HomeMy WebLinkAbout020-1437-17-000Wisconsin Department of Commerce • PRIVATE SEWAGE SYSTEM
Safety 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
Tank, Scott Hudson, Town of
CST BM Elev: Insp. BM Elev: BM Description:
TANK IN ORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic
~ ~~
~ z6o
Dosing
Aeration
Ho ding
TANK SETBACK INFORMATION
en o it n a e
ep Ic ~ O t ~ I c `._.~
osmg
era Ion
o Ing
PUMP/SIPHON INFORMATION
anu ac urer eman
GPM
o e er
I rl n oss ys em ea
orcemal e
c°~nty. St. Croix
Sanitary Permit No:
488127 0
State Plan ID No: ^~
Parcel Tax No: , I
020-1437-17-000
Section/TownlRange/Map No:
22.29.19.2722
STATION BS HI FS ELEV.
Benchmark
3.(~v
O _zo
Alt. BM ~ ',~
' f
~S.
Bldg. ewer Z p'
0 i
0 •9S
t t net 52,r
T ~Z.Sb f
t t ut e ~ ,/
3
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ne
0 om
ea er an. ~ Z ~ C7D,S-I 1
S , 's
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nu. 51
o . ys em ,~j a
e o i
qq. 20
ma~6a..ie gt 3.i!oo p~,Zd~
over
DIME ONS
J? ~ ~.-
Q 1
/ D P.4 •
~~ -
INFORMATION CHAMBER OR ~ 5
~. ~21 + ~~ ( UNIT A ~,L. ~~o.
UIJ 1 RIDU I IVIY .7 i a 1 ~~r~
~~
Length Dia_~ Pipe )
Lengt
Dia pacing ~ ~ ~ ~
x Pressure Svstems Onlv xx Mound Or At-Grade Systems Only
BedlTrench Center Bed/Trench Edges Topsoil i Yes ',J No ~ ~ Yes (~] No
S
COM~Fr1tIT :/ (Include code discrepencies, persons present, etc.) Inspection #1;__)_WrY~{„(~ySp Inspecrion ~z: ~ ~
Location: 8 8 Herita a Court Hudson, WI 54016 (SE 1/4 SE 1/4 22~T,2p9~N;-~R-19W) Kell Est tes Lo 17 Pf a~rcel No: 22.29.19.2722 rt
1.) Alt BM Description ~B ~ ~~ ``' 6+~ ~ uTe`'Q"''-'" _"" ~) 3~'~' `~~ _lu ~ S ~>~'L. 3~O -~
2. Bld sewer len th = Z, ~ ~ ~I 3F -~+'~ 3~ ~ ~S~~eQ
9 9
-amo ntofcover-~~~~~Z`~. ~ ~- ~1 ,~„_f~., ~ r~ Z,(QO 7)
----T
Plan revision Required. (___] Yes ~No I TAI
Use other side for additional information. ~`_,°'°-1,' ~~t ~O ~ I `~~
-- - - mature1------ _ }p,~
SBD-6710 (R.3/97) _-_ ~~~ ~ 1,.9 ~ ~. 1 ~E~tiS~~"~"' ~" 11LSP~~p~q
i
:.acrd spiv ion Cowry
` s m 201 ~V~!li-~ae}t4R~ton Ave., P.O. ox 7162
~seons~n
D Madison, WI 53707 - 71 2
~0~) ~~51
~ Sanitary Perrrtit Number (to be filled in by Co.)
