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HomeMy WebLinkAbout032-2148-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division I INSPECTION REPORT Sanitary Permit N o: (ATTACH TO PERMIT) 420511 0 GENERAL INFORMATION State Plan ID Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. N Permit Holder's Name: City Village X Township Parcel Tax NV Smith, gerald I Somerset Township 032 - 2148 -40 -000 CST BM Elev: Insp. BM Elev: BM De scrip ion: / /L, TANK INFORMATION ELEVATION DATA (,(, IaL(� --�o TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 1 Septic Benchmark Dosin g — 66 Alt. - IVy I441A ( 2• / D. / Aeration Bldg. Sewer /ble. IF Ir Holding St/Ht Inlet / e U/ 0 /D&- 39 TANK SETBACK INFORMATION St/Ht Outlet (0. /0 6 Z3 TANK TO P/L WELL, BLDG. Vent Air Intak ROAD Dt Inlet Septic yJ� 12 �a -[ ' Dt Bottom ' Dosing He er /Man. �'� D �• Y6 Aeration Dist. Pipe Holding Bot. System L PUMP /SIPHON INFORMATION Final Grade�,d /es lo•S�' 09 Manufacturer Demand Stover PM � C� dh - ?i �• Model N ber TDH Lift ion Loss System Head TDH t For - main Length Dia. ist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width + Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS R �-- SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM E HAMBER CHING Ma ufacture� INFORMATION Type f System: OR }� NIT Model Number: DISTRIBUTION SYSTEM � ✓ Header /Manifold Distribution I x Hole Size I x Hole Spacing V t to Air IIntta�e 1 4 Pipe(s) 1 6/ QL Length Dia 111 Length -+ Dia Spacin SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over (yam Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center %I Bed/Trench Ed es To soil V g p U Yes No ? Yes] No COMMENTS: (Include code discrepencies persons present, etc.) Inspection # / // Inspection #2: Location: 2112 54th Street Somerset, WI 54025 (SF 1/4 SW 1/4 15 T31 R1 9W) Oak Haven Lot 24 Parcel No: 15.31.19.1295 1.) Alt BM Description = s� �6 �6 0 -26 2.) Bldg sewer length = 4 j - amount of cover = / J-ZL� a VeA Required? r Yes o = Insepctor�rs Plan revision Re q ,., _._ J�1 � Use other side for additional information. 4� � V ! Date Sign ure Cert. No. SBD -6710 (R.3/97) 1 4 C&tAu-,� 1 -& - 1k Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 , N *&c6nsin Madison, WI 53707 - 7162 Sit Address De arttment of Commerce Sanitary Permit Application Sanitary Permit Number / In accord with Comm 83.21, Wis. Adm. Code, personal inf ❑ Check if Revision �� D 5-1 may be used for secondary ses Privacy Law, 15. I. Application Information - Please Print All Information State Plan I.D. Number rty Owner's Name `d ZGO2 Parcel Number d 's Property Location ` Property Owner's A s � ,� �, iC,E � �� �•S 34 $ i4; S l3 N. R City, State Zip Code Phone Number Lot Numbpr B1ock.Number Subdivision Name tIIflber s . s ` G II. Type of Building (check all that apply) Ar's ❑City 0 1 or 2 Family Dwelling - Number of Bedrooms 3 ❑village ❑ Public/Commercial - Describe Use Qf9'ownship ❑ State Owned it/ �� Nearest Road 3'X ' III. Type of Permit: (Check only one box on ' e A (numbering scheme for internal use). Complete line B if applicable) A For County use 1.9 New 2 ❑ Replacement Systm 3 C1 Replacement of 6 11 w Addition System Tank Onl Exist= stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) n�j Y U • LC QG� 44,9 Non - Pressurized In -Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized in -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 3 1.1 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other J V. D' eatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rat Systlevatio Final Grade Required Proposed Rate(Gals./Days /Sq.Ft) (Min.Anch) * Elevation )e VVI Info Capacity in Total Number Manufacturer Prefab Site J Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks / Septic or Holding Tank Dosing Chamber VII. R tree risibility Statement - 1i, the undersigned, responsiibility for installation of the POWTS shown on the attached plans. P! r' ame (Print) _ Plum 's Si M ft"RS Number Business Phone Number Plumber's Address (St, City, tat, Zip Code VIII ount /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Is Age Signature o Stamps) Approved ❑ Disapproved Surcharge Fee) (b ❑Owner Given Initial Adverse S D lif�vy. Determination IX. Conditions of Approval/Reasons G -3 , S l/H• -r-e- � � wza 11 � �,�„ �� -_-�- � .tam Ae- e tom (to the y) for the em paper less than p x 1 es m size la � d - S D-6398 (R. 0 t1cio wit on P /6���„ Yn¢e.