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HomeMy WebLinkAbout020-1163-40-000 ST. CROIX COUNTY ZONING DEPARTMENw AS BUILT SAM[TARY REPORT r , Owner 42. 7 Property Address T City /State f c - rni, t,, SY ©/ �p yING X Legal Description F Lot /_ Block 5E Subdivision/CSNI-# '/a .V,, ' /4, Sec. eL TAN- 7U W, Town of ,�c�nsoo�/ PIN # - o SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION Tank manufacturer wr'FkS Size ST/Pe 4,yal Setback from: House 1 ? 4 Well -- PAL '— Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to esh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: 1 �( Width s' Length Number of Trenches 2 Setback from: House 35 Well -- P/L -- Vent to fresh air intake > Pd' ELEVATIONS Description of benchmark Ayb Elevation ioo -y Description of alternate benchmark Elevation Building Sewer STMT Inlet F .2, t-P ST Outlet 7 >. 5 PC Inlet � / fi -W PC Bottom Header/Manifold a z 9/. t Top of ST/PC Manhole Cover W. 9 � - Atib Distribution Lines (/) 5/ a Bottom of System Final Grade Date of installation , y /ff' Permit mber 7� V A?7 State plan number Plumber's signature / License number .2-> Date / PYlf -' inspector % « %c�os+,.�rauD -t Complete plot plan �* 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. rr' PLAN �s , �s' Gar � k \ \ We r , is � ,� ©��r� L oT �4rz�✓E.Q �1 = 7d / o f 7-A4. ��o D CO . v C is- GI`F�•tis��' d�c©�� -9 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division $T . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarype�mit�ly�.: Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)]. 3GG bbtti5 1J A NS UCTION [A6bSB !V illage E] Town of State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel - o: lGU- w'Y,c cy,s b !" ��- 1163 -40 -000 TANK INFORMATION ELEVATION DATA A9800578 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. SepticS C, Benchmark 3- �( Dos' SZZ� �g (06' Aeration Bldg. Sewer R 3.09 Holding St/ loof Inlet TANK SETBACK INFORMATION St/ �K Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake a " Septic l..c��' 3 �d �l�- NA Dt Bottom Dosing NA Header / Man. /� ?z Aeration NA Dist. Pipe ;/ Holding Bot. System /Z PUMP/ SIPHON INFORMATION Final Grade S .7 Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss F oK6 main Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM - BED/TRENCH Width Length No. Of Trenches No- Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSI SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM L I a urer: INFORMATION TypeO /LCrn , / 3 B Number: System: tre s 3� OR UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) C / / x Hole Size x Hole Spacing Vent To Air Intake Length __ Dia. Length 6S Dia. r 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 Topzoil ❑Yes ❑ No ❑Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.20.945- 947,SE,NE 294 EDGEWOOD DRIVE - LOT 17 � P144 n Plan revision required? ❑ Yes Q-No - Q Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. s ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i N* 6 SANITARY PERMIT APPLICATION 01eE W and ashn consin 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. 6 • See reverse side for instructions for completing this application State Sanitary l Number Q The information you provide may be used by other government agency programs ❑ Check if rewisl5in tJ previous 4 plication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 1/4 E 1/4, S T .