epartment of Commerce ~ I Z~
Sanitary Permit p~li @II~ Stato Plan I.D. Number
In accord with Comm 83.22, Wis. Adm. C petso in o
'
maybe used for secondary purposes
vary La ) Project Address (if different than mailing address)
I. Application Information -Please Print All Information ~p ~ ~~l ~ nc~2
O
`
Property Owner's Name Parcel #
Lot # ~ 7 BI
ock #
'
Property Owner
s Mailing Address property Location
City, State Zip Code Phone Number -2~ %, ~{E -%, Secti~ ~_
--gy~pp cucle
~
II. Type of B tiding (check all that apply) _
~ 5 ` T<~L N; R E o,/,
S
1 or 2 Family Dwelling -Number of Bedrooms Subdivis' n ame C
^ Public/Commercial - Descn'be Use
^ State Owned -Describe Use
^ V' e p
^City ag i~ownshi of
III. Type of Permit: (Check only one box on tine A. Complete line B if applicable)
A_ ,~NewSystem
^ R lacement S stem
eP y
^ Treatinent/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
l V. T of POWTS S stem: Check all that a
Non -Pressurized In-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Singte Pass Sand Filter ^
Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter . ^ Aerobic Treatment Unit ^ Rxirculating Sand Filter ^
Recirculating Synthetic Media Filter Leaching Ch ^ Dri Line ^ ravel-less Pipe ^ er ( ain) `
V. Dis ersaUTreatment Area Information: ,v~cJ Q
Design Flow (gpd) Design Soil Application Rate( f) ispersal Area R fired (sf) Di ersal Area
sp posed (sf) System Elevation
VI. Tank Info Capaci m Total Number
tY anufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units w/ P PL~~'~1 Concrete Constructed Glass
New Existin
~
1
--;
~
g ~Q
,~
/J/
Tanks Tanks
Septic or Holding Tank /
Aerobic Treatrnent Unit
Dosing Chamber
VII. Respo sibility Statement- I, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans.
Plumb ame 'nt) Plumber's S' a MP/MPRS Number Business Phone Number
~
_
Pl bet' Address (Street, City, State, ip ode) /
~'~~ ~ - ~" ~ J -
VIII. Coun /De artment Use Ont
Approved ^ Di r ved Sanitary Permit Fee (includes Groundwater Date Issued Issuin Agent Signatu (No Stamps)
Surcharge Fee) ,,~~{{~~
^ easonforDeni UU-' !3
IX. Conditions Approva
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced /maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable codefordinances.
Attach complete plain (to the Ca.mty only),for the system oo paper not less than S1I2 x 11 inches in sine
SBD-6398 (R. 01/03)
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~. 2- 1223
WiscensinDepartmentofCommerce SOIL EVALUATION REPORT ~~ ~ ! n~~ p 1 ~ 3
Division of Safely and Buildings in accordance with Comm 85, Wis. Adm. Code feel Soil Service
Attach canplete site plan an paper not less than 8'h x 11 inches in s¢e. Plan must Cou '
include, twt rwt limited tn: vertical and troritorAal reference poird (HM), direction acrd L-._e._.:._:.:~...~_.w' ~~"~'
petrerrt slope, sc~e or dimemsions, north arroar, and taeatiarr and dstance to nearest road. Parcel LD.
Pending
Please print ail i»h-nnatron. R ~ ~
Personal inforrnatiar yrou provide may' be used far sstmndaY W cPrivaer La<r, s.15.Q4 (,) cm»- p~
Property Owner Property Location
Reliant Developers LTD Govt- Lot SE 114 SE 114 S 22 T 29 N R 19 W
Property Owner's tUlailirrg Address Lot # Block # Subd. Nary ~ GSM#
9900 Va~ey reek Rd. Suite 135 17 na KeAy Estates
City Gva~t~~y State Zip Code Phone Number City Village ~ Town Nearest Road
MN 55125 651-731-3174 Hudson Heritage Ct
~9"~
~~ 91
~2
(23r,
~; New Carstructice Use: ~/ Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement Public w carrtrrercial -Describe:
Parent materiat outwash plakts and stream terraces Flood plain ;~, if ~~~ na
General comments
and recommendations: System elevation 98.20ft trenches spaced and depth to tx~de 6.OOft beknrtr grade
8a++>g # Bonng
110
/ Pit Ground Surtace elev. 104.20 ft. pepth to in,
limiting factor ~ A~ Rate
Horizon Depth Dominant Color Redox DesL~tiar Texture Structure Corsistence Barndary Rods G PD/ft=
___ _ *Eft#1 *Eff112
1 0-12 10yr3/3 none sll 2msbk mfr cs 1f .5 .8
2 12-23 1Oyr4/4 none scl 2msbk mfr gw na .4 _6
3 23-32 10yr4/6 c2d 7.5yr5/6_ sicl 2msbk mfr gw na .4 _6
4 32-59 7.5yr4/4 none sUls 2msbk mfr gw na .5 _9
5 59-110 7.5yr416 none ms osg ml na na .7 12
orb
t3oring # _ Ong
110
r~ Pit Ground Surface elev. 104.20 ft. Depth to in.
