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HomeMy WebLinkAbout026-1072-70-300 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisiotj INSPECTION REPORT Sanitary Permit No: * - 420525 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: Miller, Sam I Richmond Township 026- 1072 -70 -300 CST BM Elev: 1 Insp. BM Elev: BM Description: - 3 s 1 a - 3 5 1 csT >M, z al?`5 , 3gDA50 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 1 Jr ZGa� o •�s a -7-3s Dosing Alt, BM � 0� ZS► Aeration Bldg. Sewer �, Q Holding St/Ht Inlet SUHt Outlet TANK SETBACK INFORMATION �-3b TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > ( Za I Dt Bottom Dosing Header /Man. 1 Aeration Dist. Pipe (a f ZiSS q�.3S Holding Bot. System Final Grade '" I PUMP /SIPHON INFORMATION r S•310 160 ®S" Manufacturer Demand St Cover GPM Model Number TDH Lift F ' n Loss System Head TDH Ft. Forcemain Len th I Dia. SOIL ABSORPTION SYSTEM ) 3 -I' 2• t� BED /TRENCH Width Length 1 No. OM hes PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1 1 ./ •yr .- :3 1 SETBACK SYSTEM TO ``SSII GGUU P/L JBLDG WELL LAKE /STREAM LEACHING Manuf turer: INFORMATION Type Of System: r CHAMBER OR S L UNIT Model Number: It DISTRIBUTION SYSTEM Hnifold U Distribution x Hole Size x Hole Spacing Vent to Air Intake LL Pi _ ( gth_Dia L ength Dia Spacing �� O SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded r Mulched BedlTrench Center Bed/Trench Edges Topsoil Yes ij No ]Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: O Inspection #2: Location: 1437 140th Ave New Richmond, WI 54017 (NE 1/4 NW 1/4 25 T30N R18W) NA Lot 4 arce o: 1.) Alt BM Description k4 25.30.18.380A30 = t"""p° � � 2.) Bldg sewer length = 29 736 " f_ .� am o of cover = "' � ,� _p,� Q•s' �? CAS 3) �' : 'ND c9' "� 'j � . � . - - - - - -- _ l\ �.�� q / - - -- -- — - - -- — P1a{t rslon Use other side for additional information. SBD -6710 (R.3/97) Dat�f Insepctor's Signature Cert. No. ` qo�z.& - A r I Sanitary Permit Application 201 W Safety & [ia s Division ' in accord with Comm 83.2 1. Wis. Adm. Code W. W Washinngton Ave. See reverse side for instructions for completing this application PO Box 7302 N* eons Personal information you provide may be used for secondary purposes Madison, W[ 53707 -7302 Department of Commerce (Privacy Law, s. 15.04(I)(m)) (Submit completed form to county if not state owned. Attach complete Tans to the county co onl y "ste ,«on less n 8 -1/2 x I 1 inches in size. County State S 'tary Permit Nun1ba ❑ hock irkrishih rprevious applicati n State Plan 1. D. Number I. Applic ation Information - Please Print all Information Location: Property Owner Name Property Location Ct)J'�liY Nt h /4N414,SIST_ W c_ Property Owner's Mailing Address C5 . = Lot Number Block Number City, State Zip Code one Numbe Subdivision Name or CSM Number ❑ City I. Type of Building: (check one) ?� �/L )/G S ❑ Village ❑ 1 or 2 Family Dwelling -No. of Bedrooms : , a own of (� ❑ Public/Commercial (describe use):_ 3 k G fr' 0 < < N � Q N 0 ❑ State-Owned - � * l t ' /4 T (L67 Ru e Nearest Road I t `'h �'i �.QlCaCs Parcel TaxNumbes(s)p2k 1 A2 2 -70'3� III. T e of Permit: Check o one box online A. Check box on line B if a livable ❑ Addition to A) 1. New 2. ❑ Replacement 3. Li 5 Replacement of 4. Existi Ad System S s em S stem Tank Onl rmit Number Date Issued B) ❑ A Sanitary Permit was reviousl issued Pe IV. Type of POWT System: (Check all that apply) ❑ Sand Filter ❑ Constructed Wetland & n-pressurized In- ground 4_V 'A [ !