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HomeMy WebLinkAbout040-1197-50-000 ST. CROIX COUNTY ZONING DEPARTMFN AS BUILT SANITARY REPORT Owner :5 Property Address S T City /State C;C)6 ZONYNG OFFIC Legal Description: \` Lot ­9 Block — ubdivision/CSM # 1 /4 , 1 /4, Sec., X,�f N -RZLW, Town of - PIN # - SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/P9 / Setback from: Hous Well 115 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 SYSTE Type of system: Width 75_ Number of Trenches Setback from: House 2�/ Well P/L 3s Vent to fresh air intake � s ,r ELEVATIONS Description of benchmark Elevation "I 12�!, e Description of alternate benchmark - Elevation .161,9s Building Sewer -. ST/HT Inlet 5e' ST Outlet PC Inlet 7 -/ 9 y ,O PC Bottom Header/Manifold ;O 87,2y Top of ST/PC Manhole Cover �� 3 Distribution Lines ( () ( ) Bottom of System ( �Q4 �� ( �_�, 79 ( ) Final Grade (j /) � q� ) 2j-,!:g ( ) Date of installation / / P mit number �s" State plan number Plumber's 7signatt re License number Date Inspector Complete plot plan � t � i 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 �k 1/ �G 3 � INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353139 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: Peecher, B. Shawn & Deb I Town of Troy CST BM Elev.-.- Insp. BM Elev.: BM Description Parcel Tax No.: .d r I (yo . a �.¢., — CST Vu, *1.. 040 - 1197 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic &W Benchmark Q ,'30 lop.3o 10'0.0 r Dosing Alt. BM a• ' e 1. 93 Aeration Bldg. Sewer 8.5-0 Cu. 50' Holdi St /Ht Inlet 9 j TANK SETBACK INFORMATION St/ Ht Outlet �, S TANK TO P/ L WELL BLDG. Aeintake ROAD Dt Inlet Septic >a� r > ( r 3 Or 1 NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe /V 0.9 Holding Bot. System S 12��(s . •3`f PUMP/ SIPHON INFORMATION Final Grade Ma facturer emand St cover �- 0 g2- 3 Model mb GPM f' d 0 Ids O T Lift Friction System TD Ft Forcemain Length H ead ist. To Well SOIL ABSORPTION SYSTEM 12 NBLTRENW Width ( Lengt ► No enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION S S DIMEN I )N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Maanufact rer: ' SETBACK CHAMBER n-- Model Number- INFORMATION Type Of System: tom' 30 ti �0 �0 OR UNIT �i u DISTRIBUTION SYSTEM ' Header/Manifold 4% Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia - gt ia. pacing / t fo j SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over r Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Y s E] No E] Yes E] No COMMENTS: (Inc de code discrepancies, persons present, etc.) Inspection #1: l / `f/ "Inspection #2: -f- / Location: 557 High Ridge Drive, Hudson, WI (SE1 /4, NE1 /4, Section 4 T28N -R19W) - 4.28.19.899 Plan revision required? ❑ Yes No Use other side for additional information. 1 0 - 5 1 OZ- O 1� " X SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 5 § " b " . T e 9 3 ; + e , ; .W + 4 ... .( .., l._.. ... .. e.e.....a Y € b i a 0 �." ._mP... c—«... .m.. �,.. " "m...«. -..� ...,� ".. ---._ ;..me m.g. �..,......... _.A ,� ".".. .... ....�p..„.....e....}.,m„,.».».� >,....�.�...wm"... . . ........... F ... ���.. 3 .. _. .... .. — " " . ... ... e" E f t E a § € F + t � E a � a A s + .,tea .a .. .. w.. N...,..,,.... >.d. ","... ..��..: "....., � „e..._.. .....__..- ....w.... ... .�..._.. . __ aa.m. .m..." ... ... ......... ....... ... ........e ..�. .. � - ��1! Safety and Buildings Division .��/SCOnS %n S ANITARY !E!�IT ` ' 1T1ON 22010 B Wa iington Avenue In accord w IL m. Code Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) forth m, o t less county than 81/2 x 11 inches in size. L° • See reverse side for instructions for completing this a ti o47 q State Sanitary Permit Number Personal information you provide maybe used for secondary purposes , (3Check it revi ion to revious application [Privacy Law, s. 15.04 (1) (m)]. -S� tate Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRFI4T A FA I }+ ' Propert Owner Name o L ion / 1/4,5 T , N, R or& Property Owner's Maili Address Lot Num er Block Number i c 1 ' City, State Zip Code Phone Number Subdivision Na e r CS umber / Sr ( ) T YPE BUILDING: (check