HomeMy WebLinkAbout020-1169-10-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety ar,6 Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 515283 0
GENERAL INFORMATION State Plan ID No:
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 Parcel Tax No:
Richie, John C. & Susan I Hudson, Town of 020 - 1169 -10 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
07.29.19.1048
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length 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 Bed/Trench Edges Topsoil
Yes no RD Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: ! ! Inspection #2: ! /
Location: 321 Highview Rd. North Hudson, WI 54016 (SW 1/4 NW 1/4 7 T29N R19W) Ranchwood Lot 20 &21 Parcel No: 07.29.19.1048
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? FW� Yes ❑ No
Use other side for additional information. L1
SBD -6710 (R.3/97) Date Insepctors Signature Cert. No.
Con9m�1 C�.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 St. Croix
IS Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce 515 2' 9 3
Sanitary Permit Application State Transactio ber
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appro riate governmental Project Address (if different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Application forms f t e P WTS are ./
submitted to the Department of Commerce. Pe onal information you provide set rcc y Same �/f ' Z I 91 , k G�
p urposes in accordance with the Privacy Law, s. 15
I. Application Inform n —Please Print),]] Inf 2dG ,
Property Owner's Name / Parcel #
John & Sue Richie / 020 1169 - 10 - 000 JUN 2 3 Z010
Property Owner's Mailing Address Property Location
321 Highview Road ST. CRQIX COUNTY
PLANNING & ZONING OFFICE Govt. Lot
City, State Zip Code Phone Number SW %, NW %4, Section 7
Houlton, WI. 54082 715 - 222 -8983 (circle one)
T 29 N; R 19 E or W
II. Type of Building (check all that apply) �� Lot #
El or 2 Family Dwelling — Number of Bedrooms ( 4 ) 20 & 21 Subdivision Name
Q u AI ftw►� Block # Plat of Ranchwood
El Public /Commercial — Describe Use Na
❑ City of
❑ State Owned — Describe Use CSM Number ❑ Village of
# & � Na ❑Town of Hudson
�.✓ �y� / 1 f / f'/ U�ta
III. Type of Permit: (Check o one box on line A. Complete line B if applicable)
❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner c l IZ-7 w 2
W. e of POWTS System/Component/Device: Check all that apply)
W
Eq' Non-Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Disp ersal/Treat ent Area Informatio :76 filtrator "Q-4" standard chambers & 4 pr. end s, Wieser Concrete filter canister w/ Pol Lok PL -525 effluent filter
Design Flow (gpd) Design Soil Application gpdsf) Dispersal Area Requir (sf) Dispersal Area Propose (sf) System evation
600 gpd 0.40 gpd/sq. ft. 1,500 sq. ft. 1,543.20 sq. ft. 97.00', 98.00', 99.00', & 100.00'
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks o g y p
Septic or Holding Tank Na 1 250 1,250 1 Wieser Concrete X
Dosing Chamber Na Na Na Na
VII. Responsibility Statement- I, the unde signed, ass a responsibility f ' lation of the POWTS shown on the attached plans.
Plumber's Name (Print) LP mbe s Sign MP/MPRS Number Business Phone Number
James K. Thom son MPRS 30021 (715) 248 -7767
Plumber's Address (Street, City, State, Zip Code
340 Paulson Lake Lane, Osceola, WI 54020
VIII. Coun /De artment Use Onl
pproved tsapprov Permit Fee Date Is ued Issuing nt Signature
er Given Reason enial $ �� ' Z5 /Q
IX. Conditmffdereasons for Disapproval
"1 Septic tank,.effluent filter and
dispersal cell must all be services / maintained
as per management plan provided by plumber.
2 4"Ibeck requ�'emettts must be maintained
/'od rw1c;es:
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD -6398 (R. 02/09) Valid thru 02/11
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2216
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must ty St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to near 020 - 1169 - 00
rceI I.D.