} ❑ Mound ssurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line Cl At- rade ❑ Aerobic Treatment Unit ❑ Recirculating ❑Other: V. Dispersal/Treatment Area Information: l Design Flow (gpd) 2. Dispersal Arca 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation Elevation G rade Required �t�l Proposed _ 13 Rate (Gal . fl.) (MinJinch) 11 °I 6,3 ©fit aG VII. Tank Capacity in Total fl of :tcturer Pre! .b Site Steel Fiber- Plastic Gallons Gallons Tanks Con- Con- glass luformation — crete structed New Existing Tanks Tanks ❑ 0 0 _ 11 ❑ ❑ ❑ ❑ ❑ Responsibility Statement 1, the undersigned, assum res onsibili for installation of the POWTS shown on the attached plans. Dusincss Phone Number Plumlxds Namc onint) Plumbcr's alure (no stamp MP/hil'RS No. !YIIk.E ( D oyta, (I z .z�03�6 /0z- �16s - 1y2 . 7 Ptumbcr s Address (Street, City, State, Zip C e) e r n't& r l� . ' m--- ,� ! j3 ✓,,0 e �✓ Al IX, County /Department Use Only Sanitary Permit Fee (Includes Groundwater Date Issued Iss in Agenl Signature o stamps) ❑ Disapproved ry � Approved ❑Owner Given Initial Adverse Surcharge Fe W 2— Determination FCon�tions o Approval /R o for Disapproval- �. �M t�M� Q0.) C.sW . L i I - Sanitary Permit Application Safety &Buildings Division 201 W. Washington Ave. In accord with Comm 83.21, Wis. Adm. Code PO Box 7302 See reverse side for instructions for completing this application Madison, WI 53707 -7302 1 \4 1 sc , on.Sin Personal information you provide may be used for secondary purposes (Submit completed form to county if not Department of Commerce ( Privacy Law, s. 15.04(1)(m)) l Y state owned. Attach complete plans to the copy onl sI e n less n 8 I/2 x l I inches in size. County state S 'tary Pe it Nut c ❑ k Nevis revious appliutt n State Plan 1. D. Number S'r- C Zo m 19 c7zb LOCatIOrt: i. A lication Information - Please Print sll Information J Property Location Property Owner Name t r, S�YL M1 �`�Q ---- "tCI:�GUIJiViY I/4N�14 S ?JT��N,R� o roperty Owners Mailing Address - I G O P Lot Number Block Number ��.. . O Subdivision Name or CSM Number City, State Code Phone N P � g (, 2 7 (' 17 0 � 4 Z 1 1 ? r✓ LA 16 71 ❑city I. Type of Building: (check one) ? - rtae)ye s ❑ Village ❑ 1 or 2 Family Dwelling - No. of Bedrooms: X Z 'Town of 0 ? ! 1 /4 0 N ❑ Public/Commercial (describe use):_ � * I i _ 14 - TRH l u (I ` l� ❑ State - Owned Nearest Road r r 5 cel Par Tax um Nber(s) 42G- •7d- 3 0 III. T e of Permit: Check �;�;�ent e bo on line A. Check box on line B if a licable 5 ❑ Addition to A) I. New 2. ❑ 3. ❑ Replacement of 4. Existing System S s em S Tank Onl Date Issued Permit Number B) ❑ A Sanitary Permit was previously issued IV Type of POWT System: (Check all that apply) ❑Mound ❑ Sand Filter ❑ Constructed Wetland on- pressurized In- ground 4-15A C 14 ❑ Single Pass ❑ Drip Line Pressurized In- ground ❑ holding Tank g ❑ At- rade ❑Aerobic Treatment Unit ❑ Recirculating ❑Other: V. Dis ersal/Treatmcnt Area Information: t. Design Flow (gpd) 2. Dispersal Art a 3. Dispersal Area 4. Soit Application 5. Percolation Rate 6. Systcnt Elevation Eleva on G ra de Requiredt� Proposed (2154 Rat c(Gai (M inlinch) I fie` O. .,--, D •S �(or3 '00! VII. Tank Capacity in Total /1 of acturer Pref ,b Site Steel Fiber- Plastic Con- Con- glass Information Gallons, Gallons yanks crete strutted Now Existing Tanks Tanks ❑ ❑ ❑ ❑ Responsibility Statement 1, the undersigned, a ssume res onsibili for irutallation of the POWTS shown on the attached plans. p�incss Phone Number 1'lumbc� s Si ature (no stamp MP/hiPfLS No. �/ Plumbers Name (print) � / ♦ � z _ 0 6 f �. � � 2 /14 //c- � 4 D *,4 j 1 J fe 4+ Plumbers Address (Street, City, State, Zip C e) Ps/ IX. County /Department Use Only Iss in A en( Sig n ature o stamps) ❑ Disapproved Sanitary Permit F a (Includes Groundwater Date Issued g ` g �Approvcd ❑ Owner Given Initial Adverse Surcharge P I 2Z Determination X. Conditions ogAppr - /R 0s for Disapproval: 6A.Q— i LA ..