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(n m y o m n. mm w n N Q 3 O b O CD p Iv CD R O 0 ~ O a °O (D ti r 'f 'Stale of Wisconsin NOTE: WELL CONSTRUCTOR'S REPORT Department of Natural Resources tf Form 3300-15 Rev. 12-76 L~ White Copy - Division's Copy Box 7921 Green Copy - Driller's Copy Madison, Wisconsin 53707 Yellow Copy - Owner's Copy L COUNTY CHECK ONE: Name St.Croix ® Town Q Villa e E3 city Warren Section v'Section Township ]Range 3. NAME CIWNER DAGENT AT TIME OF DRILLING CHECK (4 ONE 2. LOCATION 1 0 29--N 18-W Joe Slater OR - Grid or Street No. Street Name ADDRESS R. R.1 AND - If available subdivision name, lot & block No. POST OFFICE Robert Wisc. 54023 4. Distance in feet from well Building Sanitary Bldg. Drain Sanitary Bldg. Sewer Floor grain Storm Bldg. Drain Storm Bldg. Sewer 1 Connected Ta: answer to in nearest: appr (Ropriateecord C.I. Other C.l- Other CI. Sewer QtherSewer C.I, Other C.I. Other ~y block 8 1 12 10 Street sewer Other Sewers Foundation grain Connected t Sewage sump Clearwater Septic Holding ;Sewage Absorption Unit Swagemp C.I_ Other Sump Tank Tank 'Seepage Pit San. Storm Other Sewer Seu Seepage Bed pr. earwa er Sump rwa er I 65 Seepage Trench 31 i Privy I Pet Pit: Nonconforming Existing Subsurface Pumproom Barn Animal (Animal Silo Glass Lined Silo Earthen Silage Waste -F- n utter Barn Yard With Pit Storage w/o Storage Trench Or Pit Well Nonconforming Existing Pen Facility Pit Pit Pump Tank Temporary Watertight Solid Manure Subsurface Waste Pond or Land Other (Give Description) Manure Liquid Manure) Storage Gasoline or Disposal Unit Stack Tank Structure Oil Tank {S pecify Type) 5. Well is intended to supply water for: 9. FORMATIONS Family Home Kind From (ft) 1 To (ft.) 6. DRILLHOLE Dia. (in.) From (it.) To (ft_) Dia. (in.} From (ft.) To (f t.) Gravel ace 6 Surface 170 Sand stone $ 1,46 I ~ I Litre stc~`e 146 170 7. CASING( IN, CIJTtBI1G AND SCREEN aterla , eight, pecification Dia. (in. & Method of Assembly From ft.) To UQ 6 Steel pipe new Surface 59 Weight 19.45 T&C J ~ ASTt s 5 89 U.S. Steel 10. TYPE OF DRILLING MACHINE USED Pitless Adapter Rotary-hammer Q Cable Too] Q mud & air ! Jetting with 8. GROUF OR OTHER SEALING MATERIAL w/drilling Kind From (ft.) To Q Rotary-air Rotary-hammer I G1 Air w/droirng mud & air O f Water 5C~ Q Rotary-w/drilling Drove Surface y mud ~ Reverse Rotor t Well construction completed on [arch 27 19_79_ 11. MISCELLANEOUS DATA above final grade Yi Test: - 2 Hrs. at GPM Well is terminated 12inches ❑ below Depth from surface to normal water level 100 Ft. Well disinfected upon completion XJ Yes No Depth of water level when pumping 112 Ft. Stabilized X Yes ❑ No Weg sealed watertight upon completion X1 Yes O No Water sample sent to State laboratory on -April 10 _ 1938- Your opinion concerning other pollution hazards, information concerning difficulties encountered, and data relating to nearby wells, screens, seals, method of finishing the well, amount of cement used in grouting, blasting, etc., should be given on reverse side. Signature ~Lf! Complete Mail Address r C Registered Well Driller 1 R. R.1 Box 6 Say C1tXoWi-qC- 54723 State aturnsin NOTE_ WELL COMS11vUCTOWS REPORT Department of f Natural Resources Private Watcr Supply %Vhite Copy - Division's Copy Form 330U 15 Rev. 2-79 Box 7921 Green Copy - Dr iller'sCopy biadison, Wisconsin 53707 Yellow Copy - Owner's copy I- COUNTY CHECK W)ONE: Namc St Croix ® Town ❑ Vill O city I arren 1 etrun or Gov'✓ t Section Township) Range 3. NAME U OWNER ❑AGENT AT TIME OF DR_ILLI CHECK (Ji ONE 2. LOC S.1, 30 29 Ifl Elwin _ stew-art T i 1902' OR - G reet No. Street or Road Name ADDRESS AND If available subdivision name, lot & block -No,- POST OFFICE ZIP CODE Roberts W is. 5402 4. Distance in feet from well Building Sanitary Bldg. Drain Sanitary Sldq. Sewer foof Drain stor Idg. Drain Storm B Ieig_ Sewer _ Connected To: to nearest. (Record 40 C.I. Other C._ Other CJ.,$Swer Other Sewer C.1 Other C.I. Other answer in appropriate g block Street Sewer ' Other Sewers Foundation Drain _Connectetl to Sewage Sump Clearwater Septic Holding LSewa AbsorptiUnlt MaHopper or San_ Storm C.r, Other Sewer ewage CIOther Tank Tank Retention or ump Pnuema[lc Tank earwa er earwa er 80 age Bed Dr. Sump S age Trench Privy Pet Pit; Nonconforming Ex istingSubsurface Pumproom Barn Animal Animal Silo Glass ined Silo Earthen Silage Earthen Waste ---tGutter Barn Yard With pit Stor a w/o Storage Trench Manure Basin Pit Well Nonconforming Existing Pen Fac- y Pit Or Pit Pum p Tank Temporary Manure -Watertight Liquid iManure I Subsurface ~ Waste Pond yr La nd .Manure Storage Basin Other (Describe) Stack or Platform ' Manure Tank or Pressure {Gasoline or Disposal Unit Concrete Floor _Only Basin Pipe Oil Tank {Specify Type} Concrete Floor an d Partial Concrete Wal 5. Well is intended to supply water for: 9. FORMATIONS Rual Rome Kind r~ From (ft_) To (ft_) 6. DRILLHOLE - - Dia. (in.) From (11.) To (ft_) (in.) From (ft.) To (ft.) Surface 155) - - 21 __f__ T____ _ 20 B 20 155 Line StOne l 150 I55 10 surface 7. CASING [NlRR, `UP- P" ADD SCREEN r atertal, tF'erg}It, Specification Dia. (in.) Mfg. _&N ethod of Assembly from (ft.) To fft.) 6 Novo Steel Pipe Surface 150 ASTM A-I20 19:45 T&C 1200, Psi. - - 10_ E OF DRILLING MACHINE USED Maass Pitles Rotary-hammer w/d ri I li ng 8. GROUT OR OTHER SEALING MATERIAL Cable Tool mud Q air O Jetting with Kind From (ft.) To (ft. Rotary-air Rotary-hammer I Q Ali ❑ w/drilling mud air - water Rotary-w,/drilling Cl a~ Surface 20 mutl ❑ Reverse Rotary Dreva 20 150 41 construction completed on 9 I_$ 198 H. MISCELLANEOUS DATA above Yield Test: 2 Hrs. at __U1 . GPM Well is terminated 'inches ❑ below final grade Depth from surface to normal water level T Od Ft. Well disinfected upon completion Yes ❑ No Depth of water level) I 0 - when pumping Ft. Stabilized Yes ❑ Na Well sealed watertight upon completion Yes © No Water sample sent to State laboratory on _ 9 26 19$_`3- Your opinion concerning other pollution hazards, information concerning difficulties encountered, and data relating to nearby wells, screens, seals, method of finishing the well, amount of cement used in grouting, blasting, etc-, should be given on reverse side. Se nature / i Busin ss Nam~ e/ /~~Complete Mai]' g Addtesc ~ R stered~ell Driller i ST CROIX PLANNING & ZONING MEMO DATE: May 18, 2012 To: POWTS file #38466 - 1983 permit Code AdministraupFROM: Pam Quinn, POWTS Inspector #665054 715-386-4680 RE: 950 70th Ave. POWTS evaluation Land Information & Planning 715-386-4674 According to our records, a sanitary permit was issued on 6/3/1983 for a 2 Rea] Property bedroom-sized Private On-site Wastewater Treatment System (POWTS) to be 715-386-4677 installed on the above property. However, there is no indication that the installation was inspected and there is no as-built drawing from the plumber who obtained the 875-386-g4675 permit. I understand that the house was constructed and in 1993 a water and 7115-38 septic inspection was completed by county staff (see attached report). At minimum a county reconnection sanitary permit would be necessary to obtain a