Please print all information. Revie By Date
Personal information you provide may used fcf�6Ardy® y Law, .15.04 (1) (m)). ` � LJ6
Property Owner Property Location
John C. & Susan J. Richie Govt. Lot SW 1 NW 114 7 T 29 N R 19 W
Property Owner's Mailing Address JUN 6 6 LU I U Lot # Block # Subd. Name o1CSM#
321 Highview Road qT rRoix C OUNTY 20 & 21 Plat Of Ranchwood
City State " rpr) Utd%6kFFICE J City __] Village J Town Nearest Road
Hudson WI 4 16 1 715 - 222 - 8983 Hudson Highview Road
I New Construction Use: V1 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
1/f Replacement J Public or commercial - Describe:
Parent material Glacial Till Flood plain elevation, if applicable Na
General comments
and recommendations: Site suitable for conventional POWTS dispersal cell with 0��4 _� pd /sq.ft. /day loading rate. Recommend
installing 4 trenches, elevations to be 100.00', 99.00', 98.00', .00'.
Boring # I Boring
J Pit Ground Surface elev. 106.08 ft. Depth to limiting factor >126" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2
1 0 -10 1Oyr3/3 none sil 2fsbk mvfr cs 2f,1m 0.6 0.8
2 10 -18 1Oyr4/4 none sil 2fsbk mvfr gw 1vf,f 0.6 1.0
3 18 -33 1Oyr4/6 none sicl 2msbk mvfr gw 1vf 0.4 0.6
4 33-45 10yr416 none sil 1 msbk mvfr cw - 0.4 0.6
5 45 -60 7.5yr4/6 none cost 2msbk mvfr gw - 0.6 1.0
6 60 -92 7.5yr4/4 none cost 1 csbk mfr cw - 0.4 0.7
7 92 -126 1Oyr4/6 none s Osg dl - - 0.7 1.6
Fil Boring # Boring �/4Q
✓J Pit Ground Surface elev. 106.48 ft. - I D loth to limiting factor >118" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -13 1Oyr3/3 none sil 2fsbk mvfr cs 2fm 0.6 0.8
2 13 -24 1 Oyr4 /4 none sit 2fsbk mvfr gw 2fl m 0.6 1.0
3 24 -36 7.5yr4/6 none sit 2fsbk mvfr gw 1vf 0.4 0.6
4 36 -44 7.5yr4/4 none fst 2fsbk mvfr cw - 0.4 0.8
5 44 -91 7.5yr4/4 none cosl 1 m &csbk mfr gw - 0.4 0.7
6 91 -118 1Oyr4/6 none fs Osg mi - - I 0.5 1.0
Evaluation of so "- 118" completed with hand shovel through bottom of soil pit. ,r 114
* Effluent #1 = BOD 5 > 30 < 220 mg /Land SS >30 < 15 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < 3 mg/L
CST Name (Please Print) Signatur . CST Number
James K. Thompson �� 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020 6/9/2010 715- 248 -7767
Property Owner John C. & Susan I Richie Parcel ID # 020 - 1169 -10 -000 Page 2 of 3
31 Boring # J Boring
6el Pit Ground Surface elev. 103.34 ft. Depth to limiting factor >119" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -6 10yr3/3 none sil 2fsbk mvfr cs 2fm 0.6 0.8
2 6 -10 10yr4/3 none sil 2fsbk mvfr cs 2f1 m 0.6 1.0
3 10-42 7.5yr4/4 none sil 2fsbk mvfr cs 1vf 0.4 0.6
4 42 -51 5yr4/4 none cosl 1 msbk mfr cw - 0.4 0.7
5 51 -71 7.5yr4/6 none fs Osg ml Ci - 0.5 1.0
6 71 -119 10yr4/6 none grs Osg ml - - 0.5 1.0
Horizon #6 contains 1/2" -1" bands of 7.5yr4/6 Ifs. Loading rate reflects reduced permiability of horizon associated with banding. Evaluation of soil
from 96" - 119" completed with hand shovel through bottom of soil pit.