•Z , N. R , E (orep Property Owner's Mai Address Lot Number Block Number Z1.7 17 0 Flo City, State Zip Code Phone Number Subdivision Name orESM N r vxv ( ) 00 II. TYPE F BUILDING: (check one) E] State Owned o 't Nearest Road E3 Vil[age Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF u AJ 111. BUILDIN USE: (If building type is public, check all that apply) arcel Tax Number(s) a 1 E] Apartment/ Condo 1 ®20 — //6 7 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor R creational 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_ F] Replacement 3_ E] Replacement of 4. E] Reconnection of 5. E] Repair of an System System - _____ ____ -___ __ _______ ____Tank Only Existing System _� _ Exi sting S ystem -- -- - 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 0 Seepage Trench 22 ❑ In- Ground Pressure ! 42 ❑ Pit Privy 13 ❑ Seepage Pit .2 — S,,S ST ' 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) #/ �•3r Elevatio y 3 - 8 #z e' Feet F 9-? ' Feet Capactt VII. TANK in allons Total # of Prefab. Site Fiber- Exper INFORMATION New Existing Gallons Tanks Manufacturer s Name Concrete st Con Steel glass Plastic App Tanks Tanks eptic Tan "dmg -- mm COQ ❑ ❑ ❑ ❑ ❑ ump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ I ❑ I ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of a onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No S m MWMPRSW No.: Business Phone Number: PI ber's Address (Street, City, State, Zlp Code): v Z1VA0 X oA IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing en Signature (No Stamps) A roved Surcharge Pee) l�jj pp El Given Initial Q�/�j Adverse Determination V v I � ! la&44W X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: tj S8D4M (R.11A*j DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, f Yrwber C 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 mairiitained. 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. k X. County / Departgjant Use Only. Complete plans °andspecifications 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. { DAVE FOGERTY PLIRMNG Ucensed Perk Tester & Plumber 83233 83289 Foo g�eerty Heights Road ROBERTS. WISCONSIN 3 Pho 749- 6 y� -- 0 OA t p/ x I 7 xs"' 47 TO� OF i sC. T �SSU N/6' t o L 6�tS�ldlE `ly�s � \ • = Fd�trvd GOT �E,yenic R w /�'oD \ 4� s \ Az tL�I/v — is r po, 3 avcp �s�c �. sErd�x .9ticvuvrEv ,�.�, f Wiscongin Department of Commerce SOIL AND SITE EVALUATION ? Division of Safety and Buildings Page _ of y ,Z 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. # ? -- 3 -- O 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 Owner Property Location /� L �'� C / _ Govt. Lot S� 1l4� 1/4,S/ L T�9 N,R �O E (or� Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑Village � Town Nearest Road New Construction Use: R Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4'J_0 gpd Recommended design loading rate bed, gpd /f? trench, gpd /ft Absorption area required 1::74 __9 bed, ft f12 Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) */ — fb. It (as referred to site plan benchmark) Additional design /site considerations ZX, 0 5;UL,0 A4 —� .�� r — zz/;, C / {Ej Jr/ �` anwteyzlz . , , Parent material A,? 04 Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system s U [I S JZ U S❑ U [1 S❑ U ❑ S PIU ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots / Bed ,Trench `7 O —z Z 4S S C 7 J� X3.2- 3 Ls _ .� Ground elev. ft. Depth to limiting factor , > 1 9z - Remarks: Boring # .� .2 Z - 3 zm 51. w M 4 c s a - A4 L- Ground —9 G WZ- elev. 9� ft. Depth to limiting 7J�I fact 9r. > Wi n. Remarks: Z _ ,AWX T .f/� To �,�/?•r� iy`I CST Name (Please Print) ^t Signature y Telephone No. Address Date CST Number // A0 PROPERTY OWNER Z)f-IN- ��I�,�/: SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 � Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 4i Af v A �s G Z q -20 Ground . 