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HomeMy WebLinkAbout026-1126-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430163 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: Linneman, John Richmond Township 026- 1126 -10 -000 CST BM Elev: Insp. BM Elev: _ BM Description: Section/Town /Range /Map No: l c4. 5 II({, F3: � 12.30.18.771 TANK INFORMATION '7, I J ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septiq Benchmark osing Alt. BM Aeration Bldg. Sewer r'. v e. Holding St/Ht Inlet 13 l St/Ht Outlet 1 TANK SETBACK INFORMATION 7. 1'� 9g p� TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ti 3 -1 r t n ?4I f .� Dt Bottom Dosing Header /Man. C- /& , 3 111.4 ra .3 �iti•91 Aeration ist. Pipe Holding Bot. System 5'v� r � •� 9�! •/ Final Grade efe V, PUMP /SIPHON INFORMATION (e el X Manufacturer Demand St Cover GPM 3.1 /O /•Z7 Model Num S s -! e.. N �. / / , v � . 1. TDH Lift rich ss _ System Head TDH F orcemain Length Dia. I SOIL ABSORPTION SYSTEM , ,- :r Y - BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS -3 I0 2_.. SETBACK SYSTEM TO I P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR cz- Type Of System: NIT Model Number: / D ec> -1 V+ZnJ i is'J11— �L�' t .— 13 L� DISTRIBUTION SYSTEM Header /Manifold d r «r-- Distribution w _ x Hole Size I x Hole Spacing Vent to Air Intake " Pipe(s) Lengt Dia L tl l-ength Spacing J SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded 1 xx Mulched Bed/Trench Center r U ` Bed/Trench Edges Topsoil " Yes D No L Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: /t- / f";' Inspection #2: Location: 1642 Water's Edge Drive New Richmond, WI 54017 (NE 1/4 SW 1/4 12 T31N R18W) Water's Edge Lot 10 Parcel No: 12.30.18.771 1.) Alt BM Description * �>-�� ti 2.) Bldg sewer length = ^- 35 f P �f'-` C �; o �✓ cl C- C.e +r cit � f• / l 1�C% J a A- - amount of cover = I Z cl E r az d� 6 a pG� i oNS l l - Plan revision Required? 7 7. z i Yes No Use other side for additional informatXn SBD -6710 (R.3/97) —� Date Insepctor's Signature Cart. No. l Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7082 11VI sconsn Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261-6W O 16 3 Sanitary Permit Application State Plan L D. Number In accord with Comm 9321, Wis. Adm. Cods. Personal in%mudion YOU M ovidn Ai may be used for secondary Purposes Privacy taw. 5.0+1(1 xm) Project Address (if d' amt than mailing address) / I. Applieat%n Information - Please Print Ali Infor�matida ✓ l �.{ a Owners Name Parcel M Lot ' (� Block X L d,h ►h l1Q r ; p _ Owner's mailing Address 7 A tv 4 va v `^ Y., Section l City, State Zip Code "Mwtqumber V t, S 5(a — T tc S1_ B r � EL Type of Building (check no that apply) 7 Q� u/ £` K or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ❑ Pubdir/Can wArcW - Describe use f S ❑ State Owned - Describe Use a Z () - ❑city ❑vinW Of III. Type of Ptrwit: (check Only sire box on Wte A. Complete line B if applicable) - A ' Plea+ System ❑ Replacement System ❑ TremnentlHolding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Paumit Renewal ❑ Pemit Revision ❑ a mge of ❑ Permit Transfer to New List boas Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of IPOWIS S Check all that P(Non - Pressurized let- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pans Sand Filter ❑ Constructed Wetland ❑ Pressurized in-Ground ❑ Holding Tank is Treatment Unit ❑ Recirculating Said Filter ❑ Recirculating S their Media Filter Lacking Ch er amb Lune vet less Pipe Older err - V. Wreatnreat Area Inform mica: Aga Flow (� Design Sail Application Rate(gpdsf)� Proposed (SO SD 57 00 , q 1S VI. Tank Info Capacity in TOW Number ufaixurer Prefab S Sted Fiber Plastic Gallons Gallons of Units Concrete Constnxxed Glass New T. T ` 1� err 1 aMbis Tads f (oo Aeraae Treats , i teak 0 dMsin`cbsm6er VII. Respoasi tatement 1, tirc modersigmed, ass . resp.WbV6 for des the POWTS skews on tic attacked plans. P 's Now F mber Business Phone Number 3 [S S Plumber's Address (Strect, City, State, ' ) c'tv\ , mow "'A . Coun rtment Use O 13/ APV,,,d ❑ DMW W,,d Sa tort' P Foe) ee includes Groundwater ing t Sigma ) �v 1 77/7 ❑ owner civet Rasa, for Denial Sanitary Permit F 0 IX. Conditions of Approval/Reasons for Disapproval 3 �^ `yti CmJ' S 3— : t� SB —6398 (R. 08/02 /� �w 7T �� P�� I I ' i �•lo�ra °�Il � h �;t,_rtQ .t!r�c�.,�.i ' -_ ' ! ;__�1_'� �y_ 1S_ca,>- 1� - -Si i ��3a.