HomeMy WebLinkAbout026-1153-03-000 i
WLnsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix
Safely and Building Division
INSPECTION REPORT Sanitary Permit No: 453352 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:
Marek, Darin I Richmond, Town of 026- 1153 -03 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
19.30.18.1141
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake OAD Dt Inlet
Septic Dt Botto
Dosing He er /Man.
Aeration t. Pipe 0 4A u � I
Holding Bot. S tem
PUMP /SIPHON INFORMATION Final Grade
Manufacturer emand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to ell
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches IT DIMENSIONS No. Of Pits Inside ia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL NKE7kTREAM LEACHING Manufacture
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SY EM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to it Intake
Pipes)
Length Length Dia Spacing
SOIL C9YtR x Pressure Systems Only xx Mound Or At - Grad Sy ems Onl
Depth Ov r Depth Over xx Depth of T- Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ee ed /Sod a
Yes E] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection Inspection #2:
Location: 1487 94th St. New Richmond, WI 54017 (NE 1/4 NW 1/4 19 T30N R1 8W) Glen View Lot Parcel No: 19.30.18.1141
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover = 41- 4`
Plan revision Required? E] Yes [
Use other side for additional information.
Date Insepctoes Signature Cart. No.
SBD -6710 (R.3/97)
A l
Safety and Buildings Division Coantye --
201 W. Washington Ave., P.O. Box 7162
ICOn Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
(608) 266 -3151 q5 35 irtment of Commerce
Sanitary Permit Application °� State P� I.D. Number
In accord with Comm 83.21, Wu. Adm. Code, personal information you provi Proj� Aeldress i f different than trailing address)
may be used for secondary purposes Privacy Law, s15.04(I)(h)- y h
W qtf - S f
L Application Idormation - Pie= Print AU Information
1Y _ 1 Lot tt Block g
� t
Property Owners Mailing Address a PODPerty Location
o _ / Sectiarh/
City. State C
Zip / Phone Number /
f Iy W N f or
��
II. Type of Building (check all that apply) Su rvisioa Name CSM Number
/A r 2 Family Dwelling - Number of Bedrooms
pubiidCommarcW - Dcscribe Use - c Y bwasblp of
State Owned - Describe Use — �
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) p Zb - 11 3 - 0 3 - � b . // /
A ' env System Replacement System Treatment/Holding Tads Replacement Only Odher Modification to Fang System
Permit Transfer to New List Previous Permit Number and Date Issued
B. Permit Renewal � �LR!!!io- a of
�S3 3 5 Z IO �2 9l0
Before PAp'eration Plumber Owns `
IV. T of POW TS System: (Check all that appl
n - P�essuayod In l3mund Mound _> 24 in of suitable soil Mound < 24 in. of suitabl4 soil At -Grade Single Pass Sand Filter
Constructed Weiland Pressurized in and Holding Tank Peat Filter Aerobic Treatme n Unit Recir+crlafing / Sand Fil
Recirculating Synthetic Media Filter Chamber Drip Litre Graveldess Pi Other ( �) `
V. Di reatmeut Area Information: Dispers Pow (st) System Elevation
Design plow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Rexlnatod (st) A
/� ` .� T 6 ltl prefer Site Steel Fibbr Plastic
VL Tank Info �PtY Told Number Mann[actarer Glens
Gallons Gallons of Units Concrete COnstructed
New Existing
La Tanis
Sepaoor Holding Tads
Aerobic Treatment Unit
Dosios Chamber aftselied
VII. oasibili Statem - I, the surd eel, a nsiblli for htstallation of the POWTS shown on the Phone Number
Plu s Name (Print) Plumbers MPlI1dpRS Nu
2 Z 6 9 , L - f J�
Plumbers (Street, City, State, tip ) j
/l ! L
VIII, ttment Use On1 Date Issue Agent Signature o Stamps)
Approved Disa�p Sanitary Permit Fee includes Cmwadwater k
Surcharge Fee) D J0 ?)
veer Reason for a
IiX. Conditions p r � `"` �` ''^ �`�
SYSTEM OWNER: t-�- o` ' kt COCts`s"�
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber. (J
2. All setback requirements must be maintained \ Sy$ C I,, •�,•
as per applicable code /ordinances. J
Attath piek plant (to the County only) for the system oa papepaper not gi/L x 11 inches is
eoar n
�2:ct- bQ.tM.
