HomeMy WebLinkAbout020-1414-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
538859 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
McCormack Classic Construction LLC, C/o Sc Hudson, Town of 020-1414-40-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/00-0 )406D 10 6 3~f, 20.29.19.2612
TANK INFORMATION EL VATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /2 Benchmark o. D v, o
Dosing b / Alt. BM
!J-0 0
Aeration Bldg. Sewer 4c.~, eo
Holding SUHt inlet toe t /
0 9~. Z
Q al
TANK SETBACK INFORMATION St/Ht Outlet
~-3
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Z l+/ _ Dt Bottom
Dosing
Header/Man.P 1p4-p
&A,
I
Aeration Dist. Pipe
Holding - Bot. System O 92.10 `
Final Grade
PUMP/SIPHON INFORMATION S- -7. ~
Manufacturer Demand St Cover Z
GPM
Model Number TDH Lift Friction Loss Head rDH Ft
Forcemain Length ia. Dist. to II
SOIL ABSORPTION SYSTEM ( 22 p,'
BED/TRENCH Width I 17q,4-gg, Length No. OTrenches PIT 1--- DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manu re
,l
INFORMATION CHAMBER OR
T Of System:
UNIT Model Number: P-b4 IQ
DI IBUTION SYSTEM j C l
Header/ nifold t~ Distribution Ix Hole Size Ix Hole Spacing Vent to it Inta
/ tf Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only S(~ 41-t d
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
BedlTrench Center t Bed/Trench Edges Topsoil
Yes No ~ Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #11: It / / / 11 Inspection #2:
Location: 727 Martin Ave Hudson, WI 54016 (SE 1/4 SW 1/4 20 T29N R1 9W) The Glen Lot 18 ~R Parcel No: 220.-299..19.261122
1.) Alt BM Description = I bP ~ CdJA- um,!z ~.~&j E # /+~-c~~`
2.) Bldg sewer length 4 VU
- amount of cover
Plan revision Required? Yes No Q r
Use other side for additional information.
SBD-6710 (R.3/97) Date Inse tors Signature Cert. No.
-wLgdl. Softly and Dim County
~ 2tl1 W WY 53707- Bea 7162 S uy PamttNambe:(v be ilikdm by Co )
4~ P licot1.on Tra onNumber
-Io accot+daace with s. 8321(2).Wis. of ~ form to the ~ptopriatc ~
MR is facquikod ab~ ~P o b ~rBns ~ state-owned POWTS are Pmt Address C¢ tbaa ma address)
\ y~ zv=w may he used for secondary
itaacosdawc; Stats
A/1 rim, ,Q/!e.
rtope~eyoaD.e~$Name 72-7
/ Parod s
SGoTT GK 4or•y"-a 626 - /y/ - 5~0 - UO~ PfbPMY Location
Ptopcrw Owaer's M L r , . v.,,
-5-70? ZWR
City, Soft Zip Cade Phone Nomber CAML Lot
sE 0 K section ao
uOSo.J ~1 Z" syo/L 7/s No - o?.? (Circkand-
b Type of Builldik (check aH that apply) Lot # T o~ 9 1~ R
X, fat RamdyDoeeMM-NmnbwcjBedtooms S~visam Name
❑ -DesaB►eUse ak c•~ Bh>a~ ~ ~iz~.✓
❑ StWcOwned-D=cdUUse, CSMNamber of
2 ~.~1- Ce.llS c,J Z2~-Z I Gl,.~,,,.ao ~Towaf uD~o~
II[L Type e#Penwit: (c ba* eaaty ease eat rMe A. C.apkbe Doe B i f ap )
A ONeNSyshYn ❑ ReptaoemeaSysa9em ❑ T Ta kRepiaccM"d only ❑ fh wA6dWwMato
R- ❑ Pea Rt ❑ FemaitRevisioh ❑ CbmwofPhmbcr ❑PF~itTtaas6rto%m ListPtevhm PaniftNmobwaadDaft lssaed
BeBOte)~mon pyMeer .
