HomeMy WebLinkAbout020-1415-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
• INSPECTION REPORT Sanitary Permit No:
• 538724 0
GENERAL INFORMATION (ATTACH TO PERMIT) 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:
McCormack, Scott D. & Bonnie L. I Hudson, Town of 020- 1415 -60 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown /Range/Map No:
c /(o , �� ,Q — 3 GS f 20.29.19.2624
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1� 1 ' Benchmar
raw e d- /d Alt. L., 43 J-0, -, S. 9 8. z S
Aeration Bldg. Sewer
'7,95
Holding St/Ht Inlet
— 6 - , 3 s. 7
TANK SETBACK INFORMATION St/Ht Outlet
5 95. y
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 0 � , / /1 Z � I 7 3 Dt Bottom
Dosing 0 Header /Man.
Aeration Dist. Pipe 9 l7 `,y•
Holding Bot. System
—4— e%
PUMP /SIPHON INFORMATION Final Grade 5 S� g /
Manufacturer Demand St Cover
GPM �1tic.� CoJ�.L- 5. — / 1 5 I FT, Z S
Model Number
TDH Lift Friction Loss System He TDH Ft
Forcemain Length ` Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 _
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEAC HING Manufacturer: 1 /
INFORMATION CHAMBER OR
Type Of System, J 111 / /
J tOv�� /5 3�, N UNIT ModelNumbe /�
DISTRIBUTION SYSTEM Sow /y�,�r� �1� #z feu/ r
Header /Manifold i i / Distribution x Hole Size x Hole Spacing Vent to Air�ntake S 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 d/Sodded Seeded /Sodded xx Mulched
Edges g p
Bed/Trench Center / Bed/Trench Ed Topsoil
es ® No Yes Q No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 441 Swift Circle Hudson, WI 54016 (NE 1/4 SW 1/4 20 T29N R19W) The Glen Lot 30 C Parcel No: 20.29.19.2624
1.) Alt BM Description = F ' -1 'L% Go,/ 6z- GO vet L-I l ( 7e, (ew S
2.) Bldg sewer length = Z
- amount of cover Fe. � /� S
Plan revision Required? 0 Yes XNo rf Z Z 16
Use other side for additional information.
SBD -6710 (R.3/97) Date Ins ctor's Si ure Cert. No.
VV�
con merce.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
s o n s i n M�� WI 53707-7162 Sanitary Permit Number (tto be in by Co.)
' It Of 3 Z
Sanitary Permit Applicat*0 S tate Transaction
In accordance with s. Conn. 83.21(2), Wis. Adm. Code, submission of this for n ntal
unit is required prior to obtaining a sanitary permit Note: Application fo r woed are Project Address (if di raent than ligg address)
submitted to the Department of Commerce. Personal information you prov r secondary •/ L
p urposes in accordance with the Privacy Law, s. 15.04(1 m), Stab.
L Application Information - Please Print All Infarmatiop2l RE IV W
Property Owner's Name Parcel #
A / " /< 0 - /yl.S - !D -000
Property Owner's Mailing Address
Propert Loin
.28 1� �dE ST. CROIX COUNTY Lot NING Govt. City, State Zip ode
T p ,- 4, S41 '!., Section " _
u O.✓ IJ.L $S 7 1SS 746 - .?// T '> ? N; R / � o�W
X 1 1. 1. Type of Build' (check all that apply) Lot #
xy 1 or 2 Family Dwelling- Number of Bedrooms 600 Subdivision Nance /
Ok Gd A- P 14 vt, . Brock # r r '6 F PubliclCoam>ercial - Describe Use ` Z/ 9 eity�
(] State Owned - Describe Use CSM Number Sege -of
Town of 010-s J
III. Type of Permit: (Check only a box on line A. Complete line B if applicable)
A- New System ❑ Replacement S
yttem ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain)
B. O Permit Renewal O Permit Revision O Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dam issued
Before Expiration Op �� !
IV. of POWTS stem /Com nent/Deviee: Check all that apply) /4-- m (TJL
X Non- Pressurized In- Ground O Pressurized In- Ground Om-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
O Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (exphun) S k ! 3 V. Dis rsalfIrreatmout Area Information:
Design Flow (gpd) Design Soil Application Ra sf) I Dispersal Area Required (sf) Dispersal Area Pro sf) System Elevation
60 .7 857 / 857 y 9Y, 2 9-? 93.4
VL Tank Info Capacity in Total # of h4anufictu er
Gallons Gallons Units 2. New Tasls Existing Tangy i3 v o 8 s
QQ /' c`i
�✓ (J� � �� rn � m 'w C7 a
Septic or4W k
/ -- ,700 / / SE.c �o,JttErc ✓'
Dosing Chamber
VII. Responsibility Statement- L the undersigned, assume responsibility for insbdladon of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's tore WA41M Number Business Phone Number
Plumber's Address (Street, City, State, Zip Cow)
S5 Z-fe
VIII. JcGoan /De artment Use Onl
Approved Perm/i�tFee�j Date s ed Issuing tSignature
Liver R for Denial $
M. Conditions of ApprovaMeasons for Disapproval
SYSTEM OWNER: �' 40 �
1 Septic tank, effluent filter and gGj G, .N%t2 / �� 3/�
dispersal cell must all be serviced / maintained
as per management plan provided by plumber. e L/ i/H —� b7.t/73•
as per applicable cft1btMfRT f "forthesyste® a admbmitt npapernotlesstha 1lmchesia r
o J: cX4. 1
SBD- 6398 02/09 Valid this
(R. ) 02/11
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Private OU -Site Wastewater Treatment Sys (POWTS)
Iad "nd Tide Sheet
Owner: / i< 6'r adce< (� srAcee rfaA/
Project Name and System Type /���0/tM.yCK GLA.sf /L GG�Si'tNGY /a,/ 7 �A. �^/L�lau.�0 �OC✓T'S
Location: `,d � _i
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ejC - 5 - 44 D Z. r - o ���r �' t r.✓
Legal `ptio
// o �...r oc /�uoso.✓, fir, C.¢vx C.
Townd*County
Contents: Page l: /.viEx I�JT�E S.v��r
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Credential Number. ./yam .22 - - Date: �d -,�� -tea l� •.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN page .3 of Y
FILE INFORMATION SYSTEM'SPECIFlCATIONS
Owner
�o Q it /! Tio.✓ c Tank �Pa�nY 10d al - .0 NA
Permit # s b a Septic Tank Manufacturer NA
� g PARANIETE#iS Effluent F'kw Manufacturer QES T 0 NA
Number. of Bedrooms 0 NA Effluent f=ilter Model GF- /0 0 NA
Number of Pubic Fatty Units .-- lj NA Pump Tank Capacity al )WNA
F.st}mated flow (average) Od gaUday Pump Tank Manufacturer 0 NA
Design flow (peak), (mated x 1.5) 60 g al/day Pump. Manufacturer D NA
Soil Application Rate aVd _ /ftz Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ,ANA
Fats, ON & Grease (FOG) 530 mg/L 0 Sand /Gravel Filter 0 Peat Filter
Biochemical Oxygen Demand (BOD.) 5220 mg/L 0. NA 0 Mechanical Aeration 0 Wetland
Total Suspended Solids . (TSS) 5150 mgA. 0 Disinfection 0 Other:
('retreated Effluent Quality Monthly average Dispersai Ceft(s) 0 NA
Fmchemical Oxygen Demand (BOD S30 mg/L Xin- Ground (gravity) 0 in- Ground (pressurized)
Total Suspender! Solids (TSS) 530 mg/L XNA 0 At -Grade 0 Mound
Fecal Collform (geometric ream) _-M . O.Drip- line 0 Other.
Maximum Elftuernt_Partide Size Y, in dia.. 0 NA Other. 0 NA
0 NA Other. 0 NA
* Vakres typical for domestc wastewater and septic tank effluent. Other 0 NA
MNNTENANCE SCtM3ULE
Service Evem - .. Service Frequemy
Inspect condtwn i of tank(s) 1� set(s)
nk(s) At least once every: O month(s) (Ma�drrnaii 3 years) 0 NA
-
Pump out contents of tank(s) When combined sludge aril scum equals one - third- of tank volume 0 NA
mothn(s}
Inspect dispersal cell(s) At least once every: 3. R n t h (Maximum 3 years) 0 NA
/ ,C$ months) 0 NA
Chu effluent fitter At least ones every: 0 years)
inspect., pumP 0 months)
carrots & farm At legit once every: 0 yes) Na
0 months)
Rush laterals and pressure test At least once every: 0 year(s) k " -
Other: At least once every: 0 month(s) p NA
D
year -
0 NA
3 2 00 - CE OWSTRUCTIONS
00
inspections of tanks and dispersal cos shall be made by an individual carrying one of the following Hamm or certifications:
Master Humber:, Master Number Restricted Sewer, POWTS Inspector, p0WTS Maintainer; Septage Servicing Operator. Tank
Inspections must include a visual inspection of the tanks) to identify any missing or broken hardware, identify an cracks or teaks,
measure the volume of combined sludge and scum and too check for any back up or porKrmg of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The pond'ung of effluent on the ground surface may indicate a failing ccmdition arnd'reWw" the
irnmediate notification of the lord regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume: " the entire
contents of the tank shall be removed by a Septage Servicing Operator aid disposed of In accordance with chapter NR 113,
Wisconsin Administrative Code.
AN other services, kx*jd'mg but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shalt be performed by a certified POWTS MahYtaimer.
A service report shah be provided to the local regulatory authority within 10 days of completion of any service event.
START UP ANb OPERATION Page Y -of ./
For now constr Prior to use of the POWTS check treatrre nt tank(s) for the presence of painting- products or other, c herniceis
that may impede the treatment process andlat damage the dim celds). If high cancentradons are detected have the coMenffi
of the tankW rernoved by a septage servk*w operator prior to use.
System start tip shall not occur when soil demote are *omen at the infiltrative Surface.
Duritg pow outages punnp tanks may fip.above normal iaghwatar levels. When Power k restored the excess wastewater will be
d'scba VW to the dispersal cell(s) in one large doh overbadirg the CONS) and may result in the backup or surface discharge of
efElentt. To avoid this situation have the contents of the punm tank rernoved by a Septage Servicing Operator prior to restoring
power to the effluent pump or conga_ ct a *Pl rnbw or POWTS 'Maintai to asskt in manually operating the pump controls' .to
restore normtal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over. or otherwise disturb or rea
the a
within 16 fast down slope of any mound or at -grade =V absorption area,
Reduction or elimination of the following from the wastewater stream may improare the performance and prolong the We of the
POWTS: anti baby wipes: c bums; cmdon c O te swabs: de w herbicides: floss; diapam. diakdect�ts; ffat; fold da� drm (surnp water. fr Wt and peelings, g asoline . - grease,
herbs ides: '' : -maid;mfiana, on,
painting products; i s8thtary nopkirm morns; and water softener brine.
When the POWTS falls andlor is perr+wtnently tal0en out of fallovwng s"" s hall be take to Insure Insure that the system is
��
properly and M �bim l Wit d in wWh Corni ! 83.33, Wisconsin Admi 1 Co de:
• AN pmig to tanks and pits shall be disconnected and the abandoned pipe openings maW.
e The contents of all tanks and piss shalt be removed and pmperdy disposed of by a Septage Servicng Operator.
• After pumping. as taroks and pits shall be exeavaud-and rernoved or the* covers removed and the void space filled with
sof gravel or another inert solid material.
CON ENIINENK."1f PLAN
If the POWTS falls and cannot be repaired the topowig measures' have been, or mum .be taken, to provide a code compliant
reltt SyeCent:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The area should be protected tram disturbance and cow action and should not be ittrigW mpon by
required setbacks from a ftting and proposed structuie, lot knee and wells. - Failure to Protect the replacernent area win .
result in the need for a now "AM and sibs evaluation to establish a suitable repiaeenient area. Replecortert systems must
comply with the rules in effect at that tame.
E3 A suitable replacemma are® is not maiable due to swim* mWer sod worts. Barring advances it POWTS
technology a hording tank may be inn 1 0ed *as a last resort 1b replace the failed POWTS.
