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HomeMy WebLinkAbout020-1395-16-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building1Division INSPECTION REPORT r{ 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 Carria a Homes Inc. Hudson Townshi CST BM Elev: r Insp. BM Elev: t BM Description: " ~ ~ ~ ,0 p, .O v ~.,. ~. CST N~l TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic u 2.ob Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ S~ ~ (' t ~---- Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Num r TDH Lift riction Loss System Head H Ft Forcemain Length Di SOIL ABSORPTION SYSTE / ~ ~ _ __ / pz .., ~~. ELEVATION DATA county: St. Croix Sanitary Permit No: 399574 0 State Plan ID No: Parcel Tax No: 0 0 ' 9 - - tsv'D STATION BS HI FS ELEV. Benchmark ~ ~ ~ • a ~ Alt. BM 3'ZS~ cZ. Z ~, S Bldg. Sewer ,~j~+C~ ~ (CSC SUHt Inlet 6' ~° 4 ~o, SUHt Outlet Dt Inlet Dt Bottom Header/Man. ~ 3, ~ r og Dist. Pipe • 3 S' .l r Bot. System Cs~ ~ 1 5,ps' `, o o• $~ ~ Final Grade wus ~ `" 1A'D I ~. SO St Cover 3.2 ~ oZ. NCH Width Leng , No. Of Tr nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS t 3 9~~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING M ufacturer: = ~s INFORMATION CHAMBER OR ibDt t F~.S~ T e S stem: YP }(Y ~ S~ r ~ ~s .~.- '~- UNIT Model ~r~enr n~j C Cr ~O / DISTRIBUTION SYSTEM Header/Manifold Length~Dia M Distribution ipe ) Length Dia Spacing x Hole Size le Spacing Vent to Air Intake ~ S 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 Bed/Trench Center Bed(rrench Edges Topsoil Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:~Ik1 I (7 / DZ- Inspection #2: Location: Hudson, WI 54016 (NW 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 16 arcel No: ~y,~ 1 J Alt BM Description = l~~f ~~ -' "-` ~ ~' 1~ ~ ~d` 2.) Bldg sewer length = -+ 3p - amount of cover = (a' ~ 1 ~~/ _ 1 ,sa,~" ~ ~,S ~, d,~tpOl, ~ `~'~` ~-- Plan Fevision uired? L~ Yes No ! _ S' J~'~)e th r s' a fQµr~ additional i ~ ~~ ~' +b Z ~ S6D~97) ~r~ E~ ~ Date Insepctors Signature Cert. No. ~ t~Meoed+ ~~ /_' ~ S"4 ~- T, ' lr~ ref ey n,; ' ,,~; ll ~ ~, __ --, 1 Ot Z' i ,• lI41~ Id ~Idt00is1i . ~ ZONING a4iY ~ ~;' 1 f ~ ij~.1 ~3 k 9x. ~S~ tear ~atu ~ ~ o~+ dax an i~~~t ~~ ~ ~ ~~~ ~, s fl ltap3tar-~t+t et e G ~ ~ lung ~, ~1 dw~ t~ ~-'~ ~ lr~ K ~ ~~ ~d `~ ~ euso ~~ 1,b,~N~~ad $~ ~ i,~ .11 D llatlr 8~w q-- -- ,~ ~,~,~.,, .. ~.,~.---- titmeWr ~ ~~ i __ ~r -bozo 6Z( ~~c~o .' x ~~ d c3~~ s, , ~r~ ~ah_ ~39s'_16-ood AE SG. ~.~li c ~ YlS ~,,,.,,,, ~ r ss-0 coalern~+ww~d ~~ ~ Da~+L.Sn. dfipywww wn• -. ---- -- ~ ~`eV~rFOrl ~.~s~wdaagl.~ ~ t~~ q~. ° ~ 9,~,Sv • ~~ ~~ tisi~~~ ~ ~ I r QZ1ii BLS' ~ (/' ~s~~ - 3la ~~~~~~c SG a~~e~ ' ~ / ~~7 ~cv ip! ~11R~tt~ , Q G1tiD~i j b owa~r otv~ar ~t ~ Z~5-, ~' - ~ ~ 9Z2. I ob SCt~w~~ Salary u+.d ~ui1dir~s L,•.;s:ca '` ?.~1? w. W,taa Av~• , p.C 9ax 71l~ '; ~ ~, apt ~~~~ - ~:~ Peru Apl~cat~Q~ ate. w+r. tom, preo~i io~r~laa! v~± p:o~ida -- c r ~ ~r- ~~- - -• I ~~ A: l A ~~ i~ ldA H V` 1 ~' a T 'y. a !4 n ~~ ~ K ~ D Q 1 ~ ~ !