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HomeMy WebLinkAbout038-1196-40-000 V Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT St. Croix 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)]. 363984 Permit Holder's Name: ❑ City ❑ Village ❑ T6wn of: State Plan ID No.: Warner, Jeff Star Prairie Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: P 0 , Y 038- 1196 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic * r] Benchmark �- q -Z `d Do Alt. BM 4 3� Aeration Bldg. Sewer H Ing Ht Inlet o TANK SETBACK INFORMATION �/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Air Intake Septic t6 0 ' n (b ' NA Dosing NA Header / Man. i:, 3 Aeration N Dist. Pipe r I H g Bot. System (a) r I r I PUMP/ SIPHON INFORMATION Final Grade 3, urer mand St cover Model Numbe G TDH Ift Friction stem TDH L oss e orcemain Length Dia. Dist. ell SOIL ABSORPTION SYSTEM t e C - BED/TRENCH Width r Le gth No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION P I DI MENSION S SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu actuc : SETBACK �. INFORMATION Type 0 ) 3 r / '�" ' "" o Num b r: System: G VK�7v� DISTRIBUTION SYSTEM Header/Manifold C/ r/ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. r LengthW__7?S_Dia. /�_ Spacing _j� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of T x Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No E] Yes [] No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: ©D Inspection #2: Location: 1336 216th Avenue, New Richmond, WI 54017 (SE 1/4 NW 1/4 13 T3 IN R18W) - 1331181028 Pine Acres -Lot 33 n 1.) Alt BM Description =' a� tau dVM ' Cl 81 2.) Bldg sewer length= /fl �- amount of cover = > + ck h1 V A� j 0 � 4S �¢cv Plan revision requ red? ❑ Yes 12 No r Use other side for additional information. SBD -6710 (R.3/97) Date Inspecto ' ignature Cert. No. V ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I � E E m _� _ m. _ tt 1 3 340 2j Ave— Sanitary Permit Application Safety & Buildings Division ____ __--- In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. War reverse side for instructions for completing this application PO Box 7302 `�sconsl Personal information y may ou p y provide be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach complete plans (to the county copy only) for the s s a er not less than 8 -1/2 x 1 I inches in size. county State Sanit Permit Number ❑ Che , ' n �rsv application State Plan 1. D. Number [ r2o a 1 1... I. Application Information - Please Print all Information '� Location: Property Owner Name ; , l C y f n Property Location �E1^F \W) FfW EIZ C CU (1 ( ,V �- f c..)C 1/4 `u VI A, S 13 T 31,N, RA or Property Owner's Mailing Address t. ? ZOO Lot Number Block Number 12 1 �i ZN AYG ST C ROx ��'� 33 ) ' City, State Zip Code ho �.' Subdivision Name or CSM Number FFICE nR.L:Srt 1AkE 7Y1>\d 55025 : pIgg- Aomr_S ° O II Type of Building: (check one) t 9 ❑ City O O 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): N J T own of ❑ State -owned SMP TRIM L III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest go�c� "r A) 1. %Iew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel T {L ax . Number(s) System Tank Only Existing System 1 9lwl - t) () - DP�D B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued 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 -grade i ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: VDis ersal/TreatmentAreaInformation: US) W_ - " L ii ii tl 1 SILL- t✓f /obC.a, 9/JFi Li gAinKs c� 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) Min. /inch) Elevation 37_7 61 1. Z 95.2 99.5 VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ 1:1 ❑ 11 f � la�O 2 WEED Q i FT VII Responsibility Statement I, the undersigned assume responsibility for installation of the POWTS shown o ttached plans. Plumber's Name (print) Plumber's nature (no stamp ): M O. Business Phone Number R�x 1 223 2_42_ 1 - 7)- , S - 2q - 2 ri i Plumber's Address (Street, City, State, Zip Code R b x 2! S t�& SS9_P_ vsr 5Al0 M VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse charge Fee) Determination 4P aag 6D IX. Conditions of Approval /Reasons for Disap roval: *- 2 �` SF0 7/00) Z cJ�4'^^�a SBD -6398 �'R. + Aa l 2 � , q CD Q CD O aD ,, ZZ Lij Z cn w t1'r Q: V ti clj S N G Cl 72 CL ? o w V7 c� \� N • Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 8'/s x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal referenc �, direction and �� e)e s , I( percent slope, scale or dimemsions, north arrow, an cptiar bird rli to nearest road. parcel LD.