HomeMy WebLinkAbout020-1306-90-000 ST. CROIX COUNTY ZONING DEPARTMENT,,
AS BUILT SANITARY REPORT REEIVEQ
Owner ► L p T K OR N �:I �� � 4999
N
Address '1 QR 10 t LA o e 1 sY CPDY
City /State k\l o S g N W i S (_
�� �, oouasv
ZONt14Gt�FF ,�• j
�
Legal Description:
Lot 5 Block Subdivision/CSM #
'/a S G %, S Sec. d , T 19 N -R W, Town of u n S o N PIN # Cc;�b ecits
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Week5 Size ST/PC ao0 Setback from: House 53' Well O ViJ o P/L So
Pump manufacturer Model
Alarm location --`�
(HOLDING TANKS ONLY)
Setbacks: Service road Vgat tg fresh air intake Water Line
Meter location --
Alarm location
SOIL ABSORPTION SYSTEM
6p_ * s I - (,a •5 0
Type of system: �ZN- 't �1&6to(L Width a Length 0�75 Number of Trenches 3
Setback from: House 73 Well owtO P/L over, so' Vent to fresh air intake cw c?- I5('
ELEVATIONS
Description of benchmark TRoN V Al 5 1 (,u rcrj;? y_ Elevation . i UU U
Description of alternate benchmark_ Elevation
Building Sewer ST/HT Inlet ST Outlet 11 - 1 7 PC Inlet
PC Bottom Header/Manifold ToToof ST MC Manhole Cover y ( 3
Distribution Lines( (U 31 _ O 0 5 •• S O I �, , .3 S
Bottom of System (L)
Final Grade O UT U O 0 6 .0
Date of installation I 1 8 Permit number 3 U 7 $ ( State plan number
Plumber's signature a� ( License number Date
Inspector Ro � s 1 tJG{ a K
Complete plot plan
s ,
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
Ndtk : MIDW W'R O VQ(L
�x�► fi g�f�le � B� pRGUr�
CP'
G�
0
i
I
INDICATE NORTH ARROW — >
I
wisco Department of Commerce Count
PRIVATE SEWAGE SYSTEM y
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitaryf6r"9%:
Personal info rmation you provice may be used for secondary purposes [Privacy Lag, s.15.04 (1)(m)].
t er's HAEL T : r kR [] Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T61t 1306-90-000
