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HomeMy WebLinkAbout020-1395-30-000Wiscorvsin Depr,~tmerij of Commerce PRIVATE SEWAGE SYSTEM Safety and BuiYing Division yA 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 Danielson, Adam Hudson Township Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic W C-l S ~-~-- 25~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , > Zo ~` ~ 3 ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer errand M Model Number TDH Lift Fri n System Head T Ft Forcemain L gth Dia. Dis . ,eai~- ~~ i1:PU~3,e.. ELEVA ION DATA '~ St. Croix 3ry Permit No: 453477 0 Plan ID No: ••------ I Tax No: 020-1395-30-000 mlTown/Range/Map No: 25.29.19.2424 STATION BS HI FS ELEV. Benchmark I Alt. BM Bldg. Sewer Jr•(p7- 11~• ~, St/Ht Inlet (p•`fo i `3~.C0 St/Ht Outlet ~ •Ss 96 . ss' Dt Inlet Dt Bottom d a4r~t: Imo, ~~o - o. 30 .9~- . /o Bot. System Jo. ~ . ~r • ~-8 gJ•YS~ Final Grade .Sb ~S. bo' St Cover 3.b5 99•~s' SOIL BSORPTION SYSTEM p ~,p,N,,,~y~ ~ (~ (~,,<<~' } RENCH Width Length No. Of Trenches PIT DIMENSIONS o. Of Pits Inside Dia. Liquid Depth DIM , ~ Sp.t7 2 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING 1 . Manufactuu~~eer~~~ INFORMATION CHAMBER OR ~ _~ ~Wfi Type__Of System: ~ ~ I 2 3r !~` I ) Tom, UNIT Model Numb~~ V. l DISTRIBUTION SYSTEM vi •lo c,~Qe~--ip L~ Header/Manif IQ d ~ f~ ~ h Distribution Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake Lengt Dia Length Dia Spacing 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 BedlTrench Edges Topsoil Yes ~ No [] Yes 'I J No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Off. IS~r~ Inspection #2: Location: 838 Highlander Tr Unknown (SW 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 30 Parcel No: 25.29.19.2424,~-- L A 1.) Alt BM Description = N~/Q~. ~ S_~~_-n ~- -~n t"~Spea~ ,L ~ay~-d~~ Qt,~_.~~x 2.) Bldg sewer length = I~ ~ 1_` tKl~~ ~ ' --"-• ~ ~~ ~"P'~~ -amount of cover = ~~ tt~ . ~ 1` ` ~ ~~~,¢,, „~u~.~¢r-) / Plan revision Required? j__-1 Yes No ~ ~ ate: Jr Use other side for additional information. t ~ ( ___ `__ ,~~ DW~~ } I 2' _1J SBD-6710 R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division it ,. 2~1 W. Washington Ave., PA. Box 7162 '~ t~Q~,~'~~ Madison, W? 53707 - 7162 Department of Commerce (~8) 6-3151 Sanitary Permit Ap '` i n ~C~+^~,~ `' In accord with Comm 83.21, Wis. Adm. Code era I ' or an you provide ~,I/~:~ may be used for secondary s (l}(tt~, I. Application Information -Please Print A motion - C T ~~~ ST C~~ ~ Property Owner's Na me .. r O^~CF County -~ ~~YG i K Sattitary PermiSNumber (to be filled in by Co.) State Plan I.D. Number~~ Address (if different than mailing address) ~83~ N-IGµ~~+~lac-n.-t~2~~~ Parcel // L,ot ~ Block N Propetry Owner's M ailing A rasa -- -- ~- U Property Location 3~~5 ~ ~U~ !, J City, State~j Zip Code Phone Number ~~ '~'~~`~ `k,Section ~~ ~ "- ~~L ~ _ l~~ I ~ f ~~ ~a (circle of ) ~. Type of Building (check all that apply) ~ /~ T~ L. N; R~~E o~ or 2 Family Dwelling -Number of Bedrooms ~_~~_ ~~ ~~ y Subdivision Name ~ CSM Number Public/Commercial -Describe Use __ ~~-_ ~T ~ ~~ ~ << //~ ^ State Owned -Describe Use _~i_ ~ ^City^~'itlage~Tawnhslh'ip,~of(,~/,~ p~ III. Type of Permrt: (Check only one box online A. Cortnplete line B if applicable} ,, A. ~ ~D~o - / 3 9S- 3 d - a~o~ Tz i New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only I LJ Other 1~iodification to Existing System --_-~'1 8 • ^ Permit Re al ~` ~ List Previous Permit Number and Dale Issued Permit Revision- ^ Change of _.., Permit Transfer io New Before Expir ion ~-`~ ' pJumher O,~.ner IV. Ty of POWTS System: (Check all that a 1 __ _ ~ 7~` ~ ? ~ ~ Pp y) Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ~ i ^ Single Pass Sand Pilter ^ Constructed Wetland ^ Pressurized In-Grtwnd ^ Holdink 'Tank ^ Peat Filter C i Aerobic Treatment Unit ^ Recirculating Sand filter i~ Recirculating Synthetic Media Filter j L.eachi g Cham~r i~ Drip I,~ne L~~rau I-less Pipe O er (e plainj ----~--- V Dr~er~z~Treatmnn ~ .. ~7.-a :.