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HomeMy WebLinkAbout026-1118-09-000 o f c o —1 C > > 3 � ° r' co M 1 rt e� O F � 0 Z O tC � • n p� 3 f CD o O C S W N ryl =r 3 W py N D. p ro a im T 1 V 7 Qp O O O N N, O O O co 3 y w (D O o C 5'1 N � 0 a m a a 0 3 D ° o CA ° 0 _ Z V O O le i O O O W O C C Er tll CL z 000CD O -0 y 4 y CCD lr co 9 3 N U) UJ Z O p Ul CD CD O F � � 7 N ' d 0 — 1 0 CD N CL ,�. m O z G) OZ O v O CD -0 o s • CD to V N rn !! C c p N W (D d n 3 m 7 Z CD N '1 U) p T n a 0 N F C1 A Z 7 G7 O Z - -` W M * o o,- �z c " ( w N z (D D n n N C o F CD N. NE A � A N V N O O A O CD dQ O 0 ~ ~ y O C y O L � Wisconsin Department of Commercip PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463292 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: Rominski, Matthew & Monica I Richmond, Town of 026- 1118 -09 -000 CST BM Elev: Insp. BM Elev: BM Description Section /Town /Range /Map No 1 0 -6 n� 01.30.18.689 TANK INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - Benchmark r2 Q l�() ( v. 3.5 o 3, / o b. 0 Dosing Alt. BM ST- �v Aeration BI mower 3. (05 Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION S �� 76 S TANK TO P/L WELL BLDG. 5Vent A ir Intake ROAD Dt Inlet Septic � Dt Bottom Dosing �� w ] Aeration Dist. Pipe Holding Bot. Final Grade q '-f PUMP /SIPHON INFORMATION ,5 I Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss m Head TDH Ft Forcemain Lengt Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1 q v i SETBACK SYSTEM TO No JBLQQ WEL LAKE /STREA LEACHING M ure ' LS INFORMATION CHAMBER A �_J Type f System: � A / / , I f * / tJ Model Number: D IBUTION SYSTEM rod go I kt-s- al-- eader/ anifold Distribution x Hole Size x Hole Spacing Vent t e 1 Length __ Dia Length V Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over I 1� Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center /� Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Q Inspection #2: Location: 1403 174th Avenue New Richmond, WI 5�40177J (NW 1/4 SW 1/4 1 T30�N R118 Willow Valley Lot 9 Parcel No: 01.30.18.689 1.) Alt BM Description = V �� wl b� r '� r & - 2,) Bldg sewer length = 361 / ��, � , f `[ Z h � - amount of cover ��( Plan revision Required? Yes Use other side for additional information. No i J d _ �i Date Insepctor's Signatur Cert No 'BD -6710 (R.3/97) I f -- Safety and Buildings - ion County r s 201 W. Washington Ave., 6� 1 ��j n n M adison, WI 53 Permit Number (to be filled in by Co.) Department Of Commerce (608) 266.31 3 z 2 — EU Sanitary Permit Applkati State Phan I.D. Number In &Ccord With Comte 83.21, Wis. Adm. Code, personal you providgg� may be used for secondary purposes Privacy Law...,15." l m} ply ` ,� Pro' .ec Address (if different mailiag�address) 1. Appliadlon Wernatim - Please Print An lft�orenadioo 61 c IG 3 V �NING O Property owner's Na we Parcel # rY slack O N, - I f l$. o it nDPertY Owner's M ailing Address Pf operty Location A op V�.14, S� i.sxuott �— C'tty, State Zip Code Phone Number 14 t 'S circle one) U. Type of Bnil�ng (check all that apply) o , S T� N: R�E or W 6 1 of 2 Family Dwelling - Number of Bedrooms , Deal, s , Subdi ion Name CSM Num t ❑ Public /Commercial - Describe Use - IQ Oyffied ❑ Staff ' D ripe Use Ucity_Ovillage awtuhip of ` m HL (Check only one bolt A; t mplete line B if le) A Y ew S stem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only U Other Modification to Existing System B. ❑ Permit Renewal 11 Permit Revision U Change of ❑ Permit Transfer to New List Permit Number