IJ )DO a ia i ra r orn
TANK INFORMATION ELEVATION DATA A9800175
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S,15 pti Benc
Dosing
Ion Bldg. Sewer
Iding 6 Inlet _7
TANK S N 1 wu
St * Outlet ,p3 /►J. YZ
TANK TO P/ L WELL BLDG. Air intake ROAD Dt Inlet
Septic � f k -7� � NA Dt Bottom
N. Dosing NA Header/ Man.
Aeration NA Dist. Pipe f� �� s S
11.0 Ip
Holding
Bot. System i� job
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number
TDH ift Friction S TDH Ft
Forcemain Length Dia. Dist. To well
SOIL ABS ON SYSTEM
BED / idth , Lengt .l • o. Of Trenches PIT No. Of Pits Inside Dia. Liquid De th
DIME I N 3 7 DIMENSION
SETBACK
SYSTEM TO P / L L Cj WELL LAKE/STREAM L
INFORMATION Type C E CHING Manufacturer:
BER u er:
Syst N — — OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution 6peW. y x H ize x Hole Spacing Vent To Air tgke
Length_ Dia. Length ��. Dia. Spacing � /
it a
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 27.29.19,SE & NE SE 717 ORIOLE LANE
06L _ o�t 2� �4w7 �
1-1 g
Plan revision required? ❑ Yes I Y4 No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
1 4 SANITARY PERMIT APPLICATION Saf and Build Division
scons P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County ,
than 8 1/2 x 11 inches in size. 5 1, 1 �c
• See reverse side for instructions for completing this application State Sanitary� 7 Permit Nuum, bier
The information you provide may be used by other government agency programs E] Check it revision to p evrou�s pp1.tion
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Nam operty Location
C,. Q 1 E1/4 N, R E (Or) W 1/4,S a? T a9 ,
Property Owner's Mailing �ddress�� Lot Number Block Number
City S ate v C � Zip Code ne Number Subdivisi Name r,CSM Nu b
lug ��► 1,�'(s c, 9 0 1 � s 1j- WA
II. TYPE OF BUILDING: (check one) ❑ State Owned It I Nearest Road
village
Public al or 2 Family Dwelling - No_ of bedrooms wn OF rJ U1 411 Lolw
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /Condo - oiQ - 13d(p qO
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. j['New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
- ystem ________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 ❑ Specify Type 41 ❑ Holding Tank
1 seepage Trench qS )f 7 22 ❑ In- Ground Pressure r r 42 ❑Pit Privy
13 E] Seepage Pit Zat�'�nt t S r�e C � 3 X 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.) Propose (s q. .) (Gals/day /sq. ft.) (Mir /inch) N f os•6 ElVA r1
100 0 �� � � M t o 3 ; u Feet M o •,sheet
VII. N ORMATION Manufacturer's in gallon , Total # of Manu Name Prefab. Con steel Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete structed glass App.
Tanks Tank I
Septic Tan oc4rls" ,x9 F0 a UV {� I ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's S' nature: (No Stamps) MP /MPRSW No.: Business Phone Number:
v
Plumber's Address jSyeet, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
11 Disapproved anitary Permit Fee (Includes Groundwater ate ssu ISS ng ent attire (No Stamps)
X A roved Surcharge Fee)
pp ❑ Owner Given Initial �D 6) i
Adverse Determination / „
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6M (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber
�. �. N A M E _ 11 ► G� k ry.ee jfi4 p
•! A� 10 ._!_.�?_1._. ►�i� _SAN e , L . I C .E N S_.. = -.._.. aa_4v
• I) n s J
aM T P p�-
S E L ot CuKNt fi T O
0
3- 3x(7 Aft �aao y
' = 4 5' N
8
_ w•
z
Nofi� �A nCPrv� �� •� v
I
FRESH AYR INLETS AND 0BSERVAP10N FIVE
CROSS -- SE CTION
Approved Vent Cap
' Minimum 12" Above
Final Gra �e 11 (d$
4" Cast Iron
Above Pipe P Vent Pipe
To Final Grade
M Ilay O Synthetic _Coveri.ny_
-- - - -... Min. .2" Aygr.ey';il o _
Over Pipe
P
_.... _,
' .Distributi Tee
on •�—
Pipe �� _........_.I.,-
Aggregate Per-forated Pipe Below
Beneath Pipe < Terminating r
Bottom of System
L
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buikfings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
ST. cifarx
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. /
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: �U,y� /,QQ /fi /S Gi9�/D D / d • R Y LOCATION
v L % 0 ,U - GtiA /,P.ti y 5F 1 /4 SE 1/4,S T 2-1 ,N,R /f E (a) W OWNERS MAILING ADDRESS /of BLOCK # SUBD. NAME OR CSM #
P 336 TM � �oBAPPr_f ST / �z�8 f��ov��? � /�y }{UMm PD H i'lis ({ nSF CITY, STATE tIP CO PHONE NUMBER ❑VILLAGE 0OWN I NEAREST ROAD
,1_WvG /Y/V. 55101 +tUVso'j
Vf' N ew Construction Use (,4- Pesidentiat /Number of bedrooms [ ) Addition to existing building
[ i Replacement [) Public a commercial desaibe .
