HomeMy WebLinkAbout026-1153-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 453312 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 I Richmond Township 026- 1153 -40 -000
CST BM Elev: Insp. BM Elev: BM Description: fl n Section/rown /Range /Map No:
1 19.30.18.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic lfJ f }, ��� /Z �� Benchmark
Dosing � ,ji Alt. BMI-
Aeration Bldg. Sewer
� •`�7 /a9 -4 3
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet 4 ��
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic �.7 / C� / Dt Bottom
Dosing Header /Man. 1- 1
Aeration Dist. Pipe $� / d , 74
Holding Bot. System
Iz. ?
Final Grade
PUMP /SIPHON INFORMATION 7.
Manufacturer IDerrWnd St Cover / 2.
fl• ��
FE Friction Loss Syste TDH Ft
Forcemain Dist. to Well _
SOIL ABS ORPTIO YSTEM
BED/TREN Width Lg q en th No. Of Trenches PIT DIMENSIONS No. Qf Pits Inside ia. Li ui epth
DIMENSIONS C z \ \
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer � r /
INFORMATION CHAMBER OR (-�
Type Of System: UNIT
� � � Model Number:
� "T
DISTRIBUTION SYSTEM - 3
Header /Manifold � Distribution ` x Hole v
Si x Hole Spacing Vent to Air Int ke
S ` e
Length Dia Pipe(s) Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 1
Depth Over Depth Over xx Dept hh of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges ` To soil \ -
g p \ Yes L] No y Yes ; No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 918 148th Ave Unknown (NW 114 NW 114 19 T30N R18W) Glen View Lot 40 Parcel No: 19.30.18.
1.) Alt BM Description = 54- e}- d #G
2.) Bldg sewer length = 19 A � n „� P 1%)v- -amount of cover � �
Plan revision Required? Yes c/ /� _ - -. -- _ - -- _ -., — --
Use other side for additional informati 1 j
SBD -6710 (R.3/97) Date Insepctor's ignature Cart. No.
r
e
/
CZ-
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
�hi Madison, WI 53707 - 7162 Sanitary Permit Number (to be fill in by Co.)
Department of Commerce (W9) 266-3151 5 > 3 Z
Sanitary Permit Application State Plan I.D. Number
In accord with. Comm 83.21, Wis. Adm. Code, pets Iftt
may be used for secondary purposes Privacyaw, s i V O r Project Address (if different than mailing address)
I. Application Information - Please Print All Info
q1 g 1 4f8lti At, JUN 1 4 2004
Property Owner's Na me Parcel # Lot # 11 Block #
< <:���� ��.�w - 3- .dog C./ NA
r LM — IONIC G r1Pc (1-
Property Owner's M ail' Address I Property Location
1 5 CLl 't? � CL 54 'k,Section J_9�
City, State Zip Code Phone Number
V -QA t, S S T N, R�E or
II. Type of Building (duck all that apply) C\t' �¢ �� w'
!7 ubdivision Name CSM Numker
1 or 2 Family Dwelling - Number of Bedrooms 91 ❑ Public/Commercial - Describe Use t
El State Owned - cr' e t 3 J v'` '�'� City ❑VillageVownship of k; c h m /l CL
SQC OvLS O
III. Type of P t: (Check only one box on line A. Complete lute B if applicableT" - -~
A ' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all that apply)
WNon - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil E] Mound < 24 in. of suitable soil El At-Grade El Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line rave}_less pip ❑ Other (explain
V. Dhg3ersalffreatment Area Information: �[ l �
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed f) System Elevation l r
(Qp(00 , - 7 S 7 0 C -)
VI. Tank Info Capacity in Total Number Manufacturer Prefa
Gallons Gallons of Units oBZt _ Concrete Constructed Glass
New Existing
)
Tanks Tanks F� �"'^"
Septi r Holding Tank Lo" 'es ,E r,'
Aerobic Tmatrnent Unit
Dosing Chamber
VII. RespmAsib lity Statement- 1, the responsibility for ' of the POWTS shown on the attached plans.
ber's Na me t} P her's S gnature PRS tuber Business Phone Number
u n o w aa3 `71S oZ t 3S
Plumber's Addre ss (Street, City, State, Zip C e
VIII. Coun emt Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing gent Signature (N Stamps)
Surcharge Fee)
❑ Owner Given Reason for Denial 2-SD — IS ?M�J
IX. Conditions of Approval/Reasons for Disapproval 3� t?a La-
s U
SYSTEM OWNER: V"AA„ � ALAA�e� �-
1 Septic tank, effluent filter#ld
dispersal cell must all bg serviced Lmaintained .
as per management plan provided by plumber.