T PLAN
PROJECT Darrin Marek ADDRESS 1306 210th Ave New Richmond Wi 54017
1/4 NW 1/4S 19 /T 30 /R W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 8/24/04 BEDROOM 3
CONVENTIONAL XXX IN -GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of Foundation ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
Scale is 1" = 40' SYSTEM ELEVATION 89.8/89.2
unless otherwise Well is to meet all Pro 3
noted setbacks required by Bedroom
Plans Designed Using WDNR House B.M. * Property Line
Conventional Powts
Manual Version 2.0
Building Sewer 94.2 85'
Septic tank inlet 92.4 60'
manhole 97.4'
Septic Tank outlet 92.2
Header Trench 190.8 5 ,
Header Trench 2 90.2 30 , S
System elevation TI 89.8
System elevation T2 89.3
Final Grade 93.5' 25'
B -2
2 -3' X 69'
Cells with >3'
Spacing
0 '
20
rainage easement
35'
30 0'
10'
Vents B -1
Vent 7% Slope
>6 „ Standard Biodiffuser
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
6' Long 1 1 " 180'
Grade at System Elevation
34"
95th St.
4 '
Q g l R WET-
rr
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code l r I
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. R viewed by _Date
U
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). f1
Property Owner Property Location ! 7
�i�w� / ' ' Govt. Lot 1/ 14 S /t,. T_
Property Owners Mail' Address Lot # Block # ubd. me or 2 oZ IS
v/
City State Zip Code Phone Number ❑ City ❑ Vi ge wn Nearest Ro d
c�J f
Construction Us . sidential / Number of bedrooms Code derived design flow rate J� GPD
❑ Replacement C] Public or co mercial - Describe:
,n✓) ft.
Parent material V /.! � Flood Plain levation if applicable
General comments;
and recommendation
/
t�91
�� # � Boring 9 J�
1 �t Ground surface elev! ft. Depth to limiting factor t� v in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Ef##2
l 0 � 3 C'Y
0 - / j
/79/ ✓t- 1, A/ ) A ,
0 ,*- 001 -
® Boring # ❑ Boring KP it Ground surface elev. &Zft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
fq .�
::3 = - S- �. �' ZL
Effluent #1 = BOD > 30 220 mg/L and TSS >30 1 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date E aluation onducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 715 - 246 -4516
I
Property Owner _ Parcel ID # Page of
® Boring # ❑ ring �
it Ground surface elev ' ft. Depth to limiting factor in. F*Eff#1 Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/ff°
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#2
e-
�- I i✓I I✓1 ,
a Boring # ❑ Boring
Q 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/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Ong # ❑ 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 mgA_ ' Effluent #2 = BOD, < 30 mg/_ and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777.
SOD -8330 (RAM)
. Safety and Buildings Division County
201 W. Washin � on Ave., P.O. Box 7162 /
C�i�S� Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
D P artment of Commerce (608) 266 -3151
Sanitary Permit Application state Plan l N `
In accord with Comm 83.21, Va. Adm. Code. personal information you provide N
may be used for seoDailmy purposes Privacy ltt� s ( �; _, _.�. _,._� Project Addliess (f different than mailing address)
L Application Information - Please Print All Informatio
Name '? Parcel # # Block*
f I
PmpeRy Owners MangAddress /D Property �ti
3 / b t)`f'�l. Section
City, State Zip Code Pho
II. Type of Budding (ch all that apply) �/
3 Su is on Name CSM Numbs
Tor 2 Family Dwelling - N of Bed,ottls
PublidCawaucial - Describe Use ✓ � d ��
State Owned - Describe use T CAty_ vtlla8e °worship o
11L Type of Permit: (Check only one bkon line A. Complete line B if applicable)
A ew System Replacement S Treaanent/Holding Tank Replacement Other Modification to Brisling SA
B. Permit Renewal Permit Revision Change of Petndt Ttansf, o New List vious Permit Number and Date P
Before Expiration umber Owner
INV
i
IV. TM of POW TS System: (Check all that appl
n - Pressurized In- Ground Mound ;t 24 is of suitable Mound </fiL suitable so t - Grade Single less Sand Constructed Weiland Pressurized in Ground Holding
Tank Peat Filleerobic T Unit R
lu
ecirculating Synthetic Media Filter Dri s Pi ex lain �J -' / p'tit
V. Dispeirsidnresitment Area Inf rmatlon:
Design Flow (gpd) Design Soil Application Rate(gpis� DrC�pyrsal (so Dis ( S in ad ,
J ? 6
VL Tank Info Capacity in Total Number M facturer
site AMW Fiber Plastic
Gallons Gallons of Units Conc ctod Glass
New Existing
Tanks Tanks
Se* air Holding Tank
Aerobic Tweatment Unit
Dosing Chamber Tom'
VII. Resp onsibility Statement- I, the ed, rrsponsibuitty for installation of the r shown o n the attached late.
ers .