~77" ~h~'~~ ~,Rr~c-T-A t~ ~ ~ l r'"- ~+. `J Design P``low~~( esign Soi p icaf~- V/ VI. auk Info Ca sit Total ~Nt Gallons Gallons I of New Existing ~ ~,~ Tanks Tanks Septic or Holding Tank ~st'J ~ "~-' ~e9~ Aerobic Treatment L7nit Dosing Chamber i - '- -- VII. Resporl3ibility Statement- I, the undersigned, assume responsibility far Plumbe/r's Na the (Print) Plumber's Si gnamre 7--" Plumber's A1ddre ss (Sweet, City, State, Gip C'aste~} Approved ^ Disapproved Sanihary Permit Foe Surcharge Fee} ^ Owner Given Reason for Denial _ IX. Conditions oP Approval/Reasons for Disapproval 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 code/ordinances. (St~ l ~ ~ `~. ~ ~ ~ q/' S~ Glass Ration of the POWTS shnwn on the attached plans. 7MPRS Number Business Phone Number ~a ~Q9d _ s3~6 ~~~/ Groundwater Date Issued Iss~mg A nt Signature fNo Stamps) Attach complete plena (w the Couatyv Daly) for the system an paper not teas than 8112 x 11 Inches in sire SBD-b398 !R. 01103) v //s a ~ dell/ ~6~~ 6 ~~ .J. g. j ~~ . s~ g"~ ~' u ~~~"~ ____-, s y ~ ~ ~~. ~ ~ ~~~ ~~~~ ~.~.~ ~-. ~3t l ~~~ ,~~ ~~ 0 "~~,,s ~. ~,d, ~y` / i COPY //// A - ~. a n~~k'/ U"6s~~U ~J %_-_--~ ~ 6 ~~ t'~ ..1 ~. _j c ` , ~ \l g ~~ `'^ 1 ___--__ ~~~~-~ ~--~.c ~-e-~-. .Q/ I ~ ~ % ~^ ~/ C 0 ~}°~A,,s ~%~~d. J ~`y / l ~~~~ ~r ~,. ..- / ti ' lY ~ l ~ 5«.~ ({rtls lei'- '' '~ '~~"St~ ~ -~a ~-1~- ~ ~~ gs~ -~,,.1~- ~ 3, ~s~ a~ - $r ~ Z. ~~ (~= f a~ 3fa ld , 6 ~ ~r 1~,~ 5`D ~,~k~=(z,~/f~ ~c~~u~5il~ ~~s ~- ~° lz~ ~~lS~ C~ ~~~ ~~ 3.~~ ~3 .ss ~//Q~od) x 1 'Wisconsin Department of Commerce EVAL~~~F RT Page I of Division of Safety and Buildings r..-~ ~ n m aaV~~sl-r+am. ~.cx~e my / ~`q~ er n ess n 8 1/2 x 11 i es in size Plart m~1s~(J Attach com lete site lan on a ~. ~` . p p p p ~4 include, but not limited to: vertical and horizontal reference int (Bt~:c(iF on and ~ I.D. +~gad. percent slope, scale or dimensions, north arrow, and locatio dis~i~ v` Y~~V G pFFICFI ~ Please print all information. Re ~ewed by Date Personal infomtaGan you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m ~ ~ S' Property Owner Property Location °G~ V Govt. Lot W 1 /4 i(/ri/ 1 /4 S ZS~ T Z~ N R E (or~ Property Owner's Ma ng Address Lot # Block # Subd. Name or CSM# 3 0 5 ~~ ~ 3v Gen%c- I~~'ll5 City State Zip Code Phone Number ^ City ^ Vllage ®Town Nearest Road ~~f'Z ( .S~) 77'7 ' ji ~~ h ~G ®New Corutrudion Use: (~ Residential / Number of bedrooms 3 '`~ Code derived design flow rate GPD ^ Replacement ^ Public or commerdai -Describe: _ Parent material C)U-1-iAI~ 5 VL Flood Plain elevation if applicable ~/~~ ft. General certucents j y/ /2 `Y` ~~ l/` ~3, ~ U' and recommendations: 7~" Ong # ~ Boring ~- pit Ground surface elev. DU ft. Depth to limiting fador ~_' in. Soii liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff' in. Munsel! Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff# 'Eff#2 ~ 6' ~ Z - S~'~ L' - r ~^'t-+r C S . ~ v e , ~~.~ Z O ~ ~~ # ^ Boring ~ pit Ground surface elev. ~ • DU ft. Depth to limiting fador ~ in. Soil liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -5J I~ r - ;~G ( ~~5 v~~ C - ~o S/-f ~ /~ ~ r ` 5 m t ~ r ~1 , ~~ 0 'Effluent #1 = BODE > 30 < 220 mglL and TSS >30 < 150 mglL 'Effluent #2 = BODS <_ 30 mgll. and TSS < 30 mgll CST Name (Please Print) - - lure CST Number f' - L 3 0 Tess Date valuation Conducted Teleptrone Number i 13 OU ~ ~1! ~ -.~i r~1.9r ~ 7-i l.cJ i- .S-L/dZ .S` /U -i 3 ~- o y '7/3~- 7t:~ -~Z ~ y IC~ ~~ , Property Owner Parcel ID # Page ~-- of `~ ^ Boring `~ Boring # ~ Pit Ground surface elev.q,~, . se ft. Depth to IimiGng factor ~ 3~ in. Soil liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Diff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 Z y ~'~ ~~ ~ cT ~ '_ ~ 13•~ `ll• L a Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in . Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence &~undary Roots GP D/fF in. Munsell Qu. Sz. Coni. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring Bonng # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil iption Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GP D/ff in, Munsell Qu. Sz. Cont. Color Gr. Sz, Sh, 'Eff#1 'Eff#2 ' Effluent #1 = BODa > 30 < 220 mglL and TSS >30 < 150 mglL • Effluent #2 = BOD, < 30 mgll. 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. ssossw nz.~oot ~ ~ ~ ' w ` ' hnc;E 3or=3 2~.S~rl I,~~r~~~3 u__I.Eaw, r)ESl'IZII'"1-IOPJSiv i~.IN~,_u~1,Szs"1~~_.rt,lt,~r:~~~~ w NAME: ~ SCALE: 1"_-_~~)----- --------------- r ~1~ ,/~ LEVA'I~lO1J:__- -UCH _ __. h^ i ~~ ----- -- -- - -- - -f` -. DM i DGSCRII'1"[Ohl: _..}~~__a_~_~-~Lu~B_~ws ~~ J~ u~ ~_.. 13h1 2 ELEV~\'Ilc)t~: _ _ _-_ _ _ ~ S2~ ~_Z ---- I3M 2 DESCIZII' i'IOt l:-__-- - ---- _ - - --- -------- _. SY5"I"Iavl LL,I:V~\'1'I~ )rl _ _ / •~ ~ U. _ SYS"1'GM "I'Y I'I ~.:---(~v,'~-~•e_,r~~-~~v ~ ~! t ~~.. V ~~ `~ .