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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
430681 0
GENERAL BNFORMATION (ATTACH TO PERMIT) State Pl 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:
Marks, Marla I St. Joseph Township 030 - 2125 -50 -000
CST BM Elev: Insp. BM Elev: BM Des�ption: �[ Section/Town /Range /Map No:
(TD • O 1 00. 01 ►M = .0 dCt 25.30.20.1019
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic R�P d Ben mark n *- 4
Dosing V Alt. BM
Aeration Bldg. Sewer
6.9g 5.
Holding St/Ht Inlet
�-3 9 • T3
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic y t Dt Bottom
Z t
Dosing Header /Man. • 3Z
Aeration Dist. Pipe
Holding Bot. System 9.30 . 7 7 .1
Final Grade
PU P /SIPHON INFORMATION 3•%
Manufacturer Demand St Cover
GPM
Model N ber
TDH Lift P action Loss System Head TDH Ft
Forcem Length Dia. Dist. to Well
OIL ABSORPTION SYSTEM
BED /TRENCH Width t Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Die. Liquid Depth
DIMENSIONS 2
SETBACK SYSTEM TO P/L B > LDG IWELL LAKE /STREAM LEACHING Man acturefr:
INFORMATION CHAMBER OR 101
Type Of System: ,
UNIT Model Number: • t . � 22
l O
DISTRIBUTION SYSTEM
Header/ ifold Distribution Ix Hole Size x Hole Spacing Vent to Air Intake
4 Pip s)
Length Dia Lengt Dia
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
I
Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed /Trench Edges Topsoil -Yes No Yes No
-
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: �� Inspection #2:
Location: 1345 Birch Park Road Hudson, WI 54016 (E 1/2 SW 1/4 25 T30N R20W) Birch Park Lot 15 Parcel No: 25.30.20.1019
1.) Alt BM Description = IV/A'
l
2.) Bldg sewer length = 30
- amount of cover = 1 a+ • ,
(.' 3) JUG ate- 4A lyre .
Plan revision Required? Ye I No
Use other side for additional ation.
SBD -6710 (R.3/97) V f Date Insep is Signature Cert. No.
RECEIV
i
s
Safety and Buil ings Division County
1*is 20 I 4hi,gton ve., P.O. Box 7082
�On�,� ON1NG Ofon, WI 3707 - 708 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce 1-6546 O (eyf
Sanitary Permit Application Q State Plan I.D. Nrr
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s I5.04(I )(m) Project Address (f different than mailing address)
I. Application Information — Please Print All Information
Propert Owner's Name Parcel # Lot # Block #
_
operty Owner's Mailing Address Property Location
/.. A
City, State Zip Code Phone Number f Section
(circle o )
T. � � N; 1E orj
I C I .. Type of Building (check all that apply)
,LI 1 or 2 Family Dwelling — Number of Bedrooms d� y� / Subdivision Name C.SM-Numbcr
❑ Public/Commercial — Describe Use
❑ State Owned - Describe Use ❑City ❑Vil ge ownship of
U J \
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. New System ❑ Replacement System ys ep ys ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that appl
Non — Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland U Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe Other (explain)
V. Dis ersaUTreatment Area Information: P3 ) F L i l ST.
Design Flow (gpd) Design Soil Applic tion Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
Z44 1 �
L 6
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units t,I� � �6 � Concrete Constructed Glass
New Existing
Tanks Tanks (�
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned responsibility for installation of the POWTS shown on the attached plans.
Plumber' 04ame (Print) Plu 's ' it * MP/MPRS Number Business Phone Number
' ,/ / tag
P umbers Address (Street, City, tate, Zip CO
�f
U
VI! K. Coup /De artment Use Onl
Approved Disapproved Sanitary Permit Fee (includes Groundwater Date Issued [ rng Agent ignature (N ps)
Surcharge Fee 7 CIO ❑ Owner Given Reason for Denial g ) G V . -` / 0 `
> �b�tti6611�1b1f :l�proval/Reasons for Disapproval /
Sep all tank, effluent filter and �
dis cel must serviced / maintalned t �G� &� IP6
as per man g emeot plan Drovided by plumber
2. All setback requirements must be maintained ,�� w � Y `�`' n
as per applicable code /ordinances cnG�c� �gti�� "!��'� �h�.c� -X�fi� 2a
ttach complete plans (to the County only) for the system on paper no less than 8172 x 11 Inches in size
SBD -6398 (R. 08/02)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT P age 1 of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County St. Croix
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
inGude, 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 446wed Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Quest Development, Inc. Govt. Lot E 1/2 1/4 SW 1/4 S 25 T 30 N R 20 E W
Property Owner's Mailing Address Lot Block # Subd. Name or CSM#
Suite 150 10700 Old County Road 15 15 Birch Park
City State Zip Code Phone Number ity FjviIlage ■ Town Nearest Road
Plymouth MN 1 55441 ( 7�3- 595 -9512 County Road E
a New Construction UseE] Residential / Number of bedrooms 3 t 4 Code derived design flow rate 450 600 GPD
F1 Replacement ❑ Public or commercial - Describe:
Parent material f mess over out wash sands Flood Plain elevation if applicable
General comments This site is suitable as a below grade convent al system
and recommendations: tM1 v
& //� / *With alternating bands of 10yr4/4, fs, fsbi my r. ,
? bll � Cam- a rte R ao d gravel from sld lodge parking area ��. � A- C �
D �� �1 - 2 = d6 mi
Boring #
Boring f 6 �YL_ GL ! ('i07 Pt ZQ��
F
p
Pit Ground surface elev. 99.71 , ft. Depth to smiting factor >110 in. . L:
Ski lion R
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundar t
in. Munset Qu. Sz. Cont. Color Gr. Sz. Sh.