and Date Issued Before Expiration Plumber Owner IV, of POW'I'S : (C-Nec t all that ) P -Pressurimd I�-Ground Q Mound > 24 in. of sui able soil U Mound < 24 in. of suitable soil U At -Grade 11 Single Pass Sand Filter Constructed Wetland El Pressurized in- Ground U Holding Tank 1.1 Peat Filter U Aerobic Treatment Unit U Recirculating Sand Filter i ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line Gravel -less Pipe El Other (explain) V. Area Information- Design Flow (gpd) Design Sod Application Rate{gpdsf) Dispersal Area sf) Dispersal Required ( Area Proposed (sf) System Elevation � t s - 7 � �S 1 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic j Gallons Gallons of Units Q � E o br Concrete Constructed Glass New Existing Tanks Tanks o�7 Septic Hokting Tank � Aeiotuc Treatment Unit Dasiag Chamber VD. Rssponsibibty Statement I, the respor irtty fir ' of the POWTS shown an the attached plans. n7k ,s Na we ( Plumber's gtatu /MPRS tribe, Business Phone Number L)n t Plumber's Addre ss (Street, City, State, Zip Code) 6�2 .Q � 4a e � wi,on 6 VIII. ti e d Sanitary Permit Fee includes Grottrdwater Date Issued I Approv Surcharge Only Ix. gam Si re (No Stamps} Denial c� SYSTEM OWNER: 1 Septic tank, effluent filter and I dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances Arendt metspate pham (ta t6e Caaq atlf? fat tYe samara eo papa aW 1as t>rnt sill x 11 limbs In sbtc Cc,. Lo JJ lco �F ` I { .J : ; a 5 as 7 : , m 1 O'� � - �t�,� �, fl� �.Cs2. SJ�¢.}C � �cayt \� lu /r� �l�r� �_� ., i i i <r : o : I : : 3 _ : w o © � I i S _ : I : i • i ! I � � I : : _ � I i : rA , o n Ca. wl 3l'( No T Cv�p yJC c Vic_ 9a i y 5 DCLS � aao 7 a o� IN\ A (3:5 3 CPO a ` WisoonAn' Department ofcommeme SOIL AND SITE EVALUATION Page 1 of 3 I)lvision of Safety and Buildings in accord with Comm 83.05, -w Adm -. C ode Environmental By Design Attach complete site plan on paper not less than 8 x 11 inches in size. Plan `"" •\ n ty include, but not limited to: vertical and horizontal reference point (BM), directi ' h ,, percent slope, scale or dimensions, north arrow, and location and distance e�rest ro r St. Croix ,'..., Rerpel I.D.# APPLICANT INFORMATION - Please print all informatio Personal information you provide rimy be used for secondary purposes (Privacy Law, 151,04 (1 1 3 BY p ate /D Q Property Owner {� party Loitidr�i r Derrick Construction Inc. 1/4 S I T 30 N,R 18 W Property Owner's Mailing Address hit BI me or CSM# 1505 14wy 65 ,9i" t __ r ......, ` ! Willow Vall City State Zip Code PhoneNumber I , , City ' " ®Town Nearest Road New Richmond W1 54017 Richmond 140Th St. ❑ New Construction Use: ❑ Residential / Number of bedrooms 3 ❑Addition to existing building U Replacement U Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/fF .8 trench, gpdM Absorption area required 643 bed, iF 563 trench, W Maximum design loading rate .7 bed, gpd/fF .8 tr ench, gpd/IF Recommended infiltration surface elevation(s) 95.00 It (as referred to site plan benchmar Additional design / site consideration 3, 5 Parent material Loess Over Glacial OutWash Flood plain elevation, if applicable NA ft S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system jy� s u u E S El u i u S u u 0 S u u i u S 0 u El S M u SOIL DESCRIPTION REPORT Depth I Dominant Color Mottles I Structure I I GPD/fF Boring# Horizon in Munsell Qu. SL Cont. Color Texture Gr. Sz. Sh. onsisten Boundary Roots Bed , Trench 1 1 0 -6 10yr3 /2 - sil 7 7',2msbk mfr as 2f .5 .6 2 6 -36 10yr4/4 - sil 2msbk mfr as if 