one) ❑ State Owned It Neares Clad Village , Public 1 or 2 Family Dwelling - No. of bedrooms A a Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) f n l pI Q C a 1 [] Apartment / Condo 7 `t _ (! D ^ � p v r 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. Z New 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ------ System ________Sytstem _____________ Tank Only __ ExistinQSystem ______,_ Existln�S�fstem 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 ❑ 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. /i ch) -,-/_ YrQ Ele �1 7 eet Feet at VII. TANK in Capacity s Total # of Prefab. Site Fiber Exper. New Existing strutted INFORMATION g Gallons Tanks Manufacturer s Name Concrete con- steel glass Plastic App Tanks Tanks Septic Tan ❑ ❑ ❑ ❑ ❑ Lr r ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans. Plumber's me: LPr int) 7? Plumb 's ( s MP /MPRSW No.: =B;usines, P hone Number: Plum er's Address treet, City State, Zip C de): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) Approved []Owner Given Initial surcharge Fee) Adverse Determination �• UCH lG `� ,.>` r - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety& Buildings Division, Owner, Plumber l INSTRUCTIONS i 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 proper) maintained. The septic tank(s) must be pumped b a licensed pumper whenever 9 Y Y P P Y P P 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. 11. 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 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; 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. i pQ� n y 0 r ,y i Q S4 I S k M C-4 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County / include, but not limited to: vertical and horizontal reference point (BM), direction and ✓ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I. D. # r (� APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property wner Property Location r i } — Govt. Lot 1/4 1 /4,S T N,R E (oC r Property Owner's Mailing Address Lot # Block Subd. Nam or CSM# ': _3 , City Stat Zip Code Phone Number Near t Road ❑ City Village Town New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd /fi 2 ___.(,/. trench, gpd /ft Absorption area required bed, ft trench, ft Maximum design loading rate _ < 5 — bed, 9Pd /f12 gpd /ft Recommended infiltration surface elevation(s) / - �f�7�} T� g7s ft (as referred to site plan benchmark) Additional design /sit_e Parent material f�'/ f Flood plain elevation, if applicable f 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 S ❑ U ®S ❑ U 6� $ U ❑ S 9U 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 "� �' a v P Ground 3 elev. Depth to " tJv' limiting factor 5 in. Remarks: Boring # ( / IN Cd s s , Ground I J elev. r. i 9ft. Depth to limitin factor ,�i Lein. Remarks: CST Nam (P ase Pri i Signature , Telephone No. �- Address Date CST Number r SOIL DESCRIPTION REPORT a PROPERTY OWNER w� / r a P of —=..1 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench W- A Ground elev. Depth to limiting factor Remarks: Boring # 6 mZd Ground 9 ' elev. ?Zn—L Depth to limiting factor 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 # Ground — elev. Depth to limiting factor > is in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I 0 : R. 4- y Nm r 7 Z- � 73 7 -0510 • jU.. • ¢ ■ Date - • We .� • P h o n e AREA .. - I�`�,� 1` ' 260 a �;. DEPARTMENT SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS 1 115 P.O. B ox 7969 HUMAN RELATIONS l MADISON, WI 53707 Sr = ktAl2LEy 1206"1 (ILHR 83.09(1) & Chapter 145) LOCATION: SE I N: TOWNSHIP OT NO.: LK. NO.: SUBDIVISI N NAME: '/4 �/ /T24 /Ril E lo W TR - 1 HI*6-i . R I'%, Cr e COUNTY: VyER ; MAILING ADDRESS: / Sf eRoiX S HAW-) ��E�NE �o71S CNoWcfJ C(RcIE, T3 USE 6 /2^ DATES OBSERVATIONS MADE rrY�c�t NO: ORIX: CO M AL DES RIPTION C ,t OResidertce 3.