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HomeMy WebLinkAbout026-1068-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538719 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: Wefel, Paul Richmond, Town of 026- 1068 -60 -000 CST BM Elev: Insp. BM Elev: I BM Description: Section/Town /Range /Map No: / U ` 4 1 0 � V 1 23.30.18.3486 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /0J (AIL �b l � ng gtgr 2 ll� 1 Alt. BM Vr lve old I ry W Aeration F ^� r b � Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/H uV ` ,, TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Qwma 'Vv1 J 0 Septic (� S y Dt Bo�rrr ( . `� D Ing > �r , ^v L5/ Header /Man Std2 I f 7< A, Aeration Di Pip Z (° 5 2� Holding Bot. System ( Z ( Final Grade PUMP /SIPHON INFORMATION r 6 L S • q Manufacturer Demand GPM `T Model Number tS Zr3 TDH Lift Friction Loss em Head TDH Ft ` Vk Forcemain Length Dia. Dist. t ell SOIL ABSORPTION SYSTEM Z1 CdT d O BED/TRENCH Width y Length f No. Of Trenches PIT !7 IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Q r SETBACK SYSTEM TO P/L K/ BLDG JWEL LAKE /STREAM LEACHIN Ma factur INFORMATION Typ Of System: / CHAMBER O UNIT Model Number. DISTRIBUTION SYSTEM J 6 Header /Manifold —s G (� Distribution y x Hole Size x Hole Spacin Vent to Air Intake 2 Y`~ Pipe(s) f /52 �— \ ( r Length Length V Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only f epttf ver Depth Over xx Depth of ed/Trench Ce Seeded /Sodded xx Mulched , Bed/Trench Edges Topsoil r � 3 , / Yes No ® Yes � No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 / (D Inspection #2: ocation: 1349 Cty Rd G New Richmond, WI 54017 (NE 114 NW 1/4 23 T30N I R_18W) NA Lot Parcel No: 23.30.18.3486 Alt BM Description = T 6 D �t Y1lObwl�}��� 1`�r�h /tQ(���Z(� , / I ;Idg sewer length I l U / .S� �Q(jU� � i:'�W� � v / Sly l� Z ✓� ��'� 157— amount of cover , ision Required? ❑Yes VINo r side for additional information. R.3/97) Date Insepctor's Signature Cert. No. C0f11f1Ulft2 ml.gov Safety and Buildings Division County- t 201 W. Washington Ave., P.O. Box 7162 ��. ro ) Li l seo n s n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 3 717 Sanitary Permit Application state Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental A unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing addre submitted to the Department of Commerce. Personal information u oses in accordance with the Privacy Law, s. 15.04 1 m , Stets. J �l K I. Appli cation Information - Please Print All Informatio Property Owner's N Parcel # a 7)�� 5 201Q Property Owner's Mailing Address Property Location ST. G& COUNTY / 3 c f g' g PLANNING 8 Z ONING OFFICE Govt. Lot ( J City, State Zi Code um er / /f / f� y4 � , 3 !� " � � /,, Section L N � rr-LJ \"` � 7 J�' O` - i:r p T _ N, R � II. Type Building (check all apply) Lot # Family Dwelling - Number of Bedroon - - -� Subdivision Name Block # El Public/Commercial - Describe Use ) 4t �Q.r++ �" "-� ❑ City of _ ❑ State Owned - Describe Use CSM`idmnbe�- - ❑ Vi lage of 2 5+-z54 ownof t III. Type of Permit: (Check ofily one box on line A. Complete line B if applicable) A. ❑ New System lacement System ❑ TreatmendHolding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner [ / IV. Type o POW TS S stem /Com onent/Device: Check a that apply) f i L on- Pressurizcd In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil [I Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) _ ❑ Pretreatment Device (explain) V. Dis ersal/Treat t Area Information• , Desi n Flow (gpd) Design Soil Applicatio te(gpdsf) Dispersal Area Required ( Dispersal Area Propo (sf) System Ele t' n VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks o 2 4}?� -- o - - di - -. ep c r U in r w 0 a Stir Holn g T ank rT hr 1 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume r ibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si a MP /MPRS Number Business Phone Number � Plumber's Address (Street, City, State, Zip Co I VI . County/ De artm nt Use Only _ pproved Permit `Feee Date i sued Issuing �R.... ent Signa er nial $ J 4 / • D6 , 6 IX. Condiu`i�1gg *aeons for Disapproval 3 ` �� L ' � e � Septic tank. efflut?nt filter and �b / dispersal cell must all be services / maintained ��+ �t t- Pb (`e,(� � '$0 tS as per management plan provided by plumber. n ` /JlII n a s ap afE t�at�uirem / must be maintained b ei S �'hz, � Le 4so b Ck CAA Attach to complete plans for the system