3~ l~I.SG/h~ fit~c~h ~SIO~-~4UV`~f~ pCJ`y' / S,• (i/T•7 ~i -.-- .., . W~ V ~ ~~ l~~ v ~, QA c/"` a k ~~l ,~o~as ~~ ~ 'w ~~ ~ ~~ ~ \ ~4 ~~ ~~ .r ~ Loy" LI~~ ~~ ~ ~. 't Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of ~_ Division of Safety and Buildings _ in accordance wrtn ~ F C ~ unty ~ ~5~ ~ f ih 1~~~f ` ~ art r res Attach complete site plan on paper not less than A 1!2 x f 1 c inGude, but not limited to: vertical and horizontal reference int (BM), direction and Parcel I.D. s t d. ;~rl~,e ~ n a percent slope, scale or dimensions, north arrow, and loptlo and di ~ O ~% ~ d d b Date i Please print all lnformatlo ewe ev ~( ~ ~ Parsanal in/ormalion yov provide maybe used /or aocondary purpo s (Pr3l~~cy~~fi~15.04 L'lJ~(m)). 1. V U I ~1 ` _ 3 [J r NI Pr erty Owne op ~ QCa t~ 8r r ` C <<Q Y lr-~-~ ~Joh~ 50 •~e,f/ ~ Govt Lot 1/4 114 S T N R E (or~ Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ~`~r` ~v SGC! f City State p Code Phone Number ^ City ^ ~Ilage ®Town Nearest Road {~] New Construction Use: ~ Residential /Number of bedrooms ~_ Code derived design flow rate __.L~=~~' ~~ _-_ GPD ^ Replacement Public orcommercial -Describe: _ ___- ----------- Parentmaterial _- OS1~`` S ~ -__--_ Fbod Plain elevation it applicable _-__~~!~----_-- ft• General comments ~ Ys~.t r.,1 -~ ~ -e V ~ Q a.,/e D ~ // // and recommendations: 1 G~/~~ _ ~ /~~~ i / ^ Boring # ^ Boring 00 . in Depth to limiting factor ~~ / ~' ft l G d rf ® . _ - . ev. su ace e roun pit Soil A licalion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Soiindary Roots GPO/fft in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 o ~ ~ ~~• ,~ r1 S Jl ,S` $ Z l- to ~ ~ -~ S; b r' c - 1- l l g a tN 5 o Im 1 _ ~ ~` a Boring # ^ .Boring pi( s Ground surface elev. ~~` S~ ft. Depth to limiting factor >~ in. SoB A ica6on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munselt Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 ~ 'Elf#2 i a- w - ~ `( 2~sbk ,~-~ ~ c s I,,.f .~ Z ~~,- ~o..lr ~ - ~~I Zw+sb ~~ c ~ , '.li l Nl~ Os m~ ~- I Z r4 Eftiuent M1 = BODs > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent tA2 =GODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ~ 'nature ~ _ ~S-33d a,y+~ S C. ~Lv /yL[X, Address ~ Date Evaluation Conducted Telephone Nu ber l ~ 3 ~a ~- .S~ ~n1,v~.t ~, w l r s yGZS S-~~o - a f/ 7~.5_- ~(~ U _ ~Z'~ PI ~ v M c, n Parcel ID # / ~~ ~ ~ Page _ ~ of _ Pro a Owner _ ~ ~'nS ---- 3 ^ Boring ~1 //S Boring # ~, ~ ft, Depth to Gmi6rtg tactor in• Sod A ication Ra Pit Ground surface elev Horizon Depth Dominant Color Redox Description Texture Swcn,rs Consistence Boundary Roots GPD/ft= 'Eff#1 'Elf#2 in. Mansell Du. Sz. Cont Cobr Gr. Sz Sh. ~° Z,s1 r ~S ~ ,S `~ ~ /( ~ o- _ os ml - _ .~- ,L Z 7T 91~ ,~.., ~//n Bo U ring # ^ Boring Pit Grou ft nd,surface elev. _-- , D epth to limiting a d factor _- Consistence in• Boundary oots Soil A lic GPD ation Rate Ift' Horizon Depth Dominant Cokx nsell M Redox Description Qu. Sz. Cont Cobr Texture ur Stru Gr. Sz. Sh. 'Eff#1 'Eff#2 in. a Boring a Boring # Ground surface elev. ----__-__ ft• Depth to limiting factor ___-- in. ^ Pit Soil A 1ic35on Rate Horizon Depth Dominant Color Redox Description Texture SwGure Consistence Boundary Roots GPDIft' 'Eff#1 , 'Elf#2 in. Munse{I Du. Sz. Con! Co'nr Gr. Sz Sh. I ~ I I i ~ f ' Et9uent ~1 = BODS> 30 < 220 mglL and TSS >30 < 130 mg,'L ' EfPuent ~ = 8CD5 < 30 mc~'! ar:d TSS <_ 30 mgiL "1-tte Department of Commerce is an equal opportunity service provider and employer. ! f you need assistance to access servi~cs or need material in an alternate fcrmat, please contact the department at 608-266-3151 or TTY 603-264-8777. S6D-8J JO I R.07/001 ~• I ~ ~ ~ / ` " ~~ ' OF NAME: 3oh~Svr~ LOT# ~ SLEG~AL" DESCWPTI ~I/4_1/4,S T_,N,R,_E r SCALE: I"= ~U -- ~jy~~ELEVATION: C(1U o y-~'s`.' BM 1 DESCRIPTION: -~r~0~-3~''~ ~°G~Sr~I BM 2 ELEVATION: - BM 2 DESCRIPTION: SYSTEM ELEVATION: ~y~o6 - SYSTEM TYPE: (~ n r}c ~~zJ~v~a.~ '`' ~ 1':': Aic~ L\~;~.~- ~Z' f ~ ~`~ ~ ~ ~! 