�/l� �h C 3•` -( Safety and Buildings Division County 201 W. Washington Ave.. P.O. Box 7162 V VI cousin M WI 53707 - 7162 Site Address / Department of Commerce Sanitary pest Number ✓ Sanitary Permit Application `/.� o Sl 1 In accord with Comm 83.21, Wis. Adm. Code. personal inf ❑Check if Revision be used for secondary purposes Privacy Law, 115. I. Application Information - Please Print All Information State Plan I.D. Number /A Owoer'a Name .j Parcel Number 1 2002 o32- 104/3- Va so - ?30 - % r o -� s Y Property Location Property Owner's Li.'w;:.0 FFICE :5W 54,$ ',E S N. R City Stan Zip Code Phone Number Lot N r Block-Number Subdivision Name IGSM- Nuraber S II. Type of Building (check all that apply) arm f ❑City 01 or 2 Family Dwelling - Number of Bedrooms 3 ❑Village ❑ Public/Commercial - Describe Use VTownsbip ❑ State Owned /� .e a Gt— Nearest Road 3' X rte" III. Type of Permit: (Check only one box on ' e A (numbering scheme for internal use). Complete line B if applicable) A For County use 1 Z New 2 ❑ Replacement System 1 30Replacementof 6 ❑ Addition to stem Tank Only stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Ch all that apply)(m mbering scheme is for internal use) # / R� Y �Tr�• QGt%t.�r 44J9 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Conmvcted Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 0 M Line 3 I-- /�JYrc.� -� 45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. ' tment Area Information: Desist Flow (gpd) Dispersal Area Dispersal Area / Soil Application Percolation Rate Syste= levaao Final Grade Required Proposed Rate(Gals./Days/S9.Ft.) (Min-finch) * Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New FatistinY Tanta Tanks / Septic or Holding Tank _ - 0 Dosing l7uamba :J I I VII. R bility Statement - L the undersigned, respoadbility for installation of the POWTS shown on the attached plans. Z pire�: �fflrinf?,_ PI 's S' MP1wRS Number Business Phone Number Plumber's Address (Street. City . Late, Zip Code L/ p l' VIII t /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Is Age Signature o Stamps) Approved ❑ Disapproved Surcharge Fee) 10 z ❑ Owner Given Initial Adverse �• � � � � r7 � �'�J'Yh Determination / -- IX. Conditions of Appro� eason � S/ (ti+tlryt�d k 4v L$'Ltl-741 �` © $:"dkA- -/ d to the papa less than z 1 m size compAcetepiam (to the cowAX l St-6398 Ol� (R. 0 S�ba 4o .ahrz! A r-" �16��irr I'� ^/1>? �v� Lam• 8 3. `� 4 Nil p '1 n (( � 9a� R� R y L� I t � o t„ w T � � G h, y v Th tl l.c Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 — of 3 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 x include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.O 3 - 10 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. endi Please print all information. view by / Date a Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location C�L-ral-d J- Smith Govt. Lot SE 1/4 SW 1/4 S 15 T 31 N R 19 )�)or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 11160 190th Ave. 24 na Oak Haven City State Zip Code Phone Number ❑ City ❑ village W Town Nearest Road Elk River, MN 55330 ( 612 441 -8888 Oak Haven 210th. Ave. New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate GPD c� ❑ Replacement ❑ Public or commercial - Describe: ' Parent material outwash // - 1 Flood Plain elevation if applicabl ' �� _ ft. General comments �� � ` C.