~., - ~, ~ orb ~`~-°~ - ~' ~ ~` - Safely and Buildings Division County 201 W. Washington Ave., P.O. Box 71b2 ~~ GYV r ~ ` ~~~~~~,~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) ~ De artment of Commerce (~8) 266-3151 S Sanitary Permit Application srnu Plan LD. Number personal information you provide Cade Wis Adm In accord with Comm 83 21 , . . , . may be used for secondary purposes Privacy Law, s15.A4(1}(m) ~ 4 Project Address different than mailing address} " I. Application Information -Please Print All Irtformatian 6 r {,, t~ ~ ~ `~' ~. Q `/J ~ ~.~ ' ~~ `+ Property Owner's Na me ~ Block ~' Parcel Lot A` r Property Owner's M ailing Address "~ ~ ~ rry Location i ~ ~ 3 ~.,.•._-.--_.~., _ is ~ T_,.., -~ _ ©~ ~ ~ ~ 'ti,Section ~s .5~~ i~,~c1 Zip Code City, to Phone Number , Cf ~:- d-- ~9 /~ .~~ / ^ ,~ ~ . ~ (Circle o ) E o>~ T ~Q N; R~ ~ ~ T Building (check all that apply) II „_ s . ^ 1 or 2 Fam elding -Number of Bedrooms S. Subdivision Name CSM Number ^ Public/Commercia escribe Use S ' ,'G~ .~/l.S~ _ ^ State Owned -Describe ~ ~_E,•~~t ~ ~ Wit:' rZ.~ - -~ ~ ^Ciry_^Village nship of ./`/e*~-~S/ ~ III. Type of Permit: (Check one box on tine A, Complete ne B if app able? Q2.D - 1395- 3a - • z Z A' New System ~ ^ Replac tit System ^ Treatment/Holding Tank placement Only ^ Other Modification to Existing System $. ^ Permit Renewal ^ Permit Revisi ^ Change of ^ rmit Transfer to New List Previous Permit N d Date Issued Before Expiration Plumber nor ~ ~ IV. T of POWTS stem: {Check all that I) _... Non -Pressurized In-Ground ^ Mound > ?A in. o 'table soil Mound ~ in. soil ^ At ^ s Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ ins Ta ^ Peat F' r er Treatm 't ^ ire Sand Filter j ^ Recirculatiag Synthetic Media Filter eaching Chamber ri Line ^ Gra -less a explai V. Dis rsaUTreatment Area Information: -~ a, Design Flow (gpd} Design Soil Application Rate(gpdsf) Dis r rea Required (sf) Dispers a r evat n VI. Tank Info Capacity in Total Num anufacturer Pre a itc I Fiber plastic Gallons Gallons of is Concrete structe ss New Existing Tanks Tanks Septic or Holding Tank r ~ ~ ~, ~ Y Aerobic Treatment Unit Dosing Chamber ~~ , ViL Responsibility Statement- I, th8 and d, assume responsibility for Ration of the WTS shown on the attached Ions. Plumber's Na me (Print) Plum s Si gnature MP/ PRS Number Business Phone Number Plumber's Addre ss (Street, City, State, Zip e} VIII. Count /De artment Use O Approved ^ Disapproved Sanitary Permit Fee 'eludes Groundwater Date Issued suing gent Signatur (No Stamps) ^ Owt~r Given ason for Denial Surcharge Fee} [~ r 2~-~ . 2 IX. Conditions at Approvat0 ons for Disapproval SYSTEM OWNER: 7 Septic tank, effluent biter 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 code/ordinances. SBD-6398 (R. 01103) Attach complete pleas (to the County onlyl ror the system on paper not lass thaw Sly x li inches in size i; l .. - f '' to / ~. -.--~ in f~r~ ~' - o~ ,_-_ ~~ f'~d `~ y, • ~" ,.• _ ~~ ~ r.~ ,` ~ ~' ~~~yj~°~6 ~~60 f GJ'~~ ~ 3' ~ ;~~" ~~ ~~ ~ ~! ~ i Otis ~ a'3 ' jai r ~ COp~I ~ .,~ K ~ 3 mac, .v. ~ 7-, ~` << ~~~ap-rte 1~a,•U~ ePs~.y ~~ ~ ~" ~ ~ S ~-~C'.so~~~ • '~~;2 ~ ~'~ ~ ~~ ~ ioo, `' ~----, in F~~ tom'' Q9' S n,~ ~~~ ~~ ('l y~ . ~Pr ~ ~~~~ %~ ~' ~~r~Y ~ us ~- 1 y5 ~~ I l i /. r ~5~~ ~~a ~~~: 3' ~a _~ ~ r Wisconsin Departrnent of Commerce SOiL EVALUATION REPORT Page ! of Division of Safeiy and Buildings m aoooroance wrm Comm oa, rns. r+arn. ~,.ooe st Pl i a 1 11 i d h te C~ ~ -F. c ro ~' n tes /2 x site plan on paper not less than 8 Attac comple an mu e. n s inducts, but not limited to: vertical and borizonlat percent slope, scale or dimensions, north arrow, ~~ °~ , daection and to nearest road. Parcel I.D.. . pL O - 3 9 ~ - ~ . ~.._ Please print all ~ atio . ~ ! i ~:.~ - % by Date Personal h-formation you prowde msy be used fiery ~:r , t:~,•s.~.oa (~) (m)). l 19 0 Property Owner - ~ J ',P rty Location ~~ ~ ~ - ~ ~ . ~ ~ { ~'~ Lot W 1/4 tit W1/4 SZ S T Z9 N R ) 9 E (or Property Owner's Mairarg Address ' ~; ~T G~X Bbdc # Subd. Name or CSMIf \ CO ~ Z 0 S'~ i ~~ w ir` ~H~ S e , ~ ,:. City State Zp Code City ^ V~lage [~ Town Nearest Road sti.<<t,.1u.