limiting factor ~ A l
Horizon Depth Dom~rrt Color Redox Description Texture Stnxdun: Cor~~tence Boundary Rods GPD!(t=
`Eff#'I *Eff#2
1 0-9 10yr3/3 none sil 2msbk mfr a 1f .5 .8
2 9-32 1Oyr4/4 c2d~ ~ sicl 2msbk mfr gw na .4 .6
3 32-55 7.5yr4/4 none sl 2msbk mfr gw na _5 .9
4 55-72 7.5yr4/4 Wane Is osg mvfr gw na .7 1.2
5 72-110 7.5yr4/6 none ms osg ml na na
a.!- 9 ~~~. ~ I
9~6
~ ~~o~
errxr£.vrr ~r = ~u s' su c ~ mg/1_ arxt T~ >30 ~ 1 ~ mg/L ' Effluent #2 = t30D$ ~ 30 mg/L and TSS <30 mg/L
CST Name (PfeaSe Print} __ Sgnatune: CST Nun~er
David J_ Steel ~ ~ ~ 248956
Address Steel Soil Service Date Ev~uatiorr Conducted Telephone Nutrrber
1564 CR GG, New Richmond, Wl 54017 10/232002 715-246-5085
Property Owner Reliant Developers LTD Parcel ID # Pending Page 2 of 3
Borng # , Bonng
100
10
Depth to li
ft
miting factor
110
in
Pit Ground Surtace elev. . . . ~ Applicatan Rate
Horizon Depth Dominant Cabr Redox Descriptirxx- Texture Stnkture ('.oresterrce Roofs 6PD /ft=
"Eff#'I 'Ef(#2
1 0-8 10yr3/3 none sil 2msbk mfr cs 1 of .5 .8
2 8-17 10yr4/4 none sicl 2msbk mfr cs na .4 _6
3 17-29 7.5yr4/4 none sl 2msbk mfr gw na .5 .9
4 29-110 7.5yr4/6 none ms osg ml na na .7 1.2
i~ 6 -o ~ ~~,,,,~~ ~acQQ._ ~ ~ Z~~ o~
Boring # aoring
" Efifluent #1 = BiJD $> ~ < 220 mglL and T55 >30 ~ 150 mg/L ' Effluent #2 = GODS <30 mg/L and TSS <30 mg/L
The Deparkm-ent of ~ommeree is an equal ~pp~rtunity service gmvirlee and emisk7yer, If you need a~.sice to aegis sets Eze
Boring # - ~°g
Page 3 of 3
STEEL'S SAIL SERVICE
David J. Steel 1564 Cty Rd GG
CST-POWTSM Reliant Developers LTD New Richmond, WI 54017
Lic. # 248956 SE1/4,SE1/4,S 20,T29,R19W (715) 246-6200
Town of Hudson, St. Croix Co. (715) 246-5085
Kelly Estates lot 17
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be saitable 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 soil test was conducted. Legend
1" = 40"~
• Benchmark El. 100.00Ft
p of ''/2"pvc pipe
• Alt Benchmark E1.98.85Ft
op of/2" pvc pipe
o =Borings
Boring Elevations
B1 =104.20Ft
B2 =104.20Ft
B3 =100.1OFt
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Preliminary Plat of KELLY ESTATES 1 James R. Hi~~,
Aeealw to elr swuwn Owrew a aw feY1MeN OuerW, N n. faua..n Ourl« a a. LautMa+t
Over, W to $~e/kn f2, Tsn H /M,tly Re+q~ 7y wet, Tewn el NuMen, SR Cre~+ Cennty, tMeen~w DI AAIAICDC / CAIM-ICCDC / CI ID\T
FILE E INFO
', Owner
Permit #
POWTS..O~~WN~R'S /MANUAL & MANAGEMENT PLAN,,r.,;•., Papa..., ~1
/~,~/7 ~i~~ ~~~•c SYSTEM_&PECIFICATIONS~
2
Septic Tank Capaolty ~ ' ~ ~ el ~ N','
Septic Tank Manufacturer 1 O r`.
Effluent Filter Manufacturer ~ N%•
Effluent Filter Model ~~ ~ N',.