� T°_ C -� @ el. 103 00 , s and recommendations: J ! . �, ��'�, �,, It o trenches �� 500' be o grade pa ced to code � Ej Boring Z // X. a FK] Boring # 107.00 ft. De g � Pit Ground surface elev. Depth to limiting factor - +90 Sol h (cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 none sl 2csbk mvfr qw 2f .5 .9 _ Osg mvfr gw if .7 1.2 no ne ms — 0sg ml na I na 1 .7 1.2 A-- 6 -5-_ T--I a Boring # F] Boring [I Pit Ground surface elev. 107. 00 ft. Depth to limiting factor +90 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 9 -8 10yr3/ none sl 2csbk mvfr gw 2f .5 .9 3 14 9 7.5y r4 6 none ms osa ml na na .7 1.2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L ' E5pe9t #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Gary L. Steel 98 Address ate Evaluation Condu8ter Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -3 -2001 715 - 246 -6200 i Property Owner Gerald J. Sm ith Parcel lD# p endin g P 2 of 3 Boring # ❑ Boring 3 a pit Ground surface elev. 105.30 k. Depth to limiting factor +90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure kConsistenc Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 2- 2 8 -14 7.5 r4/4 none is osg gw if 7 1.2 none ms osg ml na na .7 1.2 A- NeA/Y F -1 Boring # 11 E] ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A plication 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. SBD -8330 (R.6 /00) STEELS SOIL SERVICE Gary L. Steel Gerald J. Smith 1554 200th Ave. CSTM2298 SE'' S SW'' S15- T31N -R19W New Richmond, WI 54017 MPRSW -3254 town of Somerset (715) 246 -6200 lot #24 -Oak Haven This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1" =40' BM.= top of NW survey stake @ el. 100.00' Alt. BM.-- top of 1" pvc pipe.@ el. 104.70' � t 011 3 �o g , � I � L .2 Gary L. Steel 6 -3 -2001 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Nugo1.-ur 52 FILE INFO MATT N SYSTEM SPECIFICATION Owner Septic Tank Capacity al o NA Permit # Sept c Tank Manufacturer = o NA Effluent Filter Manufacturer 2 o NA DESIGN PARAMETERS Effluent Filter Model o NA Number of bedrooms __Iy o NA Pump Tank Capacity al ONA Number of Commercial Unit d NA Pump Tank Manufacturer )&NA Estimated flow (avera al /da Pump Manufacturer �tTNA Design flow (peak), Estimated x 1.5 5— gal/day Pump Model &NA Soil Ap plication Rate ll /day /ft' Pretreated Unit Inlluenl /ta'1'luent Quality Murrthly Averabc* cj Sand /Gravel filter t:r Peat filter Fats, Oils & Grease (I OG) 53U ntg /L ri Mechanical Aeration o Wetland Biochemical Oxygen Demand (BODs) 5220 mg/L o Disinfection O Other: Total Suspended Solids (TSS) <150 m L urer Monthly Average" Dispersal Cell(s) Pretreated Effluent Quality A n- ground (gravit o In- ground (pressurized) Biochemical Oxygen Demand (BODs) <30 mg /L p - O Mound Total Suspended Solids (TSS) <a04mg /L o Drip-line o Other: Fecal Coliform (geometric mean <10 cfu /100mL Maximum Effluent Particle Size '/e inch diameter + Values typical for domestic (non - commercial) wastewater and septic tank effluent. ** Values typical for procreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequenc Inspect condition of tanks At least once ev ery o months cars um 3 rs Pump out contents of tanks When combined sludge and scum equals one third ' k volu Inspect dispersal cells At least once every o months e s Maximum 3 rs Clean effluent filter S At least once every o months earls Inspect ntm , p ullip controls & ul:um At least once every o months o uu r(s ) ONA Flush laterals and pressure test At least once every o months o year(s) NA Other: At least once every o months o year(s) NA Other: At least once every o months o ears A 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 Se tae Servicing O M p M p g 8 erator. P 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 (' /s) or more of the tank volume, the entirt- contents of the tank shall be removed by a Seputge Servicing Operator and disposed of in accordance with ch. NR 113. Wisconsin Administrutive Code, The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s) removed by a septage servicing operator prior to use. Owner: System start up shall not occur when soil conditions are frozen at the infiltrative surfaco; During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater will be discharged to the dispersal 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 soft absorption are. 