yso - gi bed , L trench, 9P�
Code derived dairy flow ( gpd Recommended design loading rate , gpdm
Absorption area required � bed, ft2 /000 trench, ft Maximum design loading rate bed, gpdM ' trench, gpdth
Recommended infiltration surface elevation(s) -s-� E • 3 it (as referred to site plan benc hmark) XIS
Additional design I site considerations f� t�lS °�`' SID "e'4
Parent material Sc S f3l�iE'l�� �! 1 P 7 Flood plain elevation, if appliFable It
$ = Suitable for System GONV It)WIU MOUND "ROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDYKa =TANK
U= Unsuitable fors stem W [3 U (as U Cie 0 U [��s"�D U O S [IS
E
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence g Roots GPD /fi
Boring # r in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Iertdi
l y,e 3
*-3 / /' S / � e s6,e " -1-1 / Ground D yG 7 S
Depth to
limiting
Remarks:
I
Boring # _ 13 2- 5 4, 2 ,+, ,,7oW 5 7C `f i ' S
131 z 3 - 2,1, is
/0 fie 3/ —
/57 ��•e �s .�
Ground
elev. yf- Io / S"
Depth to
limiting .--F7E'
face
Remarks:
F S� Na me: — Please Print E '�'� L� I C (,t ] — Phone: 715 . 3 A; - ress: 49 S O' tilt i L. � � • � UPSOA) Date: CST Number:
nattxe: ��
This test Site APPROVED
for a conventional septic system ORIGINAL
I
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2 - 01 3
PARCEL I.D. t 1 - 0 t Sy f/U�! gbfP IlllS
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxxl3y Roots GPDIft
In. Munsell Qu. Sz. cor!t Color Gr. Sz. Sh. Bed ITmnch
2-13 /o yR LL S./ / fsA< fie x
Ground 3 3o S 7 S Ole e 7
elev. • 7
Depth to :
limiting
factor �
s
Remarks:
Boring # $' 1 f S G
Z t ,e 31 Si 2 w► S,df' �►7 ' CS /v �` S (. G
3 -7
Ground
elev. 1t P.r-A
ft.
Depth to
fimiling Z _ � — s , T
fac tor
�
Remarks:
Boring # _
/ o -/o /0 YX 3/2- S/ 4" sir a le S
2
Ground
elev. t '� �,s e /06_-& ( s of 5/ �f s6.t' .►Nf�° eta' - �S' 6
/o y, o ft. I
Depth to
O 1
limiting j
taC tor n �/
Remarks:
Boring # g
F3
1
Ground
elev.
tt.
Depth to
limiting
factor
I
Remarks:
con eeonio ncmrn
ORIO
U
lEV,4Tiov S —
�, io7s> -' N
70
13 3
13 y 111-76
3 0
,
t�
.S'v f f ES T"
7? E vc.G
how T�' �•��i __ /" 2. , o '
�
lSy
0s
3
A r
/EVlt riOA) /0
50 • L o r L
0
3 S' /.
N °30'10 "W 664.12' S
i U
z
OA F
S 45 50' 00" \N
86.82' .
