HomeMy WebLinkAbout038-1213-20-000 Wisconsin Deparf of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and fYUlding Division
INSPECTION REPORT Sanitary Permit No: 420333 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information ou provide may be used for seconds purposes [Privacy Law, s.15.04 m �-
Y p Y secondary p P I Y 1 ()( )1•
Permit Holder's Name: City Village X Township Parcel Tax No:
LaCasse Custom Homes I Star Prairie Township 038 - 1213 - 20-000
CST BM Elev: Insp. BM Elev: BM Description:
i a ���
. a s / off . ZS /ti / ' J � , / - N6 Cam.. &- s
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / � 2 Benchmark
/0 -2
Dosing „ n A lt. BM
_71;; , s i /of . s
Aeration Bldg. e
3 ZS 3:'7
Holding St/Ht Inlet Y .& _
. /D V .
TANK SETBACK INFORMATION St/Ht Outlet S. 3 Zj b
TANK TO P/L WELL BLDG. ttoAir ROAD Dt Inlet -
Septic ! Dt Bottom
33 �—
Dosing Header /Man
Aeration Dist. Pipe — ZG A p�
Holding Bot. System
s � n G - , O O
Final Grade ^t T�
PUMP /SIPHON INFORMATION LA.At /0.3 /0 a. - 7
Manufacturer Demand St Cover
GPM rK_ 5 /Q "7 -
Model N ber
TDH Lift riction Lo System Head TDH Ft
Forcemain I Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length f No. Of Trenches PIT DIMENSI No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM EACHING Me cturer:
INFORMATION .. AMBER O
TypA Of System:
UNI Model Number:
DISTRIBUTION SYSTEM b
Header /Manif I Distribution I x Hole Size I x Hole Spaci� Vent to Air Intak
I t" N Pipe(s) 'r )� 1
i Lengtn___p�Dia Length Dia a5 WSp cing -
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 \ 3.51 Bed/Trench Edges Topsoil � Yes [] No E Yes
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: 7 / 23 / 0 2 i Inspection #2:
Location: 2245 122nd Street New Richnno y'45d, WI 54017 (NE 1/4 SW 1/4 11 T31 N R18 Riv r Place Lot 2 Parcel No: IA.3
1.) Alt BM Description 0f0 �� ,,
1 s�/S' 4 / a� ✓.L�Q�.4.l - 45 1 8 3
2.) Bldg sewer length = 3'j ' � /� 'S "' kk � ''v." ` /(-ems ft4ai .5-La 10"16 ' ee9
- amount of cover = S� ®` �sy���� � '"'� t f>G �� J4,0LO&C/
Plan revision Required? [A Yes o
JJ
�
Use other side for additional information. 23��Z r� --
Date Insepctors ignature Cert. No.
SBD -6710 (R.3/97)
I
b19 090
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 JT
N) isconsin Madison, WI 53707 - 7162 Site Address
Department of Commerce -� �� `��•
Sanitary Permit Application `s Permit Number
In accord with Comm 83.21, Wis. Adm. Code, personal informati n youavdeF ❑ heck if Revision v 3 33
my be used for secondary purposes Privacy Law, s15-0411)(m
I. Application Information - Please Print All Information , S Plan I.D. Number
(' l
rty Owner's Name P 1 Number
roperiy Owner's Mailing Address J� J� - Pi t T
ro / pe�rt " y Location `� 10-
73 �� ,!/ / ` /`�v�i t4;S 1 .J N,R �CE
City, State Zip Code Phone Number Lot Nut r Block Number
// �� �� L� Q Su 'vision Name Number
1
4 ,tA
II. Type of Building (check all that apply) t�a2caR ❑City
06 or 2 Family Dwelling - Number of Bedrooms ❑Village
❑ Public/Commercial - Describe Use �f ownship
❑ state owned R 3 (� 0 7 ' �
/ - /��J� �i � � N i Sc '
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A. 1 New 2 ❑Replacement System 3 ❑ Replacement of 6 ❑Addition to For County use
stem Tank Onl Eris 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)
44 Non - Pressurized In -Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ ReckcalatiM 30 ❑ Other
V. ' rsal/Tt eatment Area Information: ^ a 0
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation 11nal Grad
Required Proposed Rate( Gals. /Days/Sq.Ft.) (Min./Inch) 7-_ 1. �00i3 Elevation
7, -7o ion i on
V
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks /nI Concrete Constructed Glass
New Existing ��,� �,� A v
Tanks Tanks
Septic or Holding Tank
Dosing Chamber
VII. Responsibility Statement - I, the undersigned, assume responsibility for ' lion of the POWTS shown on the attached plans.
Plumber' ) Plumbe ' i MP RS Number Business Phone Number
�ao3 71-T - aL� ��ys
Plumber's Address (Street, City, State, Zip e)
�
VM Count /De artment Use Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued ent Signature (No Stamps)
Surcharge Fee), , A � 5- �/� Q D
Issu
❑Owner Given Initial Adverse ��'' l �
Determination
"s,
EK. Conditions of Approval/Reasons for Disapproval
n Attach P (to the o' cz� ff
SBD -6398 (R. 5/01) .