~r' YYIh,. ~S0~Z (` ~=3: ,f ~ s k,n ~- ® New Construction lJse: ® Residential / Number of bedrooms 3 ' `7~ Code dernred design flow rate D SO ~~o O O GPD ^ Replacement ^ Public or aommer+aal - Descnbe: J ~" R Parent material OU fc~r/t.S (~ Flood Plain elevation iF applicable L General comments 5 S ~ r71 C. L G 110. f.b n - f0 S"'~_ ~-~ W w 4 I • ~ and reoommendatiorrs: l4 U ~ 2 l ~.J a : d r~. - ,-}a `I l . Si5 LD v~l of O.Op s s X33 y d !~ a~- y - o. o © Apr Pit Ground surface elev. 9~o it. t~epth to limiting factor ~1 in. ~~ # ~°1 ~'g y Sod ics>ticn Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consrstenoe Boundary Roots GP D/fl? in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 •Efi#2 -~Z it~~ X13 ~~ - 2m4b mfr cs ~ ~ ~ 5 . ~ 2 12-44 (~ ~ Si cl mShk m-~r C s - ~ y ~ ~ 3 jj ~~ , ~} I _ m S ~ ~ _. - --i 1. 2 ~ ~ ~ ~ ,~ .s. .S' 2. 5S ~ i~ i ~ ~ bh Z ^ Bonng ~ ~~# ®Pit Ground surfaceele ~ 7t~ ~~Dep~th ib'Inniting factor / 2~ in. Sod Rata Horizon Deptir Dominant Cobr Redox Texture Structure Consistence Boundary Roots GP D/lr= in. Mansell Qu. Sz. Cont. ~Olor Gr. Sz. Sh. - 'Efl'#1 }Eff#2 ~ c~ -i (~~ a'3~ 3 _ - ~ I Z.r~nC;~hk. ..rn~r cS I v ~ . S . 8 Z r ~ -) ~. ~ ~ .4I`{ - s; c.1 msb ~ -4r ~- s --- ~ ~{ - ~ 3 1~~-12c~ , ~ ..~~ 'ms ~~.. ~ -~ - , ~ /. 2 ~~- 3, s ~ „ ~~ ~_ <, • Effluent #1 = t30D_ > 30 < 220 moll and TSS >30 < 1 50 moll. ' F~tluent #2 = BOO < < 30 mglL and TSS < 30 mglL CST Name (Please ..Print) Sig_na~ture CST Number - - - Address Date Evaluation Condur~ed Tele~rOne Number 2.11 ~ ~0`~S~- ~~ec~-~-, UJ~ JZ-I~'L~ l~~ -o~ ~iS-Zy-~-yoog - ~~ _ ,~ Property Owner r' ~~• ~ ~ -- Parcel ID # Page z ' of _ 3 • Wiring # [~ Boring G~ {~~-----~-~~i ®Pit Ground surfaoeelev. / 2 • db ft. Depth to limiting fiador / ~ in• Soil lication Rafie Horizon Depth Dominant Color Redox Description Texture Structun: Consistence Boundary Roots GPD/f!? in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh: *Eff#1 'Eff#2 1 n -lz so r 313 ~; I 2~k r-r~Fr c_~ ~ ~ . ~ . ~z-iy ~c~~~r~14 `=-- ~;~-~ 2~`~k ~ ~s L~ iY-~c~~ lD~ ~kl~ . nnS ~ D~o = 3 `~ ^ ~~ # ^ Bonng ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~ ~~ ~~ Horizon Depth Dominant Cobr Redox Description . Texture Strudune Consistence Boundary Roots GPD/tt= in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. eft. .Depth to limita~g factor in. Sal lication Rate Horizon Depth Dominant Cobr Redox Descxiption Texture Structure Consistence Boundary Roots GPI in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 *Eff#2 ' Effluent #1 = BODS > 30 _< 220 mglL and TSS >30 <_ 150 mg/I. * Effluent #2 =GODS <_ 30 mgll. and. TSS _< ~ mglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material 'rn an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. ssn-s3so Rt.m~oo~ PAGE ~ OF_~/1\ ~+ "' CI V aN i ?I,PE 12" :MIN , ABOV ` G:~AA£ b ~ ~ 5'.~'RCM 1?d,UR ~ ~NI•NDAW. pR , ,..., t ,,_ FR£SH AIR INTAKE FyNxSHE~ r~RAI:~E 1 `+" C Z R T SER -~-~±~ '"" ~.9" ~MiN . ~ `( '.fir' i+i i ~ ~-w--,......»....,....._,.,,..,, I ~ ~ ~~ WA'`fiR T3VC2I SEAIr5 ,,,,` ~~ ~~RPRCV~~3 -Ip~ 3, ~ ~ INTO 5,'?~. Y p 1 ...~.... ~~:~ ~ } ~ . nJMF GF~' E1.EV . ~~x T . ~~D +~€AT~!ER~aQt~~ JL'NOZ'201v' ECX WITH C~N23UZ;' ~s. ~~~ -~ ~' ~ 2 ~ ~` GAs- i , ~ , TIG:IT SEAL AI.M ' ~ 'ON t ~ ~, ~ CFFj ~ " AS Pk vV ED BEDDING U ND£R TA?~~K ~TIG / DOQ£ 'A:JK MAI+PJFACTJREit S1~ECIFI~,Ai?~,'-5 :iL~i ~.g.CY `,~,N~~ 5~~ ~S; SE'F'~"ZC ,f..4. GAL. DOSE dv GA,~, . yLAFs."~ MA~FgC'IVAER: SWITCH TYPt : ~1!~.!.l.,,C,.....~..,... t-,~, MANUFAC'F~lRER ; „_ ~ Kile.~~ MODEL NUMBER ; r° SwI:~CH TYPE: ~~U~RED DiSOKARC£ R.AT ~~~r,p,~ exT+~AL ~i~'FER~N~~ ~~ A P PR {1'! £D `4A.YNOuL UOV,~~ W / PAL` LOC K 8 wA~rrxuG LAS~~ .~... 3} -r "!: h rr n vAPPROYED ~a~r~s wt~r~ A~PR~YEn ACAS 3 ` Ot~'O SOLID, $QIL '~~' RxSER £X:T ~'ERMYSTED ONLY IF TANK MAM3FA~?JRER HAS APPROVA? ~~N~RWxF PAS LQS* VCi~U.~i£ ~~~I~'11~Ijj~C~~wUDrrr yNG //~a , r ±+ ~f `+i ~~A ~r iti j ~+7A 4i . CAPA~ i TI t 5 : A : .~.~...,, i.'vCNES ~' .W~4~~C~,...,~.sA L . ~ : .~. ~ , INCHES '~ ..-....~....GA:~ . ~ ~ INCHES r (' 3AL. D •~ „~ s~'~CHES s ......GAY ;,,' ,: R.~ ivG AS : ER I LNR' 2 b. 23' '+-~A Ia;INIMUM NETWCiRK SUPPLY PRESSL'RPO F+AND, ZSTRIBU i I fJN FTPE ~,'~' I'EET -~~.~...,_,.,, FEES' FORCEMAI.W X .~°c~ ~'T/?3p F:". ~ ~+'^ ;, ;, ~ FEET .L.._.,, FR.;.7..3N FACTOR FE£'T +'~0?4L DYNAMiG ~fEAA ~"'EhNAL DZMEA':ONS OF FGMP TA?r'h: r"EF.T ~GOULDS PUMPS • Fully submerged in high grade turbine oil far lubrieation and efficient heat transfer. 