E3. Tim site has not been evalmated to identify a suitable replacement area. Upon failure of the POWTS a soli and site
evaluation must be perfonrW to. locate a suitable nspiaoanrent area. If no replacement area is available a holding tank
may be installed as a last mom to replace they failed POWTS.
0 Mound and at -grade soli am p 1 m systems may be reconstructed in place foAawing removal of the biomet at the
irtfiftrative surface... Rsonfougtions of sudl syseente must comply with the nose In effect at that tine.
< <WARNM> >
SEPTIC. PUMP AND OTIIEtt TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR 111 M F ICIEMT OXYGEN. DO NOT
MI A SEPM, PUMP OR OTHER TREATMENT TANK UIIIDER ANY E�1'ANCES. DEATH MAY RESMT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE OffICIR.T OR I NPOSSWLE.
ADDITIONAL OON11103IIT8
P01NTS INSTALLER PO1lVTS NIANTAIN R-
Narrre d . J - y Nye ,J KE L vG
Phone / _ Phone S:
SEP'TAGE SMVIClNO OPERATOR i- .✓ .Jo ck✓ LOCAL REGULATORY AUTHORITY
Name Name
Phate Phone 7 6 386 - 5'6 80
This document was drafted in c onweence with depcer Carron 83.22(2)(b)(t )kD&M and 83.54(1). (2) & (3), Wmcarstn Admtnistia� Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM /
Owner /Buyer �C_ r8 4 �EC. � c„�. •�� C'ael LS' /0-u G J �o ^ , GG�
Mailing Address ��� /o� iQ �/ �y,��..pc�, i, �
Property Address y�� .�� _ . ' '�}' �.�..� �. ���5� Ie k
(Verification required from Planning & Zoning Department for new construction.)
City /State 1 '(� — /u 4 1� Parcel Identification Number b GUO
LEGAL DESCRIPTION
Property Location 1UF t/a , SGV t /a , Sec. O , T d : ._� N R-1W, Town of ��..�
Subdivision P_ G�C�� S , Lot #.
Certified Survey Map# 2 , Volume , Page #
w.Q D ## q � J6 g
, Volume , Page #
�Y
Spec house 63 no Lot lines identifiable ]Ce§.> no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, 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.
Uwe 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 warranty deed recorded in Register of Deeds Office.
Number of bedroo
SIGNATURE OF rICANT 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)
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N89'54 270.16' !
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-- TOP STEEL PIPE lr*�-
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1097
Z Wisconsin Department of Commerce SOIL EVALUATION REPORT Page i of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel Sail Service
Attach complete site plan on paper not less than 8% x 11 inches in size: Plan must County St. Crob(
include, but not limited to: vertical and horizontaf reference point (BM), direction and
pereent slope, scale or dimernsfaw, north arrow and location and distance to nearest road Parcel I.D.
Please pdntad information R Date
Personal information you provide may be used for secondary purposes (Privacy
Property Owner a ;a M:' [.G rope Location
Sienna. Corporation Lo 114 SW 1/4 S 20 T 29 N R 19 W
Property Owner's Mailing Address sy n C lock# (� ubd. Name or CSM#
4940 Viking Dr, Suite 608 "`'f rJ D L 30 na / The Glen
City State Zip Cod PhornN"r. (,C,ti j itY Village jA Town Nearest Road
MIN 1 55435 9�2�3�5"�! �Q K - Hudson Carmichael Rd.
