HomeMy WebLinkAbout040-1285-00-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
• 399604 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan I 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:
Miller, Sam I Troy Township 040- 1285 -00 -000
CST BM Elev:� • ' BM O
Insp. BM EElev: BM Description: ` } � ^ q 2s LC4
` t
m t o - e . C ST' 19" t
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet 1
I
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic - $,O/ z`t Dt Bottom
Dosing de N. ,L Header /Man.
93. �
Aeration Dist. Pipe
93.43'
Holding Bot. System O Z_' Final Grade
PUMP /SIPHON INFORMATION
Manuf cturer Demand St Cover
Model 11tub er
TDH Lift riction LossSystem Head TDH Ft
Force In Length Dist. to Well
SOIL ORPTION SYSTEM 5 ,A
%W RENqtj, Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DI S 3 f 43 2
SETBACK SYSTEM TO P/L BLDG IWELL LAKE/STREAM LEACHING Manuron
INFORMATION CHAMBER OR & �-t4fY
Type Of System: r t ti Z O UNIT Model Number: to
('IS.'"I , S 31> I l
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
P' T5
Length Dia Length Dia Spacing T
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 W No no Yes No
CO MMENTS: (Include bo di pe ' pysons present, etc.) Inspection #1;_1 /�O j ,�l Inspection #2:
� Parcel No: 09.28.19.1614
L ocation: 497 Bauer Road Unkn wn (N NW 1/4 9 T28N R19W) The Orchard Lot 20
1.) Alt BM Description = C p ;,
2.) Bldg sewer length= ,Z` � -
- amount of cover
Plan revision Required? ® Yes X No / �P
Use other side for additional information.
' is —6 Insep rs Signature rt. No.
SBD -6710 (R.3/97) f'0�,� nn 0, rr
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Sanitary Permit Application ` Safety & Auildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
Nv isconsin Madison, WI 53707 -7302
Personal information you provide may . used for secondary purposes Submit completed form to county if not
Department of Commerce (Privacy Law, s. 15.04(I)(m)) ( Submit ty
state owned.
Attach com late plans to the county co only) for the s stem on a. er t less than 8 - 1/2 x I 1 inches in size.
C Un State Sanitary Permit Number ❑ Check if sion to pt Us 4p t Lion Stale Plan 1. D. Number
C I o
I. Application Information - Please Print all Information Location:
Property Owner Name t'T C^ . , a Property Location
Block Number
Property Ownees Mailing Address ; t t Number
City, State Zip Code Pfibne Number GQU Subdivision Name or CSM Number
v So LcJ Sy 'o/ ...i.� =2 7�
❑ city
II. Type of Building: (check one) ; ,j, ❑ village
❑ 1 or 2 Family Dwelling -No. of Bedrooms : `�__;,_ n
?'1'ownof
❑ Public/Commercial (describe use):_ ? 3 3 7 s
❑ State -Owned Nearer Ro
�q U� 2c7i41�
/ Q 3 - � ( � C Parcel T Number(s) o yo -
III. T 2 Chec
o Permit: k only one box opt' line A. Check box on line B if applicable) 2 _ 8 • 11
ew
1. 2. ❑Replacement '3. ❑ Replacement of 4. 5. 6. ❑ Addition to
A Existing System
stem S stem Tank Onl
Permit Number Date Issued
❑ A Sanitary Permit was Previously issued 7 7A' k
IV. Type of POWT System: (Check all that apply - g1G D av
n- ground �.F #+� Mound Non- pressurized i ❑ ❑ Sand Filter ❑ Constructed Wetland
Pressurized In- ground ❑ Bolding Tank ❑Single Pass ❑ Drip Line
❑ At- rude ❑ Aerobic Treatment Unit ❑ Recirculatin ❑Other.
