HomeMy WebLinkAbout026-1153-35-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
r , INSPECTION REPORT Sanitary Permit No:
463297 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:
LeQue Builders LLC Richmond, Town of 026- 1153 -35 -000
CST BM Elev: Insp. BM Elev: BM Description: �� Section/Town /Range /Map No
/6l:1:,> aM C-5 ob d — 19.30.18.1173
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic , Benchmark 12 5b 0 o Qa
Z 10 , /
Alt. BM
a, 3 63 ? • 1
Aeration Bldg. Sewer 7,1 7 3.5 - 5
Holding St/Ht Inlet
$.off 1Z • .7`{
TANK SETBACK INFORMATION St/Ht Outlet . -CL
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \
Septic ` i Dt Bottom
p
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System 9 .74 5/, Z (J
PUMP /SIPHON INFORMATION Final Grade q 72-
Manufacturer Demand St Cover 3- YS
�cri
GPM
Model Nu er
TDH Lift Friction Loss System Head Ft
Forcemain Length Dia. ell
SOIL ABSORPTION SYSTEM
Depth
De uid
BED/TRENCH Width � Length � No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid p
DIMENSIONS 96 (Z) Z k( P _, • _
SETBACK SYSTEM TO 77 P/L BLDG WELLL LAKE /STREAM LEACHING Manufacturer: 7 ��'J]
INFORMATION CHAMBER OR EZ t a,,j
Type Of System: / �/ �� I UNIT Model Number:
a^ e .*• o,.,�Q� �j f vd`a a f
DISTRIBUTION SYSTEM /� !d
Header /Manifold �� Distribution x Hole Size x Hole Spacing Vent to Air In ke
r Pipe(s) IIE
Lengt Dia _ Length � Dia _ Spacing
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 b Z Bed/Trench Edges \ Topsoil Yes i, ] No Yes No
COMMENTS: (Include code discrepencies, persons pre sent, etc.) Inspection #1: / / Inspection #2:
Location: 915 148th Avenue New Richmond, WI 54017 (NE 1/4 NW 1/4 19 T30N R18W) Glen View Lot 35 Parcel No: 19.30.18.1173
1.) Alt BM Description = �
2.) Bldg sewer length = 31
- amount of cover =
�5
Plan revision Required? Yes No f I _ 6� �g3 4
Use other side for additional information. __ ��, ✓ ✓✓
Date Ins is Sign re Cert. No.
SBD -6710 (R.3/97)
Safety sad $uildirtgs Division County
9 201 W. Washitlgton Ave.. P.O. Box 7162
Madb[M Wl 53707 - 7162 Y ptsrnr (m filled
De artment Of Comm f60
erce 8) 26,6 -3151
4Sz�
4anitaY Fatima Application See Plan 1, D , Number
In accord with Cam= 83.21. Wis. Atha. Colo, penoaal isdormisbun you provide - --
may be used far secondary purposes Prtvacy I.aw. s15.04(IX.) -
Project Addrtxs (if di dwn ling address)
I. App I� - > lPri� Alu tatotrt '5 / k( A
� Owtaer's Na me 1
Pareei M Lot r stack x
Property Owners U t � yS _ S ' _ u 3 1173
nt)S Adds�s
Prop�ert Location
City. • Zip Code Phone Number -A = 9 y u ` I A.Secuoo
( o cir
�� -
B.
, hype (cle )
all that may') T �5!N: R�E o
(Z 1 or 2 Fanui Dwell' — ,--
Y Dwelling - Number of 8odroorns Subdivision Name CSM Number
PubiiciCtmartaerciah - Describe h ibr use r
us 7 11ed
- Use f ity Qvinage I owt>Fhip of a n
�- Kbeck mdy eat: bait an 19ho A. B it ttppkcabie)
A. New System ❑
Rtplazxtuda System Il T i
reaunendHnW Tank
trtFt Repl�ettndat Only I.) Other ModiFicatmn to Existing System i
I
�. ❑Permit Renewal ❑ permit Revision I_l Change of ❑ Permit Transfer to New List Previous Permit Number and Date hsued -- j
Before Expiration Plumber Owner
-pretintriied 1rrGnxmd U Mound > 24 ia. of suitable If < 24 W. of able soil IJ At -Grade I_] Single Pats Sand Filter {
❑ Constructed Wedand ❑ Pmasurind In„G -und U Holding Tank ❑ Peat r-atin ❑ Aerobic Treatment Unit CI Recircutadng Sand Filter
I
Cl Recirtwlarm8 Syadsetic Media Flier Fl r)rin Lune &<— reel -kss Pipe ❑ Otber (explain)
V. Areoi Information; -�
D esign Flow (bpd) MOM SoB AWlicanim Rate(1epdsf) DispersaI Area Required (sl) Dispersal Area
Proposed (sf) System Elevation
Vl. Took Info Captrcity in Total Number Maatfacurer Prefab Site Sa:ei Fiber Plastic 1
