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038-1170-40-000
Wisconsin Oepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 515292 0 GENERAL INFORMATION State Plan 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: Ziller, Neal R. I Star Prairie, Town of 038 - 1170 -40 -000 CST BM Elev: Insp. BM Elev: IBM Description: 2 Section/Town /Range/Map No: 8 /Oa M / (- 13.31.18.824 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p f Benchmark l cJl e 7 Sp Al. T5 all" iob Alt. M n Holding d � Bldg. Sewer 34 J SUHt Inlet TANK SETBACK INFORMATION SUHt Outlet TANK TO P /L WELL nBLpG. Vent to Air Intake ROAD sHffle* t-> Septic � J \ Dt Bottom Dosing 616 / / lder/ Z ` S J Aeration Dist. Pipe 9. 3(v 95 Holding Bot. System PUMP /SIPHON INFORMATION Final Grade 6. 79 57. 'B Manufacturer Demand St Cover q '7 GPM rir',`l �cA .w�, 9 (01 Model Number TDH Lift Friction Loss System d Forcemain Len D' Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO I P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR Z 7 q2 / UNIT Model Number: DISTRIBUTION SYSTEM— o� 1 j4e.-d' Z :5 �,•aK.�c Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air AA lntake 1 4 Pipe(s) �� a I dr �l/ yr length � ` Dia Length Dia Spacing \ t/ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over j xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center .l $ Z Bed/Trench Edges Topsoil \ Yes ® No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1315 Stardusk Drive J New Richmond, WI 54017 (SE 1/4 SW 1/4 13 T31 N R18 Country Meadows 1 st Add L Parcel No: 13.31.18.824 1.) Alt BM Description= ` , �`^� GOO' /V�+�L ,����a ✓�a�C, �1�25 G��4t .' 2.) Bldg sewer length = ^ OAb T� v r r - amount of cover = ��► S W S'ature Plan revision Required? 0 Yes No � Use other side for additional information. j ` /� SBD - 6710 (R.3/97) Date Inse Cert. No. I _ commerce.wl.gov Safety and Buildings Division County 201 \v. Washington Av P.O. Box 7162 ST i s e o n s i n Madison, S A2 ID Sanitar, pe Number (ttoo be filled in by Co ) Department of commerce !I State Transactio umber Sanitary Permit Application In accordance with s. Comm. 81 21(2). Wis. Adm. Code, submission of this [orm to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state•o POWTS are Prolect Address (if different than mailing address) p urposes in accordance with the Privacy Law, $. 1).04(1 m °rmation you provide may he used for secondary a / ��l � submitted to the Department of Commerce. Persnnal inf ff ` I. Application Information - Pte riot All to ratio Parcel a Property Owner'; gir Property Oner's Mailing Address Property Location w • 1315 STA114b03 K N ZI E CR )JX COUNTY Govt. Lot City, State Zip C dipIANNING ]ab)sd e`3t�e.3 /.. �W '/. Section circle one V Euv � cc�mO�l ca l 5 T 31 N; R �_ W 11. Type of Building (check all that apply) Lot n 5 Subdivision Name I or 2 Family Dwelling - Number of Bedrooms Block tt Catj�r ?R `� ' - -DOWg ❑ Public /Commercial - Describe Use 3 � s ��''� ❑ C11% of � CS�1 N umber ❑ Village of ❑State Owned - Describe Use .$'Tl4le- Town of / r,✓ 23 Id 12L III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System p ❑ Treatment /Holding Tank Replacement Only Other Modification to Existing System (explain) ❑ Re lacement System List Previous Permit Number and Date Issued B. ❑Permit Renewal C) Permit Revision ❑Change of Plumber 70\vner umit Transfer m.e ���� Before Expiration 'f -f O IV. Type of POWTS S vstem / Cora oncnt/Device: Check all that ripply �Non-Press ❑ Pressurized In-Ground ❑ At -Grade ❑ Mound > 24 in of suitable soil ❑ Mound < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Trentrrlent Area Information: Design Flow (gpd esign Soil Application R c(gpdsl) Dispersal . rea Required (sl) Dispersal Area Proposed ( System Elevation 3 ylv? \rl. Tan n p Capacity in Total k of Manufacturer �— Gallons Gallons Units a ° ° ' �5D d _ New Tanks. Existing Tanks n I Cr� U Lr u a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement 1, the undersigned, atsume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) . PI tuber's Sign hire MP /MPRS N Business Phone Number 207 -7a 5 - 7 /S Z s"���J� Plumbers Address (Street, City. State. Zip Code) 295/3 �3QS•C �>� s�c�.