3 V / ~ EP05 APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECtFICATlON5 • Solids handling capability: 3/4"maximum. • Capacit;es: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'l~" NPT. • Mechanical seal; carbon- rota ry/ceramic-stationary, BUMA-iV elastomers. • temperature: f04°F (40°C} continuous 140°f (60`C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Molar: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset, •EP05 Single phase: 0.5 HP, 1 S 5 V, 64 Hx, t 550 itPM, built in overload with automatic reset. • Power cord: l0 foot standard length,l6/3 S1TOW with three prong grounding plug. Optional 20 fooC length, i 6!3 S1TW wiilt three prong grounding plug (standard on EP05}, Available foe automatic and manual operation. Auto- maticmodels include Mechanical Float Switch assemiyled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic Semi-open design with pump out vanes for mechanical seal protection, METERS t a W s..+ 0 0 9 s s a 3 2 0 Submersible Effluent Pump ~~ ^EP05 Impeller: Thermoplas- tic enclaseddesign far improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor blousing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated o'sl and water resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING ~' Car~lian standards AuodaUorr (CSA listed model numbers end in "F" or "C" } Goulds Pumps is ISO 9001 rtegisrored. U 2 4 fi 9 1 U 12 mj{h CAPACITY Goulds Pumps ~92oo0GauldsPumps (~~ iTT Industries Effective February, 2000 83871 .~..~ .~ uick~~ CTAA/heron /tun,r~aca slDe vlEw oGl~111JIV VItW MultiPcrt End Cap FRpNT VIEW f~ r ~~ ~~ ~~ ~ ~ sIDE vl~w roP vlEw a~~ ,'•yc a, t _ rslt ~~ r , ~ .._..r . rs,;.~~i~ ;,:.; y'ti° ~ ,. r ~~,. ~.... ~ . ` sr .,~. ~ :e A , .r~ ~ e~ ,r] ~~ Quick4 Standard Chambe~r'Nominal,~ecitications Multiport end Cap.Nominal 3peaiticatirons , j y ~ s. Size(WxLxJi) 34"x52"'x12 Size(Wx~xH~ 34"k i6"x~2" Effective E.ength ~ 4l~" Invert Fies`ght 8° ar 1.25" invert Height ~+r INF'I~TRATdR SYSTE S INC STAN~,RD_.~.I ITED w RRAN~ 'ul hC srnrr:(ura' r eqr IV of guuh rhamUer, end pIaIB: wsdye a^o other ac ~assory man -: t r. ud by In4flraro~ ('Units") wt:en 'n;l rl Prl .ntl rhxrrared ~. i d f.aGY field of an Cr J .?ptlc 9y'slern in apCOfddnat With IniriHatnr's it StluCllnts, i6 v - rrtr>v h) Iho ong ,61 purch°ser (°HC,kkn' age. 'I tfeieLMWe male tart acrd worxmarrsnrp rpr one 4ear Iran the etat¢ that the 9e[Aic permit s reseed (pr Y o septic sysla, .~x:lau,irry the Units, parvrrlpJ, hewwvor That ,f a sopt~c perml rs no( reyu r¢rJ UY aPPliCatrle knw, the waR'May oor¢rd wiN deyin c:porr Cho date thsl - alalipn of lira epHc s s. cmm~xarx:ea to a urtise 115 wa rn ty nytrl; Fir de r":st netrly Infrltratrx in wrif~ng at its Corporate Headrrunnxs 'n Urn Say~ronk Cw ,n"wtlcut wn'r;n rrlaon (151 nay of lr¢ allegrrd dP7Pf9. Ndtlt aku wJl supply mpkaCamrrnl ungs rdr Unit, ootarmined ty IM+araror rot c.overnU by this Umileq Vvarr,nry Inlil.rahu s IiaUdrtY s/mr"irtWy nxclrrdes Il+e r<rs! of rartrova! arrd/or inatal!arrcrn u! the tln"4, IUj THE LIMITED WAftHAtJTV AN1r REMEDICS iN SUf3PARAr gAPlti faJ AF [ L~(CL',i~ ~E L-RF AFlE NO i)INEH 'WARRANTIES WITH R',-=Sr~CT T~ IHE IJNi Ig, IM„LUGINIi HO IMPLIED WAFFJANTIES OF MERCHAN'TAOILI ry' OR F! i Clebb FGR A FARTICUi AF PURPOSE. (c 1 hl I miteq Warranty shall be 91U rt any pan il t P chamber sYStem Is ra r nanturo f ty xnyona roFx,r Iiwn hUllf aloe The lJn taU Wa art Urws r,pr e lend In inr,'ry¢nUl, rrMSCQta tai, 5{bCGr.A Ur ardlrr,r;i %lamaga5 Inllllratrn sh91i not 4F 1aLk for re ~aiin3s or IryWda.rxl darAago 'n r tlvrg xlss o! Prtxlu,=4Dn alyd p'UIRS, latnnr dnU mdignals, o efhazrJ CRSIE. cx Ciha losses or expsricos rnGUnrxl by ttre HUUer pr any Ihrtl Fi-atly, aJtx iG;911y exc0.rUed (ran [irn tad Wnranty cuvorage ere Uarnage to the Urvls drug to rardina: f wear and I¢,fr, all6ration, aa:idnnt, miurse. abuse or nygleCl o! the Unas, the Unil~ lra"rg SuhjaoleU to vrshicW 'raffx; rx other Caldilfnns which aro no! pannitted Gy the urRlaliation InslmeUars; tailw& io nrainfain the minimum ground coves stn forth rn the Installatkrn instruchone; the t.JarameN of in+propai malarlaLS aNO the system containirry tlx~ lMr1s: fariwe of drP : ms nr the septic sYStern Uue to Nnpmper sitirry or imprgper sizing, excessive water -rye, Vnrpmpar yreasa disposal, or unproper operation; or any other avant nJt causE'o Uv InGrUater. Thig Urnitec Warranty shall Ue voxJ .1 Itel HUdet 1 15 In rnnrpty