HomeMy WebLinkAbout038-1190-40-000 fsconsiri Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 363990
Per Holder's Name: [I City [I Village [] T wn of: State Plan ID No.:
LeQue Construction, Star Prairie Township
CST BM Elev. - - , Insp. BM Elev.: BM Description: Parcel Tax No.: (oD C5r gna _L 038- 1190 -40 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic Benchmark J ' 2 D 05.20 1 CrD • O
Dosing Alt. BM
Z. V
z 1 02 . 6
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TA K SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. V e Intake ROAD Dt Inlet --'
Septic �Sp ) 30 r — NA Dt Bottom
Dosing NA Header /Man. 7.130
Aeration NA Dist. Pipe 5 -7. 80 9�.�o►
Holding Bot. System S 9.30 %110 13 r
PUMP / SIPHON INFORMATION Final Grade
Man r D d St cover 4
Model Number GPM
TDH Lift it 7 L Iction TDH Ft
For
, Ae6ln Length Dia. Dist. To Oell
SOIL ABSORPTION SYSTEM s
E Width Length No renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION
3 68•�s l-°� DIM N I N
SYSTEM TO PA BLDG WELL LAKE/ STREAM LEACHING Manuf our r:
SETBACK `
INFORMATION TypeO n CHAMBER Moe Numb
System: 30 OR UNIT u
DISTRIBUTION SYSTEM ess /I ;z_
Header /M M nifold � Distribution Pipe x s) Vent To Air Intake
Length Dia - Sparing
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
COMMENTS (Include code discrepancies, persons present, etc.)
Inspection #1:a8aP OVInspection #2:
Location: 1353 214th Avenue, Star Prairie, W1 5402 , (NW r 1 /4 SE 114 13 T31N R18V) - 133118975 Northgate -Lot 26
1.) Alt BM Description � 30' P
2.) Bldg sewer length=
- amount of cover = y' I B
3 )qa60_ k -- C 0D - L� cn—
Plan revision required? ❑ Yes P No
Use other side for additional information. O8 I Z!2 00 • �o
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
a
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(3 s 3 ! LfclE,
Sanitary Permit Appl' n Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Code tt 201 W. Washington Ave.
N"If See reverse side for instructions for comp( this a{ Q�u -_� PO Box 7302
Personal information you provide may be use f con�cjjary Madison, WI 53707 -7302
Department of Coriihierce [privacy Law, s. 15.04(1)( ) ��� (Su ompleted form to county if not
n COUN state owned.
Attach complete plans to the county copy only) for the system, kj 0qpq n6WHMS Ma x r hes in size.
C oun t y' C r O ` State Sanitary Permit Num be O Check if revision t re pus . Sfa�e 1. D. Number
I. Application Information - Please Print all Information — - oration:
Property Owner Name l� /� Property Location
Q„ V►L �C!`i1 \ ,ryC� 1 ay-S 1 5 ` e, tom{ V 11)(0 I/4 5 E1/4, S 13 T3 N,
Property Owner's Mailing Address Lot Number Block Number
Ao&'d LOt�(o N �, O
City, State Zip Code Phone Number Subdivision Name or CSM Number
001' A 0 XQ_
11 Type of Building: (check one) '/ _/ Li City " J
X I or 2 Family Dwelling - No. of Bedrooms : 3 — pm' keuw' P1� S�f�''n'r°J ❑Village f�
• Public/Commercial (describe use):_ 9&Town of t
.5T., �r�.\ c \�-
❑.State -Owned Nearest Road ��-�( Q�
a
Pazcel Tax Number(s)
III. T ype of Permit: Check only one box on line A. Check box on line B if applicable)
1
A) I X New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System M (�
B) Permit Number Date Issued • J
❑ A Sanitary Permit was pre viously i ssued I 0
IV. Type of POWT System: (Check all that apply)
Non- pressurized In- ground ❑ Mound ❑Sand Filter ❑Constructed Wetland
• Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At- de ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dis ersal/Treatment Area Information: i o .- 'r (o
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
d Required 37S Proposed Rate :W
Proposed (MinJinch) 96 / Elevation
#50 aP �� s �� � /` 1
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
❑ ❑ ❑ ❑
ieo i< \ �b I r
I L 0 0 0
VIII. Responsibility Statement Z T — �
I, the undersi ed, assume res on ibility for installa ' of the POWTS shown on the attached plans.