Gal lons Galkont of Units Concrete Constructed Glass
New w I
Tanks Tacks
Septic Holdnag Tank
c
Aerobic Tmauneat trot
VII. .s N resposarAwy fir ' at dw POWYS tbown an the attaeLed plans.
( ) Plumber's Si gnature !MFRS umber [ Businem mom Number
a�u oc>'��s
53 s
Pl�ber•s Adore � (s treet, C;t Sate. Zip
- tin s
Approved ❑ Disapproved spr Ftrmk Fee (includes Groundwater Date issued I
Fee) 9 Si No Stamps) Surcharr ❑ eel Gt peps z Q l
IX. Cmditiotts fat
SYSTEM O i
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained j
as per applicable code /ordinances.
- - - - - - - - - - Altai eanlissa paean (tar tfre Cuawti aeRn tar the syasaw than paper awn twi Ws s1/2 x 11 loehaa is silt __1
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
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. i
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Re wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
a-h/e� "� Govt. Lot /4 S T N R E (o VW
PropeM Owner's Mailing Address Lot At Block At I Subd. Name or M#
City tate Zip Code P one,Number ❑ City ❑Village pqTown Nearest Road
New Construction User Residential / Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe: __ -____. --------- - - -. -- - - --
Parent material Flood Plain elevation if applicable %/' ft.
General m enda f ti �� r� X
and recommendations: / � -' "Or-��
e /zrg�
Bori # Ej Boring
n �� �
Pit Ground surface elev. E— 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
0
0-(D 312.
2 , C
vn b Q1 2-
PW
® eori ng # Boring
Pit Ground surface elev. + `oft. 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
ti-Ig 3 mA" C o?rn 'r 4 . (?
Z-
0 ,+
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signatur CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 ���_- �, 3 715- 246 -4516
Property Owner _ Parcel ID # Page of
FT Boring # Boring - F-�
Pit Ground surface elev. � D ft. Depth to limiting factor D 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 I 'Eff#2
,3Iz C
po-W s s41 w 2
3 -- ---- -- s �i �-► / 7//Z
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in. 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
F-1 Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit 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 mg& ' 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 -8330 (R.6100)
Soil Test Plot Pl I hn Project Name Lakes and Hill Development ird
Address P.O. Box 10598
White Bear Lake Mn 55110 �*M #226900
Lot 35 Subdivision Glen View Date 7/18/03
1/4 N W 1/4S 1 9 T 30 N /R W Township Richmond
❑ Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevation 91.6/91.1 *HRpSame as Benchmark
Alt. BM Top of Survey Iron @ 96.3' Scale is I " = 40'
unless otherwise
noted
Please note: survey was not
completed at time of testing,
setbacks from lot lines may Please Note: Tested area
change. Installer must verify may not be suitable for
all lot lines and setbacks desired building area.
before installation. Check system location
before excavating.
94' 96'
B -2
a
8%
o Sloe 0
�o
tn
B -3
AL
r
45'
30' B -1
70'
B. M. 90 ,
M
296' Property Line
..
CO LO A
EZ1 203H
It
t,ee ,• Te►eTlT 1 4
:►► 'K _,.mss`.. r•T�� t
4.625'1 ,..}
WVW ..e
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e!
�!!!!♦ T ►TT ! ". W ." T !T ►l►♦
elee►►ee ►l► ►r!i*iV
• 24
i
36"
12-112" IDIA. (h`P•)
a4d Coe
is w u 37.o'ic. %0_0 A.* hL IQ C.D. of4"p . 4°623 incite Sidewaii {2 SidewarE�} I 1� L 59 Ir<
( ?�
Void twiumc per linear 83
R = l.ls •1_ +ZSir = 3.14
t 12s/8�••rR mU.It7R,
O.D. uFccnicr �om ift
cytie�r - 2 .00
M 5 �
Ica
T
oral
Vold Seit Iwt
erbce A
i oed volume ih ag�egaar of censer �, ,, 334 •� $ � _ 3 to • ? I l2sur � 3.I4 SQ. .