2. All setback requirements mustbe maintained
as per applicable code /ordinances.
Attach —plete plans (to the County Q*) far the system oo paper not hiss than 81/2 x It itch- is size
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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.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. ewed by Dat
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
`/ J r 7� < S — J e- / j r ��1 Govt. Lot W 1 /4 S T N R E (o W
Pro ps ,' Owner's Mailing Address L t Block # I Subd. Name or M#
City late Zip Code P on e,Number City ❑ Village X Neares , Road
• / 5: ' O (
New Construction User Residential / Number of bedrooms —— Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe: _ - --
Parent material l�lfCs"��1 /aG <) /✓ Flood Plain elevation if applicable ,/Vim ft.
General comments rj✓ / f v 2 , Z J� /O / 0
and recommendations: /
M Boring #
❑ Boring �,. zoorf
fiR Pit Ground surface elev. V ft. Depth to limiting factor j L in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHF
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
® # Boring
J pit Ground surface elev. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
2
Z lz Z S L -mss mfr
u Ds kyl 2
3!•Z -4
Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg& and TSS < 30 mglL
CST Name (Please Print) Si CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 ,7 —�_.a 715- 246 -4516
bhhh,
Property Owner _ Parcel ID # Page of
I 7� 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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
� ►� k A tr 3 /17 -- 15m t •�
� t
m �.
a Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor (n• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/If
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring #
❑Boring
a Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Sal ication Rate
Horizon Depth Dominant Color Redox Description- Texture Structure Consistence Boundary Roots GPD1ff
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/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.
SB (8.6/00)
Soil Test Plot Plan
Project Name Lakes and Hill Development • Shaun Bi
Address P.O. Box 10598
White Bear Lake Mn 55110
CST #226900
Lot 4 0 Subdivision Glen View Date 7/18/03
1 /4 N W 1 /4S 1 9 T 30 N /R W Township Richmond
F1 Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevation 102.2/101.0 *HRpSame as Benchmark
Alt. BM Top of Survey Iron @ 96. V Scale is 1 = 40
unless otherwise
noted
B.M. 110' 513' Property Line
Alt
.M. 10'
Please note: survey was not
B -1 35'
completed at time of testing,
setbacks from lot lines may
change. Installer must verify 5'
all lot lines and setbacks 18%
before installation. Slop
Please Note: Tested area -3
may not be suitable for
desired building area. 0
Check system location
before excavating.
B -2
1 4 106'
0
Pro Town Road
l� h v`. ew Lot-a 'g
EZ1 203H
R!R•RwR l
2 4" 1 * ( T:�r +. -. "y �/gtq ,n�. .,. .t 12.0
♦•t
4.625i ♦::
!T•
t•i tt ii
Ti• !it l
112 Circ.
V •iR!•i,lY R _ •i!
T
•i•!• wR�•R•f! R•T••R•
ff ••lRTR•TR•R!�l RlT ;;� ;T
2# 11
J
36"
y_ .m I2 -I/2" DIA. (typ.)
Void c«fs-*- in w ,
�**� grMea u 57.4%. � i4 E4 Sg
O.D3 0f 4" pNx - 4.623 inches Sidman
t2 Sider"alis; 18414in
Vail "01""60 p "Ca"ft 3.Ia• 2 . 1125 1 6
j
t2i., t t8 = A. 117 fk:
B'Dmor"r ift
O. D, of 0cnitr cyt . f2.5 i"acbai ?.00
` Total sail laterrace Are Vold volwne in agaregm of ex+i"n Cylinder �( S.1e •� 6 'S" ' _ T y 3.14 SQ.
