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HomeMy WebLinkAbout020-1355-06-000 __w ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner // 1 Property Address �3* / A T t.—y , City /State �4 y '� c �o L) 1 � [ Legal Description: _ Lot Le Block Subdivision/CSM # 14cwe A6L t/4 t /4, Sec.7? T N -R , Town of & 4 � lb 34's N PIN # ° Zd - 13,5-S'- 0 (o C 'SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer /4.... Size ST/PC /�/ Setback from: House We112!L P/L (o Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road --- Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: L E W O Width a r Length e o - Number of Trenches Setback from: House 4: A Well t c f p/L 1 e" A Vent to fresh air intake (z5� ELEVATIONS Description of benchmark Tin, (� � f � � F � �- � F� f � � = � i � � Elevation Description of alternate benchmark - TO P n 4 G lit le ! - � N cN y X S Elevation o 1 S W p� � . 0 � � �p � �' -�' . 3P Inlet `--. Building Sewer ,G� 2 ST/HT Inlet S � (,, � �+ ST Outlet A PC Bottom Header/Manifold 10 S Top of ST/PC Manhole Cover ' 0 S Distribution Lines O it), (.r = `) ) Bottom of System Final Grade () `'� ' �I "4 t () 7 4 ��� ( ) Date of installation' /7- Permit number State plan number License number Plumber's signature / c� - 2 SLR Date 3� ` �°^ Inspector Complete plot plan � t NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. f PLAN W t4 rq& (a v�sE 7� 2� S r BAR A - INDICATE NORTH,4RROW r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344540 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER, SAM HUDSON CST BM Elev. : - insp. BM Elev.: BM Description: Parcel Tax No.: / 020- 1355 -06 -000 TANK INFORMATION V 0 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ��r �SCTb Benchmark 4( 5, 35 105',3 cm , a Dosing Wit 3 3 . O oI Aeration Bldg. Sewer Holding St /Ht Inlet L0.6S1 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic >SO' >6S' a$ � NA D Dosing A Header / Man. . 3 L 96,o3 AJ Aeration NA Dist. Pipe S 9. 3S clb, o , Holding Bot. System 10 .q2- ��( p ©. PUMP/ SIPHON INFORMATION Final Grade Man rer I L IP O:7 Model Number GPM Z, S TDH Li Lriction System TDH e Force Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ENCH Width , Lengt N - ON renches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I X 25 DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Mana,C ure : r S SETBACK CHAMBER 1 1 INFORMATION S Y y s p tem: l q OR UNIT IVIo el Number" DISTRIBUTION SYSTEM Header / nifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 124 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.) LOCATION: HUDSON 21.29.19.2072,SE,SE 818 GRANT AVE — HOMEPLACE LOT 6 Plan revision required? E] Yes No _ , Z Use other side for additional information. 1 1-4 1 co SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. e ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: —�.a. ;.�. _�� . .� 1 .� k �r 1 L [ - 7 - y zy� 1 �l T� .., I n K 1 J Al- -f AAA in! -j 1 --f--l-ninz �1414'1 FTIT - 17 - 1 w i b All e F 3 a e. ttl pp La... x � £ x f e i x ` t B e £ 4 E a r SANITARY PERMIT APPLICATION Safety and Buildings Division 201 W. Washington Avenue Visconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less Count (� than 8 112 x 11 inches in size. �t+' CM l • See reverse side for instructions for completing this application State Sanitary Permit Number 3 '1 Y�5_5 Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner ame operty Location s11/4 1/4, 5 'Z./ T Z N, R E (o W Property Own is Mail' n Address Lot Number Block Number A0 x 4 2 �— City, State Zi