HomeMy WebLinkAbout032-2107-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM C ou%' : Croix
Safety and Buifdings Division
. INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) saniwflwitNo.:
Personal information you provice may be used for secondary purposes (Privacy Lavk s.15.04 (1)(m)).
N [g fth t 4de State Plan 10 No
jjspame: ❑ City
4 hip ..
CST SM E ev.:• ��YY P
Insp. BM E ev.: BM Description: ar
f / _ `V�- %7 -20 -000
c. o — v C cs I K ) o� i9 t vo G
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS I FS ELEV.
Septic Benchm 0' p ip
Dosing
Aeration Bldg. Sewer • - i a 2q
Holdi St/ Ht Inlet
3S •� '
TANK SETBACK INFORMATION St/ Ht Outlet g: $
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet'
Air Intake
Septic t--- NA Dt Bottom
Dosing NA Header /Man.
Aeration NA Dist. Pipe , 3S
Holdin Bot. System O r
2
PUMP/ SIPHON INFORMATION Final Grade � �• '
Ma facturer Dem cover
Model N ber GPM
TDH I Lift Friction System TDH F
H ead
[ FF ; c i min Length Dia. ell
SOIL ABSORPTION SYSTEM
BED/TRENCH Wd1h I Len N Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENS �o S DIMENSI
SYSTEM TO P/ L BLDG WELL LAKE / STREAM nu adurer:
SETBACK LEACHING �� t S
INFORMATION Type O/ O I CHAMBER M e N m er:
System: Y�� OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold DistributionPipe(s) x Hole Size x Hol Spacing Vent To Airintake
Length Dia. ength Dia. pacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only _
Depth Over rw Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
it ❑
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No
COMMENTS: (Include code discrepancies, persons present, et lA syection #1. 03 /a I Inspection #2•
Location: 784 165th Ave., New Richmond, WI 54017 (SE 1/4 NE 1/4 11 T30N R19W) - 1130191006 North Bass Lake
Estates -Lot 12
l.) Alt BM Description=
2.) Bldg sewer length= . nn rr - 6%44
- amount of co c r ' • _ -r�•se t"� ��•
eye„
3 �Y S
1e�. IBS
Ss � �
4
an revision required? Yes N
eq ❑
I
Use other e for additional inform6n. ID
U side 1
J
1 'e �i0a5 _/1 R � �nspedor'sSignature Cert.NO.
SBD -6710 (8.3/97) j �/ _L.cs t(T spy
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---- .___..___. _...._.
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g� 1657 Ave
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
NVi Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce (Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number
ST G,, 3 83
I. Application Information - Please Print all Info rmation Location:
Property Owner Name Property Location
Q 4 W 1 / 1/4, S�/ T? ,N, P)7E (or&
Prope Ow ees Mailing Address Lot Number Block Number
3 `1 >Z
City, State Zip Zip Code Phone Number Subdivision Name or CSM Number
II. Type of Building: (check one) ❑ City
21' 1 or 2 Family Dwelling - No. of Bedrooms : `' ❑ Village
J
❑ Public /Commercial (describe use):_ ® Town of �
❑ State -Owned
Nearest Road
�}
Ts 1A r
ZONIN O FiGE Parcel TaxNumber(s) - :AD - C G[1
WNW
III. Type of Permit: (Check only one box on line A. Check boi* h;,tftftc�bW U 30 , 19 , 100 (o
A) 1. ZNew 2. ❑ Replacement 3. ❑ Replacement of 5. 6. ❑ Addition to
System System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
•B- Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) /C) d Elevation
/ /SO 3 2 5 3 7V , 7 i, z -- 9�, G /o Y
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS shown on ched plans.
Plumber's Name (print) Plumber's Signature (no stamps): I Mj7PR§_tW Business Phone Number
,0thf1 1s Q t i dc U Z21-171 ,� �Y• 6637
Plumber's Address (Street, City, State, Zip Code)
ev
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
�J Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination a5% fro � .-" � 1
X. Conditions of Approval /Reasons for Disapprova :
���vC.sw -t-� vvUL�+�iM. �•p�� {- e..� -YF- sL�rQA,.atil� � ��✓ � �-.. �►�,•.,.u�o�•S 1
SBD -6398 (R. 07/00) 1, arSZ l Swr,L 0.S CLk" Lji; &, V "L 6 -%SLu -R jN. rtvin — (fie — C&4.41 f t4,+
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40 7 -
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S CROi t
-�-
ZONING OFFICE
Wisconsin Department of Commerce SOIL EVA UATION RE OR (b ge of
Division of Safety and Buildings D
in accordance with Comm 85, Wis. 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. I.D. Z — O qv - 70
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
PrI rty Owner Property Location
Govt. Lot ,5j 114 ,u�114 S // T �Q N R j 9 E (or)
r ia Owner's Mailing Address Lot # Block # Subd. Name or CSM#
/ z '
City State Zip Code Phone Number ❑ City ❑ Villagq ® Town Nearest Road
Er New Construction Use: ❑ Residential / Number of bedrooms _ Code derived design flow rate SSC? _ GPD
❑Replacement []commercial - Describe:
Parent material — Flood Plain elevation if applicable ft.