✓� -rte cud o/3 VIII. County /De artment Use Only [ P ermit Fee Date I sued Issuing A Signature caner n Reason for Denial #75 IX. Condidons of Approval/Reasons for Disapproval tank,.efflUent filter and S , F�r� 9 -�-- 3 6dI .r. 7� sdt.� , dispersal cell must all serve I a m' as per management plan provided by plum tum r. n AN emerft must. be maintain s P ✓ �Gr: eK; a�'', z oaa. cod. obinsnc". ibmi u Attach to c t nlctc plans fort t sy ter n the Conty only n paper nor less than a in x I I inches In site �r acet�.�r� �.; SBD -6398 (R. 01/07) Valid thru 01/09 n� , i I St� /� S 13 TS I a R IE ,L. 07' - 7 C a utis r� Y �ha o�v4 I � x � s -�i,.f G- 3 a ate, S r, C' rco-csc �v- uArt-y �`� � �5 1-F c� t�S XN 5��� � ��t�'fw�cSFEiP alrwcr�Fa GF+teA &S G o M gNC / = /o o, o' _ rtop. F SEPTic Tio NK ��► = Lfo' I 101sconsin SOIL EVALUATIOINLREPORT #75 Department of Commerce in accord i+l s. Adm. Code Page 1 of 3 Division of Safety and Buildings Northland Plumbing, Inc. ns . Pla Attach complete site plan on paper not less than 8% x 11 inches in must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. pleas A Ada Reviewed By Personal information you provide be uRd�ceEAffaPnes (F ivaW Law, s. 15.04 (1) (m)). + al/ Z /6 Property Owner Property Location Ziller,WXpl &f Govt. Lot SW1 /4, SW1 /4, S13, T31N, R18W Property Owners Mailing Add Lot # Block # Subd. Name or CSM# 1315 Stardusk Drive ST. CROIX COUNTY 7 1 Country Meadows city L MW2AWU F fflJM ❑ City ❑ village ® Town Nearest Road New Richmond I WI 1 54017 1 Star Prairie I Stardusk Drive ® New Construction Use: ® Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD ❑ Replacement ❑ Public or commercial - Describe Parent material Glacial Outwash Flood plain elevation, it applicable ft. General comments Q , 7 9G • 43 '� and recommendations: a Boring # E] Boring ® Pit Ground surface elev. 99.03 ft. Depth to limiting factor >96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs GPDflt: in. Munsell Qu. Sz. Cont. Color Gr. Sr- Sh. •Efff1 •EfW2 1 0 -10 10YR3 /3 sl 3Sbk mvfr CS 2f - .6 1.0 2 10-25 10YR5/4 sid 2sbk mfr Cs if .4 .6 3 2 -96 10YR5 /6 S 099 ml Cs .7 1.6 1� E Boring r # E] Boring ® Pit Ground surface elev. 98.21 ft. Depth to limiting factor >92 in. Soil Application Rate Horizon Depth Dominant Color Redox Descxiption Texture SWcture Consistancl Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff/1 •Efi{2 1 0-10 10YR3 /3 sl 3sbk mvfr cs 2f .6 1.0 2 10-19 10YR5 /4 SI 2sbk mvfr cs if .6 1.0 3 19 -32 10YR5 /6 S OSg ml CS .7 1.6 4 32 -92 10YR7/6 Cos Osg ml CS .7 1.6 Effluent #1= SOD? 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = B00 <_30 mg/L and TSS <_30 mg/L CST Name (Please Print) Sign re: CST Number Michael J. Myers , u ,L 267985 Address Northland Plumbing, Inc. Date Evaluation Conducted Telephone Number 2943130th Ave Glenwood City, WI 54013 716/10 715 2654115 OD4330OL07 0) Property Owner 2511er,Neil Parcel ID # Page 2 of — ❑ Boring , F Boring # ® Pit Ground surface elev. 9s:2 to limiting factor >92 in. soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Ef t 'EW 1 0-9 10YR3 /3 sl 3sbk mvfr cs 2f .6 1.0 2 , 9-17 10YR5/4 sl 2sbk mfr is if .6 1.0 3 17 -37 10YR5/6 S OSg MI a .7 1.6 4 37 -92 10YR7 /6 cos Osg ml cs .7 14 t� 1 ' Effluent #1 = BOD? 30 < 220 mgA- and TSS >30 <_150 mgA. ' Effluent #2 = BOD < 30 ngA. 