5 .6 Ground 3 36 -51 7.5yr4/6 - is 2msbk mvfr cw - .7 .8 elev 99.26 it 4 51 -90 7.5yr5/6 - s Osg ml - - .7 .8 Sr _ Depth to limiting factor Remarks: Z 1 0 -12 10yr3/2 - sil 2msbk mfr cw 2f .5 .6 2 12 -23 10yr4 /4 - sil 2msbk mfr cw if 5 6 Ground 3 23 -30I 7.5yr4/6 - sl 2msbk mvfr cw - .5 .6 elev 98.94 ft 4 30 -91 7.5YR5/6 = S USG ML - - .7 .8 r-- Depth to limiting factor 4 29/6 - ZZ >91 Remarks: CST Name Please Print Signature: Telephone No. ( ? r9 P Thomas C. Nelson 715- 246 -2454 Address Environmental By Elesign Date CST Number Ref # 1432 120th Street, New Richmond, W1 54017 1/20/99 227387 189 PROPERTYOWNER : DemckconstructionInc. SOIL DESCRIPTION REPORT ,ss Page 2 of 3 PARCEL I.D.# Environmental By lksi Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary I Roots GPD11 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 1 0 -10 1Oyr3/2 - sil 2msbk mfr cw 2f 5 6 2 10 -22 10yr4/4 - sil 2msbk mfr cw if .5 .6 Ground elev 3 22 -31 7.5yr5/ 6 - 91 2msbk mvfr cw - 5 6 9�8.62tfftti� 4 31 -86 7.5yr5/6 - s Osg ml - - 7 i 8 Depth td " limiting factor >86 15 • yy 79 - `1 Remarks: 4 1 0 -10 10yr3 /2 - A 2msbk mfr cw 2f .5 .6 2 10 -25 1Oyr4 /4 - sil 2msbk mfr cw 1f .5 i .6 Ground elev 3 5-41 7.5yr4/6 - sl 2msbk mfr cw - .5 .6 98.16 ft 4 41 -64 10yr5 /6 - s Osg ml cw - 7 8 Depth to 5 64 -85 7.5yr3/4 - Ifs Osg mti - - .5 .6 limiting factor /� I >85 3 9 2 2 > — re�,r�c o -tom � o - 1 Remarks: 5 1 0 -9 10yr3 /2 - sil 2msbk mfr cw 217 .5 .6 2 9-2 1OyT4 /4 - A 2msbk mfr cw if .5 i .6 Ground elev 3 25 -36 7.5yr4/6 - IS 2msbk mfr cw - .5 ! .6 98.03 ft 4 36 -60 10yr4 /6 - s Osg ml cw - .7 .8 Depth to 5 60 -86 7.5yr5/6 - s Osg ml - - .7 .8 limiting factor >86 I I I I I I I I I Remarks: Ground elev Depth to limiting factor Remarks: E BY DE51GN 1432 120th STREET, NEW RICHMOND, WISCONSIN Last saved by Thomas Nelson 715 - 246 -2454 ■ xz� Willow Valley '' r PAGE 3 NW % SW %, SECTION 1 T 30 N. R 19 W TOWNSHIP Richmond COUNTY St. Croix Wisconsin �0� n �pa a � AGML q I acres o \ $u 3 (PD. 22 SCALE 1" =40 Tom Nelson BM I. NW LOT CORNER Top of iron pipe ELEV. 100' 227387 BM 2. Ground surface next to lath w/ ribbon ELEV 98.74' II v al�Q Y t�T '�i ;C.1�w� a ✓1 cL EZ1203H •...7.. .f. rfrrret low . .•, y a .t.t . of wvv V'r v 12 •.. : �., .h s r. t.w• `? .62511 .7. t 7. .f� 7f III w t ... . r e t . ►t 7.7 1/2 Ciirc. .. r .. t . ' i►"V '.rri . .rf ' vwvvwv ♦f.7f 77 •tt.. ...... •VV . f)..7 .....t. 36" I2 -1/2" DIA. (h'P•) v oid CoeCric lW m A R 'q C S++�au S7.d1c. X le EL �� O.D. oCd pi .. 4.625 jCWS S+dewalf (2 Sidew,siis} r3.34itt VGrid volumeW "FWar tt.: 3.14•( 12sJg ) 22123iu f i� = 3.13 k •t 0 -119 ft, �trotn IR 0.0, "amccrrylinder r2.5 mcliea 2.00 Void volume in a Tacal Sell IwterCaee Arp ! oC� t:7tirrder _ 3.F4 • , 6.,.� , _ 5.14 SQ. 126w/ty ( � �'.ST< - 12iniff .172 ft } a.D. nrour�de � _ l2 1 i Void volume in a P - jetted Treat, Area c +amide cylinders . � • a, t ,� � 57a > iKl1 CN ki�ifl) Sidewall ",t t tgftt = t 2 rt1. •2 = 2.Op Sq.Ft_ f Void volume at hottaa betwecr cylinders 2sis • Nw Bt } 36 - = 33,00 if otom = 12i� t fi ! Zia 1 fl ( (l.. l3 fN SQ F2 1 011) ` 1.1+x/ )j _ i 'void vuluttrc at outswlr / t t2isi ft Projected T rnc6 Area 3.Of Sq.Ft. } t 'O wets { tf? -(v vdume Tout bctwRa cyiltedetsl 0.21 S ? = (I l R 'aid volume . 0-1 17 - 0,422 + a 90 r . 