� o z ►� e W � 4 ® a I M b r L p ► La C C le x N 1 VV N 1ss � 1H . H . Q ° a '� b �r f r INA 1A AL P A t el vim• ` a +1� _• 4I O � s W � N M r ® kA �. Wiscor ;� Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor aadd�� Human Relations Owisi6n of Safety & Bbildings in accord with ILHR 83.05, Wis. Adm. Code - `" � COUNTY 7 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BMj,4*reCi on % of slope, scale or PARCEL I. # dimensioned, north arrow, and location and distancoo" 'h r est road. pending APPLICANT INFORMATION PLEASE PR *T ALL INFUMATIONI REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT NE 1/4 NW 1 /4 25 T 30 N,R 18 j(or) W Steve Derrick PROPERTY OWNERS MAILING ADDRESS LOT BLOCK # I SUBD. NAME OR CSM # 1438 Cty. . Rd. "G" 4 - . CITY STATE P pppD. PHQNE NU ❑CrfTY []VILLAGE DOWN NEAREST ROAD New Richmond, WI . 4811 'e(715) _ �"�'v` 14 0th, Ave. [ New Construction Use be ] Residential / Num i t ecropm . [ ) Addition to existing building [ ] Replacement I ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .5 bed, gpd /ft .6 trench, gpd 1ft Absorption area required 1200 bed, ft 1000 trench, ft Maximum design loading rate .5 bed, gpd /ft .6 trench, gpd /ft Recommended infiltration surface elevation(s) 96.35 It (as referred to site plan benchmark) Additional design/ site considerations trenches 3.00' below grade Parent material ' glacial drift Flood plain elevation, if applicable na ft S = Suitable for system 7o, VENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem S ❑ U ® S ❑ U @ S ❑ U l� S ❑ U ❑ S CCU CIS [RU SOIL DESCRIPTION REPORT New 1 2¢cso.." a, Depth Dominant Color Mottles Texture Structure Consistence Roots D /ft Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITIrench 1 0 -12 10yr2 /2 none sl 2msbk mfr gw 2f .5 .6 LU 2 12 -40 7.5yr4/6 none co s Osg ml gw if .7 .8 Ground 3 40 -90 5yr4/4 none sl 2msbk mvfr gw na .5 .6 , elev. 101-.2 ft. Depth to limiting factor -� •3� + h 1f'3- 9 / ;IJ41 Remarks: Boring # 1 0 -10 10yr3 /3 none 1 2msbk mfr yw 2f .5 .6 2 €_ 2 10 -52 7.5 r4/6 none cos Osg ml gw if .7 .8- 3 52 -90 5yr4/6 none Ifs Osg mvfr na na .5 .6 •� Ground elev. 1 Depth to limiting, factor +90 Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Ave., New Rich and WI 54017 Signature: Date: 4_17 -2000 CST Number: m02298 PROPERTY OWNER SOIL DESCRIPTION REPORT Pag 2 k 3 PARCEL I.D. # pending I Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Ba.x>dr'ry Roots GPD /ft in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0 -13 10yr3/3 none sl 2mgr mvfr caw 3 S w i .... ............. 2 13 -27 7.5yr4/6 none cos Osg ml g na .7 .8 Ground 3 27 -34 5yr4/4 none sl 2msbk mvfr 9w na .5 .6 , elev. cog, -3 ft. 4 1 34-60 7.5yr4/6 none co s Osg ml yw na .7 .8 } Depth to 5 1 60-90 7.5yr4/6 none fs Osg mvfr na na .5 .6 limiting factor 35 � 44 IL( Remarks: Boring # 1 0 -11 10yr3 /3 none 1 2msbk mfr gw 2f .5 - .6 4 f' 2 11 -28 7.5yr4/4 none sl 2msbk mfr gw if .5 .6 .r ................ 3 28 -70 7.5yr4/4 none co s Osg ml gw na .7 .8 � Ground elev. 4 70 -84 7.5yr4/6 none sl 2msbk mfr na na .5 ' .6 -5 -- 96.8 ft. - Depth to - limiting factor +84" Remarks: Boring # 1 0 -10 10yr3 /3 none sl 2mgr mvfr gw 2m .5 .6 5 2 10 -38 7.5yr4/6 none co s Osg ml gw na .7 .8 3 38-84 5yr4/6 none sl 2msbk mvfr na na .5 .6 Ground elev. 96 ft. Depth to limiting factor +84" Remarks: Boring # i Ground elev. j ft. Depth to limiting factor Remarks: I SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Steve Derrick 1554 200th Ave. CSTM2298 NE 4NW4 S25- T30N -R18W New Richmond WI 54017 MPRSW -3254 town of Richmond (715) 246 -6200 lot #4 -csm N BM.= nail in Norway pine @ el. 100.00' Alt. BM.= nail in Norway pine C el. 97.35' 1 = 40 ' L 3� 10 GAry L. Steel 5$ 17 -2000 'Ile T J Bi o Diff user S ChaftV l �sr Heigm Chambw HeigM 4 En d Knockout Universal End CaP Chamber 11" Stan• 14" High 16" High Av a i lable SizDimensions dard Capacity Capacity �a. i / �`.• /m:Y� i+ °_/ L �'�iIOBVS��' W r!F,CY �t..'L!'� t a+� eL... Y- e u q�yi w 1. � .VIi,K,. ey .