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. Property Owner Ziller,Neil Parcel ID # Page 2 of 3 3 ❑ Boring Boring # ® pit Ground surface elev. 98&21 I'= to limiting factor >92 in. - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD)11 in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. *Efr#1 •Efi#2 1 0 -9 10YR3 /3 sl 3sbk mvfr cs 2f .6 1.0 9 -17 10YR5/4 sl 2sbk mfr cs if .6 1.0 3 17 -37 10YR5 /6 S Osg ml a .7 1.6 4 37 -92 10YR7/6 Cos Osg ml CS .7 1.6 .o Effluent #1 = BOD? 30 <220 mg/L and TSS >30 <_150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mgA- 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. y _ I J sw'��t Sw �/y 513 T3 I nl R 18 cv Sarzrk v �►-r- y �1 t o ,S I S�q� ►����t� `fw�sMiA I aT G•ta�tG� ��kQ tt I ?k4. =goo, fot� • F SC -P'tic Tiq �.,iK � F.t �syi/�!G AA N 'bps,, Ai t b 6ct /S a y�.za \ •1• 3 3 U e " Page 1 of 4 11 0 1 12 IN I VA • SYSTEMS INC Environmental Onsire Wastewater Solutions" Leaching Chamber Design Spreadsheet Project Name: Ziller- Addition Km!/ Owner's Name Nei Ziller Owners Address 1315 Stardusk Drive New Richmond, WI 54017 Legal Description [SW v Y., Y. Sec 13 T 31 N, R 18 W • Township Star Prairie County saint Croix Subdivision Country Meadows Lot# 7 Parcel ID# Table of Contents P9. 1 Cover page 2 Calculations and Drawings 3 Management and Contingency Plan 4 Plot Map total # of pages: 4 Designer Name: Michael J. Myers License #: 267585 Date: 7/13/10 Ph. #: 715 -643 -2520 Signature: Design Methods Used "IN- GROUND SOIL ABSORPTION COMPONENT MANUAL FOR PRIVATE ONSITE WASTEWATER TREATMENT SYSTEMS" (Version 1.0) SBD- 10705 -P (R.6W) srsT> =1.�IS 0,91 Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc. Spreadsheet provided under license to Inflltator Systems, Inc by: 3hAdvisement N12486 220tlh St B&Iceville, N 54725 M- SYSTEMS INC Calculations and Drawings Page 2 of 0 Site Conditions Infiltration Elevations Site Type: Private I Trench #1 Trench #2 Trench #3 %Slope 3% Contour Elev: 99.03 Ft # of Bedrooms 2 Infiltration Elev: 96.03 1Ft Depth to limiting factor 92 inches Limiting Factor Elev: 91.36 N/A N/A Soil Application Rate: 0.7 gaVft"2/day Treatment and Dispersal Zone: 4.67 N/A N/A Effluent Quality Eff #1 1 • Cover Material Required: 0 N/A N/A In Design Flow: 300 gal /day Finished Grade Over Cell: 99.03 N/A N/A Max BOD 220 mg/I Max TSS 150 mg/I Distribution Cell Choose chamber type: Septic Tank Infil"W Quids 4 standard Manufacturer. Wieser Concrete # of trenches: 1 Volume Chosen: 750 Chamber Length: 4.00 Ft Effluent Filter Selected: Polylock Chamber EISA: 19.1 Ft2 Note: Access opening of sufficient size to be provided to allow removal of filter_ Endcap EISA: 5.8 Ft2 opening to terminate at or above grade. Required Infiltrative Area: 428.6 F12 Actual Infiltrative Area: 445.1 Ft2 Total # of Chambers: 23 Cross Section of Septic Tank Total # of Endcaps: 2 Combined Length of Cells: 94.0 Ft 12" Min Grade Cross Section of Cell 18" Min Cover Material Observation Pipe (if required) _ _ _ _ - Final Grade All joints to - be water tight D3034 or Ground Effluent Sch40 Contour Finer Pipe Leaching System Chamber Elevation 3" Bedding Under Tank Length 0 0 Ar7fm X0314 Observaltaat ObsennaUal With or 5A 40 4" pipe pipe f'VC ryas Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc. Spreadsheet provided under license to Infiltator Systems, Inc by: 3bAdvisement N12486 220th St, Boyeeville, WI 54725 Page 3 of 4 In- Ground System Management Plan pursuant to comm 83.54 W. A. C. Owner's Responsibility: The component owner is responsible for the operation and maintenance of the component. The county, department or POWTS service contractor may make periodic inspections of the components, checking for surface discharge, treated effluent levels, etc. The owner or owner's agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or the department. Septic Tank: Septic tank(s) are to be inspected routinely and maintained by department approved individuals when necessary in accordance with their approvals. The use of chemical/biological "treatments" is not required or recommended. If such additives are used, make sure they are approved by Department of Commerce, Safety and Buildings Div.. Effluent filters are to be removed & cleaned as necessary, with provisions to keep solids from passing the septic during removal. No more than 1/3 of the usable tank volume may be occupied by sludge/scum. 3 year inspection: If tank has greater than 1/3 volume sludge, tank contents must be emptied and disposed of in accordance with NR 113 Wisconsin Administrative Code by an approved individual. If the inspector does not recommend pumping of the septic tank, then the owner must be notified of when pumping should be done as to not exceed 1/3 sludge volume. Septic tank should be routinely inspected to be watertight and of good repair. Absorbtion Cell The absorbtion component must remain free of ponded surface water prior to pump operation. If 4 inches or more water level is detected in the observation pipes, the owner must be notified of possible problems/failure. The designed daily flow capabilities of the component should never be exceeded. Trees and any other deep rooted vegetation should never be planted, or allowed to grow anywhere on the component. Activities OTHER than mowing/maintenance (i.e. excessive walking, pets, vehicles, etc...) could compress the component and reduce it's absorblion capabilities and/or possibly cause it to freeze in winter conditions. Performance Monitoring: Performance monitoring must be done at least once every three years following the installation or at the time of a problem, complaint, or failure. Contingency Plan: If the septic tank or other components therein (including floats, alarms, etc) become defective, the defective tank or component must be replaced immediately to ensure that the system can operate as designed. If the absorbtion component cannot accept wastewater or ponds wastewater to the surface, the component must be repaired or replaced in its current location by removing the dogged bacterial mat, aggregatelleaching chamber cell, and distribution piping within the cell and replacing failing components in order to return system to proper working order as required. If repair is not feasible, a new system is to be constnxted in a designated replacement area 1 ........... / Jc� Tara Rr8 L OT ;f 7 C e u ,v T it `r tRZ-tea a w4 Ex�s - f,,rU 3 a Daxk i 5 r, C'rz_o -cx �o{► err �`� � 5 y sc- I a x "� � S'�A� ►� ►�r� fW4Se4 P arfiwc�Fa ii+, " &S G t� O / 0"0 A tal F �rcPT/c 7a .1K Fit �syn�lG� IRAN d ScALr °I . - Lo 264. ` 1 v N85 56' 5 N ,o0 W 2 ) ` � A.P. - v ' A.P. o '( 3 1 1 1 to % 'O o, 65 485 SQ.FT - - " cU T • A.P. 1.50 A C . z i v \ N BLDG. SETBACK L /NE �. ° ° p, 5 ,9� 128 !� m 78,851 SO. FT. b �\ A.) m 1.81 AC. .o o N C �° • g�b'0 s a 92.22 – 50` Z '�� ,' � °-p \ ( 5 )� (27� N88 * 51 '11 G+ 7A W. 620.26' ' `\ tio��`o o •Q \ 6 AR t'7> S88 238.00 8 o �qti� rFyT , r i -- 109.00 _ 675. 28 63.700 SQ.FT. \ s � arG'Q�.g2 h90o I 1 . 