and submirto the County only on, aper nut less than a r/2 x 11 inches in size GO SBD -6398 (R. 01/07) Valid thru 01 /09 PLOT PLAN PROJECT Paul Wefel ADDRESS 1349 Ctv Rd G New Richmond Wi 54017 NE 1/4 NW 1 / 4S 23 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 10/22/10 4 DATE BEDROOM CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1517 # of chambers 75 ,BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100 Filter BEST Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark Cty Rd G SYSTEM ELEVATION 93.0/92.7/92.4 4' b qrade Well is to meet all Well setbacks required by Scale is 1 " = 40 WDNR 10' unless otherwise 140 Ali, noted Plans Designed Usi Existing 4 ' Bedroom Vent Conventional Powts House Manual Version 2.0 >6 „ Quick4 Standard -W 20' p, of Cover Leaching Chamber with 20.0 ft2 of Area lv s to 5' 5.8ft^2 /pair of end caps be in fled 'f T 6 � 4' Long 12" I b �� 3499 Grade at System Elevation Old Dra d (faile Weeks St pondi o s ace) 30' B -1 4% Slope Vent 30' B -4 B -3 3-3'X 102' cells with >3' spacing 50' B-2 CI b' I/ Vents Property Line d1zo-dl Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 10 /22/10 Owner: Paul Wefel Location:NE1 /4 NW1 /4 S23 T30 N,R18W 1349 Cty Rd G Richmond System type: In- ground absorbtion system (conventional) Manuals Used: In- ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4 -5. Maintanance and Contingency Plan 6. Filter Specifications Sh t 7. Utilization of Existing is Tank form Signature License number 26900 PLOT PLAN PROJECT Paul Wefel ADDRESS 1349 Ctv Rd G New Richmond Wi 54017 NE 1/4 NW 1 /4s 23 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/22/10 BEDROOM 4 CONVENTIONAL )00( IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1517 # of chambers 75 BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100' Filter BEST Filter ❑BOREHOLE O WELL H. R. P. Same as Benchmark Cty Rd G SYSTEM ELEVATION 93.0/92.7/92.4 4' below q rade Well is to meet all Well setbacks required by Scale is 1" = 40' WDNR 10, unless otherwise 140' noted Plans Designed Usin Existing 4 j4'Long ent Conventional Powts Bedroom Manual Version 2.0 House Quick4 Standard -W 20' p Leaching Chamber with 20.0 ft2 of Area A valve is to 5' 5.8ft ^2 /pair of end caps 0 ' be installed L T 34" Grade at System Elevation 30 , 10' Old Drainfield (failed, Weeks St ponding to surface) 30' B -1 4% Slope Vent 30' B -4 35' B -3 3-3'X 102' cells with >3' spacing 50' IF Li B -2 Vents Property Line Cross Section of Quick 4 Standard -W Leaching Chamber Typical cross section for 2 of 3 cells Quick 4 Standard -W Leaching Chamber with 20.0 ft2 of Area per Chamber 5.8ft ^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 97.0 Vent Grade Len 4' 4" 4' ,A/30/34 Septic Tank 4' Long 1 5' 4' Lon14 34" Grade at System Elevation 34ade at System Elevation Spacing 5' 3 -3' X 102' Cells Observation tubeNent Same on other end To be located on end of Cells % A B System elevations: C A-93.0 B 92.7 25 chambers per cell C 92.4 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OVINERSHII' C CATION FORM Owner/Buyer Mailing Address 1 Ljeo' eA'n 1 5 0/ Property .Address 115 �- -�-Q -� D epartment for new construction ) from Planning Zoning (Verification required > �g City /State Parcel Identification Number LE DESCRIPTION 22 Property Location Y. , /VLJ V. Sec. �, T /D N R W, Town of & c Subdavision Lot # Certified Survey Map # _, Volume , Page # Warranty Deed # e> t 1 , Volume d , Page # Spec house yes ® Lot lines identifiable no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Impropor use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pub out the septic tank every thtee years or sooner, if needed, by a licensed pumper. What you put into sep sire system can affect the function of the tic tank as a treatment stags in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. $3.