(( 126x11! 3.le• l � '
t?n6�R I)
D.O. oCOatq OYh = 12 iwOLa ( 1
VOW "of Pr ojected Treaty Arta 9
+ufte " aY"Sj� cY166de"s • 2 •1 -!� ` $ )e > ,9Q 1 re
�12wrR� • as Sidewall Height r
rght = 12 in. •2 - 2.00
Void "01un60 54.Ft.
��� ec�ln� {,r 2s+ti BattWn =
36 in
= 3 -
W SQ.Ft. i
1 12®rfi " 0.2 ft' ProjeO"ed T
Void "Olms"c at ouasadr tw 11 rich area S.BQ S .pt. 4
Total v a !ate 0.117 * 0.422 + � twm s {t!2 of void w)6ea60 hetwc'en cX 0 -215 .' ? = 0.308 R'
aid v i
0.901 +0.2F3�0.tO8 =I.3r�fi,fi �
Gallons per R = 1.763 X 2.48 a 1
f - �aLaNuas aer �. fi
t
1 #
36 x to sC)
EPS Aggregate
Trench System
EZ1203H
Ring #ndus #riot Group � flaw
65 #ndus�iQ# p
Oaktund. Ti Pork Rd. $
-18060 .� 1
SCALE FU Z "z[131+ -v.r
S}RE7: t of r tt..27. -Ot t
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pOWTS OWNER'S M A NUAL & MANAGEMENT PLAN Page —
of
13 NA
N Wl i �e5 rs NA
Owner Q 3 Holding �• Permit �► Sy3 3 y C ❑ ► try
@AfiA►ME't�[ 5 0 0 3 Dogs 13 Hold Vol. $�
NuOnber of B Rttsr Mew 0" V1\,� 13 NA
Efama NeRnber of Ptd c Fat�GtY Units s #fir Model - D o —) A
E (overage) flow d
Pump Manufac"A er
Design tpOW flow = tlrstirnated x 1.51
7 p Nadel A
Soil Application Rats M " Unit
Stawwd {n E#1kmrt Guafity D SaatdlGra E�eer ❑ Past Fiber
Fats. Oil A Grease (MG) :930 rr►911- ❑ Mechanical Aeon ❑Wetland
❑ NA
'el Oxygan Derr�ar� (eoDsi 5220 mgr o O#W:
Solids tTSSi 6150 mglt. D Disinfection
Total Suspended M
Pretreated Effluent Oua6tY Monthly aveta9e ❑ NA
l
Biochamical OxV9en Demand (BOD i�30 mg/1- in- Grou��d if Yl 0 h43round WeS�ed
Total Sow (M) 530 mgA. ❑ NA ❑ Mound
51+0` cfu1100mt Q At Grad
Fecal Conform tlleornaft tr awn) 0 Ddi)-Lkw ❑ Oar.
dia.
Maximum Effheent Parade Size Ys to O NA
Other: Otftai' 0 NA
Wakiss t dantw�b0 v"ast°wster and septic folk efftttw+t.
ItRASlTENANCE SCHEDUM Swvioe Fmqmncy
Ssevie Event � s1 � 3 VOWS) ❑ NA
1217 a)
At least once sveI
kwpect condition of tndctsl of tank Volume
When combated sludgy and scum equals �''� tYs1 ❑ NA
of tanktsl 0 When the high wager alarm bs activated
Pump out contents ntrrertlttst M48I $ years! ❑ NA
Inspect dispersal aa5lsl At least once ovary: rr�ontf0ts) ❑ NA
Clean effluent fitter At least Once every: 13 mareth(a) ❑ NA
txirttrds S alarm At least Once every: 0 1
Inspect Dump. pump [3 NA
At least once every:
Rush laterals and test p moot! is) ❑ NA
Other: At least 0000 61 1:3 Vaud ❑ NA
or certifications:
lS/►WTENANCE 11I ,'7IONS art � caRYxtg are of the following hCene s oper ator tpumperi.