~ ~ ~y i ~(,~SG S1 ~ 7`-~ 0' `~ _~ v J ~~ M ~ ~ ~ ~ ~~ -~~~ ~~~ ~~~~ N ip t0 R n ~~ 3 ~ ,~= o ~• ~ a n n 0 ~ ~ r. v ~ ~ ^o Sl: d ~~ T '~. r`` N ~ "~ Q ~ ~ Q 4 y 3 y 0 ~ S ~L/- Cif r J .~ 1\~ J l~ `~ ~~~ ~ ~~ ~ '' ~~~ \' ~g~\ ~,~ ~ ~~~~~ ~~~~ g~5 ~'~ ~,9,,s ~° N 3 ~ ~~; o -- ~ n a °° Q r v ~ ~ ^o v~soons , Deparanentorcommerce - SOIL EVALUATION REPORT Page I o~~ Division of Safety and Buihiings . ~ m aoooroance wmr wmm ~, vv~. f+am. was ~' , 11 i i S 1/2 d ¢ th l Plan must S C O ~ ~es e. an x n n s ess Attach compote site plan on paper not inducts, but not limited to: vertical arM hori¢ontaf refetenoe dire ction and Paroel 1.D. . percent slope, scan or dimensions, north arrow, and t d nearest road. P/ea~ print aIi i ~bn. / ~' ~ 1 'S ` by Date(( r N ~ Z ~ Personal inrormatlon you pnnide mey be used for dgya ) (m)).. . s. 9 . 1 •i Property Owner - ~ ~ `~ P .- _ V .. • ~ ;.; ,Z ~3~t ref W 1 /4 ~ 1!4 S 25 T Z~j N R I ry E (or Property Owners Maiflny Address ~ - Y ~ ~ X -• Lot ~ Block # Sutxi. Marne or CSMIf ~ .. City fate Tip Code PhtZne . , ^ Y~lage ~ ToMm Neared fto~t _ ._ :. ... ~Sti: l l wa.~r 1'fl v~., f'S"a ~Z ( ~`+`~' K~ -;- °, ~ ~ <; d ® New Construction t1se: ® t2esidentol / Number of bedrooms _ ~ Code derived design fbw rate h~Sd ~6 O O GPD ^ Replacement Q PubNc or commercial - Deserts: Parent material Ov •(-c~a.s L. Flood Plain elevation if applicable G Z 2 . I ft. General comments S ~ S ~ rvt e, I e Jaf.b n - 4 2 _ -lo - and recommendations: ~ U ~ e, I •e.J a. ~-; o ri - G o . ~~ # ~ Boruig Pit Ground surface eov. -1 • 50 flt Depth in limiting factor l t in. Soft ication Rate Horizon Depth Dominant Cobr Redox Desc~ipdon Texture Stnidure Consistence Boundary Roots GP D/fP . in. Mansell t1u. Sz. Cont Cobr Gr. Sz. Sh. 'Eff#1 'Effl0l2 ( b-12 I O r IZ -' Sr, 2 ~~r ~ 1 ~ ~ . 5 . 9 2 12 - to 13 - 5• I Zm~b rn{Y' ~ 5 ~ • `~ 3 3/e~ (D ~y LS Ims v~r ~g ~ •"l I-2 ~ 5~-Ili, ~p ~I (~ ~ '~"'S Os yY, I - . ~ I . Z ~- 9z.~' s-~.~ .~, 0 t3oririg # ~ eon" ® Pit Ground surface eov. J - ~ ft. Depth tD lariiting factor _ 1 l ~ in. ~ R~ Horizon Depth Dominant Cob Redox Desdiptbn Texture Structure Consistenoa Boundary Roots GP D/ft? in. Mansell Qu• Sz. Cont. Cobr Gr. Sz. Sh. ~ 'EtT#1 *Eif#2 ~ o -1y z ~ - SL 2 I . ~ ~-~' . 5 2 ly-.3o. ,~.., Si .I ~ S - . S' 3 ~-llt> to - ti o . rr, t - -- . - ~ ~. Z tires cbE- 9z. o r --- ~•Z ' EtAuent #1 = BIJD_ > 30 < ?20 ma/L and TSS >30 < 1 50 malt. ' Effluent #2 = BOD . < 30 mglL and TSS < 30 mglL CST Name (f~ease Pint) S' re CST Number I~clc• w~ ~~-1~.~ w~..~-k e.r~ ,~~ ~ ~_______--- 25 330 Addrie;s Date Evaluation Conducod Telephone Number 211 3 T~ Sbrr,~- + I voz (~ - (- o - ~~s - Zy 7-5FOO8~ Property Owner ia..r ~~ ~ Parcel ID # . Page z of ~~ Boring # ^ Boring 3 ®Pit Ground surface elev. q 1 • S ~ ft. Depth to limiting factor I "Z 5 in. Sail lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflt? in. Mansell Ctu. Sz. Cont Color Gr. Sz. Sh: 'Eff#1 'Eff#k2 p -t 2 ,~ Z Sl- 2mS k rr~r C . __ l v~ , ~ - q z -Z-ZB l~ ~ ~' Si1 2 cbk rv-,-fir c 3 2 -sue I O y I mo----- ~S 1 ~c,n5 m-Fr cs • _ • : 7 1.2 ~1 so-IZS Io yl ms s m~ _ _ _ _ ~" -1: _ 1.Z ~ - ral- q2-~ __._-~ S~6 / Q~. 