V. Di ersal/Treatment Area Information: 7 Final
I Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation Elevation rade
Required Proposed Rate (GalsJday /sq. R.) (Minlinch)
VII. Tank Capacity in Total 4 of Manufacturer Pre! ,b Site Steel Fib Pstic
Gallons Gallons Tanks Con- Con- g
Information — crate °t ; - , rted
New Existing
Tanks Tanks ❑ ❑ ❑ ❑
5 ,07`�t'� /Lto0 WEIS t
❑ ❑ ❑ ❑ ❑
Z►4
EL 60 7 r 4 7".�
VIII. Responsibility Statement
1, the undersigned, assurn res onsibili for installation of the POWTS shown on the attached fans. pLLSincss Phone Number
('lumber's Si nature no sta M IPRS No.
P!um!xrs
Name (joint) g (
Plumbers Address (Street, City, State, Zip Code)
IX. County /Department Use Only
Sanity Permit Pee (Includes Groundw atcr Date Issued I ui Agent Signature o stamps)
= • Disapproved n
�kApproved❑Owner Given Initial Adverse Surchar c Fee) / (l3D O
Determination Z
X. Conditions of Approval /Reas for Disapproval:
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76"
Chamber
Height
a O 00 0 00 00 00 0o ao 00
AH th'r Diffuse' sizes can —
withstand H-10 loads when
with Pr X Qrad0d Chamber
WW 8011$. A rYlY11' Height
of g over. i8
req M-140 The End View
1 AF BipDiffuser i
is for H -20 loads•
A of 1W of cover is 34°
requlr M *2A loe�ds.
4" Knockout
I
Universal End Cap
I
AVCdlable Sizes ' ; ' ,
Length 76 76" 76"
Width 34" 34" 34
Height 11" 14" 16" v
Invert 6.5 9 11.3
10
1398
. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of _ _- 3 ---.-
Division of Safety and Buildings in accordance with Comm 85, Vft- Adm. Code ACE Soil & Site Evaluations
Attach complete site plan on paper not less than 8 x i i inches in size Plan must County " St. Croix
indLKI% but not limited to: vertical arid, ogmWWp" point (BM), dimcdon and
percent slops, scale or dimemsions, -10WV and )&*kand distance to neared road. Parcel I.D.
040-1039-60-000, ID#9.28.19.132
Meese Date
R By
Personal inromiabm YOU WOVKWO used purposes (1 w, s. M04 (1) (m)).
Property Owner Property Location
Miller, Sam
Govt Lot NE 1/4 NW 1/4 S 9 T 28 N R 19 W
- 1
Property Owners m "' ailing Add�ess , -7 11
--�
Lot # - - 1 - Block # Subd. Nam or CSW
P.O. Box 151 20 Plat Of Miller's, Orchard
City
C Town Nearest Road
City p Code Zi Ph _j _j Village
,0
Hudson 'VVR 1 54016 (715 ) 3$6 i69 Troy
Bauer Road
Mr Now Construi:tion Use. R& be 4 Code derived design flan rate 600 GPD
Replacement Public or comrnercial - Describe.
Parent material Glacial outwash Flood plain elevation if applicable — na
General comrnents
and recomrnenclations: Recommend installing 2 trenches at Tx 90.625 using 29 high capacity MoDiffuser infiltrator chambers at
system elev. = 93.00'.
Boring # I Boring
#A Pit Ground surface elev. 99.03 ft Depth to limiting factor > 131 " in. Sad Applicabon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Cormterice Boundary Rooft ffff#1 a PW/ f P
- "E — *Eff#2
1 0-10 1 Oyr3/2 none sil 2fsbk mvfr as 72f 0.5 0.8
2 10-22 1 Oyr3/4 none so 2fsbk mfr cs I f 0.5 0.8
3 22-28 10yr4/4 none sl 2msbk mfr as 1f 0.5 0.9
4 28-34 7.5yr4/6 none is Osg ml cs - 0.7 1.2
---------------- — -- - - - - -- ----- ---- ------ --
5 34-72 1 Oyr5/6 none s Osg m I gs 0.7 1.2
6 72-131 1 Oyr5/4 none s Osg ml 0.7 1.2
Boring 2 Boring # Bauv
01 Pit Ground Surface elev. 98.83 ft. Depth to limiting factor > 130" in. Sod AWnfion Rate
Horizon Depth Dominant Color Redox Description Texture shchn Condsterice Boundary Roots GPD/W
*Eff#1 -Eff#2
1 0-9 1 Oyr2/1 none sl 2fsbk mvfr as 2f 0.5 0.9
2 9-17 1 Oyr3/3 none sl 2fsbk mfr cs I f 0.6 0.9
3 17-25 1 Oyr5/4 none sil 2fsbk mfr as 1 f 0.5 0.8
4 25-36 7.5yr4/6 none Is Osg ml cs 0.7 1.2
5 36-69 1 Oyr5/6 none s Osg ml gs 0.7 1.2
6 69-130 1 Oyr5/4 none s Osg ml 0.7 1.2
Effluent #1= BOD ? 3-0-< 220 moll, and TSS 4< 150 mg/L Effln - BOD.S.30 mg1L and TSS --W Mg/-
CST Name (Plea" Print) Sig re: CST Number
James K. Thompson —
Address ACE Soil & Site Evaluations Date val
340 Paulson Lake Lane, Osceola, WI 54020 4/23/01 715-248-7767
t39,V
Prey Omw Miller, Sam Parcel ID # _ 040 - 1039 -60 -000, ID #9.28.19.132 Page 2 of 3
F Boring
3 � # 1� Pit Ground Surface elev. 98.43 ft. Depth to limiting factor > 128" in. Sol Application Rate
Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Rods GPDr
*Eff#1 *Eff#2
1 0 -12 10yr2 /1 none s l 2fsb mvfr as 2f 0.5 0.9
2 12 -22 1 Oyr3/3 none sl 2fsbk mfr cs 1 f 0.5 0.9
3 22 -34 1Oyr5 /4 no ne sil 2fsbk mfr as 1f 0.5 0.8
C �,cj$D 4 34-40 7.5yr4/6 none Is Osg ml Cs - 0.5 0.9
16 5 40 -78 10yr5 /6 none s Osg ml gs - 0.7 1.2,
6 78 -128 1Oyr5/4 none s Osg ml - - =0.71.2
Hor #5 contains two 1" - 2" discoirthuous bands of Om 7.5yr4/4 Is at 42" & 48". Loading rate of horizon adjusted to relfec:t reduced penniability -
izon
associated with banding.
[ ] Boring # I Boring
lA Pit Ground Surface elev. 97.81 ft. Depth to limiting factor > 123" in. Application Rate
Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Rails
*Eff#1 *Eff#2
1 0 -17 10yr2 /1 none sl 2fsbk mvfr as 2f FOY 0.9
2 17-31 1 Oyr3 /4 none sl 2fsbk mfr cs 1 f 0.9
3 31-56 7.5yr4/6 none Is Imsbk mvfr cs 1f 1.2
4 56_88 1Oyr5/6 none s Osg ml cs - 0.7 1.2
5 88 -101 1Oyr5 /4 none s Osg ml gs - 0.7 1.2
6 101 -123 1Oyr6 /4 none s Osg ml - - 0.7 1.2
F #
Ong 16 Pit Ground Surface elev. 96.94 ft. Depth t0 limiting factor >118" in. SW Application Rile
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods CMW
"Eff#1 *Eff#2
1 0 -12 1Oyr3/2 none sil 2fsb mvfr a s 2f 0.5 0.8
` / 2 12 -21 1Oyr3 /4 none sil 2fsbk mfr cs 1f 0.5 0.8
g. 3 21 -29 1Oyr4 /4 no ne sl 2msbk mfr as 1f 0.5 0.9
4 29-54 10yr5 /6 none s O sg ml Cs -
5 54-83 10yr5 /6 none s Osg ml gs - 0.7 1.2
6 83 -118 1Oyr5 /4 none s Osg ml - - 0.7 1.2
Horizon #4 contains 1" - 7' bands of Om 7.5yr414 Ifs. Loading rate of horizon adjusted to relied reduced permiability associated with banding.
* EMLwd #1= BOD s > 30 < 220 mg/L and TSS >30 < 150 mg& * Effluent #2 = BOD <30 mglt. and TSS <,O mglL
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 depm1ment at 608- 266 -3151 or TTY 608- 264 -8777.
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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.
54 Wis. Adm. Code and the In- Ground
i management Ian complies ,
Th lies with Comm 83 p p
9
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specification
Sanitary Permit Number 3 6 e
Number of Bedrooms
Design Flow - Peak (gpd) C o
Estimated Flow - Average (gpd) L
Septic Tank Capacity (gal) F z- So
Soil Absorption Component Size (ft
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) 4 12 I
Maximum Influent Particle Size (in) 1 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 se and outlet filter shall be assessed at least
once every 3 years by inspection. TIO outlet filte
shall be cl as neces sary to enure
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
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
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3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION DORM
Owner/Buyer
/L 4.1
Mailing Address 'A �s
Property Address 4
(Verification required from Planning Department for new construction)
Ci ,�'�y� -S D Parcel Identification Number y
tY
i.Ft wL DESCRffi4N
1 / 4 , �'/4, Sec. �, T O N -R � 1 own of
property Location �- ,
�' ?�
Subdivision W AV Lot #
CetrtiQed Survey Map #
h y 8 3 hp13 , Volume Page #
Warranty Deed # !p
3 -a 7 l < , Volume S' s Page # 3 ?r
Spec house yes O no Lot lines identifiable N(yes O no
could result in its peernature failure to handle wastes, Proper maintenance
Impsoper use and maintenanceof your septic system could What you put into the system
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper
can affect the function septic lion of the tic tank as a treatment stage in the waste disposal system.
e owner and by a
b th
a to submit to St. Croix Zoning Department a certification form, signed Y 1
The owner 11� s ProPetsY t 1
ma:terplua►ber, j plumber. restricted plumber or alicensed pumper venfymng � () the on -site wastewaterdisposa tank is less than 1/3 A111 of sludge.
is in propel operating condition and/or (2) after inspection and pumping (if necessary), septic
maintain the
requirements and
a to ma pr i va te sewage disposal system with the standards P
Uwe, the undersigned have read the above requ g
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating a your septic system. has been maintained must be completed and returned to'the St. Croix County Zoning Off
within 30
days of the ILWee year ex mrati n date.
DATE
S1t3N K • APPL CANT
' knowled e. I we am (are) the 6wneds) of
certify that all sta ts on this form are true to the beat of my (our) g ( )
• e e of a warranty deed recorded in Register of Deeds Office.
81 0
DATE
1 - A jVft 6VAPPLI
•••••• Any information that is m may result in the sanitary permit being revoked by the Zoning Departn'"L
•� It " -Ada 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
l ,O
a STATE BAR OF WISCONSIN FORM 7 - 1996 632796
TRUSTEE'S DEED KATHLEEN H. WALSH
Down.nN,,,Wer VOL 1555PAGE323 ST. CROIXOCO., WI
DANIEL S. SOLBERG AND KARLA J. SOLBERG
RECEIVER FOR RECORD
� ll-01 -2000 8s30 AR
TRUSTEES REEK
as Trustee d EXEIRT 1
SOL BERG - AND DANIEL S. KARLA 1. SOLBERG REVOCABLE CERT COPT FEEL
tED APRIL , _ COPY FEE:
TRANSFER FEE: 28110.30
RECORDING FEE: 10.01
for a valuable consideration conv without warrant to PAGES: 1
E. !TILLER, A SINGLE PERSON
rlocarttwp Areo
Grantee. -. _.....-- -- ......... ..
the following described real estate In ST . County. !Nwm v4 Rant"" Address
State of Wisconsin: SAN MILLER
PART O F.THE NA OF THE N AND THE SW OF THE NWk AND THE P.O. BOX 151
HUDSON. WI 54016
NEk OF THE NWk AND THE NWk OF THE NEk AND THE NWk OF THE
SWk OF SECTION 9, TOWNSHIP 28 NORTH, RANGE 19 WEST, TOWN !
OF TROY, ST. CROIX COUNTY, WISCONSIN AND MORE PARTICULARLY.- :- ---,:_:_..-,--: --
DESCRIBED AS FOLLOWS: BEGINNING AT THE NORTHWEST CORNER OF 040 - 1038 -60 040 - 1039 -60 - 000
SAID SECTION 9, THENCE SOO'50'54 "E ALONG THE WEST LINE OF 040 - 1039- 7n - nna
SAIDNA 2626.30 FEET TO THE WEST QUARTER CORNER OF SAID Patc+ wer"katimrMxt"
SECTION 9; THENCE S00'45'32 "E ALONG THE WEST LINE SWk OF
SAID SECTION 9 150.31 FEET: THENCE S56'24 "E 70.00 FEET: THENCE N59'15'17 "E 850.85 FEET
THENCE ON AN ARC OF A CURVE TO THE RIGHT 102.10 FEET AND WHOSE RADIUS IS 403.00 FEET AND
CHORD BEARS N07 "W 101.78 'FEET; THENCE N00 11 E 569.05 FEET; THENCE 588'45'38 "W
250.00 FEET; THENCE N00 1 W 350.92FEET; THENCE S88'57'07 "W 512.29 FEET; THENCE
N00 100.00 FEET; THENCE N88'57'07 "E 250.31 FEET; THENCE NO3'10 "E 202.31 FEET;
THENCE N32'19'49 "W 95.25 FEET; THENCE NO2'24'54 "E 136.96 FEET; THENCE S87'34'15 "E 198.63
FEET; THENCE SO1'54'33 "W 149.41 FEET; THENCE N89'46'50 "E 148.76 FEET; THENCE S2'27'16 "W
256.95 FEET; THENCE N88'37'07 "E 1065.55 FEET; THENCE N89 ° 12 1 30 "E 325.61 FEET; THENCE
S00 "E 10.00 FEET; THENCE N89'12'30 "E 354.46 FEET; THENCE N01 "E 587.22 FEET;
THENCE N55'31'03 "E 651.90 FEET; THENCE N38 "09'35W 413.25 FEET; THENCE S89'31'02 "W 142.03
FEET TO THE NORTH QUARTER CORNER OF SAID SECTION 9; THENCE S89'12'35 "W ALONG THE NORTH
LINE OF THE NWk OF SAID SECTION 9, 2666.45 FEET TO THE POINT OF BEGINNING, SAID PARCEL
CONTAINS 96.52 ACRES AND IS SUBJECT TO ANY EASEMENTS OR RESTRICTIONS OF RECORD.
:I
Dated this day of °GTOB 2000 .
L M2 Gi eV (SEA1a u YQ A tOw p , AI O (SEAL) t
DANIEL S. SOLH KARLA J. SOLBERG d � ' I i
how Thaw
AUTHENTICATION ACKNOWLEDGMErNT
SiertabrnW State of Wisconsin,
, ss.
Count
n came before mt this day of
authanticated this day of 11r above Ranted i
TITLE: MEMBER STATE BAR OF WISCONSIN v to r '
(If na, tree known to be the person - ob 6 - who executed the foreping
authorized by 5706.06. Wis. Sots.) rumen and acknowledge the ynt
THIS INSTRUMENT WAS DRAFTED BY l L
H EYWOOD& CARI. S.C. 204 LOCUST STREET _ staw of WISCOl
HUDSON, WI 5 4 0 16 Notary Public. State of Wisconsin
My commission Is permanent. (If nq c. state expiration date:
(Signatures may be atuhencatad or acknowledged. Bah are not 1 I )
necessary)
..... ...... __... ...
'Nu WP r N ry s,p,atr n.,a V ttptl ar MtntM War tha Nrwura .
STATE EAR OF WISCONSIN WwAmm Low sw+ Co . Inc
TRUSTEE'S GEED FORM No. 7 - IMO = ra,e,res. wr
.............
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