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater dispo sal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read do above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Depar micat of Commerce and the Departmont of Natural Resources, State of Wisconsin. Certification s ' that our septic system has been maintained must be completed and returned to the St. Croix County Plan g & taimg Y within 30 of the three Zoning Department days year asp iration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the of a deed recorded in Register of Deeds Office. property described above, by virtue . N f S APP CANTS) DATE L l � ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warrant deed from the Register of Deeds Office and a copy of the certified survey map if pp h► reference is made in the warranty deed xv. 0$/05) Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 9 9 Y g 9 9 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure, use alternate area and install new tested replacement area. Option #2. stall system at a lower elevation, by removing chambers, removing biomat, and install new system. Option#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: Shaun Bird 715- 246 -4516 St. Croix County Zoning 715 -386 -4680 Pumper Tom Mondor 715 -246 -5148 Shaun Bird #226900 w o 2 (Xb to C p voo _ LLJ U I CAu-� W m r a. 0711 r � 29 ti 0 N low O aapp 0 CL LL lL � M r � cV 01 N 0 O N 0 d d N U to 3 N rn r . LL �LL O ap d 1[> tp ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK `ibis is to cer�tr e t I hav ins cted the septic tank presently Nerving the residence located at: fUE ` %, N ;, Section T R I % W, Town of . 1 � — . Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. ,ast time serviced: �Q ) D? d flow back occur from absorption system? ^^ Yes _ No (If no, skip next line) Approximate volume or length of time: gallons minutes capacity: Construction: Prefab Concrete Steel Other - - - - -- t4anufacturer: (If known) : �c/t/�i?pc�/r✓ Age of T (If known) ,: I- —,f f (" nature) (Name) Please print (` itle) (License Number) - / Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the bes of my knowledge will conform to the requirements of ILHR 83, Wis. Code (except for inspection opening over outlet baffle). Name ���l�� 3//2- 1 � 2 Signature MP /MPRS �� � PAID Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code 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. ©p? d o S - k- Please print all informatio Re* ad by `$ Date Personal information you provide may be used fors vary s. 15.04 (1) (m)). u /-6 Property r Property Location �ovt. Lot L 1 /4 /4 S 23T JON R E Property Owner's Mailing Address C t # I Block # Subd. me or CSM# City StaV Zip ode Ph f f ❑ City ❑ Village '-�'7o Nearest Roads �� ?.w f C�L�'� New Construction Use' esidential / Number of bedrooms Code derived design flow rate GPD Replacement Ry Public or commercial - Describe: Parent mated a Flood Plain elevation if applicable 14 ft. General comments "de / 'O - p and reoornrnendations: / System Type System Elevation 93, F ❑ Boring Boring # I ® pit Ground surface elev&I L ft. Depth to limiting factor / /y 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 jo y - 11 3 Boring # ❑ Boring / Pit Ground surface elev. Y ft. Depth to limiting factor l tn. 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 2.7 • Effluent #1 = BOO > 30 < < 220 mg1L and TSS 30 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please PnnQ - - - CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 a 715- 246 -4516 Property Owner _ Parcel ID # Page of Boring # ❑ Boring 1 19 Pit Ground surface elev. ft. Depth to limiting factor P / in. mil 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 r 3 ( rw � Z 10 FF11 t 4 / f , / 1 I ryt a / 9 Boring ❑ Bon g # Pit Ground surface elev. ft. Depth to limiting factor -t-'� 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. n 'Eff#1 `r\ •Eff#2 -� r ❑ Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon 'lepth 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& and TSS < 30 mglL 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 (8.600) Property Owner _ Parcel ID # Page of Boring # ❑ Boring 3 Ground surface elev. ft. Depth to ' limiting factor �1- Pit P 9 Soil Appli 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 r 311. 10 -�0 1�1 � ' Dec l ? 