6 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth bo limiting facts in. ~~ nation ~~ ri n H De th Domirrdnt Cobr Redox Descxiptiort Texture Structwe Conse Boundary Roots GP D1f~ o zo p in. Mansell . Qu. Sz. Cont. Color Gr. Sz. Sh. 'E~ "E Bonng # ^ Boring - ^ Pit Ground surface elev. ft .Depth tD limiting factor in. Soil lication Rate Horizon De th Dominant Redox Desdiption Texture Struc~w'e Consistence Boundary Roots GP D/iP p in. Mansell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BODS > 30 <_ 220 mg/L. and TSS >30 <_ 150 mg/L * EtAuent #2 =GODS _< 30 mglL and TSS < 30 rrrg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the departmerrt at 608-266-3151 or TTY 608-264-8777. sen-sago ~rt.o~roo~ J - s PAGE ~ OF~_ NAME 14 r k•E- ~ ~ LOT# ((n LEGAL DESCRIPTION,t1~ '/a,Uw'/a,S 25 T z~ ,N,R (q E (or~ SCALE: 1"= yU_1 BM I ELEVATION /40 • d BM 1 DESCRIPTION •fa p o ~' z " ~ U~ ~P e. BM 2 ELEVATION 9 ~• ~ ~ BM 2 DESCRIPTION {T,~o ~ Z '~ pyc. ~~'~e SYSTEM ELEVATION ~ . 7 y ALTERNATE ELEVATION q 0.7 U CONTOUR ELEVATION4S.So, g7.so~ 14..5'0 X _ -t- ~ 5 ec . 5 ~G~~S q.o i 4• 4Yt• •. SIGNATURE ,%~l~- ~~~ DATE G - ~ - a ~ _ 'w T' ~ Private 4nsite Wastewater Treatment System Management Plan Septic Tank And Gravity in-Ground Soii 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 SB®- Table 1: SYStem Design Specifications Sancta Permit Number 5'~ Number of Bedrooms Desi n Flow -Peak ( pd) va Estimated Flow - Avera a (gpd) o-o Se tic Tank Capacit (al) f'Z Soil Absorption Component Size ft) < < Type of Wastewater omestic Table 2: Soii Absorption Component -Limits of Reliable Operation Se tic Tank Component Soil Absorption Component Desi nFlaw -Peak pd) i Z $'1' ,~ Maximum influent Particle Size (in} 1/8 Maximum 8006 (mglL) 220 Maximum TSS (m L) 150 Table 3: Mair-tenance Sch®daie Se tic Tank ins eck andior service once every 3 years Outlet Fil#er Inspect once a year and clean at least once eve 3 years Soil Absorption Com onent ins ect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stets. The contents of the septic tank shalfi be disposed of in accordance with NR 113, Wis. Adm. Cade {Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se tic tank and outlet filter shall be assessed at least once every 3 years by inspection. Th outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge shoo! not a removed unless provisions are made to re ai~so(ids -in the tank that may slough off the filter when removed from its enclosure. tf the ~a' Q~a.~.e~t v~ `~ Management Pian for a Septic Tank and Soft Aosarption Component filter is equipped vutth an alarm, the filter shalt be serviced if the alarm Rs aot'rvate~c! .ontinua~.