�t- -�� - �+=� _ _. I , Jo I i I I j / J i g , L .�_t It a , I �1�b pock - _ �G,Sr��Io_' _Gum- aS!BrS --- �� f •- I ' `. i - �;J -- I I I � i 1 ' 1 I I ---------- 4 I 1 ' i i ff i : r l _ I • � � i ' i I I i I j - i -� � I i I ! I I I ' I : �0 , , /y f I 1 : I , I ; I ' i I • I : : : l • I , I I ' I , Leh � nnernar.. �y ht l,J_ s N r 4 Am gym_ -'To a' , � c � P-Q•� Lf, rs ` �t � 4 r j ILI' c i u ihro m a4-�— � 1 203H t err•w• itfj esR.wRs 'w r 7 AM 7 R �� ►* ►►! • 'T' R ► r 4. 62 519 r!R �.h -y.� ♦!! * sw w. w♦ w ► w v, wR ►w I f w ► w �. 112 Circ. wwle .... ►•w! -. 3 6 ft y DIA, Void Wvft as 37.4% typ.) ~ ; hL 12 Y "°aw+te //// Sfde }d tz.iR J f �,a - a.ttzrf� � 3 i1 of Oco cY +lode, =72.5m ^Tehrs IR boat w1w� in a mmgft erc u, "ftda _ (a T+ua! Sri! 4ter/a K Ares ! d Q.p ofo eY a t2isrq °3,,a•1 }•.t�®- a 3.14SQ, i y � "'ofarrxe iw oiasit{e a / . t2 IV J'sar _ 40, fr 1'ro3etYed Tr"eh drea I "Old wlurrx ar from be�� Yti S'�walt yeigAi : t3 io •2 - 2 00 S4.R. � 1 •oitt2irr� , 2 q��ae*� _0:13ft�oteam= a6ire_ oum j.pp Fi. j at sld� - l t 2iw ; h $q i n41 E�;d t? of yopt MOlo�ne P'filected Trreck Area . $ a_ 117 r +reeve c S AW a.4ZZ w rlf+�efsl t ad (t c :sue o.4ar per i} _ l.T63 X r t 1 i ! I EPS Aggregate Trench System EZ j ss n�a:,st, r-I OUr3 ow ' �okiunds PCIrk Rd_ { t. Wrr�cansin Department of Industry SOIL AND SITE E V A L U I Page 1 of 3 Laf ' and Human Relations 1 , ,Division of Safety & Buildings in accord with ILHR 83. Adak C e R�tE UNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in si an must include, f�iat \ S Cro'x not limited to vertical and horizontal reference point (BM), direction and r slope ale(cS CEL I.D. # dimensioned, north arrow, and location and distance to nearest road. ...1, ��� t Gr Ap +� � ndin c= S UN F f IEWED BY DATE APPLICANT INFORMATION PLEASE PRINT ALL INFORMATI �, c►GE PROPERTY OWNER: LOCATp Derrick Const. Inc. G t7T8 7, (j W 1/4,S T 30 N,R (or) W PROPERTY OWNER':S MAILING ADDRESS 0C # SUBD. NAME OR CSM # 1505 Hy #65 10 na Brushy Mound Lake CITY, STATE ZIP CODE PHONE NUMBER []VILLAGE TJOWN NEAREST ROAD New Richmond WI. 54017 G15) 246 -2320 Richmond 14 0th St. [� New Construction Use ] Residential / Number of bedrooms 4 [ ] Addition to existing building j ] Replacement ( ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 ed, gpd /ft trench, gpd /ft Absorption area required 858 bed, ft2 750 trench, ft Maxi um design loading rate • 7 bed, gpd /ft - 8 trench, gpd /ft Recommended infiltration surface elevation(s) 94.1 to - site p hmark) Additional design / site considerations trenches spaced to code 4.00' below grade Parent material outwash " - pimd wff&%t&,irappricabIe na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem CI ❑ U Cit ❑ U I CI ❑ U FE] S ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ... 1 0 - 10 r 3/3 none sl 2m r mvfr 9W 2f .5 .6 2 12 -30 7.5yr 4/6 none is ` osg mvfr gw if .7 .8 Ground 3 30 -11 .5 r 4/6 none ms os ml na na .7 .8 elev. 98 ft. Depth to -� �• (�� `� �' limiting factor +110 Remarks: Boring # 1 -1 l r none 1 2m r mfr 2f .5 .6 F2 2 `: €« 14 -39 7.5 r 4/6 none sl 2msbk mvfr if .5 .6 Ground 3 39 -10 7. yr 4/6 none ms oSg mvfr na na elev. 9 7.95 ft. Depth to limiting factor +100" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. 6v W154047 Signature: Date: 6 -1 -2000 CST Number: mO2298 PROPERTYOWNER Derrick Const. Inc. .,SOIL DESCRIPTION REPORT Page 2 Q1 3 J PARCEL I.D. I pandi Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .. 