1 0 -100 10yr2/2 *fs lfsbk mvfr
vto 00 ile-• - ms s
k;'r 151 kOYi
c�
65/ ,
lit — G x
7 2 tz/ov
F - 2 Boring # Boring [] 98.75 >110
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDN
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. " Eff#1 "Eff#2
1 0 -9 ** (U o gravel ** ** ** cs **
2 9 -22 10 r2/2 vfs Osg mvfr cs - .4 .6
3 22 -54 10yr5 /4 sicl lvf mfi cs - 2 3
4 54 -110 10yr3/2 lvfs Osg mvfr - - .4 .6
w
Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L " Effluent - BOD < 30 mg /L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Thomas C Nelson 227387
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, WI 10/20/01 715- 246 -2454
1
, aaodvl a
2 3
Property Owner Quest Development.Inc Parcel ID # Page of
3 Borin # Boring
g ❑ Pit Ground surface elev. 99.05 ft. Depth to limiting factor >110 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 *042
1 0 -8 10yr3 /3 - is lmgr mvfr cs if .7 1.2
2 8 -110 7.5 r5/4 - s Osg ml - - 1.2
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
❑ 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 /L * 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.
S1113- 8330Test (R.07 /00)
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Feb 03 04 07:01p Marla Marks 651- 351 -1666 p.1
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ST CROIX COUN'ry
SWITIC 'i•ANK MAINTUNANCi3 AGIM
AND
OW t i Slllil Ct31vrwICWI'ION FORM
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owlier /Buyer 0 V`4 4.
Wiling Addrea
Property Address
(Vecificaliau tccplilcct fiunt 1'1an11itll; 11cpaltutertt fo IN can action)
City /Slate 6- .• s�,�, it Parcel idewilicadint Number i
L t.GAL DECSCHIP ION
Prope Location F � /,. �W '�, tics. Z 5� , '}' �Ql�- 1t,'2(,Zw, 'I'owit of _{41
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Spec house 0 yes /41 110 1.111 lines itit;nlili:lbic,l� yes ❑ no
S�'S'!C'LCM lyttl IN11'Lt
Ituittoper use and Inaimlella "cc Orynt,1 sc tit it: aystcnt could Icsolt in its Ill eare fill e 1'ait tit CID 11,1111lawastes- Ikoparuta4rteluuee
It10 ae lie /auk every trues yeah us stroller, if needed by a licensed pumper, Wllal you put into the system
consists of puulpiag ou t p
can atY• eat'1110 functi of. the septic. took as a llcalrrteat stage in 1110 wOstc r l irl10 i
7110 pmperty owner agrees to st,tastit w St. Croix 70111mg Depatuncul a ccllfficalion form, algned by the owmct and by ■
sttastpr plumber,)ourucynlautrtu»tbar. I call icted plumber w a licensed l uutper velifybfb lilac (I) dw on - s il o waslewaytsrdlaposal system
is i proper ollemilag condition and/Or(L) otter imllccliuu slid imtnptiug (if stecessory), rho aci lie lank is Ices alien 113 full or sludge.
liwe, the utukralgued have read llle ahuve Icquimact,ls and agree to s»aintalm the privalc ecwagc disposal system with the standards
eel fortis. betels, ac set by Ilia Dellaslalcat of Ctilllnlelcc Still the I)cpallmlemt of Nalural itesourecs, State of Wiscooeio. Certificati
staling tat your septic system has been utaiulriued unlsl be completed and Icttnacil to isle St. Croix County ZoalnE Office wit 30
days of throe year expirpilaq data.
SIGNATURE OF APPL1CAW
R GRELT-109AIM
I (we) certify that all•stStemlenls list this farlm ale it tic In file test t,f Iny (nor) k1 lic gc. 1 (we) am (arc) hoe owael(s) of
the properly described ab e, y visit,* of s wauanty decd tectudcd it, Itegister of lrcctls 17t1icc.
