HomeMy WebLinkAbout036-1032-60-000 `Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count
INSPECTION REPORTt. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitag No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑ Village ❑ own of: State Plan ID No.:
Hammes, Leo Stanton Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
1 ��� 036 - 1032 -60 -000
too . TANK INFORMATION ELEVATION DATA N, 3/ /7,
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic c- Benchmark • 10 I al. to pip -0 / nvoq
Dosing Alt. BM 1. /� oS -9S r
Aeration Bldg. Sewer 2-
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 3. 0 3• b5
TANK TO P/ L WELL #BL to
i ntak e ROAD Dt Inlet I Septic — NA Dt Bottom
/
Dosing NA Header/ Man.
Aeration NA Dist. Pipe f 3 :�►
Holding
oldin Bot. System 13•S0 If 3. (00
I`F• 8'� 92.z
PUMP/ SIPHON INFORMATION Final Grade s'� $ •'f c� it r
3t %_1VvU1
Ma facturer %an /S to , c�
Model ber
TD Lift Friction System TDH F
H ead
Forcemain Length
SOIL ABSORPTION SYSTEM
BfB kTRENC Width Length r N Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME e I � DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING
l ��te9
INFORMATION Type O r CHAMBER o el Number:
System: c I00
TV
� f0O OR UNIT
DISTRIBUTION SYSTEM
Header nn ,_f, � Distribution Pipes) ole Size x Hole Spacing Vent To Air Intake
Length Dia. -` Le Dia. Spacing TZ
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
C n
ud ude c endci e r� , r nc s rs t ns o /(DI m6p linlIff-L;
Location: ZI3� Countylzoad�widlQ�ior��,1� c (l�TW 1/4 SE 1/4 14 T3 1N R17W) - 143117210
1.) Alt BM Description = -::�r "o.. te-
2.) Bldg sewer length = 2,o D
- amount of cover = $ "S cojc./ .
Plan revision required? 0 Yes 5ff No
Use other side for additional information. 01- 1b 0 1 S
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
Washington Ave. Wa
In accord with Comm 83.21, Wis. Adm. Code 201 W. PO Box 7302
lv See reverse side for instructions for completing this application
r - -
Personal information you provide,tle;used•,tor�,econdary purposes Madison, WI 53707 -7302
Department of Commerce ' . , ti (Submit completed form to county if not
[Privacy S. T5' 04(lW)y state owned.)
Attach complete plans (to the county cop )forth s on paper. riot less than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Num r ,., ❑ Chec i p um/go previous`application State Plan I. D. Number
I. Application Information - Please Print all Information Location:
Property Owner Name i* r n Property Location
L 0 07,0 -e t A►'Y 1 1 /4& 1 /4,S /Y Tjj ,N,$! E(or)
Property Owner's Mailing Address 1 Lot Number Block Number
I e
City, State Zip Code -Phone Number Subdivision Name or CSM Number
II. Type of Building: (check one) ❑ City
❑ 1 or 2 Family Dwelling - No. of Bedrooms: 3 `� ❑ Village
❑ Public /Commercial (describe use):_ M Town of
❑ State -Owned S a 11 -'7 To h
Nearest Road T .
C e /
Parcel Tax Nu be
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 1 :
A) 1. 11 New 2. Replacement 3. ❑ Replacement of 4. 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)
XNon- 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: 2 ,' �� S
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Sdil Application 5. Percolation ate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. k Elevation
ft.) (Min. /inch) -�-�' r
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
❑ ❑ ❑ ❑
e e ) 1
ZIA
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the POWTS shown on hed plans.