Plumber's Print) Plumb MP/MPRS Number Business
Plumbers Address (Strut, City, State, 4p 00 J n
VIII. Coun /De artment Use Only
Disapproved Sanitary Permit Fee (includes Groundwater Date Issued �uingt� (No
Approv
l
Owner Given Reason Denial Surcharge) ` ✓ d
IX. Condidons of ApprovaUReaso or Disapproval
STEM OWNER: __ - `
1 p lc an , effluent filter and - 0 3
dispersal cell must all be serviced / maintained 3� Cp!/�i.�-
as per management plan provided by plumber. r_
2. All setback requirements must be maintained h,
as per applicable code /ordinances.
Attach complete plans (to the County only) for the system oa paper not left than $In z I I inches in sine
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PLOT PLAN
PROJECT Darrin Marek ADDRESS 1306 210th Ave New Richmond Wi 54017
1/4 NW 1 /4S 19 /T 0 R 18 W TOWN Richmond COUNTY ST. CROIX
r
MPRS Shaun Bird 226900 DATE 6/24/04 BEDROOM 3
CONVENTIONAL >00( IN -GRO ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK I
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chamb rs 22
,BENCHMARK V.R.P. Top of Steel Fence Post ".- ELEVATION 100' Filter abel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 101.5/100.0
Alt. BM Top of Survey Iron @ 96.5' Plans Designed Usin
Conventional Powts
Scale is 1" = 40' Manual Version 2.
unle otherwise Vent
noted Well is to meet all >6 „ St dard Biodiffuser
setbacks required by of Cover ching Chamber
WDNR ith 3 1. 1 ft2 of Area
6' Long 11 "
Grade at System Elevation
34"
Pro 3
Bedroom
House
30'
2 -3' X 69' cells with >3' spacing
B -3
-2
Vents 5'
% 95th 4.
B -1 lope 5'
10'
184' Property Line
B.M.
t. 406' Property Line
B.M.
ST CROIX COUNTY
ENANCE AGREEMENT
SEPTIC -TANK .
OWNERSHI CERTIFICATION FORM
P
J p/
Owner/Buyer I 10 -- ._ ---- --
Mailing Address
Address D ) ----
Property requ ired from Planning D epartment for new construction
(Verification requ 0 Z
parcel Identification Number
3 -D3
city /state (l
LEGAL DESCRIPTION
1 / , A sec /1, T-5-12N - -V Town of A�
�
Property Location _._-- /• Lot # �..�.
Subdivision �-, , page #
Volume ,�-- -
Certified Survey Map #
Page
a 'Volume # � ._L_1 ---
Warranty Deed # � S 3 �
Lot lines identifiableXyeS 0 no
Spec hous�eS Q no
Premature failure to handle waste Proper maintenance
S YSTEM TE NAN of your septic system could result is its p a licensed pumper* what You put into the system
r�AIN
Improper use and mamtenan `e three years or sooner,
consists of pumping as a t reatment if needed by stem
is out the septic tank every n t stage in the waste disposal system
can affect the function of the septic tank signed by the owner and by a
Department a certification fours, Sn disposal system property o wner agrees to submit to St. Croix Zoning Dep er verifying that (l) onsite wastewater
,he lumber, restrictedplumber or a licensedpump the septic tank is less than 1/3 of sludge.
masterplumber after �p in if necessary)
condition and/or (2) i and Pumping ��
is in proper operating rvate sewage dispose system with the standards
rsi ed have read the above re and agree to maintain intain the p i
Uwe, the wade b'n the Department of Commerce and the Dep
ni of Natural Resources, State t Zoning wi 3
set forth, herein, as set by twined must be completed and returned to the St.. Croix County Zor�g
stating that your septic system has been main
of the three Year c iration date.
DATE
SiGNA"1VRE OF APPLICANT
O WNER CE 10FICATION ) knowledge. I (we) am (are) the o wner(s) of
I (we) certify that all ta on xa my deed rerecorded in R of Deeds Office,
descri a above, by virtue of a
th property
(� DATE
�„�
SIGNATURE OF APPLICANT De artrneat.
Any information that is mis * * * * **
* * * * ** - MprOsented may result in the sanitary pern it being revoked by the Zoning p ice
his a lication a stamped warranty deed from the Register of Ds e d m the warranty deed off
** Include with t PP a copy of the certified survey map if
MaIntenance and Contingency Plan for a Septic System
Maintenance Plan d once every 3 years.
1. Septic Tank is to be pumps
'
er is to be cleaned once a year. Please not
a larger fitter is being installed in
2. Effluent fitter
order to extend the maintenance interval of the filter; inspections pipes at the ends of
3. Once ev,,ry $ years, cells are to be inspected via t he P
the cuts.
age, and water conditioner discharge into the sy em.