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; treat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONEMENT 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 ch. 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: 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. o 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. o 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. to 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 the time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC PUMP OR OTHER TREATME NT 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 INSTALL POWTS MAINTAINER Name Name Phone S Phone SEPTAGE SERVICING OPERATOR PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone From PHONE No. : 441 8727 Oct.01 2002 10:07AM P01 ION M't.k,1i),'sl�i6?rj.Y' d. %as�v .t.T.rrlti•st �! O1' • ,n , p . �. mi w � I ry f• ; _r,,:�yC:,;:'v *r'Q', ta., ?s+':,.t.K ;1 :4 F', `:, d.vi.S:;ai' , f`�gsk'a "a«.:e1R.Y;:. L'. i2 U✓ ti .., ' %4' a Why �'S '�1 < �tJt �..I,� :.,/'r.;.•`lx�+d,�,} 1:'- .f•, 'L:• „'i •t.dt; °est,:�;':,.� <rl+,h Pe ke�'Tf'i ? {:.� ,,, ,, ,. , Y ;''., ,!'Y�' �,.:,,.. �:;1C.T� ” +,�� I�t. � I� . � . 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S' .t. e�.1C;e� d; da rkb'ti , +4' 9 S�r.Si' RK ai Mi, °':td lu S:(i:.v1'.d YS'a' KF ?$: Ar :.�. rt r s;��S 01 ",;'. f ly, 15 ,V 4; ., MV"wn �.Y»'''y� Ski' tk t.$':<. f9YsT:' FDC, t '! 1 7I!`. Sar :7E�,t',^tl.!s't+d't, " »5;,4d.lfl �l�:: 6. iXe46S. YX�7N! 75>. S' �I:' f: 4: t'> 3?. IP4! Artik: �rl1 A':" 7�Ea, fa�Ya�PIS '.�•r•4'�f::?l1SiY+C+1T. ���1'ss *, ' � s'+>LYV ,�. idl` (.+A":ilif�e,w( l,7:M'Its:.V xutl,tr it�'re��ia:,ncr is rr:a'tis.; fa~, r.,.� vs'ar3R'AY.scM .dra•wrT a • Vol. 1128PAGE584 STATE BAR OF WISCONSIN FORM 2 -1999 1& 4x75 WARRANTY DEED KATHLEEN H. WALSH Document Number REGISTER OF DEEDS S'f. CROIX co., WI This Deed, made between Leslie A. Coo - RECEIVED FOR RECORD 10 -01 -2001 9:45 AM — - . - ---- - WARRANTY DEED Grantor, and F orest Oaks Condos, I nc. , a Minnesota Corporation, EXEMPT D 17 - - CERT COPY FEE: COPY FEE: TRANSFER FEE: _ RECORDING FEE: 11.00 Grantee. - - PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lots 7, 8, 9, 10, 12, 22, 23 24 nd 25, Oak Haven, St. Croix County, Name_ and Return Addrew I Wisconsin. kA ctN �i &J 10 0 ) FAA Zuo %4 V`10 $OK 149 This deed is given in partial fulfillment of that certain Land Contract Act,—, 1 sof 017 between the parties hereto dated September 22, 2000, recorded September 032.1043 -40- 000;032- 1043 -50 -000; 032 - 1043 -80 -000 27, 2000, in Vol. 1545, page 571, as Doc. No. 530634. and 032 - 1043 -90 -000 Parcel Identification Number (PIN) This is not homestead property. OE) (is not) Exceptions ,,t //olIwarranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of _ _A ugust 2001 • Leslie A. Cook AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WiSCONSIN } ) ss. St. Croix County ) authenticated this day of —___- _ _ Personally came before me j8ilr,.PL iv I day of August 2Qbt2 : $ he abonamed p named - - - - - - - -- - -- -- - -- - - - - -- _ 3 Leslie A. Cook - - c TITLE: MEMBER STATE BAR OF WISCONSIN (If no(, to me known to be the perso ed,the for going - inst u t nd ackno ed authorized by § 706.06, Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina O land _ H WI 54016 Notary Public, State of Wisconsin -. My Commission / If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) _ ,� � y lC� C! I - -- .) * Names of persons signing in any capacity must be typed or printed below their signature. 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