Plumber's Name (print) bees bees Signature (no stamps): MP PRS No! Business Phone Number
Plumber's Address (Street City, State, Ziil Code)
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
(� Approved ❑ Owner Given Initial Adverse Surcharge Fee) 6 ,
Determination Z Z SC �/ Z Zop ( -
X. C of Approval /Reasons for Disapproval: ��uod p�a:� i �� r C a(`
CjC�S�rr9 � �c CCh�if4pl� S A parCe Curreyt71 �{a5 "s �cs�
pq�i < io� �� bsvrh� Grd� h GLt� �� Mee./
SBD -6398 (R. 07/00)
03/30/2001 15:26 7152686637 GILLE TRUCKING PAGE 05
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County 6 � 1- C 1'O � , F•
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. 77
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. v t 3 b • I o&?— — 6
Please print all Information. Re • wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 3h-?- Q
Property Owner Property Location
L C o + M ar + 4, Govt. Lot N Lt31 S r; 1/4 S) / T31 N R 17 E (o W
Property Owner's Mailing Address Lot # Block # P"Aarre or CSM#
f;,jty ` r State Zip Code Phone Number El city E] Village R) Town Nearest Road
11'7 - r s y�� (_9 -37'fo 5+ �• Ca,
❑ New Construction Use: 0 Residential / Numberot`bedreoixis -3 Code derived design flow rate $ � GPD
[ Replacement ❑ Public or comh'►ercial Describe:
Parent material i a. p �-'� y,� Flood Plain elevation if applica tale _. _._.__ .� ft•
General comments �� �S f 'r(Z �h.[ {n $ : / •1� 5 <<GOr►1M�ncG
and recommendations: M n
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Boring CE
n9
a pit Ground s
Boring # f 0
t�fact3 ble . _ ft ` ` Depth to limiting factor °� in. Soil Application Rate
Horizon Depth Dominant Color Redau.,de cr)ppoh xture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. 60 E3olor Gr. Sz. Sh. `Eff#1 'Eff#2
5 L ?F6 k 1.. L w S
3 2.38 7l , 5'18 Vi L c � 1 or . - 7
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Boring
F:� Boring # l
Pit Ground surface elev. _ 7' L7 ft. Depth to limiting factor in. Soil A
pplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rants GPD/ff° T ?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Ef `#2 Q L
L aF(o F 5 r h
q- 3s - 7. sy / 5 L_
y s -15 . 7ti y1 -1 SL_ aF'SbW IAJ
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Effluent #1 = BOD > 30 <_ 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD __i30 mg/L and TSS < 30 mg/L `
CST Name (Please Signature CST Number
P 'nt
+ a i
Address 61 Date Evaluation Conducted Telephone Number
�sYam,
a ,
Property Owner IV VVN fw S Parcel ID # 03� - I p ;L - -60 Page � _ of
F-31 Boring # ❑ Boring
[�j Q Pit Ground surface eiev. (og y ft. Depth to limiting factor J D o in.
Soil nGPD/ff on Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Ef'Eff#2
L ;2F5 u. t w t F as '
S
4-9 - 10 7.5'199 y ! .
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F1 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
E Boring # Ground surface elev. _ ft. Depth to limiting factor in.
E] pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I '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.
SBD4330 (8.6100)
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3/1312001 14:10 7152483588 SUPERIOR AUTOMOTIVE PAGE 01
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* G 6A. ' SOIL EVALUATION REPORT Pops -,Lot
e wM rAW 85, Wls. Adm. Code cQI _
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Proloft OMRtera Mm WV Addrdba Lot M Block M 51100. Marna or CSW
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p z5yco7 �� aLld -37yo �� vv. G.> , Pep
❑ Now conovudlon Use: ® ResiderM Number of esdtootrta 3 _ Code dsri -ed desist foul rate SIN GPD
U O Plftic or co mmmial - Desoto: - - - - - -
Pore" rt WAM* — 1 a oi-J D v t L. I cA -ice Fbod Plain elevation if OPPllcaete _.., n
: Iv�..y t SASS S + .7 - S �f `S ' - raEn,tr, a s
and T, 1
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PII Ground suAactl YIYV 102 R. bapin eo wnitinp fact" � � h. Sol Rate
Horizon Depth DoWnwm Color RoJux Description Texture Structure ConaWtonom Boundary Roots
in. MuneeN Gu. Si. Cam, COW Gr. St. Sh. — •E01 `E
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Horizon Depth Dominant Color RtiJux 1511 ption Texture Structure Consistence Boundary Roots GPON
In. Murtsell Ou St. Corn, Color Gr. Sz. Sh. I 'EW1 `EQfr2
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AA�ees t 0 Evelustim Coridutied Tolachone
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H/13/ 2001 14:10 7152483588 SUPERIOR AUTOMOTIVE PAGE 02
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.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer - 0 — !rr in -e S'
Mailing Address / / c/ �!� 14
Property Address .2 Fs
(Verification required dom Planning Department for new construction)
City/State G Parcel Identification Number O 3 <o 16 3 2 - (o a 60 0
LEGAL DESCRIPTION
Property Location NW '/4; '/4, Sec. 3 / N -RAW, Town of S 7E ,'70 1- 7
Subdivision . Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # ,2e10 '5 , Volume — ' e ll-S — , Page #
Spec house ❑ yes4o no Lot lines identifiable iKr yes ❑ 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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
3 //6 /a!
Sl&NAMR9 Olz APPLICANT DATE
OWNER CERTIFICATION
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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
* * * * ** 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
03x!30/2001 15:26 7152686637 GILLE TRUCKING PAGE 02
-- _�. � .• ,, , y4 ava y 000 ' bl QU co ZONING
!� lih 001
Private 01 rslte Wastewater Treatment System Management Plan
Septic Ta i k And Gravity in- Ground Soil Absorption Component
Pursuant 1 a 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 o; Gomm 133 and 84, and the conditions of approval by the department, agent,
or governmental 1 snit The approved plans and permits for system are on file at the county
zoning or health c epartment.
