HomeMy WebLinkAbout020-1353-58-000 . _ ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner �r " c �c,�(�
Property Address e'31
City /State 1/111 11 c
Legal Description:
Lot �- �' Block Subdivision/CSM # Cdr -et �G 4
'/a S4/ ' /a, Sec. 3l • TAN -R : Town of fib✓ J5- C-, PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:�
�/
Tank manufacturer e ( �
S ems' Size ST/PC 0 - > % Setback from: House 1 Well P /L
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: Width = Length - 7 S Number of Trenches -Z
Setback from: House cfe- Well _ P/L !j , Vent to fresh air intake 30+-
ELEVATIONS
'Pea
Description of benchmark S' a S Sw ` Elevation
Ll1d -
Description of alternate benchmark v 01C re Elevation
Building Sewer ST/HT Inlet ` 5 3- ST Outlet PC Inlet
PC Bottom Header/Manifold '7 Top of ST/PC Manhole Cover -
Distribution Lines ( ) 3 - 4�
Bottom of System
Final Grade
Date of installation /Orvermit number 3 E 7 1 .S State plan number
Plumber's signatur License number ,! }.� / y Date
Inspector
Complete plot plan �
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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.
PLAN VIEW
INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count 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)]. 353150
Permit Holder's Name: ❑ City ❑ Village ❑ T5wn of: State Plan ID No.:
Schaar, Richard & Betty Hudson Township
CST BM Elev.:• Insp. BM Elev.: BM Description: Parcel Tax No.: 0® - /
CST B * 1-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ZSp Benchmark Q
Dosing Alt. BM r
,30 .so
Aeration Bldg. Sewer (
Holding St /Ht Inlet 911 -4 q6 - 3 Z. ,3Z
TANK SETBACK INFORMATION St/ Ht Outlet $.q3 9 S• 19
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >go ' NA Dt Bottom ----
Dosing NA Header / Man. t
9• l g3.b9
Aeration NA Dist. Pipe 9• if q 3.
Holding Bot. System
o•SI 42.2
PUMP/ SIPHON INFORMATION Final Grade .1g 9 ;.52
Manufacturer Demand St cover �d
Model Number GPM 8PA (A) f (v t
o�. a 9'°1 •
TDH Lift Friction System TDH Ft
Fi
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM Z k ars -Q,
4W/ RENC Width Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME NSFQ iNS
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manua ure :
SETBACK INFORMATION Type Of CHAMBER M e Num er:
System: Cov.,V1, 3 r OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold a Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length�� Dia. if Length Dia. Spacing
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 I ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #l: 12/ I '+ / 941nspection #2:
Location: 631 Hillary Farm Road, Hudson, WI 54016 (SE 1/4 SW 1/4 3 T29N R19W) - 36.29.19. Cottonwood Ridge -Lot
58 ].) Alt BM Description = 4 11 _ ,l__ �'(S ux
Tr(' d'�'"n
2.) Bldg sewer length = I?.a
- amount of cover = � �8 " S,eZe . Ca�6��
V or c � � l /
Plan revision required? ❑ Yes No F
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Use other side for additional information. 3 1 10
Y SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
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)]. 353150
Permit Holder Name: ❑ City ❑ Village E3LTown of: State Plan ID No.:
Schaar, Richard & Betty Town of Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /1/
Ld- . 04 I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic W " I z Benchmark a 0 O/
Dosing Alt. BM 3 .3o S a
Aeration Bldg. Sewer
Holding t/ Ht , In 13Z
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
I ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe t� ( T
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand St cover
�
Model Number GPM . 36 i_q r 6 ,
TDH Lift Friction System TDH Ft .4 k5^4
H ead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM f . ` 3 9 S. f 6
WtDd RE Width Lengt � / No renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 7 , DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING M uu c r: 6 /Q
INFORMATION Type Of C(g� Ul �/ 3 f �.�.. OR UNIT R M Num
System: e - elGt
DISTRIBUTION SYSTEM
Header / Manifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length�iq�i Dia. � Length Dia. Spacing
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 _ p�
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: AZ / /a /" Inspection #2:
Lo cation• 31 Hillary Farm Road, Hudson, WI (SE1 /4, SW1 /4, Section 36 T29N- - 2 .1 , L—
01 30�0 . ;E'o"> lg`` �6`
—�7_4 Z %3
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert . No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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F akwL �V Safety and Buildings Division
*L c on si n SANITA Y PERMIT APPLICATION 2 01 W. Washington Avenue
P O Box 7302
In accord with ILHR 83.05, Wis. Adm. Code
Department of Commerce Madison, WI 53707 -7302
•' Attach complete plans (to the county copy only) for the system, on pa County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application O Stii nitary Permit Number
Personal information you provide may be used for secondary purposes t4r ' ` �md 'j 11 dteck revision to previous application
[Privacy Law, s. 15.04 (1) (m)). — , w State r10 .D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL I ZRMA6I6` P=
Prop rty Owner N me Pro iohf°
C'l� , v i - , s _ T 1 A i t TA, S N, R /e E (00
Property Owner's Mailing Addre s um Block Number
N " Cl
City, State Zip Code Phone Number Su i i N Ol C umber
20 jte?