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SIM Olt APPLICANT DAB
i
Any iafo►ntalion that is Buis - m•aseutcd ma y tesull its lire sanitary pcsmril hcial; ,evoked by lite Zoabig Departmaut. ••�•••
•• include with this aptlitcatlou: a clatatpxt wattant,•.dccd fiuur iito-hegisict [,f deeds Off'. • - ••_.,- -
culty of-Itfc ZvOrlics1 ita'vey 1111)) if�isfelcl is'tua in lire wamulX tic Sd
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FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity, a l ❑ NA
Permit ilf , Septic Tank Manufacturer O NA
IV WT DESIGN PARAMETERS Effluent Filter Manufacturer O NA
Number of Bedrooms O NA Effluent Filter Model 21 �1 O NA
Number of Public Facility Units ONA Pump Tank Capacity a l A NA
Estimated flow (average) g al/day Pump Tank Manufacturer .0 NA
Design flow (peak), (Estimated x 1.5) al /da Pump Manufacturer A NA
Soil Application Rate gal/day/ft' Pump Model A!f NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease IFOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA O Mechanical Aeration O Wetland
Tot al Suspended Solids ITSS) 5150 mg /L O Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ,?�In Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L �NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510' cf /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size (Y, in di a. O NA Other: ❑ NA
Other: O NA Oar: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ m rl,1
� ea r s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ year lads) (Maximum 3 years) 13 NA
Clean effluent filter At least once every: 1 7 ❑ month(s) ❑ NA
earls)
❑ month(s) ,d NA
Inspect pump, pump controls & alarm At least once every: ❑ ear(s)
Flush laterals and pressure test At least once every: ❑ month(s) JdNA ❑ year(s)
Other: At least once every: ❑ month(s) [3 NA
O earls)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground'surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
_
START UP AND OPERATION Page of 3_
For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals
that may Impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have two 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 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, overloading the cell(s) and may result 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 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) water; fruit 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 shall be taken to insure that the system is
properly 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 properly 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:
�' uitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
SIMM The ent wea- 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.
Th s' �nbe a aluated to ' tt a su itable repl eme area. Upon t u of the PO soil and site
ev lu do erfo ed to I to a suit le repla ant area. f no r acement ea ' ailable a n k
m y e ilast re replace the fai TS.
❑ 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
POWTS IN TALLER' POWTS MAINTAINER
Name Name iy ,
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone _
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54111, (2) & (3), Wisconsin Administrative Code.
1�
P & W 5 �S u u 749449
STATE AR I C IN F R 3 1998 KATHLEEN H. MALSH
QUIT CLAIM DEED REGISTER OF DEEDS
ST. CROIX CO., NI
Document Number
RECEIVED FOR RECORD
This Deed, made between _ —__ —_. 12/18/2003 08:30AN
Marla R. Marks,. single per QUIT CLAIM DEED
EXEMPT #
Grantor,
and Marla R. Marks and Thomas R. Smith, as joint _ REC FEE: 11.00
tenants with a right of s — COPYSFEE: 201.00
_ CC FEE:
Grantee.'" PAGES: 1
Grantor quit claims to Grantee the following described real estate in
St. Croix County, State of Wisconsin:
Recording Area
Lot 15, Birch Park Name and Return Address
Marla R. Marks
1178 Bergmann Drive
Stillwater, MN 55082
,I
030- 21 -50 -000
Parcel Identification Number (PIN)
This is homestead property.
(is) (is not)
Together with all appurtenant rights, title and interests.
Dated this 13th day of Dec 2003
(SEAL) - 1 IG±, y" :12- 71Y)Ct. L (SEAL)
k Marla R. Marks
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of UU&NU G, Minnesota lI
ss.
C'5�u' _yyttun Counyy. J
authenticated this day of Personally ca a before me this J day of
1Lw� i�1�� _ 20113_, the above named
Marla R Marks a single perctin
TITLE: MEMBER STATE BAR OF WISCONSIN _. to
(If not, me known to be the person --� who executed the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Piemier Title Insurance Agency, Inc.
7300 Metro Blvd., 11300 Notary Public, State of Wmm -tn I` VlVl( SC fa-
Edina, MN 55439 My F ommission Is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not �1 GWl - � -- - - ..... 2'66
necessary)
EMILY SCHWENKER
O NOTARYWIBLVC- MINNESOTA
Names of personssigning In any capacity typed y mun De or printed below their sig at re.
STATE BAR OF WISCONSIN My Comm. Expires Jan. 31, 2005 Blank QUIT CLAIM DEED I lil"u Co.. Inc.
Q FORM No. 3 - 1998 i rnnwauxee. Wis.
6513,795264 1 =.i ih! F' GOF7r1 h.i
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