1 ?w g € 12ra f� •
574- .422 W O.O. oroasxuie cy4nders . 12 6es J 1
Void -tome in Outside olio = 2 •3.ts �° Projected Trnch Area
llxiatR� •.57as 901 w Sidewatl )
Height = 12 in. •2 1
= 2.00 sq.Fl.
kotd volr:me ai bomm fern cyN F 6n Bottom =
36 in = 3.00 Sq.Ft.
�(t2inrR 32 tr ��` jj.r� a° J R' �
• lrziePa� ' t
rea
`<ord vul
cant at outside bottom P'otKted Trese6 A 5.0® Sq.FI.
t O (t72 01void volume between cylinders) 0.2 Is ZZ - 08 w
'fatal 'aid volume 4.1 17 - 0,422 + 0.901 4 . it l
215 + .
Gallons pa R • f .76 0.108 1 763 ccubrc ft I h
3 X 7.43 . t
- 3aLa.Naos
1
36x it) �� s6
EP
y Aggregate
Trench System
EZI203H +
Ring . Qw
lrldustrial Group
65 Ind trial Park Rd.
+Oaklond, TTt 18060
Q���� f Wru_ s
SCk( F ILE WAIr-.
�•7li--vst / d 1 ft -27-01 t
i
' MANUAL &MANAGEMENT PLAN Page ---� - °
POWTS t�V1►NER'S
SYSTEM! �T(t " S �S D NA
E S+i TWN Tank Marwfactnrer W gal
wrier L ` D pose D "ding Vol. N
errnit # z tank Manufacturer 0
PARf4MEtERS o NA 0 S 13 pose 13 Holdinil
vol- gal
lumber of Swirooms A uent t
Menufactwer �P ✓L e� O NA
Effl
+lumber of Public Facility Units Effluent FRW Model - '� — g a — 1
A
Estimated (average) flow pump Manufacturer
Design (peak) flow - (Estimated X 1.51 (� C7 Pump Model
Soil Application` Rate p )knit
Standard In uentlEffltatrnt Quality Mor rthly average D SwxVGrsve! Filter D feat F ilter
Fats, oil & Grease (FOG) 530 rngn D NA D M Aeration D Wetland
Biochemical Oxygen Derrnend (BWJ 5220 m91L. p Dish D Other:
Solids (TSS) 515o re-
Total Suspended Solids
average Disperse! DNA
pretreated Effluent Qua Disperse! Celi(s)
530 mgn- !n- Grounnd (ay) D M- Ground ��
tBOD
Biochemical Oxygen ❑ NA
Total Suspended Sow 'M' :530 mg/l 0 At -GrOde D Mound
mean) OW cfullooml DNA D Drip -V(ns ❑ Other.
Fecal COMOM ( ye in dia. 0 NA
Maximum Effluent Particle Size D NA
i] NA tor dorrieditil- wastewater and °optic tank eftlut "R'
Other.
•Nobles typical
MpBtTENANCE SCHEDULE Service 6tegoerwy
Ser Am Event rnotnifiis) tt� 3 years) ❑ NA
At least once eve"Y= s)
inspect condition of tank(s) When combined sludge and sc Urn e
one -third Ti of t vow p NA
Pump mnt contents of tank When flee high s) wagon' alarm i ge dvirted
E3 mortthis) (Me1�um 3 years) ❑ NA
At least once every: ❑ NA
inspect dispersal ceps) At moct( )
At least once every El motith(s) A
Glean effluent filter
At least once every: 0 ) A
Inspect pump- pump controls & alarm ❑ mondn(a)
At least once every' D yew(s) �1 NA
Flush laterals and pressure test D menttn(s)
pttner:
At least Once every: D tlapr(al q NA
or certifications:
INSTRUCTWNS b an irrdnvidusi carrying one of the ptage follow Operator (punww)-
MIrls Ef n cam shall be made Y or. POWTS Maintainer, Identify any cracks or
inspections of tanks and dispersal Sewer; POWTS Iris to O W Identify or broken hardware,
Master plumber; Master plumber of the tank(s) t � f« any missing p or ponding of effluent on the ground
Tank innspections must include a visual i s .4 lion pipes an d t for any
leaks. measure the volume of I be visually � to c h e ck the effluent levels in th ace "y indicate a failing co ndition and
surface. The dispersal ceit(s) shall The ponding of e ffl u ent on the Wound surface• oty authoritll
pow of effluent on the ground of the local any gj nt tank equals one -third (Y or more of the tank v
er R N 1 the
requires the immediate notification w ith chaipte
of sludge and Operator and disposed of in
once
When the combined by a Septa Senvn�n9 accord
entire contents of the tank be removed t
Wisconsin Administrative or p e e d components, pretreatmen
' Code-
including but not 1'rnited to the servicing of e ffluent 6 cer m of Mamt�ner.