Plumbees Name (print) PI ber's Sima (n stamps): MP/MPRS No. g Business Phone Number
Plumber's Address (Str eet, City, State, Zip Code) n
1 96 l S .a"j R tc_Itim z a I
IX. County /Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D Issu d 4ssum nt Signature (No stamps)
XApproved ❑ Owner Given Initial Adverse Surcharge Fee) /oC7 g ?r3b�
Determination
X. Conditions of Approval /Reasons for Disapproval: — • -4 10W_
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' Wisconsig Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor ara Human Relations
Division o Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 038 - 1055 -95
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION
Rr IE
BY DATE
�,�n.S
PROPERTY OWNER: PROPERTY LOCATION
Greenwood Enterprises, Inc. GOVT. LOT NW 1/4 SE 1/4,S 13 T 31 N,R 18 8(or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1416 Third St. 26 na NorthGate
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OTOWN NEAREST ROAD
Hudson, WI. 54016 (715) 386 -3674 Star Prairie I 214th Ave.
] New Construction Use [ ] Residential / Number of bedrooms 4 [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 g pd Recommended design loading rate • 7 bed, gpd /ft - 8 trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate • 7 bed, gpd /ft •8 trench, gpd /ft
Recommended infiltration surface elevation(s) 96.10 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL I HOLDING TANK
U = Unsuitable fors stem I ®S ❑ U ® S ❑ U ® S ❑ U IN S ❑ U ® S ❑ U ❑ S 13U
SOIL DESCRIPTION REPORT :*
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch
1
1 0 -12 10 r 3/3 none 1 2msbk mfr gw if .5 1.6
2 12 -26 10 r 4 4 none sicl 2msbk mfr qW if .4 1.5
Ground 3 2 _ m1 na n .7 .8
elev.
9 9.7 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -12 10 r 3/3 none 1 2msbk mfr qW if .5 .6
:...._:
>'......... :::: 2 12 -28 10 r 4/4 none sicl lcsbk mfr gw if
.2
Ground 3 28 -32 10 r 5 4 none sil lcsbk mfr 9W na .2 .3
elev. 4 32 -84 7.5yr 4/6 none cos osg ml na ,. .7 .8
99 . f7
Depth to r /
limiting
factor R CEJ
� -
+84"
Remarks: ST CRax.,
CST Name: -- Please Print Gary L. Steel Phone: 715 -246 -620 �,� fNG OFFICE
Address: 1554 200th. Aye., New RichmAnd, WI 54017
Signature: Date: 11 -2 -98 C 8
J
I
PROPERTY OWNER Greenwood Enterprises SOIL DESCRIPTION REPORT Page 2` of' -_
PARCEL I.D. # 038 - 1055 - 95 '
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourb3y Roots GPD/ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
on .................
........ 2 11 -29 10 r 4/4 none sicl 2msbk mfr gw if .4 .5
Ground 3 29 -84 7.5 r 4/6 none cos os ml na na .7 .8 •7
elev.
9 9.7 ft.
Depth to �{3•"i
limiting tp 3,
factor
+
Remarks:
Boring #
- 12 10yr 3/3 none 1 2msbk mfr Cfw if .5 .6 ,S
4 2 12 -26 10 r 4/4 none sicl 2msbk mfr gw if .4 .5 .4
Ground 3 26 -84 7.5 r 4/6 none cos 0SQ ml na na .7 .8 •�
elev. 6 f z
99.8 ft. —
Depth to Esc -
limiting io�y So /� / - �j a(c✓r�
factor
Remarks:
Boring #
.. 1 0 -12 10 r 3 3 none 1 2msbk mfr gw if .5 .6
5 2 12 -22 10 r 4/4 none sicl lcsbk mfr gw if .2 ` .3 • •2
3 22 -32 10yr 5/4 none sil lcsbk mfr gw na .2 .3 ,2
Ground
elev. 4 32 -84 7.5 r 4/6 none cos 0sq ml na na .7 ' .8
99.8 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
�t 0 'nr�4.a svi7�a 6 / e a k yet Caact Sa
Ix
Ground
elev. i
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92) `
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Greenwood Enterprises, Inc. New Richmond, WI 54017
MPRSW -3254 NW4SEq S13- T31N -R18W (715) 246 -6200
town of Star Prarie
lot #26- NorthGate
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for Y our use. The location of the test may or 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 1" pvc pipe C el. 100
Alt. BM.= top of 1" pvc pipe el. 99.75
2'
D
b I LI e
Gary L. Steel
11 -2 -98
08/02/2000 15:12 7152462579 PAGE 02
b -1996 6 : 29P4 FROM
' � " ° ""r•
501L ARID 8I1rB EVALUATION REPORT
In arrow Wm ILJqq as-as. WNL A&% Go*
MmO comps aft'Pmn &tfsapeer rmt boa Ohm a 112 x 1 f irdt" In aa�. Plan nwt iileeM+di, bw SC
m lmfad m v�loat one hoefaoeed rAlwameee:e Paint falYO. dk.etion ffd -% d 0b", ao" or ° .
dle+r,alo►+ad, noedr anar, ary bpgion dish- 0 04040 rood. 038- 105Sw95
APPLICANT INEORMAIrIGH .PLLAIE PRIli1T ALL.INFORYA110N CA
PpopEltrl CIiiNEA: .
13 F0rry RFr* MA UMw Apglr� 2�. �Mt tm I+ii�i SS tNA 13 t - 31' /1,11 18 s{ar) ry
err O tt?r ♦ stum "m aR ryas
CRY. STATE na Nord late
590 ;6 CJ 386-3674 star WOE Zl..
NM.+. coisruolldn rasa pc f I / Menbar aI W*mna 4 f ! Aeelim In ex4vq buldiep
t 1 Win► ( 1 Ptw a mmhaeeipl lee
code tw+y 60u gpd �nn� ea�ipn �Iro Iab -? � o��RS„dt �dite�
zbsapecv+ W" **W Me Oad I1 790 h * R2 Mtodietwrr �
RRVn�narabe Inb lion erltM �.raeoee{s) 96.10 'D'i"A �r oed,.aP
Adtlmd I sf, COWW 800MG am s 4�ii i.Io►ti4 b iiM da+ Iwlldrnelcl
t�fent mMwlal o+n `^ Flaoa P� Melton, Upplle" to A
U a U,U�1lgT ®Q w 111t1�1 X11 fIl TNT
s D u s D u �Is u
as C]L E3 8 130
$OIL 019CRIP nom RgpORT
Boring Nor' Depth OO TMant Color M a Ileg Taxtuea structure 3PQ/It
in. A1t,n�en Cry. SL cw t Cdw Qr. sz. 8A. Gctos Aooy 1�e0
1! 6
am
Groud — 1
9% M h
Qyr -W
.5 '.6
2 Z — � ni�1 lc`aY�k r
qna 2 i »3
Ground 3 8 -32 .1 1 r 2 . 3
s �. 4 2 -84 6 north eoa am b1 na na .7
ilCler .
Ramaskx
CST Nye:— pte..e Rine L Ste fto 7! 2464aW
1S15-U 200th, Now w� 7
Dam
� � ,q_pp C:ST TIdm1w, a=9t
Ito
W
I ql:
�i�g
up
raw
mm
mm =mum
mm mmmm
mm =mom
08/02/2000 15:12 7152462579 PAGE 04
6--03 -1966 6 : 2SPM MOM P. 2
" y �
STEEL'S SOIL S ERVI CE
Gary 1, Snot 1554 200th Am
98 Q�wood Eetmsprimm, Ine Now Rk*V710W. WI 54017
G$TM22
CSTM22 3254 N4� S13,T311w-1t1Bw (716) 246.5200
torn of Star prsrle
lot ON -Nor"t ate
mdx soil evalnaitica 4+>rs caird-ted to satlary► a Ong rardZemm aft, it mw or way
sst m saltabia !or rear vie. "e looet or stye "tent aer as flap Uft m ao 8bWM
as pezzenent sat 11T W mare soot ertabiietred at the t ime 00 feet ells aenduetwa
BM. top of 1" v4c pipe o el. 1004
Alt. Ak.= top of 1" pvc pipes 0 el. 99.75'
$ 01
io
3a` Ar
Onry L. Stool
i1�2 -9y8
08/02/2000 15:12 7152462579 PAGE 01
N.
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N or � �-
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code
each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3 (O
Number of Bedrooms
Design Flow - Peak (gpd) LSD
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal) O
Soil Absorption Component Size (ft)
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption omponent
Design Flow - Peak (gpd) -56
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not. removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address S7 e �C �4
Property Address /3 53 °F 0r_
(Verification required from Planning Department for new construction)
614'^ �T0�l M% t'
City /State 40 Parcel Identification Number D d S S
LEGAL DESCRIPTION
Property Location NO '/4 '/ Sec. T 3 / N -R. W Town of R. ►" 1 � -
Subdivision 1 V O r'A Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # (4 2-fo a l , Volume �SZB , Page #
Spec house ❑ yes PQ no Lot lines identifiable 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.
I/we, 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
da s of the clue year expiration date.
SI NATURE OF 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
ti rope described above, by virtue of a warranty deed recorded in Register of Deeds Office.
"...__._. 74/
'GNATURE OF APPLICANT DATE
Any information that is mis -re resented may result in the sanitary permit being revoked b the Zoning Department.
} P Y rYP g Y g P
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
152 a '
VOL p'
62686,1
STATE BAR OF WISCONSIN FORM 1- 1998 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Greenwood Enterprises. Inc. a Wisconsin RECEIVED FOR RECORD
corporation Grantor, and Dennis LeQue. a married person Grantee.
Grantor, for a valuable consideration, conveys to Grantee the following 07- 24-2000 9:40 AN
described real estate in St. Croix County, State of Wisconsin (The "Property "): WARRANTY DEED
EXEMPT #
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 59.70
RECORDING FEE: 10.00
PAGES: 1
Recording Area Address
Name ��Qcrtc� #- � e
ciao 5 , a.l,,,� 11( r
t ws
cam- 03� 5
038 - 1190 -40
Parcel Identification Number (PIN)
This is not homestead property.
(s not)
Lot 26 of the Plat of NorthGate, recorded in the Office of the Register of Deeds for St. Croix County, Wisconsin on May
20, 1999 in Volume 7 of Plats, at Page 46 as Document No. 603503.
L
Together with all appurtenant rights, title and interests.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances
except easements, restrictions and reservations, if any, of record.
Dated this af,� day of 2000.
GRE D ENTERP ,
By:
* *J e . Rusch, its president
By:
* *Mary ft. Ru is s ry
ACKNOWLEDGEMENT ACKNOWLEDGMENT
STATE OF WISCONSIN ) STATE OF WISCONSIN )
) SS ) ss.
St. Croix County St. Croix County )
Personally came before me this C90 day of July, Personally came before me this day of June
2000 the above named James E. Rusch, its president 200 the above named Mary R. Rusch, its secretary to me
to me known. to be the person(s) who executed the known to be the person(s) who executed the foregoing
foreg . g instrument and acknowledge the same. instrument and acknowledge the same.
N tary Public, State of Wisconsin
M y commission expires H - 4- 0 1
g —Q1
Notary Public, State of Wisconsin
THIS INSTRUMENT WAS DRAFTED BY My Commission is permanent. (If not, state expiration date:
Lois A. Murray, Zilz, Estreen & Ogland, LLP )
304 Locust Street, Hudson, WI 54016
(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 DEW 9rATE BAR OF WISCONSIN
FORM Na 1 -1998
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 800.666.2021
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