46 AC. '�i ow e0 ✓O/Nr oR/v£wAr 6 11o\ s 9 6T EASEMENT r0 LOTS 6 Q 7 I e F of 1 m M �� a o PAGE 7.95 3 m 84.537 SQ.FT.O N� _ i o w — - -- - -- m I 1.94 AC.h �o °• 119,032 SQ.FT. :� o N to o 2.73 AC. Z 0 Z I a� N88 '34 ' 10 "W 190.00' e-� m 304.60' e 2 • — 15 152.30'— PAGE 863 'T" N8844'0D "W 45 .90 �I o Z �I (U � �I I— oil 1 2 QI >I C DU TRY ME DC ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer /le/e� Mailing Address Property Address (Verification required from Planning Department for new construction) City/State A1~ ?•eW,~ vii w/ Parcel Identification Number LEGAL DESCRIPTION Property Location SW `` /,, Jw '' '/,, Sec. /3 , T s't N -R /F W, Town of -S"r4ole- lAtA'. Subdivision ���°� Y �h�.c►Jo� p , Lot # 7 Certified Survey Map # Volume , Page # Warranty Deed # , Volume Page # Spec house ❑ yes ,M no Lot lines identifiable Ud yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof -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. 1L 7 SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this for are true to the best of my (our) knowledge. I (we) am (are) the owners) of m the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNA �OF DATE •••••• Any information that is mis- represented mV result in the sanitary permit being revoked by the Zoning Department. " Include with this application: a stamped warranty dedd from the Register of Deeds office a copy of the certified stuvey map if reference is made in the warranty deed �j p State liar of W, Fw.,1 ? - 1981 5ZS349 WARRANTY [�::En3 DOCUMENT NO. i! YOz L7P.� f l a� R EG I STER 'S u�TjcF t� - -- - - - 5f. CROW CO., V ;1 ; is ReddforlPtacc a a I Gary BrunciiK _ MAY 1 1895 I' i L 8:00 A. .i i convc sand varrants to 1. 1 y I e hu�b� tad and.•wife; ii II _ THIS SPACE RLSERVEO FOR nFConoir,G DATA the following described real estate in _ .. -St. _CrniX County. State, a `': isconsin: ! t Is ' (parcel Identification Number) r! -r '=� ., S ' %rat A ' s + - V, - TOLd:•: C.f Ct Prni ri'- it ij -U i , %'L � L j% + tfluuvw �.. St. Croix County, Wisconsin. i; #J TOGETHER WITH AND SUBJECT TO joint driveway easement with Lot 6 as sb.)wn �I on Plat of Country Meadows First Addition. q h (+ if II tl 1 . li I ! 1 ( Phis _ 1S ri ` - Ot__ __ _ - homestead property. II j (is not) - �I f I. Exception to warranties: Easements, restrictions and rights -of -way of record, I; if any i 1' Dated this - -- — day of Ftprll_. .... - - - .__ ..— . 19 95 ;I ` 1 II I 1 it l3£ALj t- STEAL) II b - _ 1 _ _ Gary Brun l.ik !I -- (SEAL) - _ - - - - (SEAL) u AU'1'1JEN'1'IC.A'1 - 10N ACKNOWLEDGMENT signatule(s) Gary. Bl STA - 1 F OF WISCONSIN CS. autFenticat4d this day of 95 Personally came before me this _ day of 19 the above named Kristina Ogland - rlIi I.. , ,jLK BEER STA1'F. BAR OF WISCONSIN If not. C : h mornctl by ?06.06. Wis. Stars.) - 7 � to n,r kno�sn to be thr. person who executed the f, +rtgoing Insuumcnt and acknuHl_dgc the.amc. • ...'rlijk1r:Nr "AS ryHAFTEt; E+v Krishna. Ogland A ttorney at Law �7 >tarc Public Counts, WI'. •tiiel:.u,,„• .,•:. h ;,whentiLate•d or acknowledge..;. Roth are not MN commirann n perm•utent. (It nut. state c(piration date: �� 1i: 17 t•.i r ot; it til 111 7ku 01 tt l�t'�)ti S7'. .t r + - _ tf)R�t So -- toff_' + a __ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and /or dose tank presently serving the following residence: (Street address) /3 J S T r , 6 h, — located at: '/4, - ii!4 1 /4, Section /3 , Town 3 1 N, Range 1 � W, Town of , cL , St. Croix Count ��- n y Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /'noc� Construction: Prefab Concrete ><" Steel Other Manufacturer (if known): y w + — Age of Tank (if known): /g 9.q Permit number (if known) _7- 96 ZZ (Licensed Plumber Signature) (Print Name) z67gFs (Title) (License Number) MP /MPRS ry (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 0cn z -0 c b �1 r ID m v • v a C: (D `�° d co \ 1 (n m z ° j W! U w w O• m j C O (D N ?