4. Owner agre to limit greases, garb
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
Y from s stem
7. WatershEi!d is to be diverted awa Y .
8. Dischargla into system is not exceed those required as per Comm. 83
cy Plan
Ifs stem fails, determine cause of failure, use altemate area and install new
Option # Y
system in tested replacement area.
r elevation, by removing chambers, removing biomat,
option #2. Install system at a towe
and install new system.
O ion#3- No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace ,any other failing components as needed.
Plumber: Sihaun Bird 715 -246 - 4516
St. Croix County Zoning 715- 386 -468
Pumper Tom Mondor 715 - 246 -5 148
i
I
Shaun Bird #226900
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page __4 of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code n
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. D
Please print all information. a Date a (
Personal information you provide may be used for ps Law, s. 15.04 (1) (m)). !!V
Property Owner t }} erty Location
J � Gott. Lot t /4 S T� N R E (o W
Property Owner's Mailing Address Lot # Block # Suubb'd. Name or M#
fate Zip Code Pane Number C' ❑ Village To NRoad
City L
P w dY 9
-
<% _;
n fl � i
Code derived des
New Construction Use: Residential /Number of bedrooms 3 Cod 9 ow rate GPD
❑ Replacement ❑ Public or cgirnmercial - Describe: — _______ -- ----- - - - - -- - - --
Parent material Flood Plain elevation if applicable �I1/ /105 ft•
General comments
and recommendations:
S
❑n
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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2
a 0 �s m r
S
i 'ViX
® Bori ng #
9 Boring Pit Ground surface elev. l= `� ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
o - a m C M .s
I jr ,3 6 - yl� ens M N r
Effluent #1 = BOD > 30 220 mg(L and TSS >30 50 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54t17 — //— �, 715 - 246 -4516
Property Owner _ Parcel ID # Page of
FT El Boring
Boring Bon # 14 Pit Ground surface elev. � v 5-. ft. Depth to limiting tailor � � U in. - go - flApplication Rate
Horizon Depth Dominant Collor Redox Description Texture Structure Consistence Boundary Roots GPD/ff?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
rn
Z p -Z a t��� • `�
a Boring #
❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor (n• Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Appl ication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD. > 30 220 mg/L and TSS >30 < 150 mgll_ ' Effluent #2 = BOD <_ 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
SBD -9330 (8.6100)
Soil Test Plot Plan
Project Name Lakes and Hill Development Shaun Bird
Address P.O. Box 10598 /4 '//
White Bear Lake Mn 55110 tl
CSTM #;A900
Lot 3 Subdivision Glen View Date 7/1 8/03
1 /4 N W 1 /4S 19 T 30 N /13 W Township Richmond
Boring . Well PL Property ❑ g Q P Y Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevation 101.5/100.0 *HRpSame as Benchmark
Alt. BM Top of Survey Iron @ 96.5' Scale is 1" = 40'
unless otherwise
noted
Please note: survey was not
completed at time of testing, Please Note: Tested area
setbacks from lot lines may
may not be suitable for
change. Installer must verify Y
desired buildin g area.
all lot lines and setbacks Check system location
before installation.
before excavating.
g
0
0
3
0
0
105'
103'
B -3 101'
4 -2
35'
17% `n
Slope 55'
B -1 °`
10'
184' Property Line
B.M.
AIL 406' Property Line
M.
2 5 4 6 P 2 4 7 - 7 59320 �\
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED R EGISTER O
TT. CROIXCO. , WI
This Deed, made between Hillvale Development Limited Liability RECEIVED FOR RECORD
Partnershil? Grantor, 04/12/2004 11: 45AN
and Darin H. Marek
WARRANTY DEED
Grantee. EMPT #
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00
TRANS FEE: 139.70
(if more space is needed, please attach addendum): COPY FEE:
Lot 3, Plat of Glenview in the Town of Richmond, St. Croix County, CC FEE:
Wisconsin.
PAGES: 1
Recording Area
Name and Return Address
026 - 1153 -03 -000
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights - of - way of record, if any.
Dated this day of April 2004
* * Hillvale Development Limit Liability Partnership
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ — STATE OF _ )
) ss.
- �r� Cy L• — County )
authenticated this _ dayldtti' jC
NQ n$1r1 Personally came before me this day of
V V ISCD _ April , 200 _ the above named
Hillvale Development Limited Liability Partnership
*
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Slats.) instr oacknowe same.
THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Oglan Hudson WI 54016 Nota Pub _
My C fission is permanent. (If not, state expiration date:
(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. Information Professionals Co.. Fond du Lac, WI
STATE BAR OF WISCONSIN 800 -655 -2021
WARRANTY DEED FORM No. 2 -1999
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