All other services. shalt be perf ion o f any s event.
units, and any servicing at intervals of S12 months, within 1 O days of GMW 12102
report shad be pro vided to the local regulatory a Y
A service
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products, solvents or other
chemicals that may impede the treatment process and/or damage the sod dispersal cell(s). if high concentrations are detected
have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when sod conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess
wastewater will be discharged to the dispersal cattle) in one large done 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 cis. Do not 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, fiat;
foundation drain (sump pump) discharge; fait and vegetable peelings; gasoline. grease; herbicides; meat scraps; 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 shah be taken to insure that the system is
property and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property 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
If the POWTS fails and cannot be repaired the following measures have 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 and should not be infringed upon by
ro
required setbacks from misting and proposed structure. hot limes and wells Failure to protect the replac ement area will
result in the need for a now sod and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the nines 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 failed 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. If no replacement area is available a holding tank
may be Installed as a last resort to replace the faded POWTS.
❑ Mound and at -grade sod absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT 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 11111POSSIBLE.
ADDITIONAL COMMENTS
POWTS IIiISTALLER POWTS MAINTAINER
Nave 0 v\ Plarrne
'One ( S Phone
SEPTAGE SOMCING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name srt C r 2.Q
Phone Phone `Z [ S . 3 97(o . D
This document was drafted by the staffs of the Green Lake, Marquette and Woushwe County Zoning and Sanitation agencies in comptlance with
chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1). (2) & (3). Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address f Bp}C 1 c 11 ]f ('w\j.
Property Address C//
(Verification required from Planning Department for new construction) l
City /State _AJ �e rrj ln'r Parcel Identification Number
LEGAL DESCRIPTION T �
Property Location, �_ AMOA � ' /, Sec. TN -R �� W Town of
Subdivision ---N. 4 j k -.P LX , Lot #
Certified Survey Map # . Volume , Page #
Warranty Deed # - i - i?SeS1 . Volume 2 Page # 30
Spec house yes O no Lot lines identifiable O yes P'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
masterptumber, journeyman plumber, restrictedplumber or a licensedpumperverifying 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 I/3 full of sludge.
Uwe, the undcrsiga have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth herein, as y the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification at your tem has been maintained must be
completed and returned to the St. Croix County Zoning Office within 30
jays f the three piration date.
—
5I E O APPLICANT DATE
7DN ER Cl R I A TION
I we ertify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
e raperty cribed above, by virtue of a warranty decd recorded in Register of Deeds Office.
laZ7f tE
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 dced from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty dced
1�
U 2 7 3 7 P 4 3 0 7ssgs1
KATHLEEN H. WALSH
State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX Co., WI
RECEIVED FOR RECORD
Document Number Document Name 01/26/2005 10 : 36AN
WARRANTY DEED
EXERT #
THIS DEED, made between Hillvale Develop Limited Liability Partnership REC FEE: 11. 00
TRANS FEE: 131.70
( "Grantor," whether one or more), COPY FEE: CC FEE:
and LeOue Builders, LLC, a Wisconsin Limited Liability Company PAGES: 1
( "Grantee," whether one or more).
Recording Area
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant N ame and Return dress
interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is '
needed, please attach addendum): Q � - w
L r ,
ot 5, Plat of GlenView in the Town of Richmond, St. Croix County, Wisconsin.
026 -1153- 35-000
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 TA'/If `� aL J`i
(SEAL (SEAL)
* *Hillvale Development Limited Liability Partnership
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
authenticated on STATE OF rn I ^r )
ss.
COUNTY )
*
TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on
(If not, the above -named Hillvale Development Limited Liability
authorized by Wis. Stat. § 706.06) Partnership
to me known to be the person(s) who executed the foregoing
THIS INSTRUMENT DRAFTED BY: instrument and acknowledged the same..
Attorney Kristina Orland
Hudson, WI 54016
Notary Public, State of
My Commission (is permanent) (expires: 3 o, )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003
* Type name below signatures. INFO -PROTM Legal Forms 800- 655 -2021 www.infoprofonns.rom
r �
MARLENE J. NELSON
NOTARY PUBLIC-MINNESOTA
. MY COMWSSION EXPIRES 1,31.2005
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