This marts Cement plan complies with Comm 83.54, Wis. Adm. Code, and the In -Ground
Soil Absorption C )mponent Manual for Private Onske Wastewater Treatment Systems SBD-
10587 -P (RON)
Table 1: Rstern Design 3pecifieatlons
Sant airy Permit Number 3 8 9
Num tWr of Bedrooms
Dee.' rn Flow - Peak (gpd) so
Estimate I Flow - Avem e ( ) 3
Se tic TanK Capacity al /
Soil Aboaq ton Component 31ze
7y )e of Wastewater Domestic
Table ;r; Soll Abso on Component - Limits of Reliable O ermlon
Septic Tank Component Soil Abs lion Component
benign Ficit i � Peak (gpd
Maximum influe vi: Particle Size (in) 1/8
Maximum ROD (TgL 220
Maximum 7SS (m /1„ 150
Table 3: Maintenance Schedule
Settle Tank Inspect and /or service once eve 3 years
Outiei Miter Inspect once a year and clean at least once eve 3 years
Soil AbSo do i Component Impact once every 3 years
The se tank shall maintained b an individual certified to ser iI ba s eptic tanks
ep Y
under s. 281,48, Q Ztats, The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Aclr i. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, See rage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The opera fling condition of the septic tank and outlet filter shall be assessed at least
once every 3 yea! 's by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. "rho filter cartridge should not be removed unless provisions are made to
retain solids in thi ! - tank that may slough off the filter when removed from Its enclosure, If the
03/30/2001 15:26 7152686637 GILLE TRUCKING PAGE 03
- -- - �,, ,., as �RA w 4U AU 1002
Mai aiagement Plan for a Septic Tank and Soil Absorption Component
filter is equipped N 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 I inve its contents removed when the volume of scum and sludge in the tank
exceeds 113 the 1 fluid volume of the tank. If the contents of the tank are not removed at the
time of an asses rent, maintenance personnel shall advise the owner of when the next service
needs to be perk rimed to maintain Issas; than maximum scum and sludge accumulation in the
tank.
Manhole i is ers, access risers and covers should be inspected for water tightness and
soundness. Acuo as 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. ExF cased access openings greater than 8- Inches In diameter shall be secured by
an of ileave lockil 4;I devisee to prevent accidental or unauthorized entry into the tank.
No cm i should antler a septic or other trevtment or holding tank for
any re coon without basing in null compliance with OSHA silandards for
entanie lir a confined spy, The atmosphere within the septic or other
treatm ant of holding tank may contain lethal ganw, and rescue of a
person 1 ifirom the interior of the tank may be d/Ali'cuit or Impossible.
Tank abal ulonment shall be in accordance with Comm 83.33, Wig, Adm. Code when the
tank Is no longer aired as a POWTS component.
Soil Ab grotion Component
The soil a morption component serving this structure is designed to accept domestic
wastewater from s residential facility. The limits of operation of this component are shown in
Table 2,
The long,e rl br of a soil absorption component depends greatly on proper and timely
maintenance, am ' ,System use within or below the limits of reliable operation. Good water
conservation prase tires by all occupants and the Installation of water conserving plumbing
fixtures are key fc ,Oors In extending the useful life of this component.
The soil a x5orption component'as 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 p pes, and a visual inspection for any evidence of surface seepage or discharge
frorn the compon. int. On steeply sloping sites, areas of erosion should be identified and
reported to the a mer for repair. The surface discharge of dorrmtic wastewater or sewage
from the system 1 i prohibited and considered a human health hazard.
Traffic arc and or over the soil absorption component should be avoided particularly
during winter magi iths. The compaction or removal of snow cover over the component may lead
to hydraulic failur t by freezing. This type of failure is usually temporary, but is difficult or
impossible to rep sir until weather conditions improve. In general, soil compaction over this
component will re duce diffusion of oxygen Into the soil and dispersal cell, which may lead to
more intense, an I earlier, organic clogging of the soil.