3 ~ '~ ~ ~o~ ~ `~ , ~+ ,~ i~ ~~ --` SIGNATURE: DATE: 5 _ z ~ -" ay Sal'tay and Buildings piv;clan ~SC~I~IS~~ 201 w. Washington Ave., P.O. Sax 71b2 Madison, WI s3'1a7 - 7162 De artment of Commerce {bob) 266.3151 Sanitary Permit Application PA~~'~ In accord with Comm 83.21, Wis. Adm. Cade, personal information you provide tray be used for secondary Purposes i'~rivacy~ -94(1}_.... . E~Fir/1~~; ~ ~"I i. Application Inlott'watioa - PiQate print Alt Itaf lien Property Owner's Na me r Property Owner's M ailing Address City, Star ~~',v~- II. Type•o! Budding (eitetk all that aPPIY) ~1 or 2 FamUy Dwelling -Number of Bedrooats ~" Public/Commercial -Describe Use _~ ^ Sgtte Awned -Describe Use ~ , l~Q~ ~ III. Type o! P+st'mit: (Check only one box on 1 A' New S eplacement System ~\I(L ,L t.., _ 'ONIN~ OFFI~ F ;ip Coda Phone Number ,.~y...~s i 9~z - p3.s, County .~ ~` ~ Yd .' S~ ~ Sanitary Permit Number (to be filled~in by Co.) ~~ 4~-S"0 .~~ ~ ~// „ . ,.. it ~/./~ Pmject s ~ different than mailing address) reel ~ Lot M Block ar a s ~' Property Location ~~ , ~ _ .Q /~~ q, S~ ~a,Section ~~ cucle > T~N; R ~~Boty' v r Subdivision Name ~,/ CSM Numbat~ . ~ [_7Ciry_I A, Une B iP Replacement Only j B. ^ Permit Renewal nge o ,permit Tr er~~ + Z-st Previous Permit Number end ate sued II Before P~piration Plumber Owner ` ~ ~f ~ ~ O~ f iV. T o! POWT5 8 stem: {Check ail that a 1 f Non Pxeaturized Ia-f3round ^ Mound ~ 24 in. of suitable soli L`7. and < Z~ in. of auirable soil ^ At-Grade ^ Single Pass Sand Filter fl Cotutructed Wetland ^ Pressurized In-Ground ^ Floldin T Filter ^ Aerobic Treatment Unit ;J Recirculating Sand Filter ~'~ liecirculetiug Sytathedc Media Filter Leaching mbar ~ Drip Line C Gravel- Pipe ^ Outer {explain) _ I .. Yp ^ o~ a s rw^sa^vs^^ n~ W awaurw~suuu: 7 ! ~// D " ~ ~ l `~ v~` ` j Design Flaw (gpd) (p Design Soil Appllcedon Rate(g r ~ A er a sf) Dispersal Area P ~~ ~ ed a ~ ~ 5y tam BkvalionnJ iJE ~~` ~ V VI. Tank Isti'o { Capacity in Gallon Total Gallons Num r of T u Manufact~ r ( 1' ab Concrete to Constructed , Steel Fiber Glass Plastic 7 Ntw Tanks Existing Tanks I ! ~ Septic or Holding Tank 1~,3,~ 4 Aorabic Treatment Unit ~ i Dosinj t'~amher ~ VII. Retponeihwty Statemetet- I, the ibadersi , assuoae ras ~ ttslbili! for allation of the WTS slwwn oa the attached ~ Plumtur's Na ma (Print) Plumber' Si gnature /hiPI2S !Number Business Phony Number Plurnber't Addre ss (Street. Gity, Sulu, Zap Code} r ~Approvpd ^ Disapproved Sanitary Permit Fee (includes Groundwater J?§t lssu suing Ag t Si azure jT Stamps) Surcharge free}.~~® (yp /7~ 2 ~ ~- ~ Owner Given Real Par Denial ` ~ j~ IX. Conditiong o! Approval/ for D#sapprova# '" waaeu cotnatak alas (to tds County only) for tbs system on paper not taco than 81/a x 11 iac6es in sire 58D-6398 (R. 01/031 ~e ow ~~,~.~-ter`=mod' C~~r oddrs<</ ~ ea. ~ ~ .. Wisconsin Department of Commerce flivicinn of Safaty and Ruit(tinnS SOIL EVALUATlOI~EPORT Page _~ of _~ in accortianca with Comm 85, VYis. Adm. ~~~ i Ple County ~` ze. n m Attach complete site plan on paper not less than 8 1/2 x 11 inctres in s include, but not limited to: vertigl and horizontal reference point (BM), direction an ~ r percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel LD. Please print all infornaatlon. Personal information you provide may tre used for secondary purposes (Privacy Lavs, s. 15.04 (1) (m)). viewed b Date Property Owner ~11 O~ Property Location Govt Lot ~ 114, 1!4 S aQ 1" ~ " N R E (or) Property Owner's Malting Address Lot # Block # Subd. IVame or C,~M~Q ~ e (~~' ~-/ City State Zip Code Phone i~dumber ( ) ~ (;jty ^ Village ~ Town Nearest Road ~C[ a~ LGX' ~] New Construction Use: ~ Resident"ial /Number of bedrooms ~~ _ CocJe derived design flow rate _~ •~t~t~ ~_-_ GPD ^ Replacement ^ Public or commercial -Describe: _ -_--___ -------------------- Parent material ___~kW G Slr~ ---_--_- Fbod Plain elevation if applicable _-_~~1_~__---_--_ fl• General bomments , / and recommendations: .5~.~~~ ~ ~ .