Borin g # J Boring /I Z
J Pit Ground Surface elev. ti-7 f I ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # J Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD S_30 mg /L and TSS < 30 mg /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 department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00) A.C.E. Sal & Site Evaluations
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Conventional POWTS Index & Tilte Sheet
Project Name: Richie 4 bedroom Replacement Conventional POWTS
Owners Name: John & Sue Richie
Owner's adress: 321 Highview Road
Site address: Same
Project Location:
Subdivision: Lots 20 & 21, Plat of Ranchwood
Legal Description: SW1 /4NWIA, Sec. 7, T.29N., R. 19W., Town of Hudson, St. Croix Co., WI.
Parcel ID #: 020 - 1169 -10 -000
Page 1 Index and Title Sheet
Page 2 Site Plan
Page 3 Dispersal Cell Sizing Calcualtions
Page 4 System Cross Section
Page 5 System Management Plan
Page 6 Filter Specifications
Page 7 Treatment &/or Filter Tank Cross Section
Page 8 Parcel map
Page 9 Septic Tank Maintenance Agreement
Page 10 Certification for Utilization of existing septic tank
Page 11 Waranty Deed
Attachments: Soil Evaluaiton Report
Mater P be2Rest�r te d Service: James K. Thompson, De 't. of Comm. Credential #30021
Signature: Date:
Page 1 Of 11
Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01)
S Well
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DISPERSAL CELL SIZING CALCULATIONS
1. (4 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 600.00 Gpd design Ylow
2. Infiltrative capacity of native soil = 0.4 gpd/sq. ft.
3. Absorption area required: 1,500.00 sq. ft.
4. Absorption area as proposed: 1,543.20 sq. ft. (76 chambers total)
Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA
1,500.00 sq. ft. — (4 pair endcaps)(5.80) = 1,476.80 sq. ft.
1,476.80 sq. ft. /20.00 = 73.84 chambers required
Number of trenches: 4 na, 19 chambers per trench (76 chambers total)
Trench width: 2.83'
Trench length: 78.00'
Trench spacing: 8.00' on center
Total system area w/ 5' trench spacing: 38.00'x 78.00'
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Conventional Septic System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system
maintenance and maintenance reporting shall be complied with.
Septic Tank
Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be 5 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank
that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be
serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water
tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of
service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater
than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division.
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface
within and above the system and will promote frost penetration during cold weather months. Cold weather installations
(October - March) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of diversion valve. Effluent to
be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1
year period. Afterwards, effluent dispersal to be alternated between cells to allow use of each cell for a two year period.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil
absorption cell to bring the system into proper operating condition.
Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715)
248 -7767 or the St Croix County Zoning Department at (715) 3864680.
Pg. 5 of 11
.EFFLUENT
FILTERS ��Lx
"The PL -525 has 525 linear feet of 1/16"
slots. It has an automatic shut off ball. When
s PVC
the filter is removed for cleaning, the ball will ' ° e's Alarm - Accepts '� - - - -� eate i on handle
float up and temporarily shut off the system
so the effluent won't leave the tank. No other
52r linear feet
filter on the market can make that claim!" °f,l16' ,
Ifftration sluts Rated for over
� 10.000 GPO
Accepts a" & 6" -
SCHO. 00 Pipe a `\
Ya \ '
Gas deflector
5 __ Automatic shut -off
ball when filter
Is removed
"The PL -122 has over 122 linear feet of 1/16"
slots. Rated for 1500 gallons per day, and < Handles 112" PVC
can be manifolded together with other PL- a Alarm
Switch
122's to double or triple the GPD. It has an
122 Linear h,
automatic shut off ball that stops flow when — ''ft /t6in.h
Filter Slots
the filter cartridge is removed for cleaning.
Comes complete with it's own housing, no
}. Filter Housing
gluing of tee or pipe and no extra parts to with Ad apt
Pipe Adapter
buy.
Gas Deflector
Automatic
Shut -Off
Ball When
Fiher is
Removed
From Tank
Order # Model # Description List Price
PK -525 PL -525 Effluent Filter System 203.50
PK -122 PL -122 Effluent Filter System 62.50
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer a C-/C ,/ 4�sli? 2tj5 - ! / - f
Mailing Address 3- Ai _ecJ tCOCL✓. 5
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location 5 C"� 1 /a , /) M) 1 /a , Sec. 7 T 1 N R-Zf W, Town of ffu Son
Subdivision _ Pla't� Lot # ?-082
Certified Survey Map # d4 , Volume 16 Page #
Warranty Deed # �07� , Volume , Page #
Spec house no Lot lines identifiable es
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. Uwe 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
SIGNAT 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. 08/05)
P . 9 /i
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) .,321 �(�,- {� �oa� located
at: 5 cJ '/4, 19cJ ' /a, Section Z , TownN, Range W,
Town of �(/ o ,-, , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.2 h
5 and it (they)
g q ( Y)
appear(s) to be functioning properly.
Most recent date of inspection or service -:I'u nc 9 ;2-0/6
Did flow back occur from absorption system? Yes P-" No
(if no, skip next line.)
Approximate volume or length of time: j4 allons minutes
Tank Capacity: /,,zso
Construction: Prefab Concrete t.-� Steel Other
Manufacturer (if known): u-) eser- &Inar42 c.
Age of Tank (if known): _ Z/ e ss
Permit number (if known) wn
(Licensed Plumber Signature) (Print Name)
ADZ.
(Title) (License Number) Wt1MPRS
Q"e�
ate)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
111111 11111 VIII II11111III 111111111 illlll 1111 1111
* 9 0 2 6 9 8 1
State Bar of Wisconsin Form 3 -2003 90269$
QUIT CLAIM DEED BETH PABST
REGISTER OF DEEDS
Domment Number Dowumentxame ST. CROIX CO., WI
RECEIVED FOR RECORD
08/26/2009 10:45AM
THIS DEED, made between JOHN C. RICHIE and SUSAN J. RICHE, as joint QUIT CLAIM DEED
tenants EXEMPT I 8M
( "Grantor," whether one or more), REC FEE: 11.00
and JOHN C. RICHE and SUSAN J. RICHIE, as tenants in common PAGES: 1
( "Grantee," whether one or more).
Grantor quit claims to Grantee the following described real estate, together with the Recording Area
rents, profits, fixtures and other appurtenant interests, in St. Croix
County, State of Wisconsin ("Property") (if more space is needed, please attach Name and Return Address
addendum): Attorney Barry C. Lundeen
110 Second street
o n
Lots 20 and 21, Plat of Ranchwood, being part of the SW /, ' of the NW /, f Section P.O. Box 469
7,129N R19W, Town of Hudson, St. Croix County, Wisconsin. I Hudson WI 54016
THIS DEED GIVEN PURSUANT TO THE TERMS OF A JUDGMENT OF
DIVORCE BETWEEN THE ABOVE PARTIES GRANTED IN THE CIRCUIT
COURT FOR ST. CROIX COUNTY, WISCONSIN 020 1169- 10-000
Parcel Identification Number (PIN)
This is homestead property.
(is) (is not)
Dated
Y ,
/ r
(g (S
' John C. Richie * Susan J. Richie
(SEAL) (SEAL)
+k i
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) U_vM
S i STATE OF WISCONSIN
M � )
L -F
authentic V v ) ss. � '�
St. Croix COUNTY
G
* Personally came before me on
TITLE: MEMBER STATE BAR OF WISCONSIN the above -named John C. Richie and Susan J. Richie
(If not,
authorized by Wis. Star. § 706.06) to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
Attorney Bang C. Lundeen
Hudson WI 54016 Notary Public, State of Wisconsin
My Commission (is permanent) (expires: )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO TIES FORM SHOULD BE CLEARLY IDENTNIED.
QUIT CLAIM DEED A 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003
• Type name below signatures.
1 of 1
C l E 14:' 1 ?15b4 ?5181 4JIESEE' CUNT =:BETE
F1 PAGE i_
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LE-3• „ 1' REV N0, DATF-•
M O RAWN BY:SKT
a SEPTIC MANUAL W18 VS HWr %W" ROCK, VA 54750 DATE: ONUARY 2005
�° REV. JAN. 2005 800 - 325 -8456 �nL0 HOLE W- MISUMN DOX