7 •�' elev. , XZ- Depth to limiting factor -(p Remarks: Boring # o�z /C /c , Ground elev. ft. Depth to limiting factor >1p�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 # - Q rY v -Z/.> &t 1z F17 f0.3 l KLY6 S— IA4r/ — Ground L. elev. Depth to limiting O• factor ; Remarks: Boring # r ' v 4 5 -- - 3 S ,r L — . & Ground 6— S S SG L- elev. JF Depth to limiting factor 7 n. Remarks: 7y SBD -8330 (R. 07/96) ME FOGERTY PLUMBING Licensed Park Tester & Plumber' #3233 0289 F Heights Road ROBERTS, WISCONSIN 540 Phone 749 -3656 e 7 C 4K v $K _ 70 "90, F 7 #2 So 7 /t /-F, r. f' e, /4A,- /P ( * *CC V REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION PERCOLATION TESTS (115) P.O. BOX 7069 MADISON, WI 53107 _114 & Chapter 145.045) Ski N r--4T.QWNSHIF U t` NICIPALIT171 — 01 V.summ IoNNANIE: I'AL zo C I N. / = .1 1. 4 /4 N/R ur� 6 (3 1, u A ­� r\J Vff U &t L.0 pm 6'4 T 6 S T C I k 6 4o �'T 1 4 Is') USE DATES OBSERVATIONS MADE NIP PROFILE TFS [New OReplare NA " E Roe. AGu Al #v C ON Itt m I Ilk RATING- &- Site suitable for system U- Site unsuitable for system KITH M SYST M u NT) iadwm&m JREjSN'STEM-IN-FILLrOLDlf MMENDEn SYST (o ptional) [3uj� E) S k u 131 D I1 Portnlatu>n Tests arc NOT required DSICiN_ IiATF.' - -~ T— I hi-V Purtitist of the telvied arom 1% iii:he under s.1-10.09WIfil, ititileaw r rFloodplain, indicate Floodpiam vIay.;j*?1: PROFILE DESCRIPTIONS . . . . . . . . . . . . . . . . . "' -- H E 1 Q (j E! Q k N 79 A C L R, TEXTUHE, AND DEPTH NUM DOHIN 'r L ip MACTFA OF NUMBER DEPTH tH. F L FVA TION TO BEDROC IF Q -0 ISEE AR131W. ON L VACK.' i*75 _ ion : 4 7 > 7.7 1p -7 62 2"gL'SL /9"'ge L B_ S aO AJ e 1&'� C- NorvL > 9.7 < /4 & 31 gm L ii, :7 Ao C I al T .. ......... - L m I L " A SHPT S 13- PERCOLATION TESTS W9 ()F_PT}j WATER IN HOLF TEST TIME OROP IN WAI Eli [EVh'L-INCHCS Fq A I'F: K41 INC VA 11:' HFS Ai1jenSWELLING INTER -M N. PFR INCI I cr, 'r, I S rimi, A'j 1-p ; N V. P j 'C Y- -1 VI; PT PLOT PLAN Show lorations of parcobillon tests, soil r hill and the dimensions of suitable soil arses. Indlesta scale tit distances. IMSCTOW W11.0 11V 0!, I l a nd v"lic-41 Avvotioii rottrence prilots aril show their cation t it) the plot plan. Show tho st,olary elevation at all borin tind tha t firr.ctitv xiti w !(, y vnt .0 land SYSTEM ELEVATION IN 5 , v 14 17 IL 1 J. I a t . \00 11 PArcnitiuon Tests arm: W(JT requirod l uitbil.91 . 4 riA r t:: y II army purhun „I the rrrtou Droll IS n, :ne A r undbi :►ifd.99l� ►Ibl, indlc�tY: CUSS / tsp.QAI -L Lr Floodplain, indicnte Floodplaur elev:.t::•n: ' V PROFILE DESCRIPTIONS U(.)FtltdG 1'(31 At H l' I• UN � AT -IN . I AR"�'A�TFA OF . IL ITFI i'HICKNESS, C(SI�R, 'fCXTl1NE, ANIJ I)FI'TI I NUMBER plif'fN to. ELf:VAI'ION - �[� OCK IF O U5fRVtt F ARG IiV.Oti t7�:i:_Y._' -.—__ - -- �' I 75 lob .4� n1oNE > 7.75 ri' ._N _�?~ �� 7 fl "�i. i9''$a L 3G" &w. $a.nf 5, L ta �Z'' (1K. ►/ S,L R C- B- 3 G,� �a3.5 l nloNt ` so�'F,� B Fo A S PIT C S I e B- PERCOLATION TESTS _ f RA I'* AIfJU I 1"1 f1EPTF1 WATER N Ul F. TES (l IM r --A Irf Ct INCI I NLMl3EF1 INCHES. - _AFTE RSWELLING INTEf1VA •Tg�� -rl --- - -- - - -- + n - j - O Pf A r iLAtl.f:.L. ,�... __ - t�:.LC _��._�_ r r , I.- _. _.. �• _ - �_E.