~~ ' z e ,~ s,r,e, d~ , ~ D Bo r ~-- Boring # ~ ~ ®' Pit Gr elev. O. ~_ft. Depth to iimitin _ -- Soil A lication Rate Horizon De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fft p in: Munsell Qu. Sz. Cont.. C~br Gr. Sz. Sh. 'EfflR1 'Eff#2 Boring # ~~• Boring L~pit Ground surface elev. ~,~ GI__ ft. Depth to limiting factor I I~ in. Soil A ication Rate Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlftz in. Munseil Qu. Sz. Cont, Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 Ni ,/ "~ ~~ _~ _~ EtOuent f~1 = BODS > 30 < 220 n-9!L and "r ~ ~S >3 < 150 mgll. ' Et-Grent #2 = BOD <_ 30 mg! nd TSS <:~ mg/L T Name (Please nt) Signature CST Number ~~ ~Ch• l~.rr1G~ ~'' ~ 25 Address Date Evaluation Conducted Telephone Number 2.1.E-'~ 84~'' ~~~- ~ c .~oZS 7/ ' v-OZ7 Property Owner _~~~~! ~15L'~ Parcel ID # Page __ ~ of _~ U Boring j ~, L . Bo ~J I Horizon ring # Depth in. 2 Grou Pit Dominant Color Munsell nd surface slay g~, s~ ft RedoxDescriptbn Qu. Sz. Cont Cobr • "' • D Texture epth to Imxtmg Structure Gr. Sz. Sh. 2 factor Consistence (n• Boundary c Roots I~ Soa A ic •E~GP .5 ation Rate DItFEfi#2 ~-~ - 5 2 ~2- Zlv-I2Z l0 - 5 ~ cS _- .~7 l , Z U Boring Boring # ^ Pit Ground,surface elev. ___ ft. Depth to limiting factor __ in• Soil A lication Rate nda B Roots GPDIft2 Horizon Depth in. Dominant Cobr Munsell Redox Description Qu. Sz. Cont Color Texture Structure Gr. Sz. Sh. Consistence ry ou •E~ Eff#2 Boring Boring # Ground surface elev. ____~ ft. Depth to limiting factar ____ in. ^ pit Sol lication Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont Cobr Texture Structure Gr. Sz. Sh. Consistence Boundary Roots.. GPD/ft2 • 'Eft#1 'Eff#2 `Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mglL 'Effluent #2 =GODS < 30 mgfL and TSS < 30 mglL •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. SBD-8330 (R.01/001 NAME:~~~M ~~n LOT#~'_LEGAL DESCR] SCALE: I"= ~~ ~m ~ ELEVATION: _ I D ~ ~ ~ BM 1 DESCRIPTION:~~~, ~ n~ ~-. ~ ~a~o r ~ r BM 2 ELEVATION: BM 2 DESCRIPTION:_ SYSTEM ELEVATION: ILS ~ Z ~ SYSTEM TYPE: I C ~U e ~t ~~ rc~ - ~ PAG~~OF~ _I/4 1/4,S T___,N,R, E(ot)W .V ; _~<::, ~y4ij. TE> ~: ,~: :_ .~ ~~,.`~ ~~~ 6,ti ~ ~ /~ ~`' ~ ~ ~ ~~ ~~ O ~~Y~ ~b~t ~~~~ ~~ ~ ~~ Qo- ~~ _-_ ~~~ _ _ SIGNATURE: ./1..~ ~c31-,h 1~~- ~ [fem. ~ Saft;ty and Buildings Division County ~ ' ' 201 W. Washington Ave., P.O. Box 71b2 X ~'a r ~rL ~ ~~ ~s~~~s' MAdison; WI 53707 - 7162 Sanitary ermit Number (to be filled in by Co.) J r De artment of Commerce (608) 266-3151 Z Sanitary Permit Application Stan Plan I.D. Number personal information you provide Wis Adm Cade 21 In accord with Cottun 83 , , . . . may be used for sewndary purposes Privacy Law, s15.04(1}(m) Project Address {if different than mailing address) i. Application Information -Please Print AU Inforlnatio -" - ` ~""1'-'7 r # ~ ~ LZ ~ f ~~N ~.~ ' ~ T T Property Owner's Na me ? `yP~aercn~el-#~_7 Lot # Block # Property Owner's M ailing Address ti i Property Location Y4 .',v r S '~~ ~'~ ~ l ~,Secdon ~ ,S'f.J~ '~d City, State Zip Code ~.~.. a.. na'1~b~"~~~ ._ <,v 1.~ S'S`~t' ,S- 4'61- .~vf :, ~~6~ (circle o ) ~ N; R~~ E o~W ~ (check all that a l ) f Buildin II T ~,` g pp y . ype o a ~ amber Subdivision Name CSM N ~1 or 2 Family Dwelling -Number of Bedrooms lCommerci l -Describe Use bli ^ P / ~ G !. L° a c u ^ State Owned -Describe Use i ~ ^City_^Village ~'ownship of Lc sp ~// III. Type otPermlt: (Check only a box on tine A. Complete line B if app! le) OZO " ~ ~ '-'i'o-' ~0 • Zb ~~ A' New System ~ ^ Replace nt System ^ Treatment/Holding Tank placement Only ^ Other lion to Existing System B. ^ Permit Renewal ^ Permit Revist ^ Change of ermit Transfer to New List Pr ous r u r Before Expiration ,Plumber wncr IV. Ty of POWTS S stem: (Check all tha t) - l>b ,Non -Pressurized In-Ground ^ Mound > ?A in. suitable soi ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter O Constructed Wetland ^ Pressurized In-Ground oidi Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculatin S thetic Media Filter ^ Leaching Cham ^ Dri Line Gr vel-less Pi ^ Other (explain) V. Dls real/Treatment Area Information: ~ Dispersal Area Propos ystem Elevation Design Flow (gpd) Design Soil Application Rate{gpd Dis sal Area fired (s ~ VI. Tank Info Capacity in To Number Manufacturer Prefab Site Steel Fiber Plastic Gallows Ga ns of Units Concrete Constructed Glass New ExisdnE Tanks Tanks Septic or Holding Tank ~ ~6 ~ ~,` c'S' ~r Aerobic Treatment Uait !