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HomeMy WebLinkAbout020-1353-25-000 i s Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: ( ATTACH TO PERMIT) 395113 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: Panek, Luke Hudson Township 020 - 1353 -25 -000 CST BM Elev: Insp. BM Elev: BM Description: {G 6 (6d All in ( oak- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Benchmark i✓ ?'.5e f z Sd f,tq to P? /6 U D [2,9___ Alt. BM Aeration Bldg. Sewer 4 H mg it Inlet g// /2, 2S r . y TANK SETBACK INFORMATION 8/it Outlet 4 12,S? 9 , / TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / � —' Dt Bot 20 Dosing Header /Man. ti T # - 7.7/ Aeration Dist.Pipg / Yc L /f ir �u'Pr G .bi r' lel R a• l 9 � °cP Holdin Bot. System x i , L /6. /s i ' g '8 9, e4 92 A/ PUMP /SIPHON INFORMATION Final Grade I „ t �.� if s�' 93 4 Manufacturer Demand St Cover 0- A p .7r I --------- GPM 8 1df-ZO ! Model Number — 14 r H. e 3 J o b. 41 ?Y / H. r TDH (Lift Friction s stem Head TDH Forcemain Le Dia. Dist. to SOIL A SORPTION SYSTEM /0 l', r S , /4 BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / s r 3 SETBACK SYSTEM TO V P/L BLDG WELL LAKE /STREAM I M n fa�rer: INFORMATION Type Of System: HAM OR 3 YP y 4 r ■ r + r -, T Model Numb /.I.,1 ' L / 160 — Pee 13;/1 7 s DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake j/ q Pipe(s) / / ._. Length 3 F Dia / Length / Dia / S p a c i ng — 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 [0 Yes [ ] No I] Yes r* No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 12 / t 7- /0/ Inspection #2: / / Location: 670 Hillary Farm Road Hudson, WI/ ) 54016 (NE 1/4 NE 1/4 36 T29N R19W) Cottonwood Ri Parcel No: 36.29.19.2025 ilea-. e1 S ri/ /� (confer) ��� ' 1.) Alt BM Description = o Y 5 4.k- h/( 5 /tif (I Q,, S C 4 i c. - Sp 4., 2.) Bldg sewer length = _ // S - amount of cover = y y2 rl 24 ✓ — -- Plan revisi�ii FzBqui�ed? Yes G � N ( 1p / / Use other side for additional informati.n. ,� Z i /Z ( , 1 — �u._ 1 ... . _s i 4 �� kb SBD -6710 (R.3/97) , Date Insepctor's;r • ure Cert. No. k We k C/ .A o 1 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 \V'sconsin Personal information you provide may be used for second u oses p Madison, WI 53707 -7302 Department of Commerce (Submit completed form to county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number $Check if revision to previous application State Plan I. D. Number S 6- 3 9_C77 3 L Application Information - Please Print all Information Location: Property ( f� Owner Name Property Location �yI Z ff /a /" 14 *jig kr1 /4, S I T 1'" , R (o Property Owner's Mailing Address Number Block Number 1, J3 i 7r C/-- _ ;.— City, State Zip Code Phone Number Subdivision Name or CSM Number ., ,, CA.." S-( C ,Cs / � ' � / G 3 - .mac''d 6: 7�kt.'f II. Type of B (check one) ❑ City cfP 1 or 2 Family Dwelling - No. of Bedrooms : ❑ Village ❑ Public /Commercial (describe use):_ '` r J � Town of ❑ State -Owned Nearest a 51;1i ti W � ' / Parcel T berg III. Type of Permit: (Check only one box on line A. Check bo tin line B if applicable)_ A) 1. ;New 2. ❑ Replacement 3. ❑ Replacement off;, 4.. , \ ` . ,,✓ 5. 6. ❑ Addition to System System Tank Only _ Existing System B) Permit Number Date Iss ed ACA Sanitary Permit was previously issued 3 9 S // 3 74 y ,.1.vrr/ IV. Type of POWT System: (Check all that apply) i lon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: 1 I s V. Dispersal/Treatment Area Information: c' 0 B ata — c - g. 2, 1..2 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) tipj ' T% - C Elevation VII. Tank Capacity in Total # of anufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks p IS ❑ ❑ ❑ ❑ J 1s 6 T° 0.5 - 0. 