Pump Tank Capacity a1 ~ Nr'.
Pump Tank Manufacturer ,~ N~',
Pump Manufacturer fz~Nr
Pump Model hJ`NA
Pretreatment Unit
^ Sand/Gravel Filter
O Mechanical Aeration
O Disinfection : `
^ Peat Filter `
O Wetland
O Other: NA ,
~ `
Dispersal Celllsl
~In•Ground (gravity)
^ At•Grade
O Drip-Line O NA
D in•Grouhd (pnasurizadl
D Mound ° - -
^ Other; -- 1
Other. ^ NN
Other: O Nti
Other. O NA
DESIQN PARAMETERS
Number of Bedrooms O NA
Number of Public Facility Units A
>atimated flow (average) ~ ~ al/da
Design flow (peak), (Estimated x 1.51 al/da
Soil Application Rate 7 al/da /ft~
Standard Influent/Effluent duality Monthly average '
Fats, Oil & Grease (FOG) 530 mg/L
Biochemical Oxygen Demand (BODE) 5220 mg/L O NA
Total Suspended Solids (TSSI 6150 mg/L
Pretreated Effluent duality Monthly average
Biochemical Oxygen Demand (BODb) S30 mg/l,
Total Suspended Solids (TSS) S30 mg/L f~NA
Fecal Coliform (geometric mean) S10' cfu/100m1
Maximum Effluent Particle Size Yo in dia. ^ NA
Other: ^ NA
"Values typical for domestic wastewater and septic tank of fluent,
.~~, ..
IVINIn11CrYFinIVC 01+nGVVa.~
Service Event Service Frequency
Inspect condition of tank(s)
At least once every: ^ month(s) ' Maximum 3 years(
earls) - l ^ NA
Pump out contents of tank(s) When combined sludge and scum equals one-third 1Y,1 of tank volume ^ Nti
Inspect dispersal ce(lls).
At least once every: ^ month(s) ' (Maximum 8 years(
earls) - O NA
Clean effluent filter At least ones every: ~ ^ ear( ilsl ~ O Nh ~'
O month(s) ~N~,
Ins act ump, pump controls & alarm
p p At least once eve
~'~ O aerial
Flush laterals and pressure test At least once every: ^ monthlal
O earls) ~~
Other At least once every;. ^ month(s)
^ earls ~''NA
Other:. .,,
-
^ NA
MAINTENANCE INSTRUCTIONS ' " '
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certification:,:
Master Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Servicing Aperator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any oracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or pending of effluent on the ground surface:.
The dispersal ce(lls) shall be visually inspected to check the effluent levels in the observation pipes and to ohaok'•for any pondin5
of effluent on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and requires thv
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 11:t,
Wisconsin Administrative Code. - '
All other servioes, including but not limited to the servicing of effluent filters, mechanical or pressurized o0mpononts, pretreatment
units, and any eervioing at intervals of 512 months, shall be performed by a certified POWT$ Maintainer.
A service report shall be provided to the local regulatory authority within 1 O days of completion of any service avant.
OMW Ia/0 t
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 celllsl. If high concentrations are detected have the contents
of the tanklsl 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 fa restored the exoea# wastewster will be
discharged to the dispersal celllsl In one large dose, overloading the oolllsl and may result In the baokup or'~urtaoe dlacharyu ut
effluent, To avoid this situation have the contents of the pump tank removed by a Septage Servicing Oporetor ptbr to restorinu
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls r.
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 :~~ ~~;
within 16 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 cr,~:
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dlslnfectants; f~,~
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides;;:meat scraps; medications; o,
painting products; pesticides; sanitary napkins; tampons; aril 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 i>
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 Servioing Operator.
• After pumping, all tanks and pits shall bu excavatod and removed or their covers removed and the void spaoe filled wiur
soil, gravel or anothor inert solid material
CONTINQENCY PLAN
If the POWTS fails and cannot be repaired the following measures have bean, or must be taken, .to provide. a.code complier.:
replacement system: ... , :; ~- ;,:
~A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absOrpti-,n
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon .y
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area v; Ali
result in the need for a new soil and site evaluation to establish a suitable replacement area, Replacement systems m~sr
comply with the rules in effect at that time. ~ "'
O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in .POW
technology a holding tank may be installed as a last resort to replace the failed POWTS.---•°~ ~---~- °- -
C7 The site has not been- evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and s:;~.
evaluation must be performed to locate a suitable replacement area.. If no replacement area is available a holding ta~~r.
may be installed as a last resort to replace the failed POWTS.