1 0 -11 10 r 3/3 none sl 2m r mvfr gw 2f .5 .6 2 11 -36 7,5 r 4/6 none sl 2msbk mfr gw if .5 .6 Ground 3 36 -96 7.5 r 4/6 none ms OSQ mvfr na na .7 .8 elev. )5.7 ft. Depth to limiting factor +96" Remarks: Boring # 1 0 -11 10 r 3/3 none sl 2mcir mvfr C1w 2f .5 .6 '" 4 2 11 -37 7.5 r 4/6 none sl 2msbk mvfr if .5 .6 4 .i. Ground 3 37-100 7.5 r 4/6 none ms osq mvfr na na .7 .8 elev. 9 Depth to limiting factor + Remarks: Boring # 1 0 -8 10 r 3/ : 3 none sl 2m r mvfr gw 2f .5 .6 5 8 -32 7.5 r 4 none sl 2msbk mvfr w if .5 .6 Ground 3 32 -84 7.5 r 4/6 none ms osg mvfr na na .7 .8 elev. 93 ft. Depth to limiting factor + 84" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) e fi STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 NEQSWq S12- T30N -R18W New Richmond, WI 54017 MPRSW -3254 town of Richmond (715) 246 -6200 lot #10- Brushy Mound Lake 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 test was conducted. N 1 " =40' BM.= top of 1 pvc pipe C el./ 100.00 Alt. BM.= top of 1 pvc pipe C el. 94.75 X� 2► � , d airlyl. Steel 6 -1 -2000 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of =f�E sysT>:�Il WECMATIONS Owner �TK>�i c Tank Ma ufacbxer i �S �+rs ❑ WA a � - K h h Vu e rV�G1t'. VOL gal Permit 3 SeP> Q` Dose Q Hold�rng v Tank Marntfactexer �NA DESON PAPJUW rERS Number of Bedrooms Q NA Q Septic Q Dose Q Ham VOL gal of Publ FwWdy Units NA Effh: :MWWfactum Manufacturer Q NA Estimated tavwege} 'mow 0 Effluer Model 0 b Design � afM Pump D NA pump Model Monthly average` Pretreatment Unit A 530 mg/L Q Sand/Graval Filter Q Pont Filler Biochemical Oxygen Demand (BODJ 5220 mg/L Q NA Q Mechanical Aeration Q Wetland Total Suspended Solids (TSS1 6160 rng/L Q Disinfection Q Other: Pretreated Effluent Quality i Monthly average Manufacturer Biochemical O xygen Demand (SOD,) s3 nV)L Dftpersd Cen(s) DNA Total Suspended Solids (TSS} 530 rng/L ! At-Grade Q Mound NA Pfin- Ground t� Q hrEiround 4paessurizedl ' OOmI � ° Q Fecal Colifomn {Iheometric mean) S1 _ Q Q Other: maximum Effluent Particle Sue Ya in die. Q NA Drip -Line Q Na Other: Q NA Outran 43 NA •Values typical for dornesdc w astimmW and septic tank effluent. MAPitENANCE SCHEDtILE Salvias Event Servk:e AeY 1;zRai(s Q NA Inspect condition of tanktsl At least once every: f� 3 years} �S( When combined sludge an d scum equals orm -third (Y of tank volume E3 NA Punrnp out contents of tank(s) Q When the high water alarm is acdv m Q martthts} (Maxknum 3 } O NA Inspect dispersal call(s) At least once every: s) monthfsl Q NA Clean effluent triter 5 ��'�� t least once eweury: s? d morith(s1 0 NA Inspect pump, pump controls & alarm At least once every: p s} C] M0001(s) Q NA Flush laterals and pressure test At bast once every: Q ts} Q month(} C3 CJ NA At least once every: 13 } ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying am of the following licertsss or certifications: Master Plumber-, haslet Plumber Restricted sewer, POWTS Inspector, POWTS Maintainer; Septage Servicing Operator (pumper). 'lank inspections must include a. Visual inspection of the tannic($) to identify any missing or broken hardware, y any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or pondwo of effluent on the ground surface. The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any po"ng of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fading condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one -that lY or more of the tank volume, the entire contents of the tank shah be removal by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, Pretreatmen' units. and any servicing at intervals of 512 months, shred be performed by a certified POWTS Maintainer. A service report shall be provided to the local reguWtary au#wtty within 10 days of completion of any service event. GMW 121021 START UP AND OPERATION pogo _;V st For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may InVede dye trot process and/or danw*e the sod dispersal eeii(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicirig operator prior to use. System start up shall not occur when soil coriftons we frozen at the infiltrative surface. DUMS extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal caM(s) in one kLW dose and may overload thorn resulting in the backup or surface discharge of effluent. To avoid this siuotion have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plurriber 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 calls. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the Fife of the POWTS: antibiotics; baby wipes; cigarette butts, condoms; cotton swabs; degreasers; dental flans; drapers; dis&tfecta�nts; fat; foundation drain (sump pump) discharge; fruit and vegetable Peel gam. grease; herbicides; meet scraps; medications; oil; Painting Products; pesticides; sarutary napkins; tampons; and water softener brine. ABANDONMENT When die POWTS farts and/or is Permanently taken out of service the following stets shall be taken to insure than the system is Property and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • AM piping to tanks and pits shall be disconnected and the abandoned pipe openings seated. • The contents of all tanks and pits shall be removed and property disposed of by a Septage Serving Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with SON, gravel ar another inert solid material. CONTINGENCY PLAN If the POWTS faits and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system. �l A suitable replacement area has been evaluated and may be utilized for the location of a replacement soft absorption 1 system. The replacement area should be protected from disturbance and compaction and should not be irrfrirnge:d upon by required setbacks from existing; and proposed structure, lot Ines and wells. Feikre to protect the replacement area will result In 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 Wnitations. Bedding advances in POWTS technology a holding tank may be installed as a last resort to replace the fainted POWTS. ❑ The site has not been evaluated to identify a suitable replacement axes. Upon failure of the POWTS a -soli and site evaluation must be performed to locate a suitable replacement arena. if no replacement area is available a holding tank may be installed as a last resort to replace the foiled POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biornnat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARlWM> > SPTIC PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INS�CIENT OXYGEN. DO NOT ENTER A , PUMP On OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE IilTERIOR OF A TANK MAY 13E DIFFICULT OR IMPOSSIBLE. A004MNAL COMMENTS P#?WTS 1W ALLER POWTS MAIMTAIIVEi F nx=m c C rS Narrae S a-kilb 5 ! Phone SEPITAGE SiEIMCIVG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S T - % - � ONO Phone Phone -T (S 3 (o vbfD This document was drafted by the staffs of the Green Lake, Marquette and Waushi re County Zoning and SankatWm agencies in aorrliance with dmpter Comm 8 3.22(2)(b)(1)(dl&(fl and 83.54(1), (2) & (3). Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L 'Lw4&.,cmAKj Mailing Address SAWf2,Vt%�' Nf.! S-f 2-1 Property Address /(& GA► 1t Q2 N l:nj (Verification required from Planning Department for new construction) City /State 4 gq /W. & © Parcel Identification Number 0 - 2-(c -1 / L 14 - /o -- 0 0 Q , LEGAL DESCRIPTION Property Location NC %4, S Qj Y4, Sec. L . T N -R W, Town of /�c -tFM�k Subdivision Lot # Certified Survey Map # Volume _ Page # Warranty Deed # �6 S . Volume Page # - 2 3 Spec house O yesXno Lot lines identifiable yes O no SYSTEM AIA TMNANCE 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 aad' by a masterplumber, journeymanplvmber, restrictedplumberor a licensed pumper verifying that (1) the on site wastewaterdisposal system is in condition and/or 2 after ' inspection d P operating an () mspec pumping (if necessary), the septic tank is less than 113 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification ZAXOR-4alrLICANT system n maintained must be completed and returned to the St. Croix County Zoning Office within 30 a iratii te. DATE OWNER CERTIFICATION I cc ' that all staAments on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property des bed a virtue of a warranty deed recorded in Register of Deeds Office. 