General comments
and recommendations:
Boring # ❑ Boring
Lok Pit Ground surface elev. —ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. I Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2
/Q /oy ea z_ I— -2m� /h F� CS -:2f= 5
Q-av /0 Y9 v �Q w
z - mvF� lir
C 05
C .
S
❑ Boring # ❑ Boring
❑ 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. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
i 1 `�
C + i C CEO °
N GOc 1 "
' Effluent #1 = BOD > 30 220 mglL and TSS >30 < 150 mg/L ` Effluent #2 = BOD `� mgALand " ?SS < 30 mglL
CST Name (Please Print) ignature CST Number
— 9P) 17;,S 2 2_/ V '7
Address n Date Evaluation Conducted Telephone Number
/2
Property Owner Parcel ID # _ Page of
Boring # ❑ Boring
❑ Pit Ground surface elev. 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
Boring # ❑ Boring
❑ Pit Ground surface elev. 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
F 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.
SBD.8330 (R.6/00) -
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All�)9 Gt/ 5 Tires Z Y 7 /
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of i
Labor and Human Relations
Division of safety & Buildings in accord with ILHR 83.05, 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 St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 0 3 Z A -2 } � ?p
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R VIEWEDBY ATE
9 1
PROPERTY OWNER: PROPERTY LOCATION
Ge rald GOVT. LOT SE 1/4 NE 1/4,S 11 T 30 N,R 19 ) ,E (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
11160 190th. Ave, na N. Bass Lake Estates
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®TOWN NEAREST ROAD
Elk River MN. 55330 (612 441 -8888
14 New Construction Use [x] Residential / Number of bedrooms 3 [ 1 Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gp d Recommended design loading rate • 7 bed, gpd /ft trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft .8 trench, gpd /ft
Recommended infiltration surface elevation(s) 101.0 & 97.60' ft (as referred to site plan benchmark)
Additional design / site considerations Alt site system el = q7_10 F. q9_
Parent material Flood plain elevation, if applicable ft na
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑LI CRS ❑U [aS ❑U El ]U
SOIL DESCRIPTION REPORT
Boring # Horizon
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD T/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed - none sl 2m r mvfr cs 2f .5 2 .5 r4 4 none is os mvfr If .7
Ground 3 20 -84 7.5 r4 6 none cos osq ml na na .7 .8 }
elev.
104 ft.
Depth to
limiting ,
fact A f, o
ABA
Remarks:
Boring #
I 0-8 10yr3/3 none si 2m r mvfr cs 2f .5 .6
>' 2 2 8 - 20 7.5 r4/4 none is osg mvfr gw if .7 .8
- 7. r4 6 none cos os ml na .7 .8
Ground ,
elev.
WA V t.
Depth to
f� .i
l imi t in g �3.2
fact +841, CR
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. New Ri hmo d WI 54017
Signature: y Date: 4 - - CST Number: m02298
PROPERTY OWNER Gerald J. Smit -h SOIL DESCRIPTION REPORT Page 2 of _I
PARCEL I.D. # O Z " 2 01'T �O
Depth Dominant Color Mottles Texture Structure Consistence Y Roots VrD /ft2
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3
1 0 -10 10 r
2 10 -21 7.5 r4/4 none is 0SCI mvfr crw if .7 8 }
Ground .7 .8
elev.
10 ft.
Depth to
limiting
fact _
2
36 6
Remarks:
Boring # _
1 -5 10 r3 3 none S1 2ms S
.;1.,...4..'..., 2 -9 5 r4 4 none q I I rqhk mrf r 9 w 1
3 -82 7.5 r4/4 none Cos 0s ml na na .7 .8
Ground
elev.
1
Depth to
limiting uk /p /,D' a " sYsf
factor
+82
Remarks:
Boring #
5 1
Ground 3 -80 7.5 r4/6 none Cos 0SQ ml na na .7 � .8 ,
elev.
9 9.0 ft.
Depth to
limiting
factor
+80
Remarks:
Boring #
1 0 -9 10 5^
6 2 9 -20 10 r4 4 none sil 2msbk mfr Crw if .5 .6
................
.......... .
Ground
3 20 -30 7.5 r4 4 n
4 30 -84 7.5 r4 6 none Cos 0s ml na na .7 .8
9 1 ft. �.
Depth to
limiting
factor
µ
Remarks:
SBD- 8330(8.05/92)
' STEEL'S SOIL SERVICE
Gary L. Steel Gerald Smith - 1554 200th Ave.