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Wisconsin De
,partment of Commerce SOIL EVALUATION REPORT Page Of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St. Cr07.X
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. ft a / 3 0
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 9
Please print all information. "vie by Date q
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). O r { A
Property Owner Property Location
LaCasse 'evelopm inc. Govt. Lot NE 1/4 SW 1/4 S 11 T 31 N R 1 8 )6dor) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
573 Cty. Rd, " A " 2 1 rid I River Place
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Hudson, WI 54016 1 ( 715 381 -5405 Star Prairie
[3: New Construction Use: a Residential / Number of bedrooms 4 Code derived design flow rate D
❑ Replacement ❑ Public or commercial - Describe: r M.
Parent material OutW3Sh Flood Plain elevation if applicable ft•-
General comments �0 /. �
and recommendations: sU a
ROX
trenches @ el,98.40 spac to cods' 4.00' below grade \� z
ST
M
0 •
F] Boring
g # [j pit Ground surface elev. 1 , 40 ft. Depth to limiting factor 1 20 in 9.
i AA ion Rate
Boring
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
1 0 -9 10yr4/3 none sil 2msbk mfr qw if .5 .8
2 9 -32 10yr4/4 none sil 2msbk mfr qw if .5 .8
3 32-120 7.5yr4/4 none co Os ml na na ,7 1.2
I
❑ Boring # Boring 101.00 120
2 ® 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
1 0 -9 10yr4/3 none sil 2msbk mfr gw if .5 .8
2 9 -39 10yr4/4 none sil 2msbk mfr if .5 .8
3 39 -12 ,5 4J4 none cos Os ml na na 7 1-2
7.7_
' ffluent #1 = BOD > 30 < 220 g/L and TSS >30 < 150 mg /L * E e t #2 = BO < 30 mg/L and TS S < 30 mglL
CST Name (Please Print) Signature . CST Number
Gary L. Steel Q 02298
Address a e tvalilation Conducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 6 -22 -2001 715 - 246 -6200
I
Property Owner lacasse Dey. , I nc. Parcel ID # ending Page 2 of 3
Boring # ❑ Boring
® pit Ground surface elev. 102.40 ft. Depth to limiting factor 120 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fE
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -11 10yr4/3 NONE sil 2msbk mfr qW if
2 11 -32 10 4 4 none
3 32 -12 7.5yr4/4 none t grcos k Osa ml
98. 30 4 f9 Z"V
Z1 0 - .
Sr j2.c,u��s o /
F-1 Boring # E] Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil liption 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
a Boring # ❑ Boring
El 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 'Eff42
Effluent #1 = BOD > 30 220 mg/L and TSS >30 5 150 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 (R6=)
STEEL'S SOIL SERVICE
Gary L. Steel LaCasse Dev. , Inc.. 1554 200th Ave.
CSTM2298 NE'SW S11- T31N -R18w New Richmond, Wl 54017
MPRSW -3254 town of Star Prairie (715) 246 -6200
lot #2- River Place
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your uae. The location of the test may or may not be as shod
to perranent lot lines veers not established at the time the test we aanductADd.
N
1 " =40'
BM. = top of SE lot stake @ el. 100.00'
alt. BM.= top of NE lot stake @ el. 102.25' L
vu
. lb'
Q0
10
0�
5P ��
Gary L. Steel
6 -22 -2001
i
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity a l ❑ NA
Permit # a t7 Septic Tank Manufacturer r ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Z a j� ❑ NA
Number of Bedrooms L ❑ NA Effluent Filter Model :Zoo ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) Q gal/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) la Do al /day Pump Manufacturer ❑ NA
Soil Application Rate al /da /ftz Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODd :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODd :_30 mg /L In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ 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: ❑ year(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell O s) At least once every: 13 ea�jsj(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: month(s) ❑ NA
years)
Inspect um every: Li month(s) ❑ NA
Ins
p pump, pump controls & alarm At least once eve ❑ year(s)
' ❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once every: ❑ month(s) ❑ NA
❑ year(s)
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.
I
Page of
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 may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the 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:
❑ 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.
• 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.
• 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.
• 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 INSTALLER POWTS MAINTAINER
Name Name j
Phone Phone 51�jj�
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone - 3 -- zia
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411►, (2) & (3), Wisconsin Administrative Code.
ST CRO1X COUNTY
SEPTIC TANK MAINTENANCE AGRIMMLNT
AND
OWNI?ItSlill' CI?tt'1'II-'ICA'I'ION DORM
Owner /Buyer C-4 S5'.
Mailing Address 5 7 3 !All
Properly Address
(Verification mitified fiow I'lannini; Depaiimcn( for flew consltuction)
City /Stale t51 �y�.a►rl2 _ I',trccl Ittcnlilic;llictn NIIlu1►cr d ;O/Ll$ZDDOD ZI
LEGAL DESCRIPTION
Properly Location -U %, 156� /,, Sec, , I' Iq-It _VV, 'I'uwn of 1 - 6 -� X—
Subdivision ( 1 3 jLt. ( A.., I.ol # 2-
Certified Survey ivinp 11 -- Volume , Page t/
Warranty Deed 11 J 3 Volume Page 11 G
Spec house yes Q no Ltrt lines identiliable yes U no
SYSTEM MAINTENANCE
Improper use and main(cnauccof your septic syslent could result ill ils tncntalnre failure to handle wastes. Proper maintenance
consists of pumping out the septic (auk every three years or sooner, if needed by n licensed pumper. What you put into the system
call affect the function of llte septic tank as a tica(ment singe in file waste disposal system.