11. TYPE OF BUILDING: (check one) ❑ State Owned 0 C it Nearest Road
o Village
Public a 1 or 2 Family Dwelling - No. of bedrooms fI rTown OF
l
III. BUILDING USE (If building type is public, check all that apply) Parce Ta er S_)
1 ❑ Apartment/ Condo - 3(O -'v -12
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home I 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. R New 2, Q Replacement 3_ Q Replacement of 4 Q Reconnection of 5. ❑ Repair of an
System ________ System _____ ________Tank Onl�r______________ 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 E] Seepage Bed 21 ❑ 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 ev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) r, 'I/ ) Elevation
'7 7,i ' r y .Y Feet k)�Feet
VII. TANK Capactt
in gallon s Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks I �}
Septic Tank or Holding Tank �- j U c S C Y.i ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
V{II. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name: (Print) Plumber's Si nature: (No S m MP /MPRSW NO.: Business Phone Number:
Plumber's Address (Street, City, State, Zip C /
IX. COUNTY If DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater D ate I ssued I Signatur (No Stamps)
Surcharge fee) �
�4pproved Q Owner Given Initial -, ^� b _g " ? q
" Adverse Determination ( l
X. CONDITIONS DITIO� L APP /�,tE� N FOR DISAPPROVAL:
sY p . �eg(/ sus �J�, u
TS .0 U y
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SBA- 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, Safety 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.
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.
i
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.
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Wisconsin Department of Commerce SOIL AND ,SITE. EVALUATION
Division of Safety and Buildings , . Page I of 3
Bureau of Integrated Services in accordance4ith S -1iLH 83JOR Wis. Adm. Code
Attach cdmplete site plan on paper not less than 8 1/2 x 11 inches in'size. Purrs Ggt County St
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and locatioryapd distappe rto nearest road. arcel I.D. #
APPLICANT INFORMATION - Please print all information. � pfd jf evl ed by Date
Personal information you provide may be used for secondary purposes (l rivacy 7 C
Property Owner JJ Prope[ty�dCa' n �
R IC uT ovt: , Ldt '
1/4S 1/4S3( 3 T 2 ,N,R E (ol�W,
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
13 53 Auxi-F 1� eq 4r. 5$ C044a woc,& R
City State Zip Code Phone Number ❑ City ❑ Village [W Town Nearest oad
+4 5y0)4P (-115 ) - I C-+ rid
New Construction Use: ® Residential / Number of bedrooms 3- L4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: q
Code derived daily flow LPUU gpd Recommended design loading rate 7 bed, gpd/fi • - trench, gpd /ft
Absorption area required 35 bed, ft trench, ft Maximum design loading rate 7 bed, gpd1ft trench, gpd /ft
Recommended infiltration surface elevation(s) DA A-'cLty ?�IS1[. 9Z, ?-C) ft (as referred to site plan benchmark)
Additional design /site considerations ( e It, V' Y Z - 10
Parent material 6 100-101 ll,tAiAnSh Flood plain elevation, if applicable w IU d ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ® S ❑ U ® S ❑ U [9S El U Y S ❑ U ❑ S ® U ❑ S '® U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
I 0A Iu r 3 /3 --- s► I tact c rn�'r C S �' S
/4 A
Ground IQ r y l to `— rn rn i CS • 1
elev.
Depth to
limiting
factor
101 in.
Remarks:
Boring #
I 6 -11 10 r 3/3 s 2mabk rn - P r C5 I -P • 5 •tp
C Tr CS tp
3
1 43 -118 jovr Ll 1P mg O m 1
Ground
elev.
Depth to
limiting
factor
11 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
PROPERTY OWNER y� SOIL DESCRIPTION REPORT Page —Z— of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
0-I 31 si I Z nor I • ; .
2 0q I !`f S i t r C- I • 5 • h
Ground 7j 59 -1 tq I r y /rte 5 S m I CS -
elev.
9 7•oa ft.
Depth to `• 9
limiting g2,SZ
factor q0
m in.
Remarks:
Boring #
I 6 -1 I r 31 '� 5
4 2 t1 -45 J6. y 4 si
I I
l r L11 1P m CS
Ground
elev. ,
4 G•� ft. qr, as 1
Depth to 9 �"
limiting 0`D
factor
119 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 # I v_Ip l ovr 3 sil Zry)(A rnj( - C•5 1� 5
5 2 O -y$ 1 r rYti-� G 4 5 4:
Ground
elev.
qZ m ft.
Depth to
limiting
factor
IZi ' Remarks:
Boring #
................