New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement Public or commercial - Describe:
Parent material Pitted outwash 7 Flood plain elevation, if applicable na
General comments
and recommendations: system elevatio 98.85ftArenches spaced and depth to code 4.25ft below Grad
Boring # Boring
Pit Ground Surface elev. 101.10 ft. Depth to limiting factor 112 in. Smt Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
*Eff#1 "Eff#2
1 0 -16 10yr4/4 none sl 2msbk mfr cs if /.5�� .9
2 1 -112 7.5yr4/4 none cos osg mvfr na na / .7) 1.6
Boring # "i Boring
91 Pit Ground Surface elev. 101.10 ft. Depth to limiting factor 96 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
- Eff#1 •Eff#2
1 0 -20 10yr3/3 none sill 2msbk mfr cs if .5 .8
2 20 732 .10yr4/4 none sict 2msbk mfr cs 1vf .4 .6
3 q32-62 7.5yr4/4 none c osg mvfr gw na 7" 1.6
4 7.5yr4/6 none ms osg ml na na 7 1.2
� lJ
Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L. Effluent #2 = BOD <30 mg/L and TSS < 30 mg/L
CST Name (Please Print} S' CST Number
David J. Steel � 248956
Date Evaluation Address Steel Soil Service Telephone Number
1564 CR GG, New Richmond, WI 54017 9/6/2002 715 - 246 -5085
Property Owner Sienna Corporation ParcelID# pending Page 2 of 3
F3] Bofing # Boring
Pit Ground. Surface elev. 96.70 ft. Depth to limiting factor 96 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
*Eff#1 *Eff#2
1 0-12 10yr3/3 none sl 2msbk mfr gw 2f ,5 .9
2 12 -21 1oyr4/4 none sct 2msbk mfr CS 1Vf .4 .6
3 21 -39 7.5yr4/4 none eos� osg mvtr cs na 1.6
4 39 -96 7.5yr4/6 none ms osg_ ml na na
C7) 1.2
F-I Boring Boring
Pit Ground Surface elev. ft. Depth to limitinngfactor in. S Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary . Roots GPD/ft2
*Eff#1 *Eff#2
F-I Boring # 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 GPD/ft
*Eff#1 *Eff#2
* Effluent #1 = BOt3? 30<220 mg/Land TSS >30 < 150 mg1L * Effluent #2 = BOD5 <_30 mg /L and TSS < mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
I�
Page 3 of 3
STEEL'S SOIL SERVICE
David I Steel 1564 Cty Rd GG
CST- POWTSM Sienna Corporation New Richmond, WI 54017
Lic. # 248956 NE1 /4,SW1 /4,S 20,T29,R19W (715) 246 -6200
Town of Hudson St. Croix Co. (715) 246 -5085
The Glen lot 30
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for
your use. The location of the test may or may not be as shown as permanent lot lines were not
established at the time the soil test was conducted. Legend
1 =40'
♦ = Benchmark EL 100,00Ft
Top of 'h "pvc pipe
• = Alt Benchmark EL 102.20Ft
Top of 1 /2" pvc pipe
Q = Borings
Boring Elevations
B1 = 101.1O17t
B2 = 101.1OFt
B3 = 96,70Ft
B4 = 00:OO17t
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STATE BAR OF WISCONSIN FORM 3- 2000 8 0 1 1 9 4 7
Tx:4009124
QUIT CLAIM DEED
Document Number 926330
THIS DEED, made between Premier Bank, A Minnesota Corporation, BETH PABST
Grantor, and McCormack Classic Construction, LLC, Grantee. REGISTER OF DEEDS
Grantor quit claims to Grantee the following described real estate in St. ST. CROIX CO., WI
Croix County, Wisconsin (the "Property "): RECEIVED FOR RECORD
LOT THIRTY (30), BLOCK FOUR (4), THE GLEN, TOWN OF HUDSON. St 11/05/2010 3:37 PM
Croix County, Wisconsin. EXEMPT #: N/A
REC FEE: 30.00
TRANS FEE: 255.00
PAGES: 1
Recording Area
Name and Return Address:
Edina Realty Title, Inc.
400 South Second Street, Suite 115
Hudson, WI 54016
964240
Together with all appurtenant rights, title and interests. 020- 1415 -60 -000
Parcel Identification Number (PIN)
Dated this November R 2010 This is not homestead property.
Premier Bank, a Minn or o ti
BY:
Andrew Nath, Executive Vice President
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF W1
COUNTY OF
Authenticated this November 3, ?0,1,0, ,.
Personally came before me this the above
* Andrew Nath, Executive Vice Preside fit of Premier Bank to me
known to be the person or persons who executed the foregoing
• instrument and acknowledged the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY Cheri Brown
Notary Public, State of Wisconsin
Martin D. Henschel My commission is permanent. (If not, state the expiration date:
6800 France Avenue South, Suite 410, Edina, MN 55435 02/27/2011)
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
* Names of persons signing in any capacity must be typed or printed
below their signature.
QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 -2000
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