�4.r m ❑ New Replace 1 APPiL 1 7 ' I I f0 A P j? j )e_ 1 1 p RATING: S= Site suitable for system U- Site unsuitable for system 5C -S , FMM ER T SoltTTIPE is 6 ) L S ONVENTIONAL: 11S UND: IN•GROUNdPF3ESUME: SYSTEM -IN -FILL r EJS 0LDING TANK: RECOMMENDED SYSTEM: (optional) os ❑U E - ©S ❑U [IS 0U 0U d jLY W/ Da 'SO S w SL Opt s .'O 0 ,1 /0 If Percolation Tests are NOT required DESIGN ATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: G L1kS S =� Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORINGI TOTAL DEP H TO GROU NDINATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH RILp::3E° JS°,H IN. ELEVATION ^SE WED EST. HI ric".•" TO BEDROCK IF O BSE R VED iSEE AbBRV. 014 BACK.) B- / 8,0' g 8. /0 � > o 1. or. a,, . s , �.s 'ate, s , 5: o ' rya vrc y 5 8 a . S 1. O ' 13a • �Q+v� K �S t � S r vt CS - B- S l3• > I /S 4•S UCIR� C$ r B- • S' 01 T •t . r rw• - S L4 0 U (► l2 c -s BS A `13. �0 > �d' s' Dr a,- B- PERCOLATION TESTS Ito ufr A t/ CS 4TRA7" S TEST DEPTH WATER IN HOLE TEST TIME DRO IN WATER LEVEL-INCHE / RAT MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. NE iioD-i P RI PE 11100 3 PER INCH P _ 3. 5' r 2io 1 P- Z ; ST ` 2 - -- �— y P. PLOT PLAN: Show locations of percolation tests, soil bonn95 and the durnensiuns of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. L OWE S T 'T U _ y G O i DO 7 - We v e ti SYSTEM ELEVATION I H/ i r i t I r SEE PLOT 4) C A J �. S r w i �CU>T: Q 6-" APP OV r for a coriti' �!C : �, N : YC 1 t, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): ITESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. �i°�,�� _ I /` Q 655 0 RD., UDSON�VVIS_54016 _ _ ADDRESS: ROBERT ULBWHT CERTIFICATION NUMBER: PHONE NUMB R(optional): WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. 2- Y ,? 2---- MINN. ,, C: NO. 00663 CST, NA JTION: Original and one copy to Local Authority, Property Owner and Soil Tester. W -6395 (R. 10 /93) - OVE Aftb 1 O w i � J �G �o 54 e i o I x = ` lo o � l 4- Q- h w �'� PROV J- Thts test SitQ tic sY SteC�1• I ScP jor a u 2 i i ar �tA s r Zs � jdCkTi'o.J � P12op osbf? _ � I t � � I C u t U r4 SAC ft i a Imo, 12 i D (r E 17 R u.e,.... I 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE A©REEMENT -• AND owNCRSHiP CERTIFICATION FORM ' Owner /Boyar - ._ Msti lino Address I 5t N 044 s i s y a r .Property Address IVcrtftcstictt tcgt►uc,l front I'lirinung ncpartment for now construct ion) Citytstata .��.., .� y � S � i � � Parcel Idontification Numbdt LE Property l.oCntiatt . t /., � ' /., Sac.. 4 T,,,48 14- RJU—W. TOWn of Subdivision a t c-, N V.t cwr Lour+ s +. rr tot N Certified survey Map M Volume , Page M Worronty aced M 5 1AD362. , Volume I t lob Lot linci identifiable es no � C] Spats house Q see l� no Y fmpropet us and meInic asoccof you rSr micsystcmCOwy )matureNilure to h andle wastes, Proper ms lAtenallt� + consists of o -Aoina out the septic tank cvcrY three years or sooner, tr needed by a licensed pumper. What You put into the tysle can amct the function of the sepoc tank as a acatmcnl stage in the waste disposal system. Th4 piopetty owner agrees to submit to St. Croft► Zaning Do psrbn eM s certification form, sijned by the owner sod Is masts? plumbs, Joumsyrnso plumber, restricted plumber or a licensed putmpst vetrifyins that (1) the on•sita wastewaletdieposal WO is in proper ooerstlns 6ondWen anNor (2) aRer intpeetlon and pumping (if necessary), the septia tsnk Is lose than 113 fall of slu VWt, the undetitrynod have read tluo obove N40""tionts and autte to matntairt the private sewage disposal system with the stsndar � ;, sti forth herein, as set by the Deportment of Ctnttntcrce and tilt rnpart"m of NoNra1 Resoutt es, Stat of Wisconsin. CerttficNt t' stalft d►tt your septic system has been moinlStncd must be compacted sad returned to the St. Croix County loninj Oman withie W- days of the tbreo year e% iratian date. SifiNO I..iC^N.,._.T....r....r DATE 1(we) sternly that all statements of, this roan are tnte to t11$ boil of my (our) knowledse, I (we) e m (are) she O WNI(4)', the property described above, by virtue el' a wurranty died recorded in Rayistet of Deeds Me. SI GNATURE Or APPLICANT DATE �., 06106 Arty inrom"Itition that is m,s•represet+ted nary result in the santttiry permit being revoked by tM Zoning IM1114 Mlten6 66 tncludo with this application: s stamped warrsaty decd %m the 114=11101 of 06640 office ` a copy of 1114 csrt i fiod stl map tf rerer4ne4 it ma de in the wen a nty deed 4. tta'd +8i =Stl �Nf1t,+ny�k�J 31 st�aa w.r +.