0,21 � 763 cubi ft t r, I Gallons per R = " X 7.49 - 13 _�iHsac i r / 36 x to -s tP� Aggregate Trench System EZl 203H Rin O w q Indus #riot! Group _ 65 industrial Park Rd. Oakland. T" 18060 SC+ttE FtF 1+11/1: E212py1 -.sf : S!1[EY: t w t to -29-01 fi OWNER'S MANUAL & MANAGEMENT KLAN P of , PQWTS C?W Vic► ❑ M o Co. [3 O use' Cl Holding Vol. a 0 NA emit 2 9z Tank MwWf "M gal ppRAM1 ="1 1S 0 NA 13 Septic 0 Dose d'NoMinB vo1. ❑ NA lumber of BedroBedroom Bedroom " bar Effkmt FR Merxrfaa~t�xef © C (umber of Public Facility Urnits Effluent FOW Medal Estimated lanrar+sSe) flow b�o p Manufac PA X 1 5) O0 Design !peak) flow -- . � Mold t A Soli Application Rete Mond* aver+ Prepeatmer►t Unit Standard influsntlEfluent OuaftY ❑ Sand/Gravel Rtw ❑ Peat Fitter Fats, 04 1 & Crease (FOG) 530 mgn- ❑ Mechanical Aeration ❑ Wetland Demand (3CXV 5220 mgA- ❑ NA ❑ Other mairdection Biochemical Oxygen Solids t't'SSl 5150 �- O Total Suspended Monthly average manufacturer D NA Pretreated Effluent Quality plepersd Celits) Biochemical oxygen Demand (SODj 5 ❑ NA '1 30 mgiL 'In- Ground tom) 0 hr Ground snuized) Total Suspended Solids iTSS) 534 OVIL ❑r' At -Grade ll Mound } 0~ cfu/1 0000"'d 51 ❑ NA 13 tNip-t -fie 0 Other: Fecal' Comorm tom Ye in dia. ❑ NA Maximum Effluent Particle S12e ❑ NA NA Other. +Nobles typist for d°meatic wastewater and septic tark e MptNTENAWCE SCHEDULE Service rnot►thta) py n 3 X�) [3 NA At least ounce O ar(s) y' of tank volume inspect condition of tw*(s) combined sludge and scum ems one -third tY ❑ NA the tigh water °W " is seuvated ) ❑ NA Pump out contents of tank(s) =When 0 mo �ts) nym 3 YOem At least once every: ❑ � ls) 0 NA I dispersal cell {s) At least once e`er' ❑ morath(s) A Clean efflu�ernt Fitter At } confide &alarm At tea st once every: E3 (a) O NA [aspect pump. p ❑ y Wis) At least ounce every: P F NA Rush laterals and pressure test ❑ nnorrttnIs) Other. At least once every: 0 X 11 NA can Y orra of the following licansas or certifications: C170t�iS an individual talrner; Septage S Operator !Bumpe lnspectians of tanks and &Vwsal calls sha a sew pOWTS TS Mahn iderntifY any cracks or Maatet Ptumberw of the tan k( s ) to m urkenp� hard of effluent on the ground Master t?lumber; for any for any Tank I0pectlons mus of combined sludge and affluent levels in the observation pipeS leaks. measure the y surface may indicate a failing condition and surface. The &WeMW COWS) shat! be t I pe�ng of effluent cm the ground surface. ponding of effluent of the local regulatory wt wdW- _ eq uals one -tltircd IY,1 or more of the tank volume. the requires the irrnrrnedi of Mudge and scum i n any �atmOp�tor and disposed of in accordance with chapter NR 113 When the combined veal by a Septaige S e rvic ing entire contents of the tank stub be remo mechanical or pressumzed co nponents, Rretreatmen Wisconsin Administre Code. e. of effluent fitters. not limited to the servicing certified POWTS Maintainer - Ali other services, inclu but ding ed 'on of any service event. units, and any servicing st intervals of S12 months. shall be performed by a wi thin 1 O days GMW 12/02 A service repo shell be provided to the local rel�a WY sutho Y Page of ; START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankis) for the presence of painting products, solvents or other chemicals that may impede the treatment process and /or damage the soil dispersal cellis). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shed not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal hohwatw levels. When power is restored the excess wastewater will be discharged to the dispersal deft) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do rwt drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade sod absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers: dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meet scams medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shalt be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN N the POWTS fails and cannot be repaired the following measures he" been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction rind should not be infringed upon by required setbacks from existing and proposed structure, lot Ines and weft. Failure to protect the replacement area will result kn the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the faded POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. hf no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade sod absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Recastructions of such systems must comply with the rules in effect at that time. < < WARNING> > SEPTIC, PUMP AND OTHER TREATMEIT' TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAKFANdER N cx D 0 Name Phcxue S Ptrone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL naG nl ATORY AUTHORITY P Name I/� i C> e _71-S-3 0 . j y This docum was drafted by the staffs of the Green lake, Marquette and Warshara County Zoning and Sanitation agencies in compaance with chePter Comm (2)W(1)(d)adfl and 83.5401. (2) & (3). Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer MA-Tn4cw L • � I�tob� -1 �t, t� �.►s tc, Mailing Address 5 1 1 t4anTV4 6+U;e-v 'i'i V , '"yv V-t t„Aa j'%.WS4b, \All 5 401 - 7 Property Address 1 4 . 13 3 1-1 4-- rk AA�� i-w (Verification required from Planning Department for new construction) City/State 1 `�' ( ` ��, - - Parcel Identification Number 01 0- 1 t 1 % - d 9 - O 4 Q LEGAL DESCRIPTION Property Location 14W %,, 9 ' /a, Sec. ---. • N - R 140 W, Town of r^.Q W Subdivision �N Lot # 19 Certified Survey Map # Volume . Page # Warranty Deed # �, �S 1 Volume Z5 5 . Page # © SS Spec house ❑ yes no Lot lines identiflableXyes ❑ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, joumeymanpl*nber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 fo herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification statin t your ptic system been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da the year exp' IGNATURE OF APPLICANT DATE OWN ER CERTIFI 4 certify that all tements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the de d abo;AXY virtue f a warranty deed recorded in Register of Deeds Office. r G ATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit 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 PA61ES 1 vaLcw �x 1 - -- - a Sri Cra:•�.. !�- l.cnnt � � I FAX O: _ - PHONE r: 'j 8 6► I 1 NOU R ro ►/w,s su Jo ► /wn 204 SO W 1 { it i b' diDT • 1 1 I 1 l .00 11.80./ -00N � r r ► -1 -1�� e � gg a W � w .� wS i l w: e �d A AA P Q 1� cl �~ ! w� --- - - - - -- 0 - car ' 1 9 9 �-• yi S. g ...... hl.. q a 9 1 1 � s ' At to 01181'+4 31� Ql 031 01030 _ x .0076 3.t t. 6 &OOS i i rAv 1 Q 'i I II•. 1 6•{ I l'ri t 4� 1 y� i ". i � �$� 11gg9 I 7653 1 1 9 'l Z S 9 Z P O KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI Document Number WARRANTY DEED RECEIVED FOR RECORD 66/09/2004 09:30AN This indenture, made this 4th day of June, 200 4, between Wm- Derrick WARRANTY DEED Construction, Inc., a Wisconsin Corporation, duly organized and EXEMPT # existing under and by virtue of the laws of the State of Wisconsin, located RA at New Richmond, Wisconsin, party of the first part, and Matthew L. T FEE: 11.00 Rominski and M onica