7 I Q c c.„ o ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number . 7 Alt lumber's Address (Street, City, State, Zip Code) ; `ems 7'� 5 i Y 7 lS —,?..07 ' 4 f 7±.7-4,-- £( hCr &4.--.- , (T IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) y Approved ❑ Owner Given Initial Adverse Surcharge Fee) 1 Determination 1 , Q 0 1( / / ,,,l, 4j� -A f�, ...7." PP PP X. Conditions of A roval /Reasons for Disa roval: ( J 1. Effluent filter to be installed and maintained per manufacturer's recommendations. 2. This revision was submitted to reflect a change in system orientation and elevation due to the placement of the driveway. 3. A cleanout must be installed for the building sewer. 4. Entire trench must be installed in natural soil and there shall be > 12 inches of cover over the system. SBD -6398 (R. 07/00) Safety and littildings Division County � 201 W. Washington Ave., P.O. Box 7162 r f " Cr y x- rsconsrn Madison, WI 53707 - 7162 Sites }` Department of Commerce fo 79'' A(4, � /ci.., ,/ Sanitary Permit Application sani 3 e> Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ( si ❑Check if Revision may be used for secondary purposes Privacy Law, s15.04(1)(m) I. Application Information - Please Print All Information \'‘ ie t r to Plan I.D. Number ' ': Prope Owner's Name Q 4' ' ' umber _ L % if, ZOZS :,.-1 ,i-(,.....,,...4-- it irecavo 0 - ?.5 3 -...?5 Property Owner's Mailing Address Jill Pro.. . tion l 2 54 S T C ^ ♦ . //` rL-�'k : S ,k t} N. R (mi L� a.-- City, State Zip Code P 75 r um Q rBlock Number ►CE ,,,, P vision Name CSM Number ( 75 -I 9 fi P� II. Type of Building (check all that , .1y) 11 Wiry 0.1 or 2 Family Dwelling - Number of : •. Y ' Bk per T (ow,5 S ail , lJ -• ❑Village ❑ Public/Commercial - Describe Use ERownship,„,,i p� ❑State Ownedst cad j 7/ III. Type of Permit: (Check only one box on line A (n . . ering scheme for ; ternal use). Complete line B if applicable) For County use A 1New 2 ❑ Replacement System 3 ❑ Replacemen f 6 ❑ A. .tion to System Tank Only Exis ; System B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme ' o ternal use) 44Non - Pressurized In -Ground 210 Mound 47 ❑ Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Sing Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatme Unit 49 ❑ Rec• g X� 300 ❑ Other V. DispersaUTreatment Area Information: .3(j C4c -1...� ? b!a a : ycc- Design Flow (gpd) Dispersal Area Dispersal Application Percolation Rate System Elevation ._ Final Grad / r e �,� Required Proposed Rate(Gals./Days /Sq.Ft.) r • ./Inch) g' ? i' .1 4,4 Elevation ( j i S ✓ C 4nr.o...6. /d y Q. ®,� �� - 5 - - .ro .. 7 r . ..1 VI. Tank bztf Capacity in O Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallo of Tanks , . ncrete Constructed Glass i New Existing , T !k Tanks Septic or Holding lank _ (. re/ / (,�...c c i-t:/' Dosing Chamber VII. Responsibility Statement I, th , dersigned, assume responsibl7r'ty for installation of the POWTS shown on the attached plans. Plumber's Name (Print) umber's Signature MP/MPRS Number Business Phone Number T ii9' Le., ��- — -. C -- 7 y 7(j 38 l7 q Plumber's Address (Street, City, Sta ■ , rp Code) 3f- 7 d 6h2- w--L VIII. County/Department e Only Approved ❑ Disappro Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner ' iven Initial Adverse Determination C 'i a as7o U - 7 L Ue. I IX. Conditions of ApprovaUReasons for Disapproval / / ( ' � e'✓ Glee✓. ) l� be- a �vt�t �✓. �/ Z J � Gbver U 2� .filler ) 4a 'as/�t<�cl! ai a-d Ser(1hCed (e✓ stout alRClc re Co r. n.ei,,6ct -- 3') i ofe #7 a il".7 -IC,., ; /. Mme . /r - a urn /yrn e /e w.tS de - at. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 1 , inches in she 7 o n /1/ /i p� era 41 SBD -6398 (R. 05/01) Y tc lovi t.t-4-Z5 Co-i-to" e.,2 .. — i--- 4-1 ■ SKV 4- 1 / : ? & 1 /IN ;r• I Cleo. fou.e." Rip a P e." pvc. pop 17.,„, Oct). 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H 1 - (n N O -J CI- N I ' ; 2 -w0 N . :5 Li w� N w J � I V W Z F - j} V NxR t 0 ^ID ^ F IJ -V1 1 = Z I <li.l mZw w cn y J G7 Y N ` v p .„,.- og oco °oZw a a _,= W Z O_ -I 0 Q a W Z p-I d Z m 4 Z N O U O D U 0 N am vmx aac� a� z oa z I-- z W v o a 5 z z J x O J • H « Z9 Lai J ? rIN N ° AP I MI 11 Il , i I \ ■If `� � II � � II e i I I o I „17 l iii I .£ LI 1 J 0 J Luriii\ I- 0 I « t5ti c 0 I w « 6£ o «98 .l9 • f ' Nsconsin Department of Commerce SOIL AND SJ.E,EVAt. 3 Division of Safety and Buildings Page of Bureau of Integrated Services in accordance wi (S', ILHR 83.09, Wis >Adm. Code �,// f • Attach complete site plan on paper not less than 8 1/2 x 11 inches i gize Plan mtfst: ;T Courti include, but not limited to: vertical and horizontal reference point (B ),,.direction and ._I-4 . C r0 f k percent slope, scale or dimensions, north arrow, and location and d tance tQ° fest7road J Parcel D. # �T 1 APPLICANT INFORMATION - Please print all inforniatidn. COUNTY Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy 4W, s 45.04 (1) 'm � /� 111 Property Owner J y` ,,• property Locati n i' / ///��� " r b R tchard 0 G Loot 1/4 N E 1/4,S 36 T 21 ,N,R 1 E (or WJt� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1 X53 i crkiLee - Tr. 2S C0+ --4- good R a City State Zip Code Phone Number ❑ City ❑ Village g Town Nearest Roa' Nud5on 1 1 N t, 1 5k -I0tL4 I (115 )5LIq- Q 3i 1 I ec'f-bn.,wcd 4r _ S. New Construction Use: (Residential / Number of bedrooms 3_ y Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow t,106 gpd Recommended design loading rate i 7 bed, gpd /ft • trench, gpd /ft Absorption area required Z5 bed, ft 151 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft • 8 trench, gpd /ft Recommended infiltration surface elevation(s) upef r Sc r .1 0 Lo cw.e. RS. /0 ft (as referred to site plan benchmark) Additional design /site considerations Speer q2.76 LatA+c,r+ 911• 7 v Parent material (-.- lckctO ( 60 Jo r, Flood plain elevation, if applicable Al /A• ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [1-5 ❑ U [0S ❑ U lie - s ❑ U es ❑ U ❑ s ® U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench -$ lU4r312- St_ 1mubk thi;r c-5 1 p • `I :.5 2 - I(��1 `i r/y ribK Sd 2r rn-F; c5 • 5 , -( Ground 3 y3 -12c tU m 5 os5 ml c . - I ; . 3 elev. � _ Of Go ft. Depth to . limiting factor Si Remarks: Boring # /1 1 0 -$ 10.0 ---- 5L 1 nr,Cs`bk frl- r r G..5 t• .L .5 2 2 -2 Iv yr yl'j — 5i 1 2 crvabK rn c5 - . 5 .(o 3 2 �Ig ►D c '- I� -- mS ns rr,t c5 — • .. 8 i ll Ground , ', elev. 'f&. Zo ft. ' (1;1- 9"f ' Depth to c , - ,'' limiting ■ o. 4y factor 11 1S in. Remarks: CST Name (Please Print) Signature Telephone No. A S -h u er i= (- 7ij2 7- 1' ) Address Date CST Number L/ ) 8 C,,ec(er 51- it `q .SO m (-0/ 5 (/ -/5 --S' 5 23-.3307 _ f JJ SOIL DESCRIPTION REPORT fr PROPERTY OWNER S v T Page 2 of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure G D /ft g Texture Consistence Boundary Roots t' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 l V -5 10 ye 312. 'SL 1 rrtckbk fr 4-5 I � . y . 5 Z - zz (U -1H — 5', I 2 1110.131s rn4 c_5 - 5 :. (p Ground 3 22_119 4 1 (4 , mS Usc� rnt LS _ 1 3 elev. f J g1.cO ft. • -511'k Depth to limiting . Pp L;---0 factor din. '")t A X6� Remarks: Boring # 0 -I0 t0 y r 31' SL 1 v kb\f. r E r CS y P . -i .5 Z la -2' IOyr 5; \ 2 rnabk mf c.5 -- ' 5 : • 4' 3 z9 10 v rY. 0S5 m\ GS — • 1 •�'' Ground elev. 81.20. Depth to 5 v limiting a � factor U5 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring# ( 6_4 IOyr3IL — SL. tmc►bk- mfr C_5 IC •t ' .5 5 Z 4-29 IOyr 9 `f - 5. I 2,rn b rn4 & 5 — . 