>oeing Chambtr .~,t .~o~. ~ y, VII. Responsibility Statemen I, th8 tlnders[gned, assume respon9ibility for aI ion of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature MP/ P Number Business Phone Number ~~l~ia rn .5c"ha ~~r ~ ~~7 ~ lS-3~G- 3/2/ Plumber's Addre ss (Street, City, State, Zip Code) 74 S'UV ,,~ ~ ~ ~,' < S_ D VIII. Count /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued e Fee} Surchar u' g Agent Si a e {No Stamps) ^ Owner Given Reason for Denial g 25D'--- I~ 3 IX. Conditions of Approval/Reasons for Disapproval 3\ 0 _ca lye ~ ~,~' J n ~ SYSTEM OWNER: gyp, aXt~+-. • 1 Septic tank, effluent filter and 5~~ t dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach complete plaos (to the County only) Por the system on paper not less tbaa si/x x li utct-es In sue 'L'VAAI uCC SBD-6398 (R. 01!03) i'~2,yr~a- Carte .~6 T ~S fi~ ~ ~~~..cJ /~6~,v dC ~<~L~~'~~.cJ ~Jy//~Tin~/G / ~ ~ ~- S. "~,dc.~ mar- ~ .~ ~ T ~S ~"~ ~e ~~'c ~ /~6~,y d CT ~.~.-Q~' ~~~ ~- ~ml ~p~G /Od `~ ,1~~ ~~y~ ~~ ~D v Z Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8%: x 11 inches in s¢e_ Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north art~r, and location and distance to nearest road. Parcel I.D. Please print all information. ~~ ~ Personal information you pmv~e may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). Property Owner operty Location y _l. Date ~~Z Sienna Corporation E ro.~~ e.-3 ~ ~-~ vt. Lot NE 114 SW 1/4 S 20 T 29 N R 19 W Property Owner's Mailing Address L # Block # Subd. Name or CSM# 4940 Viking Dr, Suite 608 t•, - ~ b ~ ~ ~ ~ Z `~~o ' m 25 na The Glen City State Zi Code ne ~ Vu be City Village ~ Town Nearest Road ~cQ~'r+cf MN 5 35~,Q~z=~~~~~~,~,~'&- Hudson Carmichael Rd. Y; New Construction Use: iV Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial -Describe: Parent material Pitted outwash Flood plain elevation, "rf applicable na General comments and recommendations : System elevation 95.64ft, trenches spaced and depth to codg~6~below grade ha.~-~~SS~r y ~~ lye Gc - ~i'Q, 3' cl `7. ` ~ 5 ~ ~ ~ r ~ Boring # Boring ta/' Pit Ground Surface elev. 100.80 ft. Depth to limiting factor 98 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftZ *Eff#1 ~ *Eff#2 1 0-9 10yr3/3 none sl 2msbk mfr cs 2f .5 .9 2 9-19 10yr4/4 none Is osg mvfr cs 1f .7 1.2 3 19-98 7.Syr4/6 none ms) osg ml na na -~ ~ 12 Z 5 ~! ~ ~, tam q ~" • ~ `~ (~! • 42 q~ ~~- Boring # Boring / Pit Ground Surtace elev. 100.80 ft. Depth to limiting factor 102 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 *Eff#1 *Eff#2 1 0-19 10yr3/2 none sl 2msbk mfr cs 2f .5 .9 2 19-30 7.5yr4/6 none ms osg ml gw na .7 1.2 3 30-102 7.5yr4/4 none cos osg mvfr na na .7 1.6 r----- ~it O~~- ~~.3' ~Z,~~~~ Q ~ Y ~v `' ~ ~ da~~ . ~ X13. ~>. +~-~~ tttwent rte = tic~u ~ so < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS< 30 mg/L and TSS < 30 mg/L SST Name (Please Print) Signatu CST Number David J. Steel - ~-~i%~ 248956 4ddress Steel Soil Service ~ Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 9/7/2002 715-246-5085 1105 Page 1 of 3 Steel Soil Service St Crooc B2 y Properly Owner Sienna Corporation Parcel,ID # pending Boring # ~' Boring /' Pit Ground Surface elev. 9~. ft• Depth to limiting factor 102 in. Page 2 of 3 Sotl Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' "Eff#1 "Eff#2 1 0-10 10yr3/2 none sl 2msbk mfr cs 2f .5 .9 2 10-20 10yr4/4 none scl 2msbk mfr cs 1f .4 .6 3 20-102 7.5yr4/4 none cos osg mvfr na naO7 1.6 ~~~, ~ ~~,or; "~u,~ 5 ~GUrn~~.Qit~ (~ jjr.' ~ 7 SC~t~o 7~ ,A-~~-c. -~yr{~-~ ~'r ~hl.