2
03l .30/2001 15:26_ _7152686637 GILLE TRUCKING PAGE 04
- -• _� ,,,� ai LAd Vu 4UN1NV f� 003
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Mew ��gemant Plan for a Septic Tank and Soll Aboo ptlon Component
Plantlfos Y1 deep - rooted trees and shrubs directly over or Within ten IW of the
component shoal f be avoided since root intrusion Into the component may obstruct wastewater
flow. -r(/ /{J - 4 J 4
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DOCUMENT NO. ,VOL 4.15 PAGE268 WARRANTY REED
STATE OF WISCONSIN —FORM 1
2 81005 THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE, Made this .. .... 23rd... -__day of.._..-- . -.. -_. ..June R6+GISTE" OFFICE
_ .................. ...... ST. CROIX CO.. WI&
A. D., 19.6.5.... between.... Loren- kz -,... P �..ckar.d....and.. -.Ar � ez�e . -- ......_.....
xckaxd - - - - - -- ------- .... - -.._.. ....... Recd for Record this_ 26th
- -- ------------ ... - - --- --- - - - -- - _ - -- -- - - - - -- - - - - .. - - -- day of - -- July--- - - A.D. W5 .
1.00 M.
.. parties_ of the first part and at -_�_�: ACC ,
-- - --
Leo W Hammes d
s and Margot Hammes, husband an
wife, as point tenants, - - - - -- ...... - -.. R• s r oesd� -
part_le-s of the second part, RETURN TO
W i t n e s s e t h, That the said part- 1es. _of the first part, for and in consideration
of the suns of.. -.O.ne ...Do_ liar -.- .anti.-- o-ther_.- good_..and ..valuable.-_..
considerations ... _. _ - - -. -- . --- ._..._._.__ _...___ . __ _ ._ - - - - --
_to_ .... hem.... -...in hand paid by the said partleS - -of the second part, the receipt whereof is hereby
confessed and acknowledged, ha -ve.. given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, af presents
do.. . ._ give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said partieS..of the second part,�.._._.heirs and assigns
forever, the following described real estate situated in the County of -- St. .... Cr.QiX ------------ and State of Wisconsin, to -wit:
The North Half of the Southeast quarter (N2SE4) and the
Southeast quarter of the Northeast quarter (SE's E4) of
Section number Fourteen (14), Township Number Thirty -one
(31) North of Range Number Seventeen (17) West;
- - - -- ---------------
w
1O
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate
right, title, interest, claim or demand whatsoever, of the said parAceB_of the first part, either in law or equity, either in possession or expectancy
of, in and to the above bargained premises, and their hereditaments and appurtenances.
To Have and To Hold the said premises as above described with the hereditaments and appurtenances, unto the said partieSof the
second part, and to their heirs and assigns FOREVER.
And the said Loren R. Pickard and P.i.ckar.d, parties of the first .. _...
past, _ _. -- - -. ..... .... -...
for their _ _- heirs, executors and administrators, do- ...._- --- - ---- covenant, grant, bargain, and agree to and
with the said part- 1 -e_s >f the second part, their ----- -- heirs and assigns, that at the time of the ensealing and delivery of these presents
they are. -_ _ well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance
in the law, in fee simple, and that the same are free and clear from all encumbrances whatever ---------- - ------- _. ....... ___._....------- ----- ---
.__-_..._--.-
- - - - -- --- -- - --- -._ thei r . ........I....
...
Mid that the above bargained premises in the quiet and peaceable possession of the said part leSof the second part,./.-. ...heirs and assigns,
against all and every person or persons lawfully claiming the whole or any part,thereof ---- thP—y_.will forever WARRANT AND DEFEND.
In Witness Whereof, the said part..le.Sof the first part ha. Ve..-hereunto set .the.1r.hand. r` ...- ...and seals -. -.__ .this- .2.3rd....
da.- of .June. ...... ._, A.. D., 196 5. ,
R EI) AND SEALED N P SENCE OF /YI (J /� (SEAL)
Loren R. Pickard
(SEAL)
James .... A. Drill ----------------------- - - - -- - - - - -- --- -- - - - -- ------•------------
// (SEAL)
- ..........................
H•- D, ---- - - - - -- _ (SEAL)
--- •-- - - - - -- ................................ ..............
STATE OF WISCONSIN, 1
} SS.
- - -- -- St_.-- .- CI�1X -..... - - ..-..-- County.JJJ
Personally came before me, this -- --- --- -- 23r .d ......... day of ...... . .. ......T<7.2'. 1. C'- ...........__............. ...... ............ ., A. D., 19.65....
the above named -. -I QX- e'n.- ..R. ....p. kard and... Arlene .... Zickard ---------------- ...... .................... ....... ........
_ ...
------------- - UA } ..... - --- - . ... ... .. °- °- -----........... °--- .......
to me known to be the person .S ...w Land acknowledged h same.
Q E�OsARn ; _..-- ...... ........_ - - -- --
.
Notary
Public_.._ ty,
This instrument drafted by 1 ry �.•..._�'LQ3.X__...�. Colin Wes
t, __
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