Code Phone Number Subdivision Name r CSM Number Al w e ( > z. T YPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village Public 1 or 2 Family Dwelling- No. of bedroomsw_ Town OF14 U O tV 16 III BUILDIN U E: (If building type is public, check all that apply) Parcel Tax Number(s) s W1 9 YP P PP Y r �j ,{1 ZI. � .l9 , , 1 ❑ Apartment / Condo V Z0 1 j' t% (� C) (9 2072" 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 _ New 2 E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ E] 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 [:)Mound 30 E] Specify Type 41 E] Holding Tank 12 Seepage Trench ER 4 22 E] In-Ground / 42 E] Pit Privy 13 Seepage Pit /N F� T �-- 3 k ��� 3 ❑ Vault Privy 14 ❑ System - -Fill %1.g ( l G 1't�1 S •r T ` 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) Elevation 7 Q 3 S Z,. 41510 Feet `t v g ' Feet Capacity VII TANK in Ca allo s g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanksl Tanks Septic Tank or Holding Tank l ow I W F1,Sfi; , K _ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PSignature: (No S p PMP/MPRSW No. Business Phon Number. Number: Plumber's Address (Street, City, State, Zip Code): D - 70 kdWMIL R 1106F , IL DAO 4 0 040J ! Sq U irg IX. COUNT / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A nt Signature (No Stamps) urcharge Fee) 46 Approved ❑Owner Given Initial __ Adverse Determination s MP 7�0 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) 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 -3151. .:To be complete and aerate 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. 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 the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. r:, > (A 3S Vd UJ ; m Xl r\ CYO All T C A xo F-P rn' i LAJ _ ; _ ni v ► fin Z, IN m U) � tQ V♦ _ o o c) m y U, 'JJ''''�r� W 01 N / O C S - • K` 36 ' CD CD s 6) o a a w „ "' v Co rn yaw C o � o C 7 - i CO c cr b y y 4 Ln r F y . •.`T. •.- ® _4TV, ® ®, v Q $ 02 a ) 0 19 03 c o (o - 0 C C (Q Q cn �' CD CD 3 W y =r ¢i (D Q C O C Q � .. c CD n 7 n CD � c X r 0 w 3nl� l CR x CD o 1� �° Q? c C (D CD O (D o �t (D CD ` ti 7�+ c Cn p N -d (D N C O o O X (Q .0 W (D � CS m x cn N CD Q CD :3 (D �: !k a �L ' S � C • .B Wis Department of Commerce SOIL AND SITE EVALUATION Page 1 _ of 3 i6ivision of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code • A.C.E. Soil &Site Evaluations Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must Count y include, but not limited to: vertical and horizontal reference point (BM), direction and St. C_ roix percent slope, scale or dimensions, north arrow, a�ion istance to nearest road. Parcel I.D.# APPLICANT INFORMATION - P/ ')Iation. 020 - 1056 - 90 - 000 Personal information you provide may be used or f�i'rdary purposes (Privacy w, s. 15.04 (1) (m)). RQview By Date Property Owner Property Location Miller, Sam U Govt. Lot SE 1/4 SE 1/4 S -- 21 T 29 N,R l9 W - -- — - rir , -- - - Property Owners Malting Address Lot # Block # Subd. Name or CSM# Box 151 Trout Brook Road - 6 - Home Place City Sta Zip C de ' ber ! ❑City Village [ <Town Nearest Road Hudson W 6 - Hudson Grant Avenue [_ - _ }Addition to exi sting building New Construction ( J sjioo l r troo 3 9 9 Use: Replacement -� Pub I be Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft .8 trench, gpd /ft Absorption area required 643 bed, ft' 562 trench, ft Maximum design loading rate .7 bed, gpd/ t .8 trench, gpd /ft Recommended infiltration surface elevation(s) 94.50' ft (as referred to site plan benchmark) Additional design / site