S44 ° 10'00 "E - =I
66.00'
� S7g 274���E
' 46 3.13'
78
I I v `j
So S9
�o
1
57
i
�r • -r
S89 ° 3015 ° W 942,42'
f
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I _
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer _ !�� /C'� ��
Mailing Address 7Gi yYz •5 �� �r� �✓ 5z
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number _ ,1 '—'C-7 `zz
LEGAL DESCRIPTION
Property Location A_)& V. S L /, Sec. �7 'r �1 N -R ': o:.�n of
-
Subdivision [ /7? 14111 _ Lot #
Certified Survey Map # Volume , :Page #
Warranty Deed # S - 2 7c3_, < volume
S� Page # a �d
Spec douse ❑ yes ❑ no Lot lines identifiable %qes ❑ no
SYSTEM MAINTENANCE
hmRmper me and mated= eof yca septic systemeonld result in its to ]candle wastes. Propermah* nanoe
consists of pumping out the septic tank evely three years or loons; if neededby a licensed pumper. What you put into ft system
can affect the function of the septic twk a treatment stage is 8u waste disposai
111C ProPcrtY owner agrees to submit to St. Croix Zaniag Depart a certification foam, signed by the owner. and by a
m G]ouneymanphmber; t+estrictedplumberor a licensedpumperverifying that (1) the on-ite wastewaterdisposal system
is in Proper operathig condition and/or (2) after inspection and pamping.(if necessary), the septictank is less than lI3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with die standards
set forth, herein, as set by the Department of Commerce and the
stating that year septic Departm of Natural !terourr, �; State of Wisconsin.. C.erti�.rcatiba
system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
SIGN OF APPLICANT DATE
O CERTIFICATION
I (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
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
- . / /
GN OF APPLICANT DATE
« « « « «« y 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 Dads office
a copy of the certified survey map if reference is made in the warranty deed
DOCUMENT NO. WARRANTY DEED
�7 l274 STATE BAR OF WISCONSIN FORM 2 —18821
•i 1 i�
9 ,0
... ........... .
�I REGIS �`F`ICE
Humbird land Corporation,..a Minnesota Corporation
. V10 W1
.......... ............................... .... R v �X M�'
..........:...........:... .....:......................... I
....................
APR 15 19
j1 conveyor and warr alts to .. Michael T. Creene,. • a, single person... 1 :00 P
j ... ..... ..... ................................ ............................... .................... "�tll....`+� t1JJsl.M
�• or Deed.
Matti
.. .. ... .. .... ....
..................................... ... .... .......... ....... .... nevunN To
. . . . .. ..... .......... ... ...... ................
.............................. ............................... .................. x0ir
the followiew described real estate in •. 5t.. Croix (;Dusty, —
......................
State of Wisconsin:
Lot 54, Humb•i rd Hills Third Addition, Tax Parcel No: ..............................
Town of Hudson, St. Croix County, Wisconsin
TR�Na FER
This . ,. is not ............ homestead property.
(bO (is not)
Execlition to warranties: Ealsements, restrictions and rights-of -way of record, if any
Dated this .. ....... ............. day of ........ ...April
..... ..................(SEAL) HUMBIRD LAND CORPORATION (SEAL)
. .... ......... ...... ... .......... • By ' ....................... ..
Austin J. Baillon, Its President
......... ............................... .........................(SEAL) ............................... .........................(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ............................. ............................... STATE OF I11P MINNESO
as.
Ramsey ............................ County.
atlillenticated this ........day of ........................... 19...... Personally came before me this .... ... day of
! Prj 1,,,,, ............. .......1 19...98.. the above named
................................................. ...............................
Austin J. ..Baillbn,_.President . . of
. .......... ..... ...............................
.....
• Humbird Land Corporatio n
TITLi * : AtEM11Lit STATE BAR OF WISCONSIN
(If not . ............................. ........................ ....... ........ ........................................ ...............................
authorized by § 706.06, Wis. Scats.) ................................................. ...............................
to n►c known to be the person ............ who executed the
foreg ink; instrument n'nd'•fibklfowledge the'saflfe. ` • —
THIS INSTRUMENT WAS DRAFTED By -�' . ,:'�* �... a.
Humbird..kand..Cvrvoration
.... ....................
Wy •...Fau)..A,..�a�.).ion...,..,� . n .. ...
.ti €�n+4 i ?, a
Notary Public W.ash`�na flo....... oun y, .MN
(Signatures may be authenticated or acknowledged. Both Aly Commission is permanent. (If not, state expiration
are not necessary.) date y
*Names of persona PIxnlner in nny enpneity sh.,uld he typeal tar printed ht-low Ihrir Pit- nni.mev.