��ik, �■� � !'M n t Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number 525 Number of Bedrooms Design Flow - Peak (gpd) (ems Estimated Flow - Average (gpd) qc5D Septic Tank Capacity (gal) (&'0 Soil Absorption Component Size (W) Type of Wastewater D estic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 2 Maximum Influent Particle Size (in) V 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septi tank and outlet filter shall be assessed at least once every 3 years by inspection. Th out et filter hall be cleaned as necessary to ensure proper o ion. The filter cartridge sho removed unless provisions are made to re in solids in the tank that may slough off the filter when removed from its enclosure. If the i Management Plan for a Soptic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a -Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 72 i 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address $+ t" �--- ' e tS o eat Property Address (Verification required from Planning Department for new construction) City/State y- u/ /2 Parcel Identification Number 00 LEGAL DESCRIPTION '1 _ -R Town of lbe 4 wl y, , ' , u' N .1 ti cQ Property Location � /, Sec. T .Subdivision P / rk E r c Ot e "5 , Lot # _• Certified Survey Map # 2.,.,, Volume / , Page # y*O Warranty Deed # , Volume / l` 6 3 Page # G 3 7 Spec house Y es ❑ no Lot lines identifiable Z ❑ 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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. 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 by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Cert ification stating that your septic system has been maintained must be completed and retutned to St. Croix County Zoning Office within 30 days of the three year expirat date. AP ICANT DATE •i: QVMER CERTIFICATION i; 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 propbM.described abov by virtue of a warranty deed recorded in Register of Deeds Office. PLICA DATE s « « ss« 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 J 19031 637 ` STATE BAR OF WISCONSIN FORM 1 —1998 6 8 0 7 7 E-5 `> �* WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI Document Number RECEIVED FOR RECORD This Deed, Steven J. D rri k married Man 06 -04 -2002 9t00 AN Grantor. and Sam E. Millea a single person , Grantee. Grantor, for a va ua a consideration conveys to Grantee the following WARRANTY DEED described real estate In St. Croix County State of EXEMPT 4 Wisconsin (the "Property "): REC FEE: 11.00 TRANS FEE: 135.00 COPY FEE: CERT COPY FEE: PAGES: 1 Recording Area m and etum Address - Ic nd, WI 54017 �v 'fTl rKR Rix C4rc� ( Y Q 8" 026 1072 70 300 r•3 5b A Parcel Identification Number (PIN) °I Y This is not homestead property. (Is) (is not) Lo CSM filed Vo1_14, Certified Survey Maps, Page 3946 as Do urnent N 629236, Located in part of the Northwest Quarter of the Northwest Quarter and part of the ; No east Quarter of the Northwest Quarter al in Section 25, Township 30 North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin. Together with all appurtenant rights, title and interests. none Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and Gear of encumbrances except Dated this 15" day of May, 2002. (SEAL) (SEAL) r c ' Steven . Derrick (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ~ ) } as. 1 St. Croix County authenticated thf46TAR aj BL1Ci _ STATE OF wys Personally came before me this 15th day of May, 2002 the above named Steven J. Derrick to me known to be the person who exectAed the foregoing instrument TITLE: MEMBER STATE BAR OF WISCONSIN and a kn ledge the same. (If not, L (phi authorized by §706.06, Wis. Slats) THIS INSTRUMENT WAS DRAFTED BY Notary Public, StaVa of Wisconsin Coldwell Banker Burnet � 1301 Coulee Road My commission Is erma( ent. (If not, state expiration date: Hu 3824 1 54016 < lgnatures may be authenticated or acknowledged. 7 Both are not necessary.) Names of eersons s;2nin2 in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. 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