town building permit for construction of a new 2-bedroom house. Before we issue a sanitary permit, the existing system will have to be inspected for code compliance and an evaluation report submitted by a licensed plumber or POWTS Maintainer. In addition, if building plans are for more than 2 bedrooms, the system would have to be brought up to code and enlarged to accommodate the design wastewater flow. AIL, ST. CROIX COUNTY GOVERNMENT CENTER 715-386-4686 FAX PZ@CO.SAINT-CROIX.WI.US 1 101 CARMICHAEL ROAD, HUDSON, WI 54016 WWW.CO.SAINT-CROIX.WI.US ' DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR o '4UMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.,BOX 79b_~ BUREAU OF PLUMBING MADISON, WI 53707 [3CONVENTIONAL ❑ALTERNATIVE ET777 El Holding Tank E:1 In-Ground Pressure ❑ Mound NAME OF PERMIT HO LDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Joseph Slater RR#I, Roberts, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. I ELEV.: CST REF. PT. ELEV NE SW, Sec. 30, T29N-R18W, Town of Warren Name of Plumber. MP/MPRSW I County. Sanitary Permit Number_ Thomas Wang 3231 St. Croix 38466 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. OYES ONO OYES LINO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD. JPROPERTY WELL. BUILDING. VENT TO FRESH ALARM. FEET FRO INE: AIR INLET. OYES ONO OYES ONO NEARESTM L DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. =NUFACTURER WARNING LABEL ER G COVER PROVIDED. EDOYES ONO OYES ON ES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONALNUMBER OF PROPERTY WELL VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE (AIR INLET' PUMP ON AND OFF) OYES NO NEAREST 10 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing t FNGTH DIAMETER MATERIAL AND MAHKLNG or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVER 1111I111 DIA -PITS LIQUID TRENCHES MATERIAL' PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIP' DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING. V BF LOW P P ENT TO FRESH I'S ABOVE COVER ELEV. INLET ELEV. END. PIPES. FEET FROM , LINE: AIR INLET. NEAREST-_ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES meets the criteria for medium sand. TIONS MEASURED. O NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS EYES ONO OYES ONO DEPTH OVER TRENCH: BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. OYES NO OYES NO EYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR DISTR. PIPE DISTHIBLJTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.' PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES NO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: 1BULDING. FEET FROM LINE: OYES ONO OYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. rIrLE LHR SBD 6710 (R. 01/82) [NATURE DI DEPARTMENT OF APPLICATION SAFETY & BUILDINGS IPIDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: ~s Mailing Address: Property Location: City, Village or ownshi County: % I%S iT N/R ~E (or Mi l rr I !3 ~~Ol Lot Number: Blk No:: S ion Name: Nearest Road, Lake or Landmark: State Plan 1.13. Number: '-r l- (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: PK 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER ~o MANUFACTURER: Uil~s EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): X New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): N Private ❑ Joint ❑ Public -Ta A le I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of lumber: Signatu MP/MPRSW No.: Phone Number: 7k mei 1 S.P 31 15; 5'S- Plumber's Address: Name of Designer: ® to /e L) -e tA S c a 1✓4 COUNTY/DEPARTMENT USE ONLY Signatur of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: ❑ DISAPPROVED 3 Jp/ 6.A Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) y T-re e K@trr. a ri L,,he lDoel:, sy~ ~ ! h g S+ee~ ~ ti ~ C~n~►.rrqrl'ee Y~ a7~1'4 re~,. Ir W4 Jo, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,, c DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W1 53969 HUMAN RELATIONS LOC SECTION: OWNSHI MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: '/4 4 3a /T 09 N/RXE (r) COUNT : OW ER'S BUNAM MAILING ADDRESS- WS , ~S 7-cr'te f'e)bed-77S &,'I'S. < &IC2 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: New R T DNS: 1PERCOLA ON TESTS: ~~Residence ~ ❑ Replace Q~ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDE SYSTEM: (optional) ms DU OS ❑U ®S ❑U EIS ®U EIS R7U ~e~~ eS 331jp If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. h~ If any portion of the lot is in the under s.H63.09(5)(b), indicate: d G~ 155~, b Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / /co.o C >6.50 .)A~ 6l sl /.oc') & s-/'5. gn ( .3'1F ar B- 79.~o 00 ,5'0 •~?bi-, .'5'o e#s14.ya 6 h 54 Gr B- 3 99. Sy ~9f J 0 ? ' ~0 ,P f1s l • ~8 ~h 5 5 0& S d Gr B 917 99,a G' >L. 5'0 5ofist € Byr S 4,08-&) S161- o' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHE AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ 3.33 k /b 1' orb g P- .~0 3 V IN h lv % d l P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. 1) SYSTEM EVAT N 9~• N'r ]`re ,e I.R K C Q d) rIe V. Y' o'ff' rd S , J ija ----r- pi l~ in 3 C ke r r ~ Tr C PL T~eeI 6su Q 6b_ aq~ .4. stake. fr'o os_e4 }Tome eI - ''T-24Z3 ' led I's P F i 1U r.'1 e , A-ldo` ke4 Fk v spike v 0K3j-d /'1 '316ter'r free 6' r f #ole S P~ pe~c~bles x t the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: / 176 1h 4 S Lk 41 ~ IF, AD RESS: CERTIFI TION NUMBER: PHONE NUMBER optional): , IA vie Fe A 44 0 CST SIG E: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. G~ DILHR-SBD-6395 (N. 03/81) J r. t= t - ` t s,: ' +;i~ ~ Form I C lot) Owner of P r o p e r t y _ ~C)S" ff Location of Property ''-u, SUCLiun ,'I' N 1t1F W Township "I' rer) Mailing Address 51~0 Subdivision Name Lot Number` Previous Owner of PropertyRen;npt n 1v Total Size of Parcel 10 ~reS Date Parcel Was Created Are all corners identifiable. Yes Nu Include with this applic~ition one of the totlowin,~: .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the prul,Crty PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deftd rec~jrped in the Office of the County Register of Deeds as Document No. - V d / _ ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been dul r co ded in the Office of the County Register of Deeds, as Document No. SIGNATU OF OWNER SIGNAlUHL ut (,o O,Vr4t It (it iWPL.11, ,IH [ DATE 51 NED~ DATE SIGNED CIONIMERCIAL TESTING LABORATORY, INC. 4:CAw 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 ~4~ 715-962-3121 800 - 962 - 5227 G FAX - 715 - 962 4030 Jo CROIX COUNTY REPORT DATE' 4/26;'-,. COURTHOUSE WI TION 950-70th, Rober _ECTOR« St. Croix Zoning COLL.ECTED« 4-21-93 COLLECTED' 3«04pra -,CE OF SAMPLE' Basemefit faucet ANALYZED' 4-23--, ANALYZED.12;0i' 'I ORM« 0 f:PRETATION' Bacter ' 1 PPt 10 9 . g, ~.►O Z v C, GZO ~ k. OF.,NDEGENppHr O A Lab No. 19 6 A ` J 'd PROFESSIONAL LABORATORY SERVICES SINCE 1952 IF_ I - ST. CROIX COUNTY WISCONSIN f t r t =7 r rJ b .2~ ZONING OFFICE s xz~" ST. CROIX COUNTY COURTHOUSE T ' 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 April 22, 1993 Dave Anderson Century 21 706 - 19th St. S Hudson, WI 54016 Dear Mr. Anderson: An inspection of the septic system on the property of David Coyer, located at 950 - 70th St., Roberts, WI was conducted on April 21, 1993. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact his office. Sincerely, Mary J. Jenkins Assistant Zoning Administrator cj 11 12 ~o , 363 RECEIVED '-i N ST. CROIX COUNTY ZONING OFFICE A` i R Y 6 ,~93 St. Croix County Courthouse 911 4th Street 1 ~:F{U~:k COUNTY Hudson, WI 54016 ZONING 0FICE v f. ~_._g}~ Telephone - (715)386-4680 ~ The St. Croix County Zoning Office offers the service of septic C`J and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property ca be located. Please provide the following information, enclose appropriate )fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as \ oon as possible after fee and form are received. WATER TESTING----------------------------FEE: $ 35.00 ~ - (For nitrates and coliform bacteria) 0,J WATER TESTING FEE: $185.00 ' (For VOC' S ) SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if syst is pro erl functioning at tine of ~l inspection) ` 1~yj PROPERTY OWNER'S NAME: PROP. ADDRESS: CITY Legal Description X1/4 of the 1/4 of Section _30 , T-Z-!~-N-R Town of Lot Number Subdivision: _ v FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house? If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. l Firm or individual re uesting services:(:,,.?-1 Telephone Number I - ~2- o= REPORT TO BE SENT TO: -2- l Ct ^ - CLOSING DATE. G! signature C Cave- aj_a~ 4x4j,c -41" valz 1 i i ti a I ! f i Ns, j f 1 Parcel 042-1084-40-050 07/30/2007 10:45 AM PAGE 1 OF 1 Alt. Parcel 30.29.18.473A-20 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BRIGHTKEYS INVESTMENT BRIGHTKEYS INVESTMENT C - HOLDINGS LLC HOLDINGS LLC 707 COMMERCE DR STE 410 WOODBURY MN 55125 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 950 70TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 7.290 Plat: 4599-CSM 17-4599 042-03 SEC 30 T29N R18W PT NW SE & PT NE SW Block/Condo Bldg: LOT 01 (7.29 AC) CSM 17-4599 LOT 1 Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 30-29N-18W NW SE Notes: Parcel History: Date Doc # Vol/Page Type c~jtQ t~/ c/ ,(2 09/30/2003 741930 2424/212 WD v 6 J I 09/02/2003 738359 17/4599 CSM 08/2912003 1009/69 WD orD more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/20/2004 ~ Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.290 52,900 176,800 / 229,700 NO Totals for 2007: General Property 7.290 52,900 176,800 229,700 Woodland 0.000 0 0 Totals for 2006: General Property 7.290 52,900 176,800 229,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 042-1083-90-000 01/18/2007 05:06 PM PAGE 1 OF 1 Alt. Parcel 30.29.18.471A 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BRIGHTKEYS INVESTMENT BRIGHTKEYS INVESTMENT C - HOLDINGS LLC HOLDINGS LLC 707 COMMERCE DR STE 410 WOODBURY MN 55125 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 7.000 Plat: N/A-NOT AVAILABLE SEC 30 T29N R1 8W 7A THAT PT OF SE SW Block/Condo Bldg: LYING ELY OF A LN BEGINNING 2871.4 FT W OF SE COR SEC 30; TH N TO N LN SE SW Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 30-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 10/06/2003 742722 2429/455 LC 08/29/2003 738123 2394/376 EZ-1 1009/69 WD 727/308 2006 SUMMARY Bill Fair Market Value: Assessed with: 149743 Use Value Assessment Valuations: Last Changed: 07/14/2003 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 7.000 1,000 0 1,000 NO Totals for 2006: General Property 7.000 1,000 0 1,000 Woodland 0.000 0 0 Totals for 2005: General Property 7.000 1,000 0 1,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00