# APPLICANT INFORMATION - Pl"Si pKrnt a/! oformafk ;n Pendin Personal information you provide may be used for s4eghdory purposes (PrNaq law, ). t5. (1) (m)). � y v� a Rte Property Owner °pro rty Location Lakes & Hills Development GOA. Lot 114 NW 1I4,S 13 T 31 N R 18 W Property Owner's Mailing Add r Lot Block # Subd. Name or CSM# 3 -- Pine Acres Ity State Zip Code Ph oW1@iibIC r; City ❑ Vifl4qe kTown Nearest Road ,�� ,c �✓ /c1 6'r�S�Y�, f�c ,�°a.',C, 216Th. AVE. ❑ New Construction Use: N Residenfiai4wditr' rooms 3 ❑Addition to existing building -- Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpd/ftz 8 trench, gpolftz Absorption area required 643 bed, it' 562 trench, fF Maximum design loading rate .7 bed, gpdff .8 tr ench, gpd/fB Recommended infiltration surface elevation(s) 95.2 ft (as referred to site plan benchmark) Additional design / site considerations Parent material - - - - -- Flood plain elevation, if applicable - - -- -- ft S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system MS D U ® S u ® S❑ u ❑ S u ❑ S® U ❑ S® u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/W Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Sz. Sh. Consistence Boundary Roots Trench 1 1 0 -10 l 0YR3 /3 ------------ - - - - -- I 1 msbk mvfr as if .4 5 2 10 -25 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5 Ground 3 2 -49 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- .7 ,8 , �- elev - - - -- -- - - - -- 99.5 ft. 4 49 -94 10YR4 /6 ------------ - - - - -- cs osg ml - - -- - - -- 7 8 , "�- Depth to — limiting factor >94" Remarks: 1 0 -11 10YR3/3 ---------- - - - - -- I lm mvfr as 2f .4 .5 2 11 -26 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5 Ground 3 26 -50 7.5YR4/4 - osg ml cw - - -- 7 8 elev 99.6 ft. 4 5K 10YR4 /6 ------------ - - - - -- ,�s osg ml - - -- - - -- 7 8 - Depth to —_ limiting — factor � 0 0 93 , Remarks: CST Name (Please Print) Signature: Telephone No. Jacque Hawkins "�..... y7z - J y Y,6 Add Date CST Number Ref # /� u� 4/10/00 406 PROPERTY OWNER: Lakes & Hills Development SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# Pending /.— Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary oots GPD/fl? in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ry Bed ;Trench 1 0 -9 10YR3/3------------ - ---- I Imsbk mvfr as if .4 .5 2 9 -26 10YR4 /4 ----------- - - - - -- I Imsbk mvfr gw lvf .4 .5 Ground eleV 3 26 -52 7.5YR4/4 ------------ - - - - -- cs osg ml ew - - -- .7 .8 " 98.8 ft. 4 52 -84 10YR4/4 ------------ - - - - -- es osg ml - - -- - - -- 7 8 .� Depth to limiting - -- -- -- factor > 8411 - - - -- - -- - -- - - - -- Remarks: 4 1 0 -10 10YR3 /3 1 Imsbk mvfr as 2f .4 .5 2 10 -25 10YR4/4 - - - - - -- 1 lmsbk mvfr gw lvf 4 .5 ----- - - - - -- Ground elev . 3 25 - 52 7.5YR4 ----------- - - - - -- .mss - osg ml gw - - -- .7 .8 - 99.1 ft. 4 52 1 /6 ------------ - - - - -- G5_- osg ml .8 Depth to limiting - -- -- - - -- -- -- -- factor a k Q >89 — Remarks: 5 1 0 -11 10YR3 /3 ------------ - - - - -- 1 Ims mvfr as if .4 .5 2 11 -23 10YR4/4 ------------ - - - - -- I Imsbk mvfr gw lvf .4 .5 Ground - - - -- elev 3 23 -51 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- 7 8 99.3 ft. 4 5&9 10YR4/4 -- ------------- - -- es osg ml - - -- - - -- .7 .8 Depth to limiting - factor > - 89 aq• Remarks: - - -. -_- Ground — � -- - - - - -- elev - ft. Depth to limiting factor Remarks: C -'F � 2 � R � 2 Y o M � T2 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Z' Division of Safety and Buildings in accordance with Conan 85, Wis. Adrn. Code County Attach complete site plan on paper not less than 0 1/2 x 11 inches in size. Plan must include, but not limited lo: vertical arid horizontal reference point (BM), direction arid Parcel I.D. percent slope, scale or dimensions, north arrow, and location arid distance to nearest road. Reviewed by Dale Please print all information. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4" S fc) T - N R % E (or 6& Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Villi Town Nearest Road New Construction Use: g Residential / Number of bedrooms Code derived design flow rate Y 69 GPD ❑ Replacement ❑ Public or commercial -Describe: Flood Plain elevation if applicable ft. Parent material General continents and recommendations: E] Boring Boring # I-tt Pit g l6l Ground surface elev. S �' �" 'ft• Depth to limiting factor ��J� in• ® Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •Eff # GPD /f *Elf #2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. 1 Sh. 0 '/dyes its' / J�Q ' 7 r El Soi Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor ln• l Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff #1 PD /ft *Eff #2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Efuent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L fl ber N CST um CST ne (Please Print) { Signature �aa CST um/ 1 Dale Evaluation Conducted Telephone Number Address 7z e lo/.f ' 6 Qu e "(u e G Q Ic N Gt �' ? � �� ® 0 � r , rl -� N v z r '� C' 0 2 �p U Y e 0802 -99 07:45 CROSS COUNTY ID= 7152943138 P.01 ' r • VAX r. sew. r. Ww. rw. u.. rR �. sr. Asr Noses. axon r.r. /r.• &A".r• mono r■ ....... ra ...r..r..rsr ..r• CMOS5 WUmTRY EXCAVAVWG PO 301, 2951104 CL A= RD j% ME M, WL 53009 (7M 293 -5141 DAZE: S L r�- 20: NAIr+0r= FAX NtMSER: FR O M.. FAX NIII1�i8F�: rN11 FR 0FrAGfS!NCLUDR4G COVSR SBZET: TE AND LErwil" WORMA now ]S NOT REC rVED• PL3A5E CONTACT US. IF COIVIPLB 08'02 - 99 97:45 CROSS COUNTY ID= 7152943138 P.(]2 Wisconsin Departrnenl of Commerce SOIL EVALUATION DEPORT Page — L of Division of Safely and Buildings unty ( 0' A in al:cord:lnce with Coiu1M 85, Wis. Adm. C e Co nl►ach C01 11000 sire pldn on D2per ttul less 111211 0 111 x 11 illcires fu size, Plan Must incluJe, Out Mvl limited to: vertical and hofitonlal leleir nce Vuint ldM) diieclian and Parcel l D. percent slope, scale or dimensions, north arrow, and location and distance to nearest toed. Revi ewed by Dale Please print all lnfotmation. Pcisonnl inluauolian you provide nay be used for secnndsry uliiposes (Pii -acy Law, S. 15.04 (1) ([Ti)), Property Location l 8 E for W Properly Uwllcr Govt. Lot 1/4N►a S /3 T 3 / N R d ' i ' f ' ��s ���/ at It Biotic # Subd. Name or CSM# Plopetty owners Mailing Address ,�- � A, Z 3i � er VIII Town Nearest Road Slate Zip Code Phone u Nmb City ❑ ,, t=irY }' , 4, 6 0r Z-! tt Q.J fC —ll� M/-) rSsf /G� l (.St ) � Yf' 0 / o GPD N Catslruction Use: 0 Residential I Number of bedioonis Code derived design flow rate Public or coinntefcia( - Describe: (t. � ReVlaceolent ❑ Flood Plain elevation i( applicable Parent Itiaterial ff ntS ati0ns: Boring �J 9 �+ V rn lfG Boling t/ / � ll- Depth to firtliting factor ^ Sal Appcaon Rale ® Pit Ground surface elev. Bo Roots GPD /ftz Redox Oesufpliolt Texture Structure Consistence undary •Ell #1 'E11 Horizon Depth Dominant Color Gr. Sz. Sh. ` (.2 i in. Munsell Ou, Sz. Cont. Color % > c7 In ` � ,.� ✓ f CZ c, 7S iy cs Boring D to lliniling factor in. Soil Apptl ®lion Rate t Bofiny # pit Ground surface elev. Q GPR /(t' Redox Description Texture Structure Consistence Boundary Roots *E1101 •E1102 Horizon Depth Dominant Color Or. Sz. Sh. in. Munsell Qu. Sz. Cant. Color • E(puent #2 = BOD' 30 trig /L and TS5 � 30 mp /L Effluent tit = BOD > 30 < 220 mg/L and TSS >30 < S 150 mg /L CST Number Signature , daa 0 � CST (Please Print) Telephone Date Evaluation Conducted Number Address Y�Z ��y�� 9& -02 -99 07:45 CROSS COUNTY ID= 7152943138 P.03 rA it CI l7� o N LA r� L J Q � Z D 2 Qj a w —o ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J G� 4 11 14 9 11 Mailing Address Property Address x- ro / G , (Verification required from Planning Department for new constructio City /State Parcel Identification Number Q3 LEGAL DESCRIPTION Property Location ' /o, '/<, Sec. 3 , T N -R_W. Town of Sf�k� 1 �� % C Subdivision 914E '_�C kr S , Lot # 35 Certified Survey Map # , Volume Page # Warranty Deed # 602 6 , Volume ,Page # it Spec house ❑ yes � 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. 