~ Y Boring # _ Boring ' Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS <30 mg/L and 7SS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or Boring # I Boring - - .. .. ... _ . ~.a .,. ~ubmars~~le ~- , ~ Effluent Pu~-p r* 1 ``~ V., y.., . ~~ EPA' E~}5 ''~'1 !oc ~ •~~~ • F#amM • Fucrn • • prir~p ~. Ptpop: X04 i ~ b~i~-: ~' rr1~11lW'rl.~ ~- upki~5 6PM. G~ ~ to 2~- het, ~,1 h' 1~, * ~ Mirl: prrbor~- elausmsn~ a, ,~ , tc~ (4~C~>~ndtie~ot~ 14it~ ~O°C~ ir>hrttlildl~t, d Fs~~iners; J00 ash ~ dot rlnlr~np ~~ ~~ t Soiidd hlndiir~ q~ptbili~: fit' ~Ir~dt~liJfrl, ' u;? t0 $0 BPM. p~ : up ~0 9i ~ • ~~°r +: g~ ~~ ~~ 1 a~~ !~lntl0tle 144°~.~iQ ~ 6~tten~. a~) • scs: 3fl0 senses i~b1i~ ~ i~bls ~ Nr~nin~ dtYwt dsmaoe to compons~te. Mlie~: f f1~E oOr~~O V, 60eHz~tbd8' eRPM~but(t in~overiotd with ~ ~ ~~41We~pi~550 R~PMH~~ bwilt ~ nwrso~ wllh aut~omtt~ rest. ~ P~rwtoa+d:10 foot sttodsr~d t!~-,18t3 SJTb u~kh thne pror+g around~p p1~~ GptiOr>~ ~4 foot ien~~ 1613 &J'NV with tltrp rorro groundlnp plug (~ Of1 EP05), ~~ • t~liy ~bmerQe~ ~ hips pndt turbine ou car tiot~ snd eM~er+t heat trtrKfst. RveiitW~ 14r wtioaul~a tIW Fiott#wlteb ~ ~++d pr~al ~d1~ i-. F#A1'W~1t _ _ _ ~ 1~tlst:l1termo- w ~ wn~ fir mea{tiuilc~:id prat~an. • ~M~'ilAlpNllt: Theme i vm ved ~ ht •C~1nq ~s1d 1»t. Rupged thermopisatlc design provldea supersoe strong ~ corrosion~na~e. t~torllowln~ Cattiron to e~Aolrnt hd~ttra', saeil~d'4~ 1is~ tli~8bililY. ti~Ot`~Owc: ~rtnopias~ ~ oowrw~'+~ s~dse iwlbh went r~etr! d~oU ~bw~u+~' •d~r~~yyba<!b`~ Iowan o~c~ruotion. ~~~ q~u1Ma~ m ~ ~ umbero t .,;~..,.~ ~ ~ ~ I -_-~ ~ - lY.......,.~ r ~ i w,r.j 6 Q ....~; 3 i 4 6 ' +,. 4 ' ~ o s ~ P Q ~~ CAI~AC~'Y ~;~ ~,~ r ~ ~. , , . a; ~ ^Sg '`U M P G HAM ~..K .,R ~ ~ ' " ;,SCTIOi~ A1dD aPECIFiCATltity:~ .~.....~...---------------- r i K SEPTIC TP~ ,. ABOVE GRADE ~~' CI VENT PIPE 12" MIN• OR ~ wEATNERRRilOF SL'NCTION SOX APFROVED MANHOLE COV &R + M DOOR. WIDiDOw > 2 ~ FRO WITH CONDUIT W / PADLOCK FRESH AIR INTAKE WARNING LAaEL FINISHED GRADE ~+, CI RISER ~,~ MIN. 19" IN ~ 6„ MAX . ~~,~ , -+ INLET ~ ~~ ' ~ GAS- ~ WATER TIGHT SEALS ~" ~ TIGHT ~ ppA01t~0 A SEAL ~ 30INTS WITH } _ ~ LM ApPRQYED P IPA I -PpR41tED ,,,,, „ B --F-- N 0 3' OtiTO SOLID SAIL 'IFE 3 fn?C St}L I O T . ~ F ELEV G ~ ~ OFF ~• RISER EXIT PERMITTED ONLY • ~ TOIL Ft7MP OF D MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAS SPECIFICATIONS SEPTIC / DOSE TANK MANIJI'ACTURER: GJ.~ ~ ,,.! TANK SIZES ~ DosEIC„~5,~:....,.~ GAL. ALARM MANU I'ACTURER : _~l.L. ~ ,•~-~-- "-""" MODEL NUMBER : _,~ ~~_ - SSJ I T C H TY F£ : ,,,,~,~,~.---- PlIMP MANUFACTURER: __,~Z'~ '"'-"" MODEL NUMBER SWITCH TYPE REQUIRED DISCHARGE Rf'+T£ ,~. GPM NUMBER DOSES PER DAY : _,,,,,t„~..._ DOSE VOIJJ:rIE INCLUDING F LOWBAC K : 1„,__, ~ ..- GAL . CAPACITIES : A = a, 2 ,,, xNCHES ^ _~;~~-_.-GAL B ~ , 2 I NCHES ~~,.._,,.C'~'L . C ~ INCITES = GAL. D ~ INCHES ~ ~1Q~GAL. PUMP ~ ALARM WIRING AS PER ILHR 16.23' WAO j~ FEET VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ••--~-~, FEET + MINIMUM NETWORK SUPPLY PRESSURE ~ FELT • Q FEET FORCEMAIN X ~__60_FT/1a0 FT. FRICTION FACTOR FEET _!_„_,_. TOTAL DYNAMIC KEAD ~---- ~----~ • WIDTI3 ~' TER INTERNAL DIMENSIONS OF PUMP TANK. LENGTH LIQUID ~'~~-~~ ~a.l /O~v ~ LICENSE NUMBER: ~S~d,,,_,_... DATE: SIGNED: 1I8fi PQWTS t?WNER'S MANUAL. & MANAGEMENT PLAN Page of .__ FILE tNPORMATION . Qwner Permit ~ 3~ 3Zg DESIGN PARAwAtaTERS Number of Bedroom= ~ DNA Number of Pubic Facility Unite DNA Estimated flow !average! Q ~ a da Design flow tpeak}, (Estimated x 1.5} ~~ al/da Sob Applioetlon Flats giro Jtts Standard Inftuent/Effiuent Quality Monthly average' fate, Oil 8i Qreaae {FOG) S30 mg/L 6ioohefrbal Oxygen Demand {i30Dii 5220 mq/L O NA Tote) Suspended Solids {TSSi 5160 mg/L Pretreated Effluent Cuallty Monthly average Bioohearlk:ai Oxygen Demand tBODs! s3C mg/L Total Suspended Solids iT8S1 530 mq/L ^ NA Feoat Colilorm !geometric mean! S1f}° cfu/900mt Meximuirr Effluent Pardcis Sise yi in dla. O NA ' ^ NA MVatues typloal for darriestic waatewetar and septic tarok effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ,2 ~ al C7 NA Septic Tank Manufacturer O NA Effluent Fiker Manufacturer ~ ~ ~ O NA Effluent FNter Model d' d NA Pump Tank Capaoity sl O NA Pump Tank Manufacturer r S ~, d NA Pump Manufacturer ~,~.4/ ^ NA Pump Model ~ O NA Pretreatment Unit ^ Sand/Gravel Fitter Q Meohanioa{ Aeration a Dbinfeotion ~ Pest Fitter ^ Wetland o other: NA DMNersal CsU{s) Ground tgravltyl i3 At•Cirade t7 i?rip•Line DNA C! !n-Ground {pressurkedi D Mound D Other: that: DNA r: DNA ~~~ ~ NA ~ sc u~ Ewec service !