� d. W r O O O CO 'O 7 (D N N N? O O O (O (D O (n OD W -I 3 O __ p 0 7 N j = C C (D CT O cn ° to D a N y CL 41 o� a rn C ( O 3 N �c o o 0 o CD 0 0 � <' 0 o n a CD 3 a O O O 3 A A O \ o o m 3 N N V o o o 0 6 O G a cn cn ° q m (D .. C N 41 O N CL N 7 J 0. N z (W Z D O O 0' O D a° a Z CL m m �• @ t� — 1 CD e A (D 41 y C CAD CD W Q Z (D c6 _' —1 N CL a 3 o' CL z O � OD w Z CD j I TM. W l OZ CL CD kj I I ' A Q• fi ti O a 0 W 0 b CD A (n i (D Oq N o m o b C i ti �" STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER! �°► j. ADDRESS X �� SUBDIVISION / CSM# .Illy LOT =_ SECTION 1.3 T LN -RIW, Town of ScA ST. CROIX COUNTY, WISCONSIN S74 r, PLAN VIEW? SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM = d INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ' a4 �. \ cs yam" •2 it j ALTERNATE BM: (� Q "� aJ ✓ SEPTIC TANK / PUU CHAMBER / HOLDING TANK INFORMATION �� Manufacturer: �1 ff 77 Liquid Capacity: /0 Setback from: We11 House //. Other Pump: Manufacturer Model# Size Float seperation Gallons /cycle: Alarm Location i SOIL ABSORPTION SYSTEM Width: w2 Length V Number of trenches - Distance & Direction to nearest prop. line: 'y8 5 Setback from: well: D House Other ELEVATIONS Building Sewer ST Inlet. l / ST outlet 9 - 7 PC inlet PC bottom Pump Off Header /Manifold `7 V Bottom of system Existing Grade D ".�LFinaI grade 7 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt S r 'Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo.: Pe�rpi�Hol�gr�Name� ❑City ❑Village 9 Town of: State Plan D No.: STAR PRAIRIE OIR-1170-40—nn CST tt B tt M UU1 fle CC v 1 . 11CC Insp. BM Elev.: BM Description: Parcel Tax No. i TANK INFORMATION ELEVATION DATA IQ d IARII TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t ( C� Benchmark pd Dosin r?7 3,a�� /1)3 -0 Aeration Bldg. Sewer Q.OS 9y. 31 Holding St /Winlet �. -�o 9k 16' TANK SETBACK INFORMATION St/ k Outlet Z 56 TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet Air Septic '>,-5-6 NA Dt Bottom Dosing NA Header tom— i Aeration Dist. Pipe Holding Bot. System �� c'- 5/' PUMP/ SIPHON INFORMATION Final Grade ,pfd 3 ' M Demand t6 Model Number M TDH Li L riction Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS �a �� DIM N I N act SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACH Manuf SETBACK CHAMB INFORMATION Type O //e,.., Cenr/ 0 33 • - Moe u System: l IT DISTRIBUTION SYSTEM Header,<A4anifefd' / Distribution Pipe(s) << r x Hole Size x Hole S Vent To Air Int e Length �Q Dia. Length S l ' Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or A pii@iilde Sys Depth Over / Depth Over 9.� ? o xx Depth xx Seeded /Sodded xx Mulched Bed/1 aE o Center a —� 7 Bed /Frecgt►Edges �/ — 7 Topsoil ❑ Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAI / R } IE - .1 13 3.31.18W,SE,SW,LOT 7, STAR DU DRIVE C� Ayes - 'S. C C'r✓Li2�9 y�l, Plan revision required? ❑ Yes No Q Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signaturg Cert. No. j ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION .`::� �:.� coin ri 0 O 7 In accord with ILHR 83.05, Wis. Adm. Code G�_� I STATE �T Y PE RMIT # S/�[V –Attach complete plans (to the county copy only) for the system, on paper not less than V1 cl o g, 8% x 11 inches in size. ❑ Check if revision to previous application –See reverse side for instructions for completing this application. .� ( STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. `` Si ''' �`� PROPERTY OWNER PROPERTY LOCATION j- LL I t c'/ (,,3 '/4, S 1 _ T l/, N, R Z Z(or) W PROPERTY OWNER MAILING ADDRESS LOT # BLOCK # 0 dt, �_ /. - 7 J CITY, STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑State Owned 0 ED VI VILLAGE = NEAREST ROAD 06 jid TOWN OF g, 1 ❑ Public „�1 or 2 Fam. Dwelling–# of bedroom P ARCEL AX NUMBER(S) �� 111. BUILDING USE: (If building type is public, check all that apply) 0 3 9 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. � New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION y '12 !a 'Kra o ' _ 7Z 0 r �' S Feet IOa . toC Feet VII CAPACITY . TANK Site in gallons Total #of Prefab. Con- Steel Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank k Q O 0 Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu ber's Sign re: (No tamps SW No.: Business Phone Number: �we r r1 737 711 �K7d X735 lu ber's Addr s (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sa tary Permit Fee (Includes Groundwater a e ssue Issuin Agent Signature (No Stamp ) /D Surcharge Fee) Approved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD- 6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type: VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies colt through these collected t ou ese surchar es are used for monitoring r g g o oundwater, round - 99 , water contamination investigations and establishment of standards: SBD -6398 (R.11/88) I `a 4 ; A �. A T x O � rt N ri fD ��� ~'� Z a ( i Z f b W ol CS At z cK (b 4 G a d ;r,,, d 1 4, DEPARTM OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND CC P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (��J) MADISON, WI 53707 Sc.J L� Sw �„ (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TO NSHIP/ NICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 4_ �/ /_3 /T 3t N /ROBE (or) W �1 '7 0 CO NTY: 5 _ A _ �18�__ L 4 v 0 - y z� 81 Z" Ye z USE DATES OBSERVATIONS MADE Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: ER OLATION TESTS: .New ❑Replace Z Z, RATING: S= Site suitable for system U= unsuitable for system M NVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) �1 S ❑U QS DU ® S ❑U F] S CJU ❑ S DU a If Percolation Tests are NOT required re DESIGN RATE: 4 �/ I If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: 1 1 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE AB BRV. ON BACK.) B- l 8l /40. / $/ d , - Be 'e'? B- Z A// //- 1 S ' ae , d-7 _T' a ( GiJ D — 8 .? 4 J e S p CID.S.S ' 'e// 9 /1 / z3- 5 B- U� /y��y�R. ��0 f�� O� S I 6'L - 8G" A r _ B- S ll? -5 / -fir ���J 8i -g9' s_ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- l X3 s P_ Z ''8 Z Viso P- 0 5 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show t e surface elevation at all borings and the direction and percent of land slope. .1 SYSTEM ELEVATION 9� tN t i 3 -Yr�1 , w _ 1 � • O . r i f 7 > �8 RE r °_ Of , E �T r q . �� C> 9 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: 7'0 ,.. /7 -5 ADDRESS: l CERTIFICATION NUMBER: PHONE NUMBER (optional): / (v/ Z6, 4�`�, lU Cle, 1�J. J 370 <I4 Y7Z- CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use suction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 6. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10 ") BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well is — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand < — Less Than '1 — Loam Bn — Brown 'sil — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general it — Bench Mark S e e so textures BM 9 for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. I STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS �- •� -`✓ o� © C:�L O ° PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE PROPERTY LOCATION S.E� 1/4, .