5 � F 3 I14 ID yr `1142 m OS5 mk c5 - 1 8' Ground elev. - Depth to ,x q(. y / a rk± Qo.G limiting /fin y „ rP,'7 factor Remarks: Boring # Ground elev. ft. Depth to limiting factor 'n ' Remarks: SBD -8330 (R. 07/96) Volt 3o43 S it- Go--ZS Co ► iovv icx,(4 Q.'..e-e_ X I-,, 1 8°' Pa ‘' t 1 'htZ ""`k 2/ ay, 1 of lop. c> 'Top cVz "pvc. P ( - e - 1 w'Z el ev. 88.7(9 N Luw.r vrP,-✓' S, + Y\ 2(-eu 144_1-, e(-ev t u ?,-7Z. 70 G.OW-ex' 90.70 .6..r, - 44-. r 5t . 1 a 'S • At* ©Z 1 :2, • 0 ) prt... y V •• L3A Z Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This complies management plan lies with Comm 83.54, Wis. Adm. Code, and the In- Ground 9 P P Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567 -P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms Design Flow - Peak (gpd) (Do Estimated Flow - Average (gpd) *20 Septic Tank Capacity (gal) ( 4.573 Soil Absorption Component Size (ft 5 Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. 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 Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The Y 9 P 9 septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain Tess than maximum scum and sludge accumulation in the tank. Manhole 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 one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 . Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Z v /( P e -i ei Mailing Address s _ /9-^. I I� -i. ti 0(7 Property Address (n i t 1 (1 T (Verification required from P Department for new construction) AP City/state N''c -J cn Parcel Identification Number L 9 2Qi - / 5 S; 3 ? . c7cyd 'LEGAL DESCRIPTION Property Location HI! %, %, Sec. 3K: , TAN -R /7 W, Town of 1�0 s*_- . Subdivision /'t Lot # Certified Survey Map # , Volume . Page # . Warranty Deed # , Volume , Page # Spec house 0 yes 0 no Lot lines identifiable 0 yes 0 no MnfM_-wommiNCI Improper use and mainteasaeeof your septic system could math is its p ae-fi etohaadlewastes.Proper consists of pumping out the septic tank every three years or sooner, Encoded by a lived pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the: waste disposal system. The property owner agrees to submit to St. Croat Zoning Department a certification form, signed by the owner and by s muterplmnber, journeyman phnaber, odpbmmberora licensed pumper verifyiagthat(I)theon sitewastewat rdisposa[ system is in prow 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 lave read the above requirements and agree to maintain the private sewage disposal systan with the standards set forth, herein, as set by the Department of Commerce and the Dot of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and rammed to the St. Croix County Zoning Office within 30 days of the three expiration date. ? / I / SI TURE OF APPLICANT DATE OWNER. CERTIFICATION I two certify that all statements on this form are true to the best of my (our) law/ledge. I (we) am (are) the owner(s) of the property above, by virtue of a warranty deed recorded in Register of Deeds Office. 