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT '
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer \ C kk Q `� �S e- y S C_ R 9 R R
Mailing Address a R\ r NF, V E, ( L- -
C o T --r'rA G E (f le.o 0 E
4P3 II r � a r ►►'�
Property Address L o 7 G o - ,r ,�,� w c� p D .ia G v O S o tJ
(Verification required from Planning Department for new construction)
City/State 14u Q S u W I Passel Identification Number s acs - 1 ► v- a o- o op
LEGAL DR-SCRIP17ON
Property Location 21 %, Se %, Scc. . T_2� t 9 W. Town of—� VDsoo
Subdivision C .T T 0 ijoo�, R p Lot # S 8
Certified Surrey Map # . volume . Page #
Warranty Deed # L (D .5 8 3 Volume 1 3 to . p #
Spec house 0 yes Who Lot lines identifiable byes ❑. no
SUM 1VIAfiMRNANCE
Impropa use and msnmbeasnaeof yaur septic q*m could rrslt is Hsi F t ief a= to handle wastts. ft6*=&inftx=
eaasists of pig out the septic tsmlc evexy Huse yews OCSOonff if Headed by a tioeased pumper. What you put iuW the system
can affective foctim of am septic tank as. a treatment stags in the watt &RIo d system.
Tlue. pt+opetty oWaet gum to submit to St t Zoning Departraput a oectifcation form, signed by the Own=
by a
? P - io=eymn pt= bc; te$ Wcwdph= beroraHoensodp= va va* ingdmt( I) theon- titewatewaaxdispasalsystem
isinPtoPetopmdnconditionan (/oc(2)ulai oaandp= ping.(zfmcmmy).thesep& tonlcis .lass.tti=1/3fullofslu4ge.
Uwe. tiu md=kmed have =d the above roq*ments and agree to azaintain the private sewage disposal syst=with the standards
S et forth, hexaia. •as set by the Department of Commem and the Depuft eat of KabazI R=o=cM- State of Wisconsin. Catiftcad6n
G string that Y= ap has been maintained must be completed and returned to the St. Qroix .County Zoning Office within 30
days-of ON date.
lo/ i /
GNA OF DATE
�WNLYt. CEItT�CATION
I (we) %Fdfy that all statements on this form are true to the best of my (our) kaowleclge. L (we) am (are) �e owner(s) of
the bov , virtue of a warranty deed recorded in Register of Dm & Office.
Iii I / 9 9
SIt3NA
MOAP DATE
Any information that is mis- �dodmay =tit in the sanitary permit being revoked by the Zoning Department. " "`•
•• Include with this a Ileation: a
PP stamped warranty deed from the Register of Deeds office
a Copy of the certified survey sup if reference is made in the warranty deed
STATE BAR OF WISCONSIN FORM 2 — 1982 �sO�►��:la<
RANTY DEED KATIK.EEN & YAL81t
po NQ. YOt. 1436PAGE 2 S T . °1 a� I x CO. m
_ IECEM Pat
SIT _HARD e_ STAnT and TAM .T P_ STA trr, Oil" -H!! ih00 AN
hnnhnnd and tai fa ( WNW Ka
Cuff Can FED
conveys and Warrants to RICHARD A sCHAAR and RRTTY A_ Mims
A rHAAR . httahand and wi fa t1E11 W FM 10.09
Plat i
THIS SPACE RESERVE FOR RECORDING LATA
NAME AND RETURN ADDRESS
{ the Wkmingdncribed real ovate in st _ Croix County, G
State of Wbconsin:
Lot, 58, Plat of Cottorwood Ridge, Town of
Sudon, St. Croix County, Wisconsin.
non -i i TO .0
PARCEL IDENTIFICATION R
I
This in fri It homestead ro rty
P Pe
(W (is not) �
Eueptiontowarranties: easements, restrictions, rights -of -way and covenants,
of record.
Dated this day of Jun 4p A.D., 19 9 SL
(SEAL) ni't A (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signatute(s) State of Wisconsin,
ss.
St. Croix p Cou
authenticated this day of , 19 Personally came before me this day of
. 19 the above named
u
Rir_harA n Stout and Janet P.
TITLE: MEMBER STATE BAR OF WISCONSIN t d*
(If trot,
authorized by §706 r+b, Wig. 5tatsJ I`�o * i c p impersc
person st _ who executed the foregoing
StatE dge the same.
1 THIS INSTRUMENT WAS DRAFTED BY
Janet P. Stout
-- 3 5 3 Awatukee Tr = �l 1 Hudson_ Wi. 540 t 5 unty WIS.
(Signatures may be authenticated or acknowledged. Both are not ermanent. (If noy s x,' :I`on date:
necessary: _ - - - � t / — )
• Namr cf .
" +n r I :Apachy sb r Id by typed or p t�ivi E- ow 'xtr natures.
} STATE BAR 1 3FW6CONSIN Wilit, -VnLg" Col. VC `
WABRA.'.Y DEED Fore No- 2 - 1902 _ MRwn/sl. wit
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