~siy. intemt#ttent filter alarms may indicate surge flow:E or an impending continuous ai&m1. The septic tank snail have its oonoents removmd when the volrsme of scum and sludge in the tank exude 1l3 the liquid volume of the tank. It the contents of the tank era not removed at the time of an assesemen#, maintenance per~ronnei snail advise the owner of when the next service needs to be performed to ma#ntain less than maximum scum and sludge accumulation In the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. A-caess openings used far service and asssssntent shall be sealed watertight upan the aompietion of service. Any opening deemed unsound, defective, or subJect to failure must be replaced. ,Exposed access openings greater Chart 8•int~tes In diameter sl~ail be secured by an effedlve tacking device to provent accidental or unauthorized er:try rota the tank, No one should tntsr a septic or other trwmrserirt or holding tank f'or any mason without belnQ In full compll~enae wlW p$ti-A st~tnderds t-or entartn~ a confined spare. 7~» iatanosphen whhin the septle ar other tG'+Ntiit-~lHMt of ho/dln~ tank may contalrr tsMuN firsts, and tgsaue o! a pareon flroti~ th! tnt~rior of the taR1r may br dlfpavit or lmpoaslbto. Tank abandonment snail be in accordance with Comm 83.33, Wis. Adm. Cade when the tank le no longer used as a POWT8 component, The soil absorption component serving this structure !s designed to accept domestic vvastewatsr from a residanUai facility. The iimlts of operation of this component are shaven in Table 2. Ttte tongevtty of a soli absarption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable apecation, Gaod water conservation practices by aril occupants and the installation of water conserving plumbing fixtures ens key factors in extending the useful fife of this oompane~nt The soli absorption oamponent`s operation must be assessed by inspectEan at least 4nc~ every three years. The inapec~lort shall include necording the levels of pending, if any, fn the observedon pipes, and a visual inspsctlon for any evidence of surfarce seepage ar discharge from the aamponent. 4n steeply sloping cites, erase of erosion should ~ Identxfr~ and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human h®aith hazard= Traf#ic around or over the Boil absorption component should be avoided particularly during vvlnter months= The compaction or nmaval of snow cover over ttte component may Isad to hydraulic failure by freezing. This typo of failure is usually temporary, but is dirAcult or Impossible to repair unto v+toather conditions Improve. in general, soli c;ornpaction over this component will reduce diffusion of oxygen into the soli and diaperoat cell, which may Isad to more intenser, and earner, organic classing of the safe, z ~J ManaQemsnt Plan for a &eptic Tank and Soil Absorption Component Fisntings of deep-rooted treys end shrubs directly over of within ten hat of the component should ba avoided since root intrusion into the component may obstruct wastewater flow. Contingency Plan In the event of system failure, s new system could be installed in an alternate area, 1tltith the lrfstaffation of a diverter valve, the existing system could also bs reused after a period of flu's to tour years. it fs the property owners responsibility to maintain the alternate area free from any planting of tress, shn~bs, e#c. In