6 /x?/ y 3 ATURE OAP CANT 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 wi r i �o rt�t 11 0o r AA lgl UUL •• � 2 1 3 2 P 5 3 S `_ 7m84f36 KATHLEEN H. WALSH Document Number WARRANTY DEAD REGISTER OF DEEDS ST. CROIX Co.. V1 RECEIVED FOR RECORD THIS DEED made between Brushy Mound Partners, LLP, a 02/06/2003 08:30AH Wisconsin Limited Liability Partnership ( "Grantor") and John V. EM!Pr 0 Linneman and Lynn D. Linneman, husband and wife, as survivorship marital property ( "Grantee "), REC FEE: 11.00 WITNESSETH, that the said Grantor, for valuable consideration TRANS FEE: 220.50 conveys to Grantee the following described real estate in St. Croix COPY FEE: CiEi>;R7' COPY FI6E: County, State of Wisconsin: PAS 1 Lot Ten (10), Plat of Waters Edge in the Township of Richmond, St Recardino Area Croix County, Wisconsin Name and Return Address The First National Bank of Hudso Attn: Pat 016032$ PO Box 187 Hudson WI 54016 026- 1126 -10 -000 (Parcel Identification Number) This ji-n-0 Ii-n-0 homestead property. Grantor, Brushy Mound Partners, LLP, a Wisconsin Limited Liability Partnership, is an affiliate of Derrick Homes, LLC, a Wisconsin Limited Liability Corporation. Grantor develops land and Derrick Homes, LLC is a home construction contractor Grantor agrees to sell this lot to Grantee on the condition that Derrick Homes, LLC will be the builder of the home for Grantee. If Grantee 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 Grantee, Grantee gives Grantor the irrevocable right to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. If Grantee desires to sell the lot to another purchaser before constructing a home upon this lot, Grantee gives Grantor the right of first refusal to repurchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. Dated this 3rd day of F_Rbrtruary, 2003. * L. r' ichael R. Stevens AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ST. CROIX COUNTY Personally came before me this = day of February 2093, ., _ a uthenticate d— bs__,.day of , 15 —: the above named _Michael —R, - Sihwna. and Ronaid -.L Derri as partners of Brushy Mound Pw nsrs, _ LLP, a_ Wisconsin limited liability partnership to me known to be signature the persons, who executed the foregoing instrument and 77 ripe or print name acknowle �me EIDI l.. pILLEY TITLE: MEMBER STATE SAR OF WISCONSIN ge ure -_,S Notary Public in (If not, type or print name Heidi L. Dilley authorized by 706.06, Wis. Stets.) Notary Public St, Croix County, Wisconsin. THIS INSTRUMENT WAS DRAFTED BY My Commission Expires: March 26th 2006. Brushy Mound Partners "Names of persons signing in any capacity should be typed or PO Box 445 printed below their signatures. New Richmond, WI 54017 i r - • . . 4 . to Dzip m� a w - - 132 - -- 5.98' - -95.76' 506'11,47 E 46 _1 / \ • \. — 50871'47 "E 465-96 113. n rn > N OD �• • � i \\ • 49.95' 11110 ?Y EASEN N 0 f} to D D 20.74' OD OD 0 D Of W ;o to ZF m O f �� \ y D O D ? o *7 _ _ po mA �� cn .� n cn - M M ° M m w -- D $ rn�N>1+t �! D�DF�F�D� UNi p �Ri • p�j to in r m En r r � r� V) X 0 m o D ��� cb � -nom O o, z � cb p -� m v !?n FEA r1n ` ` • '� : � M ;o BUILDING S£78ACK U • • * r •• `. \,�• m r • • • 23 5:42' - - �•. — » X109 _2 - - - _�f- 804'0 E - - - -- ` ` •'• •79"'96'• • • ORDINARY HIGH WATER MARK r u v - NO 1 Z9- _ _ ca> -- - — v AS ESTABLISHED 03 -2 8-00 H' . BY D.N.R. ELEVA AON= 976.00' i I _ i OVERALL NORTH -SOUTH 1/4 UNE: ~• �ieliy,l/avnd to, -------- N00'16'21 "W 5269.84' - - - - -- Or/gh7a✓ Cow;11.7t i title & Abe /mod Una the pupa ty owner , of the lots hos b AWnw,) asst hte e j / y, Alarm► tafrP T, + ,��hle p w d 9/ot 506'46'19 "W 16 13.62' - -_