CSTM2298 SE 4NE a S11= T30N -R19W New Richmond, WI 54017
MPRSW 3254 town of Somerset (715) 246 -6200
lot #12 -N. Bass Lake Estates
1 +40
-t M.= top of steel post C el. 100'
-4�1.t BM.= top of 2 pvc pipe C el. 103.80'
. 2 1 7
[
G ry L. Steel
4 -16 -97
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
Y ( ) P
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 the 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 S3
Number of Bedrooms
Design Flow - Peak (gpd) Lf 5`0
Estimated Flow - Average (gpd) 3
Septic Tank Capacity (gal) Drop _ 4
Soil Absorption Component Size (ft
Type of Wastewater Domestic
I
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) « - as i As
Maximum Influent Particle Size (in) U 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 se tic tank and outlet filter shall be assessed at least
once every 3 years by inspection. Th outlet filte shall be cleaned as necessary to ensur
per operat
pro ion. The filter cartridge shou no be removed unless provisions a made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic 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 may contain lethal gases, and rescue of a
Y
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
r
' 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.
3
N
ST CROIx COUNTY
SEPTIC ':'ANK MAINTENANCE AGREEMENT
AND
OWt CERTIFICATI FORM
Owtior /Buyer LO.UU 4
Mailing Address _ — .S, 0
Property Address _ r7 j_�_ /6 s ZA
(Verifioatton required fro» i Planning Department for new construction) ��-_
City/State Parcel Identification Number Z - ya - -
L EGAL DESCRIPTIO
I'ropet I,ocatitam 5' ' /�, ' /,, Si C. // . T 3a�t- �. Town of Slt?^
Subdivision Lot # /z-
Certified Survey Map # Volume Page # _
Warranty Deed # _ M 7 9 . Volume Page #
Spec house 0 yes 0 no Lot lines identifiable C7 yes ❑ no
i
SYSTEM hjA2 ENANCE
Improper use and maintenauceof your sel pc aystatn could result in its premature failure to handle wastes. Pro permaiutenance
consists of pumping out the septic tank every thrt a years or sooner, if tteadod by a licensed pumper. What you put into the gstem
can affect the function of the septic tank. as a tmi pment stage in the waste disposal system.
The property owau agrees to submit to 5t. Croix Zoning Department a certit?oation form, signed by the comer and by a
awterplumber, joumeymanpimber, reslrietedpls lrnber or a liceimtApumper verifying that (1) the oti -site wastewater disposal system
I s in proper operadug condition and/or (2) after in:' ection and pumping (if necessary) the septic tank is less than 1/3 full of s ludge.
Uwe, the undersigned have read the above requirti tttnts and ag oo to maintain, the private sewage disposal system with tht standards
set forth. herein, as set by the Departtneat of Cam umce and the Department 4f Niiural Resouraea, Stato of Wisoo xsla. Cfxtifieation
stating that your septic system has been maintainer l viust be completed rite- ttctwrned to the St. Crai*k County Zoning Office within 20
days of the three year expiration date. -
Nr'�r
P IG — NAIIM 74 UD OF APPLICANT r �,
OW CEI DEI Tel, 1.OlV
I (aye) c ertify that all statements on this : Irma are true to the b' 6,oT•tny 66T owled"' 1 (we) am (are) the owners) of
the property described above by virtue of a weirs zty °deed recorde:i is Rrtcr of Deeds Qt'fice'
Sf NATURE OF APPLICANT ATF
Any information that is mis- represented rr ay result in the sanitary permit being revoked by the Zoning Department.' +"
"* Include with this appReation- a stamped warranty deed from tho Register of Deeds office
a copy of the a rtified survey intp if reference is ittade in the warranty deed
11/30/00 12:52 FAX 17152467227 HALLE BUILDERS -.- GILLS 06
RIVER VRL.LEY RBSTRRCT F -386 -7664 Nov 8 '00 12:34 P.01
IMI. PAC[ fib?
WARHANTV DEED
REGiS`7'�'VorFICE i
ST. CROIX CO., WI {
r ew to aNOs
1t.v„n nduress � r `
.1.54t.raat &'fiLit, line. SEP $ &'•1998
"ox 149.206 2nd8f. 1 AID
, n.i.; IS•f1t7R "2✓a't1d....�i{ l.�.s�. 1
�. d aMhN �•i
I:,rcel LI >..Numtur.
conveys and warrants to CAa�fs A. Prlssct and
,Zhme F. __.rcnoifiK_l ea joint tenants the following described teal estate
In St. Croix oun y, State of Wisconsin:
T SFER�:�.
Lot 12, North Bass Lake Estates.
This is not homcstrad propetty, r l
5
Excertiun to warranties: Easements, restrictions M11 rights -of -way of record, if any. 'SR
ll;ncd this 1 4r .day of September, 1998
Forest Oaks Cantles, Inc, i .
G.' alti .l ' I nsidant
}.
"
AUTHENTICATION 1 �
Signtnure(v) Forest Oaks Condos, Inc., by Gcm1d J. p
8mith, Petsident, nuthenticated this day of
picnhbum 1998. "
I�riaina !)Oluml ,.'f.
1T1'I I:: MEMISER 1IWI'F BAR OF WISCONSIN
1'1115 INN' I'RUMENP WAS t)RAF 11Y:
\11orncp Krhmina Ouland
Iludson- \\'1 5 4016
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