teas of failure of the orfglnal system, the alternate area will bs needed. !f any trees, shrubs, etc. haw been planted on the alternate arcs, they wli! haw to bs removed at property owrtsrs expense. !f alternate area is destroyed, there an other alternative systems that can bs used, in which, could result !n added expense to the property owner, Any tank abandonment shall be done in accordance with W(sc. Cade 83.33, Any Questions rsgarcNnQ this Dads, pisses contact your local Zoning Oflics or contact the Installing plumber. Za N ~ +~•~ ~ 'ate <<,a~„ ~"'1, t S ~ 3 $ ~,, - ~ b 8 O ~ r~, v~.rr-. 0,.1~,.~..r~. ~ ~. w n, b ~ i~ c~ (? d ~~ 3'g, b - 3 ~ ~ j ~rhUm34:P1"' F'lumh~inq FA' td0. 71JJOFJ121 ~?p. 1~ 291 ~~:95Pf9 P4 sr CROIx couN•rY' SEPTYC TANK YviA.INTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owuer/Buyer C~'n/L~'J~i'~ 1~~~ ~ ~'1 ~/y.~ Mailing Address Praporly A.dtlres5 City/State lv ~'~O ~ GEC ~G t:~~~i~'r! ~ ~~ eJ e 8-~7 1 r ~ S• ~~~r~sc~ ~c~~~s ~~~ fU~ (Veri£cation required from Planning DcparGnent for tLew J'O~< <~ ~-.'4.' ;~~~-L,J W `~ " Pazcel Identification Number ~ y~G° S~ i FGrATa, DESCRiFTYO1~1 f,~ ~ ~~r~.~ /j~.-~ La'~ ~-G `~~"~ .Oc-25-~b Property Location ~ '/,, ~ %,, Sec. a S . TAN-R / 9_W, Tovcm of r~/~,~ v~.r.! - Subdivision c ~' v l~% ,b't~«~ Lot # ~.. CerEif"ied Survey Map # , 'Volume .,Page # Warranty Deed # ~'/ ~~ ~ ~ .Volume .Page # Spec house ~ yes `~ no Lot lines identifiable ~ yes ©no SYST~IVI MAI{NTENAI~ICIu Tmpraper use and maintenance of your septic system eonId result in its premature failure t4 handle waste&. Pmper maintenance consists of pumping out the septic tank every throe years or sooner, if needed by a licensed pamper. What you put into the system caa affect the fiinctiou of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. GSroix Zoning Department a certlftcation form, signed by the owner and by a mastCrPlumbcr, jotuneyman Plumber, °tcdplumbet or a licensed pumper verifj-ing that (1} tho on-site aastewaterdisposal system is in proper oparating condition and/or (2) after inspection aad pumping (if ~), the septic tank is less than 1/3 full of sladge. Uwe, the undersigned have read rho alwve rcquirenietlts ar-d 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. CertiScation stating that your septic system has been maintained must 6e completed cad returned to the St. 4oix County Zotung Cffice within 30 days of the three year expiration date. SI ATLIRB OF APP T DA'1 Lt OWNE)Ei. CER CATION 1(we) certify that all statements on this form are tnse to the best of my (our) knowledge. I (we) am (are) the owners} of the property descn'bed above, by virtue of a warranty deed recorded in Register of Deeds OlI'ice. SX ATURE OF APPLICANT DATL rr«•#* pmy inforil~tion that is mis-rtpresentedmay result in the sanitary permit being revoked by the Zoning Department. ****« ** Include with this applicRlion: a stamped warranty deed from the Register of Deeds office a copy of the certified sarvey map if rcferenco is made in the warranty deed ~{{ ~I I DOCUMENT