considerations t Parent material Outwash s & gr. Flood lain elevation, if a licable NA ft le for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank table for system ©S ❑ U ❑ S ❑ u S El ❑ S ❑ u [_j S ®u ❑ S ❑ u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure G PD1ft 2 B Horizon Texture Consisten Boundary Roots - 9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -10 lORY3 /2 No sl 1 thin p mvfr as 2f 0.4 0.5 2 10 -16 1OYR4 /4 None sl 1 th pl mvfr cs 2f, l m 0.4 0.5 - - - -- _ - -� 1 Ground - YR4 /4 -- None sl 2 msbk mfr 3 16 -27 1O cw 2f, m� 0.5 0.6 e - - 99.24' ft — 4 127 -39 7.5YR V Non gr. Is I o sg ml cw if 0.7 0.8 ml - - Depth to 5 139 -120 10YR5/4 � None s & gr. ; ! o sg i 0.7 _ 0.8 limiting � -�— -- - -- -- factor t - - - -— [ -- I — . - - -- { -—[ -- > 1 20" Remarks: -- i 2 1 0 -10 l ORY2 12 No ne sl 1 thin p] mvfr as 2f 0. 4 0.5 2 10 -24 10YR3 /4 None sl 2msbk mvfr cs 2 f, lm 0.5 0.6 elev nd 3 24 -38 I 7 5YR4/6 None [ gr. is o sg ml I cw 2f, l 0.7 0.8 - t - - -- - -- -- - -- , -- + 97.23' ft 4 38 -1 19 1 OYR5 /4 No j s & gr o sg ml - 0.7 0.8 Depth to - t [— � limiting fact 119' Remarks: - - -— — -- — — - - -- CST Name (Please Print) Signature: Telephone No. James K Thompson Z-- 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, A 54020 5/3/99 3602 1018 I - PROPE,R1°YOWNER: Miller Sam _ _ _. - SOIL DESCRIPTION REPORT Page - 2 of - 3 PARCEL LDJ 020- _1.056 -90- 000 _ A.C.E. Soil & Site Evaluations Depth Dominant Color Mottles Structure GPDIftz Horizon Texture nsistence Boundary Roots - - - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0 -8 IORY3 /2 None sl 1 thin pl mvfr as 2f I 0.4 0.5 2 ; 8 -25 10YR4 /2 None sl 2msbk mvfr cw 2f, Im 0.5 i 0.6 elev round 3 1 25 - 33 7.5YR4/6 i None gr. is o sg ml gw 2f, Im 0.7 0.8 98.90' ft - - � - 4 33 -123 10YR5 /4 None s & gr. o sg ml - - 0.7 0.8 Depth to limiting -- -- - - - - -- - - -- - - factor >123' - -- -- - - -- - Remarks;--- - - - - -- 1 0 -14 1ORY2 /2 None st 1 thin pt mvfr as 2f 0.4 ! 0.5 4 - -- - - - — - -- - - - -- - - -- - --- - -- - - -- - - -- -- - - - -- - - - -- - -- - - 2 14 -28 10YR3 /4 N sl 2msbk mfr cw 2f Im 0.5 0.6 Ground elev 3 j 28 -36 10YR4/4 None g r. is o sg ml gw 2f lm 0.7 0.8 48. �9 Ft. 4 - � -1 22 _10YR5/4 - None s & gr. o sg _ m l - - 0.7 0.8 Depth to limiting -- -� - - -- -- - -- - - - - - -- - - -- - - - - -- -- - factor ,ro • 3 I i Remarks: — - - - - - -- - -- — -- I 1 0 -10 IORY3 /2 No sl I 1 thin pi mvfr as 217 0.4 0.5 2 10 -15 10YR4 /4 None sl 1 thin pl, mvfr cs 2f lm 0.4 0.5 Ground -- - - - - -- - - -- - - - -- —_ - - -- - -- - -- - -- - elev 3 15 -26 10YR4/4 None sl 2msbk mfr cw 2f Im 0.5 0.6 98.83' ft 4 - 26 -32 7. 5YR4/ 6 _ None gr. is - - o sg _ ml - cw if 0.7 0.8 Depth to 5 3 -125 10Y R5 /4 None s & gr. o sg ml - - 0.7 0.8 limiting --- - -_ - -_ factor >125" > 125" - -- - + - - - �- - - -- - Remarks: I 1 Ground _ - - - -- - - -- - - - elev Depth to limiting -- - _ - -- - - factor f : : Remarks: _' )-4 py. 3 a{ 3 Go N It p_ _ • ■ Ob P CA rk X a ■ w ■ T ■ b C� b It w v s N 0 � p � C J I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer =I+M Mailing Address Property Address 0 1 -j' (Verification required from Planning Department for new construction) City/State 141J D _50 Parcel Identification Number �� �S S ' C r b d 0 LEGAL DESCRIPTION Property Location '/.,: E_ ' /4, Sec. 2 , T N -R Town of subdivision ( Q L i , Lot # /_ . // __ :5__ Certified Survey Map # t�0 �� 7z ,Volume ^ - , Page # Warranty Deed # s g 4 y Co , Volume 13 40 3 , Page # j Spec house yes ❑ no Lot lines identifiable '�f yes ❑ no SYSTEM NL INTENANCE 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 ex it 'on date. 6 AK 9 A F APPLICANT DATE : OWNER CERTIFICATION P(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 .described , by virtue of a warranty deed recorded in Register of Deeds Office. SJGAA TLhd 6F ICAW 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 a copy of the certified survey map if reference is made in the warranty deed 1 , tr , 1L ti. IL X84 (A YIL - i�jf?