w;rh al or thr Corms 66J }oAh in Inrs Limited Wa anty, r:,rorer. ur no avern snhu "snrator t rnspcnstrb fn any loss nr :famape rn Ine Holrlsr, Iho Unts, a any thl J PortY nlwlliny ?rim mstaJal;on w ship- rnsnr, or from any [xrxrtrcr haburly clanns ¢i Hokiar ar any In"r, parry. Fcr this umded Wananiy to npp;y, the 13n85 must ho lnsrallPd m ac:cord,vru wkt+ an site uorrdrtipns regrnratl I'rY stare an(I Icral oocles- all other applrrabla laws: anti Nt0liratcxa lrsfeNation in6iruotkx'rtr. lot No represenlativ5 of InliYrater has the aWhprky In cnanyr: or extend thrs l.imitrxf Wananiy, Nc warrrnty aPphss to arty party orha+ than the origi~ rral NoAyer, The abcvo rePresertts the Standarti Limited Warranty (rdered by IntiUralor A Imillad number err slates and Counties have dAWranl wananry nar.Gire- menls. Wry purUrasor of Units snook] rzrr,tar:E Intiltratrrfs Curprxaie HsaUquarters ~.n Uki Say[acx~k, connectiouh prgr W suer pracha:.rr. !o r,+rrtan a Copy of the applicable warran!y, and should caratulry road roar warranty prior to the txlmnase of Units. U.S. Patents. a.759.6E t: 5.6t y oaf ~ s ~ ra aaa~ c •nnr_ m ~>. ~ . - -- ~ i ~ • ~ SYS~1`EMS ! N C Environmental Onsite Wastewater Solutions" 6 Business Park Road • !?Q, Box 768 Old Saybrook, CT 06475 860-577-7000•FAX 860-577-7001 800-22t-4436 ._.-, .~~, .....~..rv~ ...... ..r,v ,w - rr0; ~,nSy.ry94 anadian Patents: 1,329,359; 5,004,564 Other patents pending. ~ ~ ~ ~ ~ ~ ' tr~,tiitrator, Equalizer and Sidewinder are rrayisl8red tredemarks of InfU[rator SystEVns Inc. Inliltratrn is a rragisterad trademark in pranpg. Infltrator Systems irx:. Is a registered trademark's Mexica. Ca~taur, Ctx'daur Swivel Connection, Mic;roleaching, PolyTufl, Snaplxk, CharnberSpacer, Rocs! xk, QuickCul. fkrckRtay a6CYC(EOVAI>!R and Oulck4 ars tmdemarNS o! Infiltrator S/stems Inc. ~J 2003 Intitrator Systarns Inc. Pentad in U.S.A, nm f onvuo_n Quick4 Standard Chamber P4WTS 41MNER'S MANUAL & MANAQEMENT Pi.AN Psge of i?~8Kifii PAt;AMETERS ' Number of Bedrooms ~{ p NA Number of Publb Facility Units NA Estimated flow leverage) ~ aiJda Design ftow ipeskf, iFstimated x 1.5) ,~~~ © ai/da Soil Application Rate al/da /ft~ Standard tnflusftt/Effluent Quality Monthty average' Fats, Ail & Grease IFOGp S30 rngfi. Biochembat Oxygen Demand {apps) 5220 mg1L ^ NA Total Suspended Solids {TSS) 5160 mg/l. Pretreated Effluent i3uaiity Manthiy average 8iachemical Oxygen Demand (St)Dsp 53+Q mg1L Total Suspended Solids (TSSp S30 mg/L U NA Frscai Conform (geometric meant 5404 afu1100m1 Maximum Effluent Particle Sixe ye in dia. DNA Other: DNA "Values typical for domestic wastewater and wptic task effluent. SYSTEM $PECIFICAT'IONt3 8aptb Tank Capacity ,~ (J al l7 NA Septic Tank Manufacturer O NA Effluent Filter Manufacturer ~ .~, DNA Effluent Filter Malel ~0' d NA Pump Tank Capacity al Q NA Pump Tank Manufacturer CBS ,~ d NA Pump Manufacturer ~,Q..~/ ^ NA Pump Model ~p ^ NA Pretreatment Unit Ci Sand/Gravel Filter ©Meahanicai Aeration ^ pisinfection ^ Peat Fi{tar ^ Wetland ^ Other: A D sal Cali{s) l Ground (gravity) ^ At-Grads a Drip•Ltne O NA D En-Around (prassurizedp D Mound ^ other: Other: Q NA Other: ~ NA ~~~ .v Na MAta~a+tAwc~ sc~out.~ Ssrvioe Event 8enrice Frequency . inspect conditan of tankts) At least once Query: ,3 ear s e lM~"' 3 Yaara) fl NA Pump out contents of tank{si When combined sludge and scum equals one-third {}y} of tank volume ^ NA in=pact dispersal cents) At least once every: ~ {sl tAll~dmurn 3 yeas? 0 NA Clean effluent fEter At least once avarv: ~trlonth aj Q NA inspect pump, pump controls br. alarm At least once every: ...---- enonthtsl Q si DNA Plush Iaterads and prsseu-s test At twat once every: .-- ~ C7 rtton at at O NA Other: at least onoe every: „_._ 0 rttonthta} o ta) DNA other: d NA MAiNTElA1ANCE INSTt;UCT1ONS inspections a! tanks and dispersal cells shaft ba made by an individual carrying one of the following licenses or oeRifications: Master PlumbeM; Master Plumber Restr'rctsd Sewer, POWTS Inspector; POWTS Maintakner; Septage 5ervicin$ Operator. Tank inapeati4ns moat include a visual inspection Oi the tankie) tc identify any missing or broken herrlware, identify any cracks or leaks, measure the volume of combined sludge and scum and to cheek for any back up or pending of effluent on the ground surface. 