NO. /J' WAIIIi.ANTY DEIDD '•, I ± ~ '~ L( ~~ ~0 ~ I BTA7E OF WISCON8iN-FORM B ~' '; ~ I THIf fPAC[ R[f[RV[D rOR R[CORDiNO DATA i r THIS INDENTURE, Made b ; RICHARD..N. PEARSON and JEAN M. PEARSON,..husband-and c~ife,....... .................................................................... grantor. S.. of....St.:...Croix .......... .............................................Countp, -Wisconsin, h~reb conveys and warrants to... CARRIAGE..HOMES _ XXI , .INC ~r ~a- _.._.. Minn~sota-corporation..... .....................................•-----....................._...._.......... I ......_...----..._........----• ...................................•-----.....................~..i..........._......_...---......-----•--- -~~ ._..~ .............................................................~.~~rantee........ of ~~ ' WasY~ing~on _____________________County or the sum of - Qne„~ollar_: and_ no1100_..(~l :00) and other,.good•_and valuable--• RtiTURN TO 5~~~?~5~~]~~~ ison----------------------•---............---.....-----.........._....._........_..............---...........---- ......_.........._ .................._.................._..............................................................................--- I' . -_ - .-. the following tract of land in._..$~:...Cry?:X._ ......................:......................County, Wisconsin: .A~.~...4~..~h~..N4i=~k~We~~„Q~artier-,-~N~),-,and,,,~lorth Half (N~) of the Southwest Quarter (SW~) of Section Twenty-Five (25), Township Twenty-Nine (29) .North, Range ~' Nineteen (19) West, St. Croix County, Wisconsin, except Lot One of Certified Survey Map filed June 29, 1994, recorded in Volume 10, Page 2782, St. Croix County Register of Deeds, as Document No. 518444. . In Witness Whereof the said grantor. S.. haVe...... hereunto set:........ their..,-,-,••_, hand 5... and seals.... this ......._......_..._.._.... day of... ~aY ..........................•-•-•--•-•--~ A. D., Y~C..2QQ~. ....................... ............................................................(SEAL) BIQNIDD AND AIDALED IN I'ItEBiCNCIS OF ... (SEAL) (SEAL) ..................................~. (SEAL) Sta~G of I~~Spta was inaton r-.....,... I..,..,~ ~~~ ~'"'0 ~ - A- n 2401 ~ M 117-M-Corporation _ Minnesota Uniform Conv~ancing Blanks (1978) _-_ MitterlDevis Co. ° St. Paul, MN 651-642-1.988 ' STATE OF MINNESOTA ss. Affidavit Regarding Corporation COUNTY OF -- ------- ----- .- - - -- -- -- - and being first duly sworn, on oath says(s) that: 1. ('They are) (____ he is) the -- ----___-- --___-. _ and the ,___-. ------------ respectively, of - ____ _ _ _-__-_Carriage~iomesXXl,-Inc- ------ ---= a __ ~innesota___-_-__ - _ corporation, the corporation nam as _` __ _- _--------- ----- ----- -- - -------- ------ in the document dated _ _.-___.______ __-, and filed for record -~- - ----- as Document No. _..-_-._---___ ---__-_-- (or.in Book _ of ___.__ ___.__ ._-.-_ Page ._-_~___.______-. _._.__.____--_~) in the Office of the (County Recorder) (~~~t~wcg9cR~lx;aq of --- .......... .. . .---_ __ -_ _.