<requsnoy !respect condition of tanktai At least once every: 3 eu e e lMatdmum S years! DNA Pump out oantsrtte of tenkls) When combined sludge and scum equals area-thkd tYs} of tank volumo ^ NA Inspect diapenal calf{ai At least onoe every: 3 marl ~lel tMatdsnurn 3 Years) DNA Clean affluent filter At least once every: . ~ ~~ta) el O NA Inspeot pwrtp, pump oontrola S alarm At least once every; ntoMh s ar si O NA Flush latereds and pressure test At least once every: .- Q man a1 si DNA ~: At feast once every: „~ ~ monl~tsi ©NA • G NA tMAINTENANC~ MISTRtiCTIONS lnapecttons of tanks and dispersal sells shall be made by an individus! carrying one of the fo{bwinp iiosnses or certifications Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tan inepsationa must include s visas! inspection of the tank{si to identify any mis:ir-g or broken hardware, identffy any cracks or leaks measure the volume of oombinsd sludge and scum and to check for any back up a ponding of effluent on the Around aurfacE The dispersal celltsi shall be viauadly inepeoted to check the effluent levels in the observation pipes and to check for any pondin of affluent on the ground surface. The pondinq cf effluent on the ground surface may indicate a failing condition and requires th immediate notifioetion of the !coal regulatory authority. When the combined aocumulstion of sludge and scum in any tank squats one-third {Yai or moro of the tank volume, the entir contents of the tank ahsN bs romoved by a Septags 8ervlcinq Operstor and disposed of in accordsnoe with chapter NR 11 WiaooneM AdmiMatrative Code. ,Alt other eervbss, InaaudMg but not tirnit~d to the servicing of effluent flitera, mechanics! or prossurized oomponenta, preuegtmen units, and any ssrvbMg at intervals cf S12 months, shall bs performed by a certified POWTS Maintainer. A service repprt anal! be provided to the local repulstory authority within 10 dllyll of compietbn of any service event. . P3go __~ Ot __ &TART UP AND OPERAT{ON • ' ~ ~ ' ` For new construction, prior to use of the POWTS check treatment tanklsl far the presence of painting products or other chemical: that may impede the treatment process and/nr damage the dispersal cell(al. If high concentrations are.. det~te~ have the content: of the tank(sl removed by a aeptage seroiaing operator prior to use. System start up shall not occur when sail conditions ors 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 dispersai celNsl in one large Joao, overloading the califs! and may result in the backup or surface discharge o effluent. To avoid this situation have the contents of the pump tank removed by a Septege Servicing Operator prior to restorini power to the effluent pump or contact a Plumber or POWI'S Maintainer to assist in manually operating the pump controls is restore normal levels within the pump tank. Do not drive or perk vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb ar compact, the are. within t 8 feet down elope of any mound ar at-grade soil absorption area. Reduotion or siimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS; antibiotics; baby wipes; cigarstts butts; candorna; cotton swabs; degreasers; dental floss; diapers; disinfectenta; fat foundation drain (sump pumps 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 andlor is permanently taken out of sorvice the following stops shalt bo taken to insure that the system i. property 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 a# by a Septage Servicing Operator. • After pumping, aN tanks and pits shall be excavated and removed or their covers removed and the void spade fitted witl