7'ha dispersal pelt{s} ehal! be visually inspected to check the effluent levels in the observation pipes and to chock far any pending of effluent cuf the ground surface, Ths pending of effluent an the ground surface may indicate a falling condition and requires the immediate notification of the local regulatory authority, When the combined accumui~ptrlon of sludge and scum in any tank equals one-third iYs) or more of the tank volume, the entire contents of the tank shah be removed by a Septage Servicing Operator and disposed of in accardanae with chapter NR 113, Wisconsin AdmiMstrative Codo. Aii other services, including but not limited to the servicing of efffuent filters, mechanical er prsssurixed 4omp~nants, pretreatment units, end any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall ~be'~rovided to the local regulatory authority within 10 days at cafnpietian of any service event. Page ~.~ of ~_ START UP AND OPERAT{ON ' For now canstruciion, prior to use of the POWTS check treatment tank{si for tt~a presence of painting products tir otherchemicais that may impede the treatment process and/or damage the dispersal celfisl. ` lf~higli~concentrations are detected have the contents of the tank{s) removed by a septage servicing operator prior to use. t- , System start up shall not occur when soil conditions are frozen at the infiltrative surface. Ouring power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater wilt be discharged to the dispersal collie) in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septaga Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer.to assist in manually operating the pump controls to restore normal levels within the pump tank. ' Qo not drive or park vehicles over tanks and dispersal celis. Do not drive or park over, or otherwise disturb or compact, the area 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 the POWTS; antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; dagreas•rs; dental floss; diapers; disinfectants; tat.' foundation drain (sump pumps water; fruit and vegetable peelings; gasoline; grease; hrsrbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brin®. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the sYStem is property and safely abandoned to compliance with chapter Comm 83.33, Wisconsin Administrative Cade: • Ail piping to tanks and pits ahaii be disconnected and the abandoned pipe openings sealed. • 'the contents of ail tanks and pits shalt be removed and properly disposed of by a Septage Servicing Operator. • After pumping, al! tanks and pits shall be excavated and removed or their covers removed and the void space fined with soli, gravel or another inert solid material. CONTliNt3ENt"Y PLAN the POWTS fails and cannot be repaired the following measures have been, or must ba taken, to provide a code compliant rep cement system; A suitable replacement area has been evaluated end may be utilized tar the location of a replacement soil absorption syatam. The repiacament area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot Nnes and welts. Failure to protect the repiacament area waif result in the need for a new soil and site evaluation to establish a suitable repiacament area. RepEacement systems must comply with the rules in effect at that time. Q A suitable replacement area is not available due to setback and/or coif iimkaticns. Barring advances in i'CW73 technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ Q 7 k site e tank D Mound and at•grsde soil absorption systems may ~be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstruciiona of such systems must carnply with the rules in effect at that time. < < WARNINQ > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAX CONTAIN L1=TNA1 t3AS$ES ANEW/OR 1N8UFFiClEN7 OXYQEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. Oi:ATIi MAY RESULT. RESCI3E OF A PERSON FROM THE INTERIOR OF A TANK MAY SE DIFFICULT OR IMPOSSIBLE. Al3DITIONAL COMMENTS POtiV't"S INSTALLER Name f~,`~/~'~c ~~-~+ ~ a1~ Phone ~ r _ ~ _ ~ ~. POWTS MAUVTAINER Name Phone SEPTAQE SERV ti OPERATOR {PUM 1 LOCAL REQULATORY AUTHORITY Name ~ Name ~-. (~ l 1l1(~__~__ Phone phi ~ S ~~, Thin document w drafled in compliance with c spter Comm 83.22{2ltb){t){dl&{il end 83.54(11, {21 8131, Wlaconsin AdmtNstrative Code. Rug 12 04 07:OOp Precision Excavating 715-684-3299 p.2 r_oi MAY-28-~3 07:19 AM ~-c c ST CROIX COUNTY sEPTIC TaNK MAiNTNpA1`~CR A~ggEMENT OWNERSHIP CERT'1FICATION FORM ~- Rte . ~ QwnedBuyer Mailing Address Property Address (YeriCeatioa required from ptanntteg u~N~•»••_..