__ St._Croix__. -- __._---------._ .__ . County, .Minnesota. 2. Said corporation's principal place of business is at . _______.__-_.______._..____--.------------.---------------- --- - and said corporation's previous principal place(s) of business during the past ten years (has) (have een at: 3. There have been no: a. Bankruptcy or dissolution proceedings involving said corporation during the time said corporation has had any interest in the premises described in the above document ("Premises"); b. Unsatisfied judgments of record against said corporation nor any actions pending in any courts which affect the Premises; c. Tax liens filed against said corporation; except as herein stated: 4. Any bankruptcy or dissolution proceedings of record against corporations with the same or similar names, during the time period in which the above named corporation had any interest in the Premises, are not against the above named corporation. $. Any judgments or tax liens of record against corporations with the same or similar names are not against the above named corporation. 6.. There has been no labor or materials furnished to the Premises for which payment has not been made. 7. There are no unrecorded contracts, leases, easements or other agreements or interests relating to the Premises except as stated herein: 8. There are no persons in possession of any portion of the Premises other than pursuant to a recorded document except as stated herein: 9. There are no encroachments or boundary tine questions affecting the Premises for which Affiant(s} (has) (have) knowledge. Affiant(s) know(s) the matters herein stated are true and make(s) this Affidavit for the purpose of inducing the passing of title to the Premises. Carriage.Homes,~!~ic~ 7j _-_ 'L!. '` ` ' Subscribe d sworn to before me this .; "._ ~- _._ ____ day of ___~ ~_ ~ __. _ _ _ __; .._. _ .' , _.2401._ (Year) ~~ ., c~~ c~~, c~a_._ _ _ ~~,~ 1GG2P~~289 W a r rk~'~ ~cc.~ .. t:,..• 648604 YATHLEEN H. WALSH ~OLim°°«~~ REGISTER OF DEEDS 5'1. CROIX CO., WI kECEIVED FOR RECORD 06-18-2001 12:45 PM WAkRANiY DEED EXEMPT q CERi COPY FEE: COPY FEE: iRANSFEk FEE: 9900.00 RECOkDIMG FEE: 14.00 PAGES: 3 ~. Axoedia; A~u ~c~. Name aad Retain Addrata =-' 1,-a,.d. T;-F lr ~ I r ~ . ~qoo s'~1.,~~ L.~k~ Zo~.d 1lJo ~.,~ $ r. k.b ~1 ~ ~ MN SS'/1Z OZo - 1069 - '70 - oo c~ Payed Idm6Gntim NaatLv ~ (~ZO--lC~6Y- ~p-vUp p2: o - I c76q _°1D - v~v b Zc~ - 1 D7O ' t'o - Cpo 020 - 1070 ~ Yv _n~ U 2 0 ~- ) o ~6 - z o- cxxJ "THIS PAiGB IS PART OF THIS LEGAL DOCO![ENT - DO NOT RFI~IOVE^ Pmne & rcaufr addrcu ad N m °'c ~rmw'nj c@w'a leta(Leredp~on. s~~ ¢oaawoe ems. CL NKwUadl• odw lyyo.+naoo1. ,.ab IVOKi Use of dit cbrrr past ocfdc an~ ~ P~'~ on A+ir Qocreeo~t Pasc fe yoer dx'mnesu and SI.CnW tor~.