soil, gravel or another inert solid material. CONTINGENCY PLAN It the POWTS fads and cannot be repaired the following measures have been, or. must be taken, to provide a code camplian replaoement system: A/A A suitable replacement area has been evaluated and may be utilized for the location of a replacement soli absorptia~ system. The replacement area should be protected from disturbanoe and compaction and should not be infringed upon b required setbacks from existing and proposed atrueture, !ot lines and wells. Failure to protect the replacement area wl result in the need for a new soil and site evaluation to astabllsh a suitable replacement area. Replacement systems muB oomply with the rules ~ efface at that time. p A suitable replacement area is not available due to setback andlor soil limitations. Barring advances in Pi3WT technology a holding tank may be fnstailed ss a last resort to rsplaos the tailed POWTS. 0 n < <WARNiNfl> a SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANt?IOR lN$UFFICIENT OXYGEN. DO ND ENTER A SEPTIC, PUMP OR OTHER TREATMiNT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RE8CUE OF PERSON FROM THE INTERIOR OF A TANK MAY SE DIFFICULT OR 1MP08$IBLE. ADDITIONAL COMMENTS POWTS tN$TALLER Name ~'~j,'~ ~~-~ ~1r'~.{~ Phons ~ r _ ~ .` ~ ~ POWTS MAINTAINER Name Phone 6EPTAQE SERVICINLt OPERATOR (PU PER! LOCAL REGULATORY AUTHORITY Name Name (x, ! A~' Phone Phone . This document was drafted in oontipliance with chapter Comm 89.22(2itbl(tl(dl&(fl and 83.64it1, 12l 3 i31, Wisconsin Adrn-nlstrative Code. Mound and at-grade soil absorption systems may be reconstructed in place fnllowing removal of the biomat at th infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. F=Fib--24-2~+'^,~i 14 23 :~ : trvtvr~ u.:r.r• . ST CROIX C~~~ C TAIL ~titiII'~CS Ao~~'~ 5~"I'I o~~, ~ ~TZOK ao~ c~wae~tBuya ~rFkl~l~t Go~/,d'e~Trof-- __ ~~ ~f3S `D~- sut~ ~0~6 ° ~~ ~ ~ ~ y~ 7~f2 p~p~y ~~ - ~ ~,~at'Aeat fos aQa censt~d~o rv~cts~ ~./L/IytD~ l,~/~• Parcel Ideatifir~on Nyfaber Ctit~-lStstar . 1 I ~~ ~ ~ 1 W % Sec.. T Z~?1,R.~._~' Town eff ~Vt~S Subdivision 1 ~~ ~- N .---- ~- ~~a{- ,ied Stt1t'~reY Map # Votusae ~---~' p'~c # t 3 ~t+'ats+m~y Deed # •. D ~ 1~ :w ~",~~y~s°no L,,~ ~ id~-~le ~ Y~ to •P~`'°~a`m"atmta~ ~a~yo~~a~~ ~~"~`~,y~, ~P~P°G ~~~mtdt6e6yQ+c°a ~~~~h„~~k~~-~r~ ~ aui-.ff+~'~ ~13an of ~ ~ oak a; a t~,at~ ~ m ~ *~ di`'p°~ ,ad by a s ea~~"lo ~ oa~iie~~ "`~toowaa 'l~s pr,pa~r owsa a,~as ~+ ~'~ 1i° St. orois l~ni~ ~ {~ tack ~ ~ dm~a 113 i~ of xi~- lttmt+exo j~Pw~Or`te'~~P~aotslitaeaedp~~ly~~ ~ ~ ~ ~~ ~[tioo ~dlot {Z) suer ~• p~~ ~'Om the vats ~ ~ ~ daa 1/'~. ebe v~doesi~ l~sve rdud 11us ~tbaMS ieq ~ the Deptttsae~ °f K ~1 ~a~i0i~ ~~ p jgea srit4ia 30 t of Co to the St- L~oi~t Go~Y tet fattL. b~~- ~ xt by t~ ~ eamplemd sad tetwnaad asssh46 ~ ~ ~ ~.~ _ DATB e. i (as) *m (qt°) tlao at+vn~tt~ of ` ~ to t?+e bat of mY ~+~~ 1ote~-1cdC t6it all ats o this farm tte ~ of Aad+c ~'0C' abo s wsrtattty dead teeotdsd is Litbit~a~ DA'L'E ~~~~~,~7Li D ~~, ss~s~• '~' ~ t 6nio~ revoked by ~ ~"~ ~ .. ~,..~, Aify ioCvrsetdti~ ii mii.eeptaseared eoaY scN1t in tlLe ~tetY Pa's s• jp,~t-de sriW this eppiicaelaa: a s~ ~'~~ d'°°d fso0~ !~ ~B~o of ~~ o~Qa a copy of the ceet~Sdx eurieY ~+P ii'taCet'eore ii saw ~°` fist .r+~-ql dcxd • STATE 8AR OF WISCONSIN FORM 1 - 1998 ' 6660$eD WARRANTY DEF,II r KATHLEEN H. WALSH Documeru Ntrrtber ynl. ~ 797PA61613 ; . . STGICROYX~CODEEMI _ ... ` AECEIUED FOR RECORD _ T.hls Deed; made between _ BBAe Cor»oration a Minnesota corporation 1Z-21001 3:10 PA '; - ~T [i' DEED -- Grantor. '` and Sienna -."-• CER1 (~ FEES - ~ -•- __ T RAN6F~ FEE: 9463.40 IN6 FEE: 17.00 ~~, ~ pA~Bs 1 Grantor, fora wluaDle eoneidcratton, _, Grantee. wnveys to Grantee the following 'i dexrl!>ed real cause in SC • Croix , ~ County. State of Wisconsin (the 'Property: Hecr:~Gn:V.Srtd '~ See Attached Exhibit A ~' Nw~eandAapinAOdrNa "~ flniv~r~t.i %~~ 5'1fn 5me,t~rlq Ur-~ ~i.l.