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. 071121 S TURF 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) f the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ) 07//2/00 SIQKK1iJRE 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 * e a copy of the certified survey map if reference is made in the warranty deed M W C' QvHl aJCCC4 VOL �525 PAGE 259 E>2� 152 KATHLEEN H. WALSH Document Number Document Title REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 01 -11 -2000 8:30 AM WARRANTY DEED EXEMPT ff CERT COPY FEE: COPY FEE: TRANSFER FEE: 94.50 RECORDING FEE: 12.00 PAGES: 2 Recording Area Name and Return Address �+ fjI * 1:Scrucu 3? 3 S C ,w? u A �y1 7 Parcel Identification Number (PIN) This information must be completed by submittcr: document title. name & return address and P1N (if required). Other information such as the granting clauses, legal description, ctc. may be placed on this first page of the document or may be placed on additional pages of the document. ote: Use of this cover page adds one page to your document and $2.00 to the recording fee Wisconsin Statutes, 59.43(2m) WRDA 2/99 215-32 (2199) E Worm No. 7 -M— WARRANTY DKED Minnesota Uniform CarveYinein Blanks 1978 Ilulslad Ic tan m, P.I..C. Cc poration or Partnership to Individual(s) yOL 1525PAG 260 No delinquent taxes and transfer entered; Certificate of Real Estate Value ( ) filed ( ) not required Certificate of Real Estate Value No. , 19 County Auditor by Deputy STATE DEED TAX DUE HEREON: $ (reserved for recording data) Date: July 6 1 20 00 FOR VALUABLE CONSIDERATION, Lakes and Hills, Inc. , a Corporation under the laws of Minnesota , Grantor, hereby conveys and warrants to Jcffrcy A. Warner Grantcc(s) real property in St Croix County, Wisconsin, described as follows: Lot 33, Pine Acres, St Croix County, Wisconsin "The seller certifies that the seller does not know of any wells on the described real property." together with all hcreditaments and appurtenances belonging thereto, subject to the following exceptions: Easements, covenants and restrictions of record. Lakes an Hill I nc. Affix Deed Tax Stamp Here By. Richard S. flelson Its: President STATE OF MINNESOTA SS. COUNTY OF RAMSEY The foregoing instrument was acknowledged before me this 5th day of July ,20 00 by Richard S. Nelson, President and the and of Lakes and Hlls, Inc. a Corporation under the laws of Minnesota on behalf of the Corporation NO "1'AItIAL STAMP OR SEAL (OR OTIIL• R T11'LL' OR RANK) n / ' SIGNATURE OF PERSON TAKING ACKNOWLEDGMENT DEBORAH L. TEICH NOTARY PUBLIC -MINNESOTA 'fax Statements for the real property described in this instrument ' MY COMMISSION should be sent to (Include name and address of Grantee): EXPIRES JAN. 31,200 THIS INSTRUMENT WAS DRAF`TE'D BY (NAME AND ADDRESS): Jeffrey A Warner Northwest Title & Escrow Corp. 1248 - 18th Ave SE 3535 Vadnais Center Drive Forest Lake, NIN 55025 Vadnais Heights, MN 55110 59865 dt uy 0) I CN 29 N 30 I *-� 65,992 sq, ft. ZI I 67, 922 sq. ft. 1.51 acres 1.56 acres LECE 69 .56' --�— � 4'0 2.3 Ni p° o so8t6 ?6 "w I �' O Denote, �9• �� /�0• ' Alums I N. o Denote: 67,930 sq.ft. r \ 166 N ��,^ 1.56 acres I w • Denotes -��' �I � (unle I o C46 Denote! s\ \ _ 2 I I� W 54,. - `36� 99' _ w S! \ , \� 1 77.69' _ s 6 Denotes 5 I ( 12ft. °� �% T I I Denot 67,220 sq. ft. q. ft. � I I N 1.54 acres Denot 32 to I �' 67,082 sq. ft. I (rec.) Denote to N 1.54 acres I (meas.) Denote (%-V 0) I I I I Vertical Datum °I .'� 362.83 N00 °49'40 "W I All Other Lot Cc I Lo W, i 1 " X 24 .. Iron F t •K, Col o ° i 34.06 228.77 I t o r o I� Distances are n d l i' I ; 0.001' and me LO Angles are corr. and measure y > > 0 8 0 100' a, o � aW rn Co a 34 z �^ o 65,768 sq. ft. I _ 7 , 778 sq. ft. 1.51 acres I I I I bl w �1 •�,/ 1.79 acres oN0 N O COh 199.4 .� W 12.00' -` w 211 5., u W ao -, 1. -�° °06'1 I S10 8 "E 211- 12 /00I M e y y __ _ -% o 00 ri a- to A �J Col 1S M A0 INN O � s �� T HENDE TODD PREPA 23 �� 1ASHOTAH, Todd M. Hendershott, RLS 2362 WI Q� Registered Wisconsin Land Survey r Dated this /7f da of � 2000 R \J�������\\\\ ' i i ns � U mi ► � � � � t • � ����` This instrument drafted by Todd M. Hendershott —