- ._._cr t�0 ...11uL_ PLOT PLAN: Show lorations of percolYtion tests, soil mitsit slid the dimansions of sultable soil arees.'lndicate scale or distances. D"scrrhe wino .I.c it!" r,:ur rontal and vertic,rl .rlrtvotioti rrterence Px,dn d ts and ,ei► calinn on the plot plan. Show 11m surface elevmion of till horinps and itm d6rctin! nnil .r,•rnl ul land dune. SYSTEM ELEVATION 1 a��• CM � tM � o -o L OT r 1, the undrt6aned, hon•by cortify that the soil teats ,eparted on this form wore rnD,le by me Irernrd with thrr trr�ue.lur : ;uul mrt!urd; stK citb•,! ,n firm ;'ns Admir Co(Ir And drat the data recorded and the location of the trots are cnrrrct to the bout of my knowlerlq« nrrrl I Minna ( 7 9 4 %IA�Y�y J Ok N��or✓ J k)N _._...__._ ___.._._._.._.._............__—. _...._.__....._._..._____....__ r; lrl' rfIFIC AT{U NNIIMU CR:jPII(.)NE NUMBER Icipmmrll: ti�6 oF�� DISTItlllll I ON: Ilrnrn, rl ..rut nor Cr +v rn 1 nr .d Amlln Ov. 1'rnlrr•rty Owl"" ill"I Srrrl I' "Oef 011 Hlt [,IIII ri;195 Ili. 0 vF1.11 ', � it ��, -� I �� -" _- i �!� � - - - -� -- ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address —- Property Address e (Verification required from Planning Department for new construction) City/State Wu)"Ap_ Parcel Identification Number e fZo — LEGAL DESCRIP'T'ION Property Location r /4, J e IA, Sec. /L , T _,, : �L N -R ' "F, Town of Subdivision Lot # -- Z - 7— . Certified Survey Map # , Volume _ t 1 l� , Page # /�07 - - • Warranty Deed # S �s� , Volume // S y , Page # !� Spec house Cl yes J R no Lot lines identifiable,® yes O no SYSTEM MAI 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 lumber, 'ourne man lumber, restricted lumber or a licensed p umper ver that (1) the on - site wastewater disposal system P .J Y P P P P Y 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. 1 /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set f rth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification slat' g that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of the 7:T expiration dale. AA lt /�lI g SIGNA1tqtt O APPLICANT DATE OWNER CERTIFICATION 1 (we) certify that all statements on this form ate true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the t petty descri d abo , by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURENOF APPLICANT 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 WARRANTY DEED Docummm NO. its Xpac %*­—W For Ucording Oat* pha ChL cc jp";� d for Recoil THIS DUD made between MICHAEL R. CT EVELAND DEC 18 1995 and ROBIN A. CLEVELAND, husband and wife as ANivorship At 10-00 A. U mar it a l property, Grantors and DELTA CONSTRUCTION, INC.- j- L-106 a Wisconsin corporation, Grantee. Werth, That the said Grantors, conveys to Grantee the f d red estate in St. Croix County, State of Wisconsin: �'� #ER W er Lots 15, 16 and 17 of Edgewood Estates Addition in the Tow., of Hudson. This is not homestead property. TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if airy. Together with all and singular the hereditanients and appurkmNKM thereunto belonging; And Michael R. Cleveland and Robin A. Cleveland warrant dW the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Izi Dated this tM day of December, 1995. SEAQ R. (SEAL) Robin A. Clevehod STATE OF WISCONSIN ss. ST. CROIX COUNTY Personally came betore me this f/k day of December, 1995, the above-named Michael R. Cleveland and Robin A. Cleveland, to me known to be the pasom who executed the foregoing instrument and acknowledged the same. IME91). BEVERS otary F ic, Stme W of Wisconsin NOTARY PUBLIC *z STATE Or- %Allsro"SN my Commission E-xpire�/-i THIS INSTRUMENT DRAFTED BY: RETURN TO: Barry C. Lundeen MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street Post Office Box 802 H Wisconsin 54016 C �O .s6'er9z it. 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