- --- --- CitylState ~to~; ~~ _~- Marcel Ideaitification Number D =SCRIpTIOLl Z` N-R 19 w, Town of ~`~o'""~ Property Location 5W `/~. ~~ `/~• S~• 25 ~ T._~ subdivision ~,r, ~.. ~---- ,Volume ,Page # Certified Survey MAP # 1 ~S~ S~~ ,Volume 2 aG Page # Warranty Deed # _.. Spec house F~yes ~oo Lvt fines identifiable' yes l7 no SYSTEM MwY1VTENANC~ tstature failure to handle wastes. Pjop°t °°° ~propertaa sad auiotenaaceof Your septic system could resin! is its pn VVbat ~ Pot iato the syitrai coasistt of pttapiaj alt the teptsc tank every thra Y~ or sooaer, if heeded by a lioeased pttmpcs can affect the fitaetioa of the ~P~ pnlc u a trt:acmeat serge ~ tt~e waste disposal ttyattan. ~ a _ D ant a caution form. ~ ~ 16e ottrnct ownts agrees to tubtatt to St. ttoiX Zoauuta cP ~ 1 tltiaan-~+~~YVatar~ tttaater pituobe~r, jotuaaymatt ptumbar~ restricted plutabetoc a lieenaedputt~ c~vet'~ ~ ~tk; taotc it leas tttao 113 ~ ~• it is proper opentiaa eooditiott and/or Cl) alto[ ~pecoon sad p~~8 ~~ vats actt+age dal ~ n^th tbs paedta4s Lave read the above [aquuemeats sad agree to maiataao ebe Pn ~ ~ W tt0a ~• ~ 1Rd and the Depasttaeat of Natustl Raon~+. DlRes vrl>y~ 30 ut tooth. ht:reip. as set by tba Deparauent of Comtoen'.a to the St. Qtoiu Gatnh- Zoatog stating that your teptia ryaetstu bas been msiogined rnust be completed and returned days of the three year exptratton date. • ~~ o ~,.~. i SIGNA OF APPLICANT DA'f B Ow C IO our Imowladge. I (wc) stn tare) th° owtgda) d I (v„a~ eectil~- that all statements oa this form an true to tde best of myo! Daads OQ,~. the property do cn'bed above. by virnte of a warssuty deed recorded in Register ~ ~ ~: .,,,~, OATS St NA OF APPLI ,A~VT ~ ~....• My iatbtmatioa that is mis-represented tray result in the sanitary portrait bai°a a'voked by tLc T.ontoi Dtpattaa*.n` ..•... ~• Include wftb tbla application: a stamped warrattry deed frown rho RePister of Deeds otGoe e copy of the et:rtifud survey Wrap if raforence is aaatk in We wturanty tltsad U 2528P 2I9 STATE BAR OF WISCONSIN FORM 1 - 2000 Document Number I WARRANTY DEED THIS DEED, made between Carriage Homes XXI, Inc., a Minnesota Corporation Grantor, and Adam Daniel~on~nd Debra Danielson > husband and wife, survivors tip marital property. Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property"): SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: !' Land Title Inc. `(,~ 190Q Silver lake Road Suite 200 New Brighton Mn 55112 Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 12th day of March 2004. Carriag omes XX~nc., 4 * Kellei St. Martin, Vice President AUTHENTICATION Signatures} authenticated this 12th day of March, 2004 'TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Greg Booth A ttorney 1 900 S ilver L ake R oad S uite 200 New Brighton Mn 55 J 12 (Signatures may be authenticated or acknowledged. Both are not necessary.) •Names of peons signing in any capacity must be typed or printed below their signature ~ .~.~ 6 .~.s ~ 6 KATHLEEN H. iiALSH REGISTER OF DEEDS ST. CROI}I CG. , liI REG£IVBD FQR RECORD 03/15/2009 O9s3OA1f RARRAIITY DEED EXEMPT 1« REC FEE: 13.00 TRARS FEE: 248.70 coax FEE: CC FEE: PAGES: 2 20-1395-30-000 Parcet Identification Number (PIN) This is not homestead property. ACKNOWLEDGMENT STATE OF Minnesota } WASHINGTON COUNTY. ) ss. Personally came before me this 12th day of March, 2004 the above named Kellei St. Martin, Vice President of Carriage Homes XXI, Inc. a Minnesota Corporation to me known to be the person(s) who executed the foregoing instrument and acknow ged the same. ~ La , ~P,r..-~•2. Notary Public, State ~' Min>tiesota ` J IViy commission is permanent. (If not, state expiration date: WARRANTY DEED STATE BAROF WISCONSIN • • NANCY J. L.ENTZ r-~ ,*~'-.~ NOTARY PUBLIC-I~I~(tJ~~9TA.- UO My Comm. Expires ~{{ ~~p~ ~~ / ~ LJG,G~ I J~.f r ~ • : ,. _ .''~ . . , i 5.792 ACRES H.W.L.=924,3 ; - , . ~ ~ ~ ~ ., ~ ~+ ~ ~' i ~~`_~ ~ ~ ~~i ~` / /~ ~ ~ i ~~ ~ ~~ w/ ~~ ~ f~ a T 3® 15 Q FT 3.561 ACRES -L14~ 78.52' \ ~ 2~ N ~, 113,198 a 2.599 A 29 ~ m 112,245 SD FT 2.577 ACRES ~' ~' \ 32 ~ • • ' ~ ~-- . _ , 118,123SQFT ~~ ~~~ :~ w 2.712 ACRES ~ `~ • ' ~ ~ ~ e h~a~ 1,Mj2~6~ . • ~ N~~ S'2,,z~,, • i ~. i Shy / ^° , ii ~3,•~_ v ~ ~ ~ 62 QG8.~8, /tea ~ / ~ G ~ ~ • / ~ /~ i 33 ~ / ~~ .,