•ea+ aa ...ar,_Wao I; DOCUMENT NO. STATE VAR OF WISCONSIN FORM 3- 1992 THIS sIACa Rasaweo row nacoeo, «c o•tA I' '! QUIT CLAIM DEED _ - r REGISTER GF�II 2 �1 ST. CROIXGW, +'" i Mel -issa -J. Mc_Int- .re 4Y..... Y .. �t f /k /a Meli.ssa..JoY 2222 .__ , need for Raa ra !, _ s G .. - - - - -- - - - -- AR 1 6 - - - - - -- .. ._.. .. .. -- - -- - M 4 99 I� quit - claims to .. Barry S a . single - person,.. _ - _ -. _ 9: A.k, _....Gr. l 1.. _ .. ............ ....... ........2222 ... ... _2222.. _ .- .... ....... ......... d - .eq ' r o Dee a . __ .......................... 2222. 2222. 2222... .. 2222 ........ ._.._........ . _ - - -. -- ..... - -- .22.2.2 ......... . . .. ...... ...... the following described real estate in .... S.t. ... Croix . ................. . County, - -: - -- - - - . ^I - • - Q -. -__- -_ -.;' State of Wisconsin: !I warunp r �w �I I it � I I Tax Parcel No: .--------- ................... Lot 26, High Ridge Court First Addition in the Town cf Troy, I� St. Croix County, Wisconsin. I' �l and Lot 27, High Ridge Court First Addition in the Town of Troy, r St. Croix County, Wisconsin. By this deed, Grantor conveys all her right, title and interest in " the above described property to the Grantee and further acknowledges satisfaction of that certain lien in Grantor's favor more specifically j! set forth in that certain Judgment and Decree entered on December 13, 4 1993 in the matter entitled, In Re the Marriage of: Melissa Joy it Peecher, Petitioner, a nd Barry S. Peecher Respor,3ent District Court ,. File Number DW 198 555, Fourth Judicial District, Hennepin County, Minnesota. I� F PT This ..- 2222... 2222.. homestead ro ert ..._._...-.-- -.....___... -2222- 1�.�.... , (is) is not) _ P P y y' _ February _ 1� Dated this - ..1 5th da of _ ... ........ ... _.._.. ......... - (SEAL) L.' 1 ' - k.Y�__ ��+- ..../. :/1. 1 Y (SEAL) II .. • M Iissa - Jo McIntyre .. .. ..... -- . _.. _... .. ....... ...... _ .(SEAL) _..(SEAL) I f. • • -2222 I' ti �I AUTHBNTICATION ACKNOWLEDGMENT " Signature(s) STATE OF i?"BeOMMN MI A ....... .......... •---...._...._....... -••- -- _---•- - -_. - ................................. --- .................... ........ . ...... DAKOTA .. .. ------ authenticated this -------- day of .. ............. ..... 19__.--- Personally came before me this .... J- 5th ---- day of FPbLL?al . ................. 19._�.E2_ the above named _Melissa_- Joy._,McInt} re_,..f /.k/a,.Melissa.Joy. ............................ Peecher,• a single__ person .......................... TITLE: ;MEMBER STATE BAR OF WISCONSIN . ..................... .......... .. , (If not . .......... ......... ....................... - ---- -- ` . - - ----'-- •___..•• "--- ....._..._..._.......- authorized by 706.06, Wis. State.) to me known to be the person __22.22.__.. who executed the - �� foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ) �T /v j /f/ Ward K. Arlderso❑ ��r.Y.. �. ( LLL - -- -- .......222 . G Grann - s,. - -- '- zann> s.,- Hauge,- ..Eider._..__- 4 i I Anderson & Keller, P.A. --- . --- -f�. -. f�+- .N ...: 12 60 - Yankee_ Doodle. -Rd. -, .. .20D *. -... . -. Notary Public ._. - ..... _.County, Wb. Mt'i My Commies expiration � (: (Swiiahlres cony be aufl enticated or acknowledged. Both me not necessary.) A A(� 19.._._...) ; Eagan, MN 55121 Gate: _ 2222. AM OAI� k ti 31 41 COUNTY �!. if�+M sNsmea of persons signing in am u w A7saa,t, par:ty sh.,uld be tyr d or printed bolo► their sig•stures. a }- 41.%TE of %R Of wl <` ONSIN �►tcrrxnm FORM N•. 1­1142 Stock No. 13003 SC - b/I 3N - 3Nil 15V3 . „ .r :W . 0 p c 07 OL �- — 0 LY _ v W v p \ N 0 r= UJ I � � - _ - . - .. J• iii VI•� T-R •'•'- r' • Z in - M cn S ,r:• W O la _ • a�., ,. co v _ O W N Q N O _ c:. : r ,Ll'JZ£ M W M,ZZ,�Z e0$ 7 0 LA- 0 cr 0 o _ ro N a r• o N rL cr ul 'n N a N W r c N cm t Z. N CD 19 / 4f ego Ze9 J: �,h d� H m f - cr AL u r. 7_ al 0 \ N p � s � d E OO SZZ •o �•.Zb,9'..g a N - I W ct N m cm ui n O h Q+ W + i v on ! h N "_ �G• .l ? .. l 33 ^ Mf Z - ;#1tic c}' u - 1 N _ -s ' �.• N - W N F ' 3 _ r lip . 00 oell