Tlie property owner agrees to submit (o St. Croix Zoning Dcpaittucnt a ceitificalion form, signed by the owner and by a
master, pluurber, Jounieynian plumber, i csh ic(cd plumber or a liccuscd pumper vet ifying that (1) the on -silo waslewaterdisposal system
is ill proper operating condition and /or (2) allei inspection and ptunping (if nccessaty), the septic lank is less than 1/3 full of sludge.
1 /we, die undersigued have read the above tcquiteniculs and agree to maintain file private sewage disposal system with the standards
set forth, herciti, as set by the Department of Conurtcrce Bud file Depailmcut of Natural Resources, State of Wisconsin. Certification
staling that your septic system has been Ilia intaincd must be completed and retuuied to the St. Croix County Zoning Office wllhin 30
clays of tit? fhr year expiration date.
O
SIONA'I'UI 1? Or APPLICANT /
DATE
OWNUM CI!:R'I'IFICATION
I (we) certify qlat all statements on Iltis tort" arc flue to the hest of my (om) knowledge. I (we) atti (are) file owner(s) of
Ilre poly des ribc bovc, by vittuc of a watianly dccd tecotdcd in Itegisler of Dccds 011ice.
SI NA'I'URLi O APPLICANT' — �—
DATR
,
* + + * +* Any Information that is uis- Icplcsculc(l stay tesull in the sanilaty perms( being tevokcd by the Zoning Department. * * * * **
** Include wills tills applieatlou: a stamped warranty dccd from file Register of Deeds office
a copy of (lie ccitified survey Wrap if tefcrence is made ill the warrant y deed
to
j599 FAU 411 C:M:3C3:B:zI&
STATE BAR OF` WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Kevin Patrick Campeau, Jeffrey Allen RECEIVED FOR RECORD
Campeau and John Michael Campeau, as tenants in common, Grantor, and 02_27_2001 11:00 AN
LaCasse Devel opment, Inc., a Wisconsin Corporation, Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee WARRANTY DEED
the following described real estate in St. Croix County, State of Wisconsin (The EXEMPT N
"Property "): CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 1290.00
The Northeast Quarter of the Southwest Quarter (NE 1/4 SW 1/4) lying west of the RECORDING FEE: 10.00
Apple River, EXCEPT the west three (3) rods thereof; that part of the Southeast PAGES: I
Quarter of the Southwest Quarter (SE 1/4 SW 1/4) lying west of the Apple River
and cast 122' Street; and the Northwest Quarter of the Southeast Quarter (NW 1/4
SE 1/4) lying north and west of the Apple River, all in Section 11, Township 31
North, Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin; and Recordin • Area
EXCEPT Lot 1 of Certified Survev Mao filed November 3, 2000, in Volume 14 Lf�Z and Return Address
P age 399h, as Document No. 632964. re t>l e-r e.— K
S 2 Kr)& - :(es AJN Ec
Above described land is subject to an easement for ingress and egress to said Lot N . CJ ( 4U 1`7
1 as described on deed recorded in Volume 1555, Page 37, and subject to all other
easements, restrictions and covenants of record.
Part of 038.1�1141-)40 lIden iTis is no[ hom
OW- / -Z/ a0
Exceptions to warranties: Subject to all easements, restrictions and covenants of record.
VV
Dated this 7 & day of February, 2001.
rck C tpeutl/ John A110ael Campeau ((�. �vi.
I en Campeau
AUTIIENTICATION
ACKNOWLEDGMENT
Signature(s) Kevin Patrick Campeau Jeffrey
All Campeau and John Michael STATE OF WISCONSIN )
('atnnaal+ ) ss.
...,,,........ i� County )
au�£�tj$. ,
Ie day of February , 2001.
Personally came before me this day of
.�1jb,''�� • . 1 r— , 2001 the above named
" =IC ' tna 0 1^dnd to me known to be the
G tut Bait s'P. TE BAR OF WISCONSIN person(s) who executed the foregoing instrument and acknowledge
0 (If i E? _ ' : the same.
�e g '•authorized "by § 706.06, Wis. Slats.)
THIS INSTRUMENT WAS DRAFTED BY
Hendrik W. Van Dyk
VAN DYK, O'BOYLE & SILER, S.C. Notary Public, State of Wisconsin My Commission is permanent.
Post Office Box 118, New Richmond, WI 54017 (If not, state expiration date: )
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
*Names of persons signing in any capacity should be typed or printed below their signatures
WARRANTY DEEP STATE aAR OF WISCONSIN
FORM Na. 2.1998
INFORMATION PROFESSIONALS COMPANY FOND OU LAC, WI 801855 -2021
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- - 122ND STREET
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