� 1/4, Section, T _,iV N -R __/f_ W o—o TOWN OF i5, ���,,,, ��e/ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 7 CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIG DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ----------------------------------------- o - - - - -- --- - - / ,E: Owner of property SS�pz9 Location of property Section /,3 T N -R / er W Townshi ° ` Mailing address /J d o Address of site Subdivision name Lot no. '7 Other homes on prope de s No Previous owner of property Total size of property X ! ,rL Total size of parcel Date parcel was created / g y �71 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X Yes No Volume and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewin g P P process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. ,jam/ FZo D Zk_ , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. - of Applicant Co- Applicant Date of gnature Date of Signature DOCUMENT NO. STATE BAR, OF WISCONSIN FORM 3 -1982 � THIS SPACE RESERVED FOR RECORDING DATA W_ UIT CLAIM Qr;E�D 518606 VOL TO' PA,f 310 . �:ol Allen L. Lunde and Gary Brunclik, d/b /a Homestead 1 *W - - - -- - - mep - - -- - - - -- - -- -- Develo nt - ------- - - - - - - -- --------------------------------------------------------- - - - - - -- - - - - -- - -- ------------------------------------------------------------------------ - - - - -- JUL 599 quit- claims to --------- Gary Brunclik 10 00 .,1 A - - - - - -- - - --- -- - - - -- - --- - - - - -- l ` %rstltia - -- - - - - - - - - -- - ----------------------- -------- - - - - -- *� j - - - -- - - - - - -- -- - - - - -- - - - -- - - - - -- - - -- -- - -- - -- --- - - - - -- I •: the following described real estate in ----- __St.-. Cr o i x - -- County, li State of Wisconsin: RETURN TO Gary Brunclik I P 0 Box 531 I I ____ Osceola, WL _54020. �I Tax Parcel No: -- -- -- ----- ------- - -- --- III ii Lots 7, 9, 10, 14, 16 and 17, Country Meadows First Addition in the Town of Star Pr irie, St. Croix County, Wisconsin. i . "APT , ii i I I I I I� This ----- is not homestead property. � (is not) Dated this ----------- - - - - -- - day of June -- - - - - -- - - - - - -- 19 _ -------------------------- - -- ---- -(SEAL) -- ----- ----- -- X- - --- _-- - -. -.- (SEAL) Allen L. Lunde -- - - - - -- ---- - - - - -- - ---- ---- - - - - -- (SEAL) - (SEAL) I _ Ga3 c 1 c AUTHENTICATION ACKNOWLEDGMENT I 1 Signature (s) --- ------ -- - ------- - -- - - - - ----- -- --- -- ---- -- --- Allen L . Lunde Gary STATE OF WISCONSIN f i Brunclik ss. --- - - - - -- - --------------------•---------------- ------- --- ----- ------- -- - - - - -- - - - - - - -- ------------ - - - - - -- -- - - -- C ount y . authenticated this y of ------- June_ .......... . 19__94 Personally came before me this -------- - --- -- --day of / f ,� - 19 ........ the above named - ---- ---- ---- --- -- -- -- -- t(U.A""-----_--------------------- Kristina 0 ------- -------------------- ------------------------------------------- - - - - -- ---------------------------- .--------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- ------------ --- --- -- --- ------ -- - - - - -- - -- -- ---- - --- -- authorized by § 706.06, Wis. Stats.) to me known to be the person ------------- who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY --- -- --------------- ---------------- ------------------ --------- ------------ Kristina O --- ------------------------- - - - - -- -- ------ -- --------------------------------- - Attorney at Law ----------------------------- - - - - -- Notar Public ------------- -------- ------------ --- -- - -- County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date- - ------------------------------------------------------- 19 --------- QUIT CLAIM DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 3-1982 Milwaukee, Wis.