7/6./0( SI91 OF APPLICANT DATE * * * *'* Any information that is mis representedmay result in the sanitarypermit being revoked by the Zoning Department. ** * *" *` Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 07/11/01 WED 08:01 FAX 715 386 4687 REGISTER OF DEEDS Qhool 1 - 6 9c347 to STATE BAR OF WISCONSIN FORM 2 - 1998 G. .4 la■ Cs lg. WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS 00eveWhi Number • ST. CROIX Ca., 441 RECEIVED FOR RECORD This Deed, tnede between 06 9:05 Aff 1727.1471.14,1 ATM TT and TARTFT . hushanel and wife., liARRAKT DEEP Cnntor, EXEMPT CERT COPY PEE: and _LUXE PEI( AMT EANEK. ,AN11_1/1 LIIPT FEE: TRANSFER FEE: 173.70 MORONS FEE: 1040 MGM , Cramer Grantor, For a valuable co uideration, conveys and warriolty. to Grantor the (n110wing • described ma1 matt 111 Cro.i•x-. Caunry. Slate a : Lot 25, Plat of Cottonwood Ridge, Town of NiteWi; AeturnAddraaa, Hudson, Scounty, S. Croix co Wisconsin. -41(714' 4 ) 1 4tet. 744E 1 4,0 4 ■5 S. */ Crantee, its successors and assigns, hereby w SLID' ‘tl agree that a single family residence only will be constructed on the subject premises. ' qieratt 3a7 00 -1353 -25 -000 Rareel;Eienitit Ntimtsr (PIM ThiSj..6 ,F11„Qt_ IlOstiestead Inquiry. (12) Iris riot) .• .• • Excapdons to swoomtios: easements, restrictions, rights-of-way and covenants of record. Dated IhIS day of My rRALIAA-Z, (SEAL) _ (sEAL.) Richard 0 . Stout Janet P. Stout. (SEAL) (SEAL) • AUTHENTICATION ACKNOWLEDGMENT Signature(a) SiAle of Wisconsin, St. Croix Count authentleseed tilts ,ya,, Pcrsonatly ramp hebir ine this day or . 20_03_ . the above named Richard O.. Stout and Janet P. .... • TITLE: MEMBER STATE BAH OF WISCONSIN ta {If riOL me known to Or Slot ii;ITAbflialikL4foieuted the foregoina authorized by 706.01:i. Vtils Stnts.) iltgrurneriL and rSTATEr,06 WISCONSIN KERNON J. SAS THIS INSTRUMENT WAS DRAT- IRO RV Janet P. Stout 4/41eri ' AW 1153 AwalnkA.P.Tr. Hudson, WI 54016 Natzry P 1, State or WIAtnain My ao rrtInto 2.ermatleni. ar not, war expiration ate: (SIgnatuers may be authertricetrd Or acitnowledged. Both are oot nem,sary) . . Nam. Of persons .4/ping In lin)/ cypnetly mute b• r prInbtcl liWow thee tdoestre. STATF FIAR OF WISCONSIN wtsconset Lepel gew O, ree WAJOIANIT DEP.D FORM Ne. 2 • 1998 ' ' — q ; 11 STATE BAR OF WISCONSIN FORM Z - 1998 1 , . WARRANTY DEED 3 c( 7 ; ke) Q Poctrmerer Nurnbr.lr 14 4 5 ---- ? 14 „ (- tf t .x--- 11 . I I This DPed, made between tt i I: _.... , i)C- — RICUARD 0_ STOUT and JANET P.. STOUT, Ii , a II husbad ad wife, husband u • Gramm. II 645?! j il mo LUKE PANEK II 11 1 1 , CI antre. 1 CC , ‘,/ii,e 4 -, ;i i, Glarilor, for a vaittable cot isideration, conveys and wail to (;I 1I the [1 )HI ti C 6 I i w7scAllmwal rMatein sL, c Ommy . Simen0 Mwmirmi, 1 , 1 (..,4"(( l ii li , ' li ri ;i#4.L.:LI: Lot 25, Plat of Cottonwood Ridge, Town of II II Name and Return Address Itli Hudson, St. Croix County, Wisconsin. 1 F I Grantee, its successors and assigns, hereby II agree that a single family residence only will_ be constructed on the subject premises. „ 11 020-1353-25-000 II parcel It) entikalion Number (PIN) This 1 no 1 homestead plopet ty (k) (is not) [ I il ii i; 1 1 i I 1 1 i l'Avflototivaumiii‘r, easements, restrictions, rights-of-way and covenants 1 of record. ,i ■ 1 i i ,afrd this day of May , 2001 . 11 t • 'TM 1 c■ A c ----1----- n----i . - Y) iul:All , I I • a • JL.i - s - +• � - _ `.4■• • t • In * TWIN HOME •••'... -:: - -- _ _�_ D.O.T. SET /J -- .. ' _ i .. - II • 24 i i ; c-7 • •...,,_} r • TS r i TWIN HOB E �; i i � i r + ; � 131,164 9G.FT 1 • Trill HOME 1 1 o II +a Is ; • • • li it • • • I i i i • s 3.050 ACRES ; 3.012 ACRES ; � t °: 133.270T. • '� 131,167 SQ.FT. i r r� 1 1 i 1.1 , r•t- �� � � i 7 i° i t i 1 l • g. � i i !! i i i i �' i r � i! ir o , to yr I ! i 11V iy ii .! i... Wits i r i 1 1 i i i, !� ;; �p'r< i; !! r t i • ;� _i H, .i ............ i � ;r • • �; + gyp � 1 y • �` `.' -- . _ �L 7__ -"---_ r � .......... • 1 = 100 SCALE IN FEET •