be made by lnsp,ectiors of t0nka and dispersal cells mower, II Via; POWTS Maeketaina% any cracks of
Neater ; Nllaater RumbOr Rest<icted of the tank(s) to iderrdfy any rw of effl0�nt o the gro0utc
trust include a vistad in for �0Y bacl� � or po for ant
leaks, m� of combined sludge sawn t � yals in the observation ipe sa X19 Condom► am the dwx*
surface. The sal cefit shaft at Viso 1► � of effluent on the Wow surface may
p rig of effluent to notification of the local m9ulsto Y bu l'Aw"'
req uires the immediate tank equals one -thins tY or more of the tank vaturrte, th
When the combined acct of s �
and scum any treatment and disposed of in accordance with chapter NR 112
entire contents of the tank shad be removed by a s 5�vicin9 Operator retreatrrter
Wisconsin Administrative C64116- fiftm, medra� or pmsstxized components. p
All other services, wckxbn9 but not limited to the son *," of effluent by a certified pOWTS Maintainer.
units. and any servicing at intervals of 512 months, shall be per of {etian of any i� 0vOnt.
A service report t be pr ovided
to the tonal regulatory Y wMin 10 days GMW (2102
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatmgnt tank(s) for the presence of painting products, solvents or other
chemicals that may impede the treatment process and /or damage the soil 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 soil 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 cell(s) 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 purrs tank.
Do not drive or park vehicles over tanks and dispersal cells. 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 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; most 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 shall 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
required setbacks from existing and proposed structure, lot lines and wells. Failure 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 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 failed POWTS.
❑ Mound and at -grade soil 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 IMPOSSIBLE.
ADDITIONAL COMMENTS
t?OWTS INSTALLER POWTS MAINTAINER
Name 'T o w ,e C - S Name
Phone (S a (O Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name EName pr /� ac n i h
Phone t S 3O 6 JOAXSMI
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with
chapter Comm 83,22(2)(b)(1Rd) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
� r
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer i LL
Mailing Address g5 c3�� � (0y- Vol
Property Address r
(Verification required from Planning Department for construction)
City /State G to (- G Parcel Identification Number Q
I�
LEGAL DESCRIPTION
Property Location - N U -) V4, l y w 'Y*, Sec. 9 , T 3 N -R I W, Town of tot ' Mb V1
Subdivision _ l ,n \ �`. : , , Lot #
Certified Survey Map # Volume ,Page #
Warranty Deed # _ 7 ��,> Volume -R Page # T ,
Spec house q yes 0 no Lot lines identifiable 'yes Q no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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
waster plumber, journeyman plumber, 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 forth, herein, as set by the Dcpartmnt of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 38
days of the three year ex n date.
— 11� I
S OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Sl ATL1FtE OF APPLICANT / Z /
DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.******
'* IncIude 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
t�
'J.. 2579P 384 763677
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Hillvale Development Limited Liability RECEIVED FOR RECORD
Partnershl_p Grantor, 05/24/2004 11: 30AK
and LeOue Builders. LLC. a Wisconsin Limited Liability Company WARRANTY DEED
Grantee. EXEMPT #
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
(if a space is needed, please attach addendum): TRANS FEE: 134.70
a COPY FEE:
t 40 Plat of Glenview in the Town of Richmond, St. Croix County, CC FEE:
onsin. PAGES: 1
Recording Area
Name and Return Address
f �fT(
1 0
026- 115340 -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 May 2004
L
Hillvale Development Limited Liability Partnership
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF f dj l iJ )
_ _ ) ss.
County )
authenticated this day of
Personally came before me this j day of
May _ _ , 2004 the above named
HiRvale 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.) instrument and acknowledged the same.
THI5 INSTRUMENT WAS DRAFTED BY LAURA E. BOYLE
Notary Public - Slats of Wleoottslrt tu jlti�- P - - P )c
Attorney Kristin Ogland * My u4nimmion Expires F eb 17 2W8
Huds WI 5 4016 _— _ Notary Public, State of 'A) i5 CcNS l Iti
My Commission is ermanent. (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 500 -655 -2021
WARRANT] DEED FORM No. 2 - 1999
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