1 Yea A ck n/),¢ A r /t 9 Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor -f-'�— in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. rf` Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ��JJ `Eff#1 •Eff#2 ,2 r G r F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. ' Soil Appl ication Rate Horizon ')epth 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/L ` 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 -8770 (ROOD) y Soil Test Plot Plan Project Name Paul Wefel Sha4Bi Address 1349 Cty Rd G New Richmond Wi 54017 CST /#2269 Lot -- - --- Subdivision -- -- - ---- Date 1 2/10 NE 1/4 N W 1/4S 23 T 30 N /R W Township Richmond ❑ Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Siding System Elevation 93.0/92.7/92.4 *HRpSame as Benchmark Cty Rd G AL Well Scale is 1" = 40' 10' unless otherwise 140, noted Existing 4 40' Bedroom House 5' 60' T Old Drainfield (failed, 30' ponding to surface) B -1 4% Slope 5 ' Vent 3 ' 35' 20' B -3 B -4 50' B -2 96' Property Line P Y 96 . ra -- :_:_ -� —_ -- •- . —.. —_ _ - -- - - - - — -- C; 1001 -4 AOCUMENT rto. STATE BAR OF WISCONSIN FOAM 1 -1988 KATHLEEN He WALSH _WARRANTY DEED REGISTER OF DEEDS VOL 1455 PAGE ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Jeanette C. Fletch, 09-08 -1999 9:30 AM ---------------------------------------------------------- a..single person ---- ---- -- -- _-- -- ---- .................................. WARRANTY DEED EXEMPT 11 - ...................... ........ ....... --- -- -- --- ---- •--- •.............. . ntor, CERT COPY FEE: and.... - Paul-. IC.•-- Glefel_.an....Iie....._ ftef eY.;.:tiusbaiid::att� "a ________ -- TRANSFER�FEEs 489.00 wife ,..as_ tenants ........ ....................... RECORDING FEE: 10.00 ..... ..._...... -- - - --- ... -- -............. -- .......... --- .... .......... - ----- PAGES: I ---------------- I .............. .. .. .. .. .• Grantee, Witnesseth That the said Grantor, for a valuable consideration__.... ....................... .......... ............ ...•.. --------- --------------- --- RETURN To Donald conveys to Grantee the following described real estate in .. .. Croiic - •- - •--•---"' - -'"""-"" 15 South Fifth Street x/1200 County, State of Wisconsin: Minneapol MN 55402 The East 166 feet of the Northeast Quarter of the 23 30 18 348 B Northwest Quarter (NE 1/4 NW 1/4) of Section 23, TownshipTax Parcel No:. ... ......... .... ...... .. ...... .... 30 North, Range 18 West, St. Croix County, Wisconsin 26- 1068- 60_000 This is ______ homestead property. xt6EsOxi xx i Together with all and singular the hereditaments and appurtenances thereunto belonging; And.. ----•-----------•-----••---•----------• •• ............................. -• - ...__..•... ------........ ........._._....._............. ................ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except zoning ordinances and recorded easements and restrictions of record, if any, and will warrant and defend the same. Dated this --- .......... 1 .1 t'. . .................... day of t°. t7![_ L77!~<t- .. .......... ---- .............. , g... ......... ...... . . ..... --------------------------------------------- (SEAL) k :.e= !14 (SEAL) J, nette C. Fletch . •-------- ------------------ -- ----- •-- .- ---........-- - - -- -• ........................................ .... ..... .................... (SEAL) .-........................... ------------- ........................ (SEAL) .......... ... ..................... I AUTHENTICATION ACKNOWLEDGWBNT Signatures) STATE OF WISCONSIN aa. _..--•-'-----------•------------------------••... ............._...._............ County. authenticated this ........ day of ------------------------_- 19 ------ Personally me before me th� .....l of S e.l Zjge :..._... 19 ... ..... the above named .............................. ---....._..._-----•- ------- - -- - • •• --•--- e C tch a sin Ie erson ..Zi;3Ai=�S °-...: _. Fly....... s__.....- ----g•-- ---P-•---- --- -- -- - � ............. ................................. ----- -• ----•- ------•-------- .._...---------...---.....-•--•-------•-•-•°---•- •-- _......._._.._............• TITLE: MEMBER STATE BAR OF WISCONSIN .. .........................•.-•........-....... ....___.__............_._..__.. (If not, ............................................................ ._..... ...._... the ----------............- ----- .......................... authorized by § 706.06, Win. Stats.) t e know to be perso n o executed the re aing i trument an acknowle ge th same. g THIS INSTRUMENT WAS DRAFTED BY London Anderson Antolak & Hoeft, Ltd. - °'---.... ' "" " " "' "° 15 South F3£Eti�treet �F12if(F' ►..... ----- .��ir>rl� - . .. - • 'nin r.......... �Firrrteapol- is,•- I.14I - -• 5<+ A2••----- ---- -•-- ---- ---- - ----- - Notary Public _�/C7.i. ....... County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if jQAhNrW fton I� are not necessary.) date . --- State of Wisconsin •Name, of .1R.I.X In any eap —Ity .houid be typed or printed below their ■iEnetnre.. STATE DAR OF WISCONSIN ►4C.R�•r FORM N.. 1 — 19A Stock No. T 3881: