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014-1010-10-200
o F r M p 7 N CD f1 A .0 A7 (D t d Uj 3 .. !- < a c — cD c N � ID ID z N N O O • N Q = N ro O N O v O N .��. O r3 ° tr CD 0) 7 O C 7 C C7 _ N 3 m a ° co ro -•. N (D CL co CD c r !� y 0 C ! CD j 3 rt 6 CD T I ` o ¢ 0 ¢ r A O TI 'D G G G N z 0 o C = N N N C) ° D N °� C a CD O O _ A O 3 0 N N cc Lo N CL oo I z z z D D o o CD a • CD v� ro c W Q z CD p 2 A N n N A O C � W A < C 3 z A Z7 �! z W F A w D N <D O. C O F G N C to fD N z C Q �p O C * y O 0) a N. O a a co m N a A o i N SU w W (D N J O Q 0 CD V A S9 oCD STC - 104 AS BUILT SANITARY SYSTEM R19PORT OWNER AR1ZG t f LA,j rzse--11► L+aA /� ;�:iUtyTy ADDRESS 2 G (o Cx -uK)T i R C) . Q 'NG FfCE ,,//�� g�77 T n /�� I - 7-0 S I i B E)TVT(ETA \7 / P AR-Ciei� 1•.J_ 'V` - I() LOT � ••� g� '50 SECTION t' T -R Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM �'1 6U►J p ti 9b' O iQ r 8 M , Gpant, 0 1P a�� l 3F3C-> p - �� NouSp +) II `U +' II X41 No Sc.At� INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of e cover. septic tank manhole p n 1 i BENCHMARK • ALTERNATE BM:- �A2A�, Ft_cx�e. 1�l C��r�►� SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: sKRUJ Liquid Capacity: low Setback from: Well q2 House Lt Other Pump: Manufacturer Model # 1✓PU411A Size K Noes /, Float seperation 7.3 Gallons /cycle: 120 Alarm Location 1 "�( �2�n� 'Bo 01 - TAk)K SOIL ABSORPTION SYSTEM Width: 3 Length 125 Number of trenches j Distance & Direction to nearest prop. line: > 15G wV---S Setback from: well: >140' House I'L7' other "Tc) ELEVATIONS Building Sewer qq , 2 5 ST Inlet: 9(o. ST outlet: c L - 19 PC inlet (,, . 1� PC bottom q2 , �� Pump Off Header/Manifold %e .(,5 Bottom of system Existing Grade 4. .1 3 Final grade 9S_ () 0,F Mou )jo DATE OF INSTALLATION: I C) Zz PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: �gVlt� C 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division ST . CROI X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarf2wwv� .: Personal information you provice may be used for secondary purposes [Privacy L r, s.15.04 (1)(m)J. LAURSEN , s DA [ ,bity llage Town of: State Plan ID No.: .K �1� CST BM Elev.: Insp. BM Elev.: BM Descrii tion: Parcel o.: O� • v' C3 6 lV crc� r,n o- 1010- 10 -•8$6� TANK INFORMATION ELEVATION DATA A9700233 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic aVt/bob Benchmark 0.21 OV 0' Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 2-3 OW cR(a, y TANK SETBACK INFORMATION ut et TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic ;>I" 4 72 1 i NA Dt Bottom Dosing w IF 1 3(, ` NA Header/ Man. Aeration NA Dist. Pipe ' (00 ` Holding Bot. System 6 `� PUMP / SIPHON INFORMATION Final Grade L e t L( Manufacturer &bLLU Demand Model Number �l Ri V GPM p,b�- (�, 0. i TDH Lift3& 1 Friction ,'>/ M ead stem TDH O Ft Loss Forcemain Length Dia. n 1 Dist. To Well - 7170 SOIL ABM PTION SYSTEM KD Width r Length No Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 2 DIMENSION SETBACK SYSTEM TO P / L BL G WELL LAKE / STREAM LEACHING Manufa cturer: INFORMATION Type O stem: > l� .,,id1� f �3/ OR UNT CHAMBER Model Number: 5 f�� DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) to x Hole Size x Hole Spacing Vent To Air Intake Length �G Dia. 2 ~ Length ia ( . I ' /Z Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only s Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present j • L� 'S• s f 5, �$. Oy �3 LOCATION: FOREST 5.31.15.75 SW,SW 2706 CTY RD Q q 3 , p,, �.x�rr ,�►�. 'b ,.e- s.� s. -�.�A . �-� Jr eL4V r rYc,� fa 1� o- IZ - (� revision required? ❑ Y5 2I No Use other side for additional information. 3 2 o l oo l SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue NV Iscons i n In accord with O Box 7302 Department of Commerce t h ILH R 83 05, Wi s . A d m. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. :5r C-0(x • See reverse side for instructions for completing this application State sanitary Permit Number, �P��l Personal information you provide may be used for secondary purposes C] Check it revision to previous app Icatio [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATIO 51 (' 20615 Property Owner Name Property Location LNU itetJ 501/4 5W 1/4, S 5 T 3 I , N R 1 5fi0r) W Property Owner's Mailing Address Lot Number Block Nu er 2_10(p QZO -PYN 70ill 4 v City, State Zip Code Phone Number Subdivision Name o CSM N�mb (115 3 —�cig ' OG k., .15 1 C-- 10 z ? I II. TYPE F BUILDING: (check one) E] State Owned E] Cit Ne�res oad Public ❑ Villag 0 1 or 2 Famil Dwellin - No. of bedrooms Tow of ' °1p Q 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 014.- 10%0— Io -zoo 1 ❑ Apartment/ 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 S ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV TYPE OF RMI A) 1.j$j (Check only one box on line A. Check box on line B, if applicable) New k � ' 2.❑ Replacement lacement 3. ❑ Re p lacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______System System Tank Only Existing System - -------- - Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 §9 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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 �t Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) f �� Elevation `' 50 315 3 - 15 1. 2 '-- q 5 - I 1 Feet Feet Ca acct VII. TANK in allo Total # of r Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App Tanks Tanks ep Ic Tan t000 10M I 5KAQ IM ❑ ❑ ❑ ❑ ❑ l ift Pump Tank ik 400 1 ❑ I ❑ ❑ E ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibi for in tallation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI tuber S' ture: (N amp MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): �y WE 1 Q I A� �fJ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater f e I ssued Issuing Age Si nature (No Stamps) Approved E] Owner Given Initial Fee) / / Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) 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 a 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 sewage 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; and Buildings Division, 608- 266 -3151. 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. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.` III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on 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. V1. Absorption system information. Provide all information requested for numbers 1 through 7. V11. Tank information. Fill in the capacity of every new /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 81/2 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; Q complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacture_ ; - section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing formation. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. I o z O � O �. C Z co W v A \ m O z co rn o rn0 m -alit N rn � < cn m 46A m • r � m � rn m 00 O O O r m �o K D n O Z Z = D 171 = C7 ;� 0 :u = I x m rn o Or O m U) z 0 Z DO o C � p �. C z z • r � �' n O z rn o C) U) � z n `� p ZZ z m C G) m L 6 . 7 + rn o�� �� C� 2 m 17 ID �.0 y��� T� CD m m e °-'•m m f m c � u. a m CD c'v n 'o ' *°—' oa m�37 aMr� HS 2 r rn d 3 0 m _< d m 0 y o D �� CD �0 3 �� �m °;D H 3o m rn s d o. 3 m m c° m 2 W `° m3 dd H ma'm3 ? < - d W O m c Q oO ? jm Ui sm ° =..a my T �`° 3 3 3 z co JlJ o. 3 �_ ;, ; d s_ o c n m 3 �N Z am 0 ad H ° o Z N 7 t0 c� < amc v D D FD 0 f m o - O �� CD > > o 3.� 7 =mew •� m ? 3 �� �• o ' to D O m 3° v '�c;d o C�� N M N H m `� -• 3 .i o 0 7 m S 3 - 7 0 Safety and Buildings Division t�•���r■rs SANITARY PERMIT APPLICATION Bureau of Buildin Water System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. - ST G20 l, • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 59 — 2,oe 5 Property Owner Name 1 . Property Location DARF, EFM �AU�S�tJ SW 1/4 SW 1/4, S 5 T 3 ( r N, R 15 V r) W Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number D,-SV— PA etc. l�T ( ) ..74 1�C.t_, # 5.31. 1515 C, II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms _ _ o Io w a n OF F 0 (ZI5_ST C,c) 4 w`f III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑Apartment /Condo QI 4 — loo— l Ol L0O 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 box on line A. Check box on line B, if applicable) A) 1. N 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 Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 KMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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) a Elevation 4-50 5 3�5 t .2 5 — ► ( Feet Feet Capacit VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank t 000 I o0o KAW ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 4,w '— ptV1 )NAT[ ❑ ❑ ❑ ❑ I ❑ I ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI m is Sign tute: (No m s) MP /MPRSW No.: Business Phone Number: W1P 135 Z15 63 - 3420 Plumber's Address (Street, City, State, Zip Code): A4 o LIT IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San ary Permit Fee (includes Groundwater D ate Issued ssuing Agent Sig ture (No St ps)' Approved E] Owner Fee) Owner Given Initial �� Adverse Determination 7 X. CQNDITION OF A P OVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) 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 a 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 sewage 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 and 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. I1. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on fine 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /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 1/2 x 11 inches must be submitted to thq county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding ank(s), septic 9 P 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 collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. r i t SAFETY & BUILDINGS DIVISION i I State of Wisconsin j Department of Industry, Labor and Human Relations August. `30, 1996 211:1 West First Street Ro'.a to 8, Box 8072 Hayward WI 54843 FRIEDI:I L PLI-1MBING-, 1414 13 AVE BARRON WI 54812 i RE: PLAN S96-20875 FEE RECEIVED: 180.00 LAURSEN, DARREN SNt- SW,5,31,15W TOWN OF FOREST "DUt Il Y OF ST CROI X W)UND SYSTEM i The Department has reviewed the above- referenced submittal. i Conditional approval is hereby grnnted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based I on chapter 145, Wisconsin Statutes, and chapters ILI,ll 83 and 8Q, Wisconsin l' Administrative Code, and is contingent upon compliance with any stipulations V shown on the plans. This system has not been reviewed for the code requirements set forth it) chapter ILHR 82 or in chapters TLHR 50 -64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or j if a sanitary permit is obtained, plan approval will expire on the day the C initial sanitary permit expires. The licensed plumber responsible for this i installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate U inspector when inspections can be made. All permits required by the city. village, township or county shall be 'i obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, I I. h ansky. Specia ist Sen Section of Private Sewage O 1 991 ( 715) 725 --2544 Pr i day's BAR 1 7316R/ 1 ItscE1vD i i I SBDA -7997 911.191941 Private Sewage System Plan Index/Checklist All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each set is signed. Your cooperation expedites your plan review and shortens plan entry time. Plan ID N Owner's Name 5gco - 10e VP/ KFIe LAU2seO Legal Description Address 15L,3 5wk 5�c,5 T31 n1 R 15 Li 24415 SW `Dct�R. PARK .t,71 J rq �,Z £ilYA+aEe/fown _ C.5 "r County Contents COUtuteidts /Spechd I structions Page # Included Two copies needed for all plans 1 x Plot Plan 2t3l Plan View/Lateral ftblittti by Mail B 2 Cross Section 4 F 5 Tank & Pump/ [] Pax Letter to (County) (Submitter) Siphon Information Circl$ +arise and l'oVide latuc #:' 5 System Sizing (Public) 6 tall for Pick - Up: ( ) 7 Other q I, the undersigned, hereby certify that the Seal (if applicable) plans and specifications submitted herewith were prepared under my directi and c ontrol. Plumber/Designer License/Registration # {Rmo F2iec)at _, VAP Address City State 14-I OA I P4 bKw- oM .s WE Signa For Office Use Only Attachments: Application PRIVATE SEWAGE SYSTEM Soil & site evaluation Fee C o L.'. : 21cc a Needed for Holding Tank Submittal: One copy of notarized holding tank ! i,' r L agreement. (Originals to County) �l,h t} ,1 t Needed for At -Grade Submittal: i PARTMENT OF INDUSTRY LABOR AND HUPaAN RE LAl NS Original signed and notarized DIVISION OF SAFETY AND BUILDINGS Application for "Use of an At- Grade" County on -site i R 'S ON6kNCE One additional set of plans SBD -10268 (N.01/96) i t ,, � ��► Si 5 T3�tJ `K % 5 0 Cob I N m f o -t 250, So RE- s�rlpc. L�a� 4loy*w 1 V Wkst4 A S96-20875 Go N w-f Q O BM 5 6N PAP. fL�<- 1,- 1od -O 4 A c,m6 P-Rc L-, 'F L ay. t o `s fnppue Tr- U 6 5'f f QC, IOmO1 (pOO 5 AU CmMB1044 - r6wk- CSKAVJ, S�(s��rh 5�3e � Ttt�Nc.�N 3 x X25 I`(louap Zo. � l N �R ��[�G'1,,.1.. ►v1P1351 jy s� To Tro L Uow q4'- ►I Cvu'f0ue + i page 2 0 5 Cross Section of A Mound Using A trench For the Absorption Area /�Si111 C -i Mca+ Sand Fill +� 6" topsoil L Trench Of 4 vi Aggre a✓tet r plowed Layer 6" Below pipet Covered With Straw, Marsh Nay Or tyhthetic Fabric r, ( Ft. -/ L I.oq tt► r 1.5 Ft. Plan View Of `lund Using A trench For The Absorption Area force Main Distribution pipe permanent Markers OWevation pipe _c::---- •-= - - - - -- 9 AL=A — -- - - - - -/ A o W _ k \ trenc � h of " �''� Aggpegate t 2 087 5 1 Ft k q.q Kt . i5 t t. B 125 Pt, J 1.4, Ft. L 14- �98 Ft , S, 12 i = Z z S� License �8 Signed 2 z t � = Plumber: tnP - 1351 bate: page Of Distribution pipe Uetaii Poe two Lateral Network il� e c 1 s tocatpd do Bottom Are Lquaily Spaced PVC Eorco Main End Cap . ° e r r Y X Pvc bistri� i�►.• piths k + Ott linie Should he Next to End CAP p I Et, Bole Diameter Inch X 48 Inches Lateral Diameter Inch(es) Y 3 b Inches torte Main Diameter _ 2- # of I��ieslaip� _ 1 Invert tjo d tlon Ot Laterals Et, S96-20875 signed: License Number: _ `13 S Date-. Page + Of - 5 COMBINATION SEPTIC TANK /PUMP CHAMBER 4" CI Vent Pipe with (No Scale) Approved Cap, +25' ,Approved Locking Manhole Cover From Buildings With Warning Label Attached Weatherproof Approved j Warning Label Junction Box Vent Cap —� 12 Minimum Final Grade � 41, 6" Minim m 4 Minimum i � 6" Maximum C.I. ; Disconnect Quick 18" Minimum �- Insp. Pipe -- - i 1/4" Weep Hole Baffles D LJ i i A Alarm B On i C *APPROVED Of f 6 JOINTS WITH APPROVED PIPE D 3' ONTO Conc. Block SOLID SOIL 3" of Beddinq Under Tank --� S96 Note: Pump and Alarm Are On Separate circuits Number of Doses 4 - Per Day Gallons Per bay /f o — Doses: 12.5 Gallons Volume of gackflow:........ cT,� Gallons Tank Manufacturer: J {CA.LJ Total Dose Volume:........ = Zo Gallons Tank Size - Septic /Pump: o Cog.. Ga ons Alarm Manufacturer: S ertt Model Number: to i Capacities: A g.2i nches or 30o Gal 1 ons Switch Type: ryieox— L)a--( _ + B 2, inches or_Gal1ons Pump Manufacturer: �, _ Ge )Un + C - r.3inches or , Model Number: + Di i nches or i g . Gal 1 ons Minimum Discharge a e:. 8 Total.....= winches orGallons Vertical Difference Between Pump Off and Distribution Pipe: ..-(;b 7 Feet Minimum Required Supply Pressure: .................. 5 Feet Feet of Force Main x 2 .1.5 Friction Factor /100 Feet: +J I feet 2 Inch Diameter Force Main Total Dynamic Head: ...= Feet / 6 Internal Tank Dimensions: Length ,, �� ; Width �j5 ( ; Liquid Depth 39 Signature License Number 1357 Date 2B (p (10til s Submersible Effluent Pump 3871 APPLICATIONS Motor: Specifically designed for the ` Single phase: 0.4 HP, 115 tttipeller: Thermoplastic following uses: or 230 V, 60 Hz, 1550 RPM, 9offil- Vortex design with built in overload with Effluent systems punlp out Vanes for m e ch a ni- automatic reset. Homes Cal seal protection. 6 Power cord: 10 foot +Farms standard length 16/3 SJTO '' Citing and base: Rugged +Heavy duty sump with three prong grounding thetmoplastic design provides Water transfer plug. Optional 20 toot §uperldr Strength and Dewatering length, 16/3 SJTW with. Corroslr�ri teslstanCe, SPECIFICATIONS three prong grounding plug. Motor Noosing: Cast iron Full submer g ed in high for dfficlent heat transfer, Pump: grade turbine oil for stmhgth, and durability. • Solids handling capability: lubrication and efficient ,;; Motor Cover! Thermoplastic 3 /4 " maximum. heat transfer, ddVAt With Integral handle and + Capacities: up to 55 GPM. k float SWkh attachment points. Total heads: up to 24 feet. Available tut automatic a n d POW table: Severe duty + Discharge size: 1 t /z" NPT. manual operation. Automatic fated oil and water resistant. f + Mechanical seal: carbon- models Include Mercury rotary/ceramic- stationary, Float Switch assembled and 0-tiitg: Provides positive BUNA -N elastomers. preset At the factory, sealing. No gaskets to replace a Temperature: during maintenance. 104 °F (40oC) continuous Stainless steel fasteners. 140 °F (60 °C) Intermittent. S9 Fasteners: 300 series stainless steel. METERS FEET - Capable of running dry without damage to e components. 25 =� 5 y a 2 r e 20 v 4 5 Z 15 n 4 J �2. t p 3 10 h 2 5 i 0 01 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m'/h CAPACITY ©1994 Goulds Pumps, Inc. Effective May, 1994 9 • B3871 Wisconsin Department of Industry, Lab%and Human Relations SOIL A TION Page of Division of Safety and Buildings in accor a with ILHR a is. � `rl � Attach complete site plan on paper not less than 81/2 x 11 inch I_ ize. PI11 %ust o my include, but not limited to: vertical and horizontal reference poi t ), dirggtkqn alpd ( y� P jT• �-Rro j X percent slope, scale or dimensions, north arrow, and location a tancea est road. el I.D. # s 014 IOI® -- lo APPLICANT INFORMATION - Please print all info . 2 0"MG eviewed by Date Personal information you provide may be used for secondary purposes (Privacy 1 Property Owner ton IDARV%ari L)1;r 5er t.j Govt. Lot f 1/4 5W 1/4,S T 31 ,N,R 1! J�*r) W Property Owner's Mailing Address Lot # I Block# PSSubd. Name or CSM# ' p .L49 �� 2,f��•A-4 � Gt.'� 31. i5 • `7J City State Zip Code Phone Number Nearest Road revs_ 'PP R-K 6YS I (I 1 )214 2Aw El city E] a e � Town o 00 New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate I•z bed, gpd/ft 1 1 trench, gpd /ft Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd/ft l trench, gpd/ft Recommended infiltration surface elevatio�n((ss)) ft (as referred to site plan benchmark) Additional design /site considerations 1 ► F Parent material 0 t )CO0 &1 Flood plain elevation, if applicable r ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S UO U S❑ U ❑ S 91 U I ❑ S [X U I EIS R U ❑ S X U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench i 1 o —ko Z5qa.4 7- 511 2 tm s bK Mir s s - 1 :.:_:. •�, b -(2 7,5Y S1 -Zvn p 1 VY4 1 SS 24 Ground -3 2 50 - LVn 1 .4S Ii • J , W -Lft. 4 5 1 ul-b K P4 Depth to limiting factor Remarks: 59 L'T CC4Wrjt-A 00 Pdn`; Boring# 1 �-- Sll "Lmg m r 3 2 • 113-- 'L 1 -1 �Fj St 1 2 1 m 1 � NP, .2. 27 5 R 4 - 55 .5 ,f© Ground 4- 1 --5 2. 414 L,5'124 `L W el ,gV 1, it• Depth to limiting f ctor in. Remarks: 5WT QQAD1,J& 00 Pgras tj CST Name (Please Print) Signature Telephone No. Address ���� Tt"1 Date CST Number 1 SOIL DESCRIPTION REPORT PROPERTY OWNER I7ATZRIJ I�Afa nl Page of PARCEL I.D.# fO /O — 1C Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench a 4-(Z -- �1 2msbk, ter S 2, & -i5 '?- 5YR.1o(Z 511 SM YV% , S 2 4 P ; .2 Ground 3 5- 7. 5 611 sMbk fn�) gS 1 e ev. q -iLft. 4- �✓- Z-�S�l R. 4 S� o R i -Be I cAb K P-41 ,'L 3 Depth to limiting ; factor 2.5 in. Remarks: S #L.-r COA - fin1G. all Parn5 1 t H - 3 Boring # F Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Nil ff �� u Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. tt. Depth to limiting factor ' Remarks: SBDW -8330 (R. 08/95) Ar T o w ii o i FQR.6 - f3i". GRo / K C-v . I It ' ® e 501 . © ± 250 ----- w � C� 1 � T Go Hw�t C� ® 15M Zr ;oo N MANY, faL. pod WFmL. � fLO-G, Ato A Pip-c- Not ev5 L 5 cl v --1 L �94 IV '* Oo 0 LA. 1 UI.�t_, C� rm3"l X51 w1 � FILED 1 MAR 2 6 1997 s KATHLEEN H. WALSH 1 Z Register of Deeds 5571 CERTIFIED SURVEY MAP SL CroixCo.,WI Located in Part of the Southwest Quarter of the Southwest Quarter of Section 5, Township 31 No CA Range 15 West, Town of Forest, St. Croix County, Wisconsin. Prepared for and at the request of: OWNER: Dorothy Laursen NOTE: The parcel shown on this map is subject to State, County and Township 4915 Fruit Valley Road laws, rules and regulations ( i.e. wetlands, minimum lot size, access to parcel, Vancouver, WA 98660 etc.). Before purchasing or developing any parcel, contact the St. Croix County Drafted by. Kristi A. Eyiandt Zoning Office and the appropriate Town Board for advice. 4 CORNER � —WEST 1/ R SEC. 5 -31 -15 (FND 2" J.P.) f UNPt_ATTED_LANDS — OF OWNER _ N 89'19 E 489.25' t I w 1 ZI r I of i I 0I r"i CENTERL /NE V)I o DRIVEWAY EAST LINE OF THE WEST 112 OF THE SW 114 OF I THE SW 114 OF SEC. 5 I o w Ki L 1 ° I b GARAGE W i Z LOT 2 1 AREA EXCLUDING_ R.O.W. LOT 1 10 N89'19'18"E c CERTIFIED_ SURVEY MAP 375,947 SQ. FT. 0 114.01' 8.63 ACRES t 3 DOC._NO.- 547206 bo I I 1 jOTAL AREA: I VOLUME _11 PAGE - 3130 IS +� 1 1 400,555 SQ. FT. i N . W I I g i 9.20 ACRES Z I v I N b I to O I � � � I w � 100' .BUILDING SETBACK FROM R. 0. W. LINE to .................:...�. o ........... ............... ... I r i SOUTH 114 CORNER I I o I ° o R. 0. W. C. T.H. "O" a6 1 , SEC. 5 -31 -15 CO, Z I (FND R/R SPIKE) S 8749' 14" W _602.36'_ - � 89'19'18" W 601.85'_ _ — -- — „ r`r , C.T.H. "O -- --- - - - - -N 89'19'18" E 2671.43'------- - SOUTH LINE OF THE SW 114 OF SEC. 5 -31 -15 SOUTHWEST CORNER �- u >. ���a>rx�ir► SEC. 5 - - C. / ; H O ���jG 01 `lS����,� (COUNTY MONUMENT) " — x�28 9 -7 RONALD F. Sp U NP_LATTED_LANDS JOHNSON = 8-1196 AMERY, WIS. e� Y • BEARINGS ARE REFERENCED TO THE SOUTH LINE OF THAPPROVED �'' O Q eo n SW 1/4 OF SECTION 5 TOWNSHIP 31 N., RANGE 15 W. �� �� SURJ��t�� WHICH IS ASSUMED TO BEAR N 89'19'18" E 0AH 2 U L 97 y������� County Section Corner Monument 7 of Record • Set 1" x 24" Iron Pipe weighing St. CROIX COUNTY a minimum of 1.13 pounds per Comprehensive Planning linear foot. Zoning and O Found Iron Pipe Parks Commit a NO TH JOB #97007 Prepared by: If not recorded s A & E SURVEYING & ENGINEERING within 30 da y of Phone No. (715) 246 -4319 approval date 150 0 150 approval shall be 2 109 East Third Street, P.O. Box 325 ap New Richmond, WI 54017 null and trod Sheet 1 of 2 f SCALE IN FEET - I GRAPHI Inch SCA LE 150 feet 11 Page Z ;O Z 1 `is r�ls�a►seo� oo O A + 'S1M A83wv NOSNHor 1 'l O1dNOi ,% z tv yre � R p�AN1eNY 0a � CLOPS IM 'puOtugOTU MaN SZ£ xog 'O 'd 6T£V -9VZ (S'LL) auOgdalej, 6UTXan.znS puej 3 1 9 v a=1ecl 981T 'oN '6au uosutor *a pjeuog Lb�B �Z 'awes aqq 6uTddew pue 6UTXanans UT 4sa103 go uMo,L agq pue x - IS Jo Xgunoo aqq Jo saOUeuTpaO UOISTATpc;ttS aqq pue sagngegS uTSUOOSTM aqq JO V£'9£Z aagdNq� Jo suo TAoad aqq ggTM paTTdWOO aneq I gegq :pagTjosap pue paXaA:rns sataepurtoq aoraagxa .-)q Jo aleos og uoT1equasaadea. gaaaJOO e ST deW XananS paT,}TgaaD sTgq geLIJ XJTgaaO osTe I •alge'EaUA 6uTaq y:lprM aqq '19L)aed pagTa6sap anoge aqq Jo auTT ggnoS aqq 6uoTe „b„ XeMg6TH Nunay Xgunoo og goa�gnS 'saaggo JO 8146Ta uoTssassod PUP p.xpoaa JO SgUeuanoO pue suotgaTagsaa 'sguawasea He o-; _;oalgns '(saaOe OZ-6) gaa3 aaenbs S55'OOV 6UTUTegUOD •6u T uuT6aq Jo gUTOCT aqq oq gaa3 Sg•TQ9 JO aauegsTp a gsaM spuoaaS 8T sagr►uTw gT 80aa6ap 60 ggnos 'auTT ggnos pies gseT 6uoTe 'aOUagg !S uo pTes Jo aagaenb gsaMggnoS aqq Jo auTT ggnos aqq 01 -1a a3 VL'Lf,L :1 aouegsTp a gsaM spuooas LZ sa:;rtuTw TT saaa6ap OO 14=11"oS ' 1 'a()'l JO auT T gsaM pteS _ ;sel 5uoTe ' aouagq : X:}unoD pTes ur 0£l'£ abed ,I.L atunTon UT papaOOaa deW XananS paTJTgaao e Jo L 1011 auTT gSOM agg 6uTaq osle sTgg IS uoTjoas pTesS Jo aagaenb -1samq -4rws aqq 3o aagaer►b gsaMggnos aq:l JO JJVH gSaM aqq Jo auTT -:lsea aqq oq 4 W 681 Jo aauegsTp a gses spuoOas 8T sagnuxw 6T saaa6ap 68 gqaoN aauagg :gaaJ ££'S8£ JO aauegstp a gses Spuoaas L'S sagnuTw V0 89aa6ap 00 gqaoN -'auTT gsaM PIPS gSvI ggTM TalTeaed 'aauagg 1aaa7 TO'VTT Jo aouegs t~ gsea spuoaas g_L sagnupu '61 saa 60 gqaoN aOuagg :gaal OV'Zg£ 3o aouegsTp a gsies spuooas ES sagnupu V0 saaa6ap 00 gqaoN IS uoT -4Oas Jo aaq.jenb gsaMggrioS p•res Jo auT1 gsaM - aqg ugTM TajTsaed 'aouagq !pagTaosap aq JO Taoaed aqg Jo BUTUUT6aq Jo quTod aqq oq,gaaJ 00'99 Jo aoUegs-tp e gsua spuooas gl sagnUTw 6T saaa6dp,68 q IS uoTgOaS pTes 10 iaqjenb q aqq Ja auTT g - -;nosy aqg 6uoTe 6uTaeaq pawnsse ue uo 'DOUagq !S UotgOaS [) Ju aauaoo gsaMggnos aqg qe BUTUUT6ag :sMOTTo3 se paq- !jDsa ' utsuoDSIM ' X:1Una7 xTOJD • qS ' gsaaOj 3o uMO,L 'gsaM SI a6ueg 'gqaoN TE dTgSUMOd, IS uoTgaas Jo aagaenb gssaMggnoS aq:; 30 304aet16 gsaMggrtoS aqq fo q.aed paddeui pue paXanans aneq I 'uasmerl XgquaoH JO uor4.001'rp aqg Xq get.(q 'gegg X3Tq.YaO Xgaaaq 'aoXanans puvI u rsuoosT.M pa ca:ls'r6aH a 'uosugor ' pTeuou ' I 3d;'El"J.'1'JIZuaJ s , HOXSAuns •ulsuooslM 'Alunoo xlojo 1S ';sajoj ;o uMOl '1sOM g; 96UDN 'y;JON t£ dlysuMOl 'g uol;oas ;o jal ronp ;saMy;noS ay} ;o aapunt) }sally ;nog ay} ;o ;god ul pa;o301 dd w )am ns C131A 1.L 830 8ZZ£ a ?ed IT 'TOA ilk • 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. ------------------------------------------------------------------- Ownerof property 0( arrt , ,a T L. urstQ oy Location of property /4 , Section J T N - W Township f 1' Mailing address 7, L d Q Address of site Subdivision name Lot no. Other homes on property? Yes No Previous owner of propert Total size of property g 7-0 S Total size of parcel Date parcel was created Z Z2_ 91 /1 7 Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house)? 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, available would be Y � ld helpful so as to avoid delays of the reviewing 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. , and that I (we) presently own the proposed site for the sewa a 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. ignature o Applicant Co- Applicant Date of Signature Date of Signature STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County r OWNER/BUYER MAILING ADDRESS '1 O L g � G1 �� CL ay g S Y a PROPERTY ADDRESS /'� (location of septic system) Please obtain from the Planning Dept. CITY /STATE (; (¢aj I_& 6 u i'S PROPERTY LOCATIO 1/4, S44 1/4, Section. / ' _T N -R W �? TOWN OF (i r S -F- ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER 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 y ar expiration date. SIGNED: DATE: 9 i' St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 i V0 L 1244PACE214 560627 STATE BAR OF WISCOI`!�IN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO. REuISTE 'a" CFFICES F1 =— — ST. CROIX CO., Wl Fwdfwpmm Dorothy D. Laursen `JUN 6 1997, 8:30 _ A M conveys and warrants to Darrin J. Laursen and Valerie '?��L -- R WJ.k L Laursen, husband and wife, as t"ut °"CM survivorship marital property, THIS SPACE RESERVED FOR RECORD DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, Landmark Bank State of Wisconsin: 327 Third Avenue Lot 2 of Certified Survey Map recorded in Clear Lake, WI 54005 Volume 11 of Certified Survey Maps at page 3228 as Document No. 557171, being located in the SW4 of SW.;,, Section 5- 31 -15, St. Croix County, Wisconsin. Also including a 30 foot 014 - 1010 -10 easement for driveway purposes over, under PARCEL IDENTIFICATION NUMBER and across the existing driveway shown on a Certified Survey Map, recorded in St. Croix County, Wisconsin in Volume 11 page 3228 of said Maps; said driveway lies West of Lot 2 of said Certified Survey Map, said easement to be 15 feet on each side of the center line of the shown existing driveway; being located in the SA of SA, Section 5- 31 -15, St. Croix County, Wisconsin. FED is not This homestead property. (is) (is not) Exception to warranties: Municipal and zoning ordinances of record and recorded easements, restrictions and reservations. Dated this day of CSC ,� , A.D., 19 9 7 . (SEAL) M i /�'��� -n SEAL) DorothA. Laursen (SEAL) (SEAL) • r AUTHENTICATION ACKNOWLEDGMENT Washington Signature(s) ,_ State Of !fknX$ SS. Clark Cuunc . authenticated this day of 19 Per onally came before me this 19 9 7 Dorot y D. Laursen_.�`� • , r _. , tea. r \�. TITLE: MEMBER STATE BAR OF WISCONSIN -- (If not, -- authorized b $706.06 Wis. Scats.) known to be the p erson who 6ecuted trie fore oin y to me p inst nt and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY -A VPO4 Bert D Petersen, Attorney at Law clear Lake, WI 54005 Notary Public, Clar County,W (Signatures may be authenticated or acknowledged. Both are not My commission is permanent (If no state expiration date: necessary.) 19 • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Vjscoosn Legal BW*,f WAADAWTV nFRn Form No. 2— 1982 1 1