M . Andersos joint tenants, partite of the TRANS FEE: 112.50 n, a COPY FEE: second part. PAGESE : 1 Witnesseth, That the said party of the first part, for and in consideration of the sum of to it paid by the said part of the second part, the receipt whereof is hereby confessed and Recordina Area acknowledged, has given, granted, bargained, sold, remised, released, Name and Return Address aliened, conveyed and confirmed, and by these presents does give, grant, bargain, sell, remise, alien, convey and confirm unto the said WESTCONSIN CREDIT UNION parties of the second part, their heirs and assigns forever, the following P_ 0 BOX 269 described real estate, situated in the County of St. Croix State of NEW RICHMOND WI 54017 Wisconsin, to -wit: Lot Nine 9 lat o Willow Valley In the Township of Richmond, St. 026- 1118 -09 -000 ounty, Wisconsin. (Parcel Identification Number) Seller, Wm. Derrick construction, Inc., a Wisconsin Corporation, is an affiliate of Derrick Homes, LLC. Seller develops land and Derrick Homes, LLC is a home construction contractor. Seller agrees to sell this lot to Buyer on the condition that Seller's affiliate, Derrick Homes, LLC will be the builder of the home for Buyer. If Buyer does not commence construction with Derrick Homes, LLC as the contractor /builder within two (2) years of the date of sale of this lot to Buyer, Buyer gives Seller the irrevocable right to re- purchase the lot for the same price as Buyer paid Seller for it when Buyer bought it from Seller. If Buyer desires to sell the lot to another purchaser before constructing a home upon the lot, Buyer gives Seller the right of first refusal to re- purchase the lot for the same price as Buyer paid Seller for it when Buyer bought it from Seller. Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, eithsr,in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said parties of the second part, and to heir heirs and assigns FOREVER. And the said Wm. Derrick Construction. Inc.. party of the first part, for itself and its successors, does .' ". covenant, grant, bargain and agree to and with the said parties of the second part, their heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and Indefeasible estate of inheritance in the law, in fee simple, and that the same are free and .clear from all incumbrances whatever, and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part, their heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will . forever WARRANT and DEFEND. In Witness Whereof, the said Wm. Derrick Construction. Inc. party of the first part, has caused these presents to be signed by William H. Derrick, its President, and countersigned by Mary Ann Derrick, its Secretary, this 4th day of June, 2004. Wm Derrick Constructien. Inc. Co orate N me William H. Derrick Presi ent R Mary A errick Secretary State of Wisconsin, St. Croix Count. Personally came before me, this 4th day of June, 2004, William H. Derrick, President, and Mary Ann Derrick, Secretary of the above named Corporation, to me known to be the persons who executed the foregoing instrument, and to me known to be such President and Secretary of said Corporation, and acknowledged that they executed the foregoing instrument as such officers as the deed of saZCo ora tion, by its authority. E1DI !» LIJTZ Notary Public St of WW=sln THIS INSTRUMENT WAS DRAFTED BY Heidi L. L Wm. Derrick Construction, Inc. Notary Pub ic, St. Croix County, Wis. New Richmond, WI 54017 My commission expires March 26, 2006