5�N,;Ci SC�{i
fi■.e1 AMM t 7
HUMBIRD HILLS THIRD ADDITION
LOCATED IN PART OF THE NEI /4 OF THE SEI/4 AND IN PART OF THE SEI/4 OF THE SEI /4, ALL IN SECTION 27,
N T29N, R19W, TOWN OF HUDSON, ST. CROI% COUNTY, WISCONSIN. lt�Ll�
NN
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t
OWNED 0 • LNDCNO
A w•ww ire R•.awNOw • Mlwwww• town aura xommaw av r
A
am coal .0001 " ° is ram an nw
K osw •+[ rr, yw.•re ,ef \•a Aa No
"we. wiw
wa• a \er =Ns fi• — e. a•-
No
J 44r 2i LOT 20 a•le
I w a•e Log
ig I y\1I"�M N i in A DITIDN 3t I — •• —Iwf 00 soon twoov to nn/a aww
Y 4 I I • r.M w■.+■s■a .lr.w.r \r .,. \ratr rar
4 ( - I IiUMt81RQ MILLS 2_IO I
�� • � S� A_vClTla_1 ?J 1�
.� .� • IM s a aw.as. sn14%oss N $"a-
LOT 46 -ft
somw ��, l �.�.rr ..,wYala• K.
.•�w
^ / \ m e " • gM tao0 It\.•Iwllal aMre
tlifrl url~I nerllal• IMOP
\a •lo■a �? / / �\ ■w
co-
{ 1 / taeron IN
fi 7 4 • OO�W
LOT 31
/ 86. • HUmom tIr3 op
1 LOT 47 IT 9 N
".so hill
� �/ y f S � • ?74/
afa
LOT 48 1
a" el n j •a/a, / n • . er LOT 62
1 i J /• 1.10 ag
Y J i
i l j LO 61 9 «.� NK
1
LOT 49 0 1 a N .O.lt !
N.oe rR.
N7 Yaw■ Q
oar basic
LOT 50 , ' ` -- -- Sam , r •.\aa l y
w "It ' ( ! , ••IN a�K
.r y
i
LOT 60 i I�
am •• Mo.r•• 1 i1 `tl a M l
Ira, rah ,
.` ` \ IT'
_......_......._....._ -.... 1
ap
LOT 52
• 1 � "mfr =_•�_ IA
LOT 51 v %:__ r•
»I /::: -JAY -LgNE _°-
o•
r OT 58 at
"'°•'• "r.rl - ORIOLE -- -LANES A
4
• LOT 56 a
,
.• � � FN M e x �
+.� •• / ^....•'• 1.1, Mall
N,gr rR.
LOT 53 wl LOT 55
tvh cartel an—* ..
S ......... a.,e Kwt, LOT 57 eY.,
LOT 54 ..t t• ■t.t..
.,.rw an 1.., • : % i•Y■tf rut n Nlr
a to rr. • 1.w Kaas II
mm rR rat 1•NaM•lal•ua
W / let a'.•. INC..* to
ANN
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fe`I ionic Ifiltl the t
._............ ... _...._....... .._... .... .... ................. ......... .......... ... •. � ...... . /........
.........
....
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8
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tonN tar eplt•.
589 W 942.42'
■. •1• •f wrlN
FLAT LOCATION 3 INTERSTATE r 94 , t.ht • •r• to N
rl...4..th th•t Ih•
\neon l.elon veYla
Q J .Y0.awr •W. IL � allt Yfh lwr •Yf Y•T
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y vision along ear IV
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rya •tl rw of r.ctl•w
— \bG 71a. 17 •f •\•c•na lw
3t rt•t Yt.•. utility
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i �._ .__ •'"�er/ the Y•. •f ►Palle
N J M ,, s , ; , L hNln •wa rrle.t.
-_� NYhlle •llll•.
SCCTMN 2? It•�rltli • NAw th• right t•
ouw� 11M. the af•..
SCALE N FEET
.t ..•xw•• e..nro w is n....r
SHEET 1 OF 2 SHEETS we r e « r• ar