� PAGE i / Document Number WARRANTY DEED This Deed, made between. - r ' Robert L Rohl a Grantor, am E Miller t� �'S I R �IS� X01: ST. CR F!'C a single person Grantee. OIX CO.. W1 Witnesseth, That the said o o a valuable consueranon of one dollar and Grantor, f r RtK I !vr IMF other valuable consideration conveys to Grantee the below 3escnbed real estate in St. Croix county, state of Wtcr %4n OCT 0 6 1998 This is ant homestead property. 9.30 ` 4 ' . . Together with all and singular hereddaments arc appurtenances thereunto M 0Nill1 belonging, .► �► And . Ir' Grantor � warrants that the tide is good• indefeasible in fee sdrpte and free and clear r lea of encumbrances except Recordm Area •t .as..onts Name and Return Addre , , covenants and restrictions trf record, ss t and will warrant and defend the same. Sam Z. tiilsr R i r m Jenlirication Number) PO Box 151 i 02064 056 -90 Hudson WX 54016 a . i A parcel of land located in the SE '/. of the SE ' , of Section 2 I . T29N, R 19W, Town of I Judson, St. Croix s County, Wisconsin, described as follows: beginning at the SF comer of said Section 21; thence N 89 °23'51 "V4' 1319.10 feet to the monumented West line of the SE '.S of the SE'/. of said Section 21; thence N00 °51'33 "W ' 980.09 feet along said monumented West line of the SE '14 of the SE '/. to the North line of the South 30.•80ths of � y the E '/2 of the SE' /. of said See ion 21 as calite out in that documentation found in Volume 838, Page 252 of the St. Croix County Register of Deeds; thence S89'37' 19"F. 626.85 feet along said North tine of the South ' 30 /80ths to the intersection of the monumented South line of the Certified Sure% Map tiled in Volume 2, Page t' 484 and the said North line of the South 3040ttb of said E '1t of the SE ' /r, thence S89 °23' 10 "E 31.88 feet to a found l" iron pipe being the SW Corner of said Certified Survey Map. thence continuing S89 °23'10 "1: 660.21 ; feet to the East line of the SE 'A of' said Section = 7 : thence S00 °51'SO"E 982.41 feet to the point of Neginning. containing 29.725 acres including rigl.. of % t =8.006 acres excluding right of %%a% ). .. Dated this _ da of tss_ T AIaFER ' Robert L Rohl AUTHENTICATION ACKNOWLEDGMENT '• Signature(s) STATE OF WISCONSIN COUNTY ST. CROIX t .,� Personally ca before me this 2 day of C-r" j4' the above named obert L. Rohl K authenticated this _day of to , me known to be the person(s) who executed tCe foregoing signature ype sjt�/and acknowledge tow ( same. t or"name l/ 't ,I type or " name v1/14.4.4 t1 c_ &) TITLE' MEMBER STATE BAR OF WISCONSIN tary Public County. pV om fission is permanent (if not. state expiration date ; g • sutfwrbed by §70606, 1ANs Slate.) O - r ` - f �- THIS INSTRUMENT WAS DRAFTED BY ? 'N a rsons signing in any capacity should be typed or Robert F. Wall then signatures (Signatures may be surtenbcated _: acknowledged Bo are tlld w 4 necessary.) Z +� . R �:. s: AdSOW I ` LOT 4 OF PLAT OF PRAIRIE VISTA SURVEY MAP CERTIFIED LOT 6 VOLUME 6, PAGE 1768. 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