+~e.4dl I~•(i vine ~-a,n ka N ~ 5533 _. ~ zo-lose-3a-oao Parch tdantiaeatian Number {q~ This 18 not homestead property. '. (!s) (IS not) ;: 2a-lose-bo-ooa 20-1048-90-000 20-1049-90-000 ' 20-1050-00-000 I~ 20-1050-80-000 ' 20-1052-20-000 ' 20-1052-70-000 Together with all appurtenant rights, lifts and interests. !~ Grantor warranu that the titre to ttte Property is gorxl. Indefeasible in tee simple and fm and clear of encumbrances except ;i Sae Attached Exhibit B. 1 Dated this 20th day of December ,i Bane r oratiot: ~ (SEAW by ~ o Neese Ite_ C of Executive Offi (SEAL,) AtJTHENT[CATION Signature(s) authenucaud thta Gay o[ 'TITLE: A1EMBER STATE BAR OF WISCONSIN (If not, at:thortxed by;706.06, Wls. Stara.) 2001 (SEAW (SEAL) ACKNOWLEDGMENT ' Minnesota State ot11YHrCeftrtRe` lI y aa. t.,,.~,.,.,,..c .f County JJJ .. Personally c Tbefore ma this + ~\) day of ' December ,~Q01 ,theabavertamed Joha M. Nasseff. Chief Executive Officer of Bane Corporation. a Minnesota corporation to me known to bo ttie pc, ~_ who executed the foregoing Instrument and a~n~t~t ~ rrte. THtS INSTRUMENT WAS GRAFTED BY .~; ~. NAMYB.QALWlLR Lockrid a Grindsl Law Firtn - -~~ waotrealatoauoNtaps Minneapo2.i9, MN 55401 Notsry E1k,StagofWisconun (Signatures may be authennnted or ecknowtadged. Both era not ~anttarvu3l is permanent. (fi not, state expirallon date: ' N'smn pl prrwra sentry m any <epactry must G typed or prlnttH! lbslow thnntanwus. ~ ~~ ~ ~~ - ri'ARNANTY DEPD STATB BAR OF WISCONSIN wacmwm ~~ B~ ~, ~ POR1i No. 1 - Ipat ~«eaee. Ws 205 S~6 Document Number STATE BAR OP wiSCONI:N FORM : • 1998 V1iARBA1~"TY DEED This Deed, ta~arde betwttest Jobta Gtea sad >l'sari Gfa, huabaad tad wife, Qrtmtor, and Biertna Corporat3oa, a eorporutoa under the lawn of Mianeaota, Grantee. t3rantor, for a valuable ttoaaideratioa eatveys to Oranua the followlnS described real silos is the County of St, Croix, State of Wbconsinc See t?xhlblt A, ettat~ed hereto a Perri Glen ~~ Fredrtluss a ayrea, r.A. ~ooo enlltury c.we Zee tteY{1 abtlb t11rNt aaaelgolY, MN aS4Q>I P~ral itietWtbation Number (P1N) 0~O.10s1.lpA00 Thu (u) (it tuff) botntsttuJ proPenY• The peroel shown on this document is t)einp added to the parcel Chown on the document recorded in Volume t 787, Pape 013, Oocumant Number 86001!0, deemed ae a parcel of land bated: to oreete on parcel, and this transaction In thereb exempt from Chapter 18 of the ST. CROUt COUNTY LANG U8E RI'sCiULATIGNt3 purettant b 8et~on 10.06 (A~(3). Tc>{ether with all apptuteaant ripAts, title and intecats. Grantor warransa that the title to the Property is Qood, indefeasible is fee Pimple and free sad dear of enetlrnbrancea except: reatrictione, eoventnu, conditions and easctnents of record, if say. Dated this day of November, 2001. AL1TItENTICAT70N Slaltnture(a) 8utlNtxicAted lhic ,dry or , ,_,,,_ TITLE: htEbtHER STATE BAR OF WISCONSIN (If let, lutborized by;706. is. Sea.) THIS INSTRUMENT WAS DRAPTBD HY Fredrikloa & Byroa, P.A. (SMM) 4000 PIllabury Cstuer 200 South Sixth Street Miarwyolu, MN 35402 6I2-492-7000 268?A9t3 <ifpee,ree nuy b weuuuidue « eektwwldpd. Rah ire not MCNNry.) 699Af~6 KATNLfsiVK N. YALSH R£OISTRR OF DBBD~ ~ ~. CROIX CO. , w RECEIVED FOR Rt;;G0it0 11/45l2YE2 lOtiRA1l Ef101Di i 1133 N 8 r t i7.~ >~: t ACKNOWI.EDGAt6NT STATE OF WISCONiIN ) COUNTY OF ST. CaOIX ) Par>;onalty ama before the ttus ~f1rt ~ day of Noregttter, 2002, the above wmcd John Gfa cad Pearl Gta, btubead sad wife, to me ktwwn w be the pawn who ex,tcvttd the fore;Dina itWrurnent lod aslulowtedae Ilfe twru. •Nau Public, Stae of M Comm Is per Qf not, aua explraNoo due: Mk:heil~ B~Ck Note Public S ~~ •Ne,Wt d 9~rroot ttia^a ~^ eM' ~~' mows ae qpa o, p,aw saw w,u w~• w,NUt+urf alto tSAtR w w wa~o-,yor poaa< v,. c • ifM ,xy.iet„n VrMnaon,l, Canpenv fm10, Leo Wyrengn laoess.~att .,. ~' ~' ` ~ +1"1 ICiJ MIr•j 1 ~ I SS ~ pF 101117( a `IIQ11 tnj i it 1 Yy 4 ~ 1 I Y ~ gL 7yJl :I4J I r r~i -~ - - 9 N~jI C:~ ~~ICJ rrl ' I~/j• ~ ( I t{ ~ ~ a G -1 ,.,,,,~ «..n > : ~t ~t7 ' '~ ,. 413, . . ~~ao ~ ~ _ 01• - - 3 ' E 41'11 SOg ~• i Sp7'151 *g %% . 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