O Mound and at-grade soil absorption systems may ba reconstructed in place following removal of the biomat at u
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNINO> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO Nc
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY REBUIT. REBCUE OF
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTAL POWTS MAINTAINER
Name Name
Phone _ ~ Phone
SEPTAQE SERVICINQ OPERATOR PUMPER LOCAL REQULATO Y AUTH R TY
Nam• Nams
Phone Phone '''
.1
This document was drafted in compliance with chapter Comm 83,2212-lblll)Id!&lf- and 83.6411), 121 ~ 131, Wlacoruln Administrative Cod•,
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
.AND
OWNERSHIP CERTIFICATION FORM /.f~~~
Owner/Buyer _ ~~G~ 7"~~ ~~ ~l f~ l1
Mailing Address ~~ l 7 $ (,4-y~, ~~Y, ~~ ~y. ~ ~ ~~~ „~~ s ~,,,r„_ ,~'S-'/ Z. Ste'.
Property Address
(Verification required from Planning & Zoning Department for new construction.)
CitylState ~ ~( Parcel Identification Number ~~~'~ - Jy~7- /7 fD~I ~. 2,~Z2~
LEGAL DESCRIPTION
Property Location ~'/4 , ~ 1/4 ,Sec. Z~, T Z ~( N R~_W, Town of ~„~ S~„T~,
Subdivision _~Q L L v ~_~~~~-~S ,Lot # ~.
Certified Survey Map # ,Volume '- ,-Page # ~-
Warranty Deed # ~~~~~ ,Volume ,Page # ~~,,~
Spec house yes Zo
Lot lines identifiable es no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper.. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the 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 Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. Ilwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
,.- ~ ,
SIGNATURE OF APPLICANT(S)
_/~ /,_;
DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. ***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
U Z8~I8 P 060
State Bar of Wisconsin Form 2-2003
WARRANTY DEED
Document Number ~~ Document Name
THIS DEED, made between LaCasse Development. Inc., a Wisconsin Corporation
("Grantor," whether one or more),
and Scott Tank and Allison Tank, husband and wife
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant
interests, in St. Croix County, State of Wisconsin ("Property") (if more space is
d, Please attach addendum):
Lot 1 , Plat of Kelly Estates in the Town of Hudson, St. Croix County, Wisconsin.
8009E.2
KATHLEEN H. NALSH
REGISTER OF DEEDS
ST. CROIX CO.. MI
RECEIVED FOR RECORD
07/21/2005 10:20At1
IiARRAHTY DEED
E%l:MPT 1R
REC FEE: 11.00
TRANS FEE: 329.70
COPY FEE:
CC FEE:
PAGES: 1
Recording Area
Name and Retum Address
020-1437-17-000
Parcel Identification Number (PITS
This is not homestead property.
(is) (is not)
Exceptions t warranti s: Easements, restrictions and rights-of--way of record, if any.
Dated
n ~.
*LaCasse Development, Inc.
(SEAL) (SEAL)
~ *
Signature(s) _
authenticated on
*
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by Wis. Stat. § 706.06)
THIS INSTRUMENT DRAFTED BY:
Attorney Kristina Ogland
Hudson. WI 54016
CKNOWLEDGMENT
STATE OF ~'~ )
ss.
COUNTY )
Personally came before me on
the above-named LaCasse Develo went Inc. a W s nsin
Corporation
~Q ~me known to be the person(s) who executed the foregoing
inYtt~i rent and achrtowlAded:d tha~same.
Notary Public, ate of ~.k1_
My Commissio (is permanent) (expires:-~~
(Signatures may be authrnticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY H)ENTIFIED.
WARRANTY DEED ®2003 STATE BAR OF WISCONSIN FORM N0.2-2003
* Type name below signatures. INFO-PROTM' t.egal Forms 800-855-2021 www.infoprofomre.oom
Tracy ~. 71~~~r
Notary Pub{ic
Mate of WiscunsirE
AUTHENTICATION
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