~ be plaerd oa adra'danat pasty of do 1Pueonria Swauee, J9.J17. WRDA 2/S16 - ~~~ 1G62P~~,:291 EXHIBIT A Parcel Identification Numbers 020-1069-70-000 020-1Ob4-80-000 020-1069-90-000 020-10~o-oo-aoo 020-1o~o-IO-ooo 020-~0~0-20-ooo r, ~1 DOCUMENT NO, __ wwalawxTY Wean ~ n ~(` BTA7E OF W14CONBIN-FORM 8 Y01- ~~~~~'^"1• ~ TNIB BIACE RESERVED FOq gECOgbINp DATA 'THIS INDENTfJRE, Madc b ,RICHARD N. PEARSON• and JEAN M. PEARSON h ....... _•••-~•••-usband and ife - ••°•••-••~ gtantor.s.. of..._St. CroiX ........................................................Countyp, Wisconsin,. h~rebv conveys and warrants to..._~~?A~ HOMES XXI INC. , a ,~ Minnesota rnrporation, ~-"""-""-•°• Giash~lrigtori __.._........_ .........................................._...... .. 'rautee........ of . ......~i~~f~g{} ......._ .....................................................................Count , 1~fYc>41fYll~~ Y or the sum of;' png_pollar_•and-•nof100,_(~1.00).•.and..other--good .and,valuable---!igFTUPN To L~,ti~~l T~'(~t CQ!?~~41@F~tion - ...- .... 1Sfi3:31/t13 /6jCC- s, I ~+~, luf(e {~. ......... ......._ ......... 5 f 1vC ....-.... ..... ~T (~ ~ ~o ti M 1L the following tract of land in....St.r...Croi~.-•-•---....... ..................................•--- ~ ~~'F `~-~ J .................................County, ~ S'J/ L Wisconsin: .A~.1..4f;...khe..N_o5.~hwe~,1:,-Q~ar~er•,itayis;~••and,-North_-Half (N~) of the Southwest Quarter (SVt~) of Section Twenty-Five (25), Township•Zwenty-Nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin, except Lot One of Certified Survey Map filed June 29, 1994, recorded in Volume Z0, Page 2782, St. Croix County Register o£ Deeds, as Document No• 518444. See Attached Exhibit A Parcel Identification Number This is not homestead property In Witness Whereof the said grantors-- haVe...... hereunto set.........t~lr hand.§... and seals.... this ........... --..._........... day of...-.. aY ....................................... A. D., Y#C.2Q01 BIONED AND SEALED IN PRESENCE OC • ••~•••.. ,..... r.. rLJTr~JIAV .-.(SEAL) ' ..............................................................................................(SEAL) (~~ g~ptd Smote of blb}h, . WaShingtOn ,• County, Personally tame before me, this.~S:.~`~.:.. day of.. ~-`-.~..-.-. ...... _ ............... ...-. ........, A. D., ~c...2.Q01 the above named ..RICHARD N. EARSON and JEAN M. PEARSON 'husband and wife ........................ to me known to be the persons--., who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT A!( D AFTED BY r ~`~~~1VIOUNTAIN Richard J. Ga~rLe~, #32864 ,:,~ NOTART Notar Public, ; - ~' NOTARY PUBLIC - MINNES07A y Y • , #114 newt. Y ..... County, Wis. 880 Sible Memorial Hw ••••••---•-••••-••- -T^+-^.*so:•+F.a• wwm ~I:iTD_ ~ MyCOmm.EzpltesJen.31.2005 hb' ~ ~,-~r--~r ~, 1736 My rnttunission (eYt ' ^ (Section 39.51 (I) of the Witcomin Ststvtu pro•idn that all instrumenH to bn recorded shall bare plainly printed or typewrigrn thereon mm4~a of the ljranton, srantees, witncues and noNry. Section 39.313 similuly requirn that the nine of the pezson who, or sovern• (<ency which, drafted such instrument, shall t.e printed, IYlkwntten, Ramped or written thereon in a les~hle manner.) WARRANTY DEED STATE OF WISCONSIN Wlxonaln Losa1 Blank OomDSnT I`ORIf No. 9 MlSwaukae, Wle, (Job 3JS Il 1 (SEAL) ............. (SEAL)