IV. TYPE OfPOW S Check aH that i
gNm"Vessomeal Ia~ ❑ Prod ba-Cmoumd ❑ A-C~ ❑ Mmmd>24 is ofsaiiable son ❑ MmW <24 i u of=MblawA G
❑ Hoid*Tmk ❑(&arDispeasplQonapoaat(w*m ❑PtttreatimeMDe ioe(enplak)
V. Area 7e~atatia>f- - /
Das'01►(~ SoidApph~im oull Aar ( DispamtArerw osed Systeat ✓
Caa -7 85,15 8 7Z. 92. V •
VL Tank fullb Capacity in Totsl # of PAhnuflimuncr
GAIRM C30111008 Unft s
NewTaats E>dstTaola /{n,.~1. / c U o o e,
/~JctJr l~ T E c 13 - a
a o~ a; m o a
a~
Dosing0 mber
VII. ReSiMMS&HUY Sta ow ent- k the UsiderdVIC4 aawouterVIVOIRSHOW far haslullbitioa ofthePOWTS shown am the attaehed phx&
Plambm.°sNa®e(Ptiat) Phm>ber's Number BusbacaPhoneNomber
Plumber's Addax (Sheer CiLyy. SUdc6 Tip Cone)
G a 98 Sr. wX aS ~uQa.~p G✓ Z~ Sy73G
vIU %e
PermitPee Date igasuee
ReasonfbrDemat $ I ✓ ~a ! r
It==
MCondidawmet iiarDiisapprovai 3)
Pao kOa
h "Septic `tank. effluent filter and
dispersal cell must all be servtces / maintained,
as per management plan provided by plumber.
2-, AR s0back requirements must be maintained
as 6111i ax*ablo code / ordinances.
Athehtoca.phieph=brthes3 1 andeta#eCaumtyeWourpaperustbwdom8inxUhKbeshedme
SBD-639$ (IL WM) Valid t hru 02nI
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Private Onsite Wastewater Treatment System
Index and Title Page
Project Name: .S coT'f ~aR•,~A~K- S/~Sa. /.►~6Ro4.✓o Ff
Owner's Name: Spa rr Ac COR~fAaK
Owner's Address: S 6t~da-
~uo~oa l~1 S5'a~G
Legal Description: 5~~ s ~✓~a?o~ o? 9& / 9 41
Municipality: Tom, V49ege, -Cit-i of hlaa so,✓
County: fit- `ito /x
Subdivision Name: re-
1~1~-✓
Lot Number: I& Block Number:
Parcel I.D. Number:
Page 1 IAIO_c x f V/ r[ e- Sf/E~ r
Page 2 f"Lor 6'~•s-.r- ~~~ROSS- .S~Gr/o.✓
Page 3 ~EPr/G YA~i~ ~~EGiF/cAl'io.✓S
Page 4 ~o~✓r5 a~1.✓E/t `s /'>•0.✓u of f Er1E.✓r l~i.~;✓
Page -5
Page 6 ~/G TE.t /%4ir rE.✓a.,,c~ ~i✓Fo
Page 7
Page 8 W P-r 4,W,,Ve;vrs - o/` ~vAt u y rie r ~E/JOa r
Page 9
Name of Designer: -7-o✓ EtKE License Number: /YP- 73133,',l
Signature: Date:
Designed scant to the Following POWTS Component Manual and Comm 81-85:
In Ground Soil Absorption Component Manual for POWTS (Ver. 2 ) SBD-10705-P (N. 01/O1)
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pap A of 4
FRE INFORMATION SYSTEM'SPECIFICAT[ONS
Owner
.S C rr /`7c Co.trr.4LK Septic Tank Capacity /,?DO gal ❑ NA
Permit if Septic Tank Manufacturer D NA
G✓/ESE"R " ~.✓Csrr!
DESIGN PARAMETERS Effluent Fgtor Manufacturer ❑ NA
Number. of. Bedrooms y O NA Effluent Filter Model - D NA
-Number of Public Facdiiy Units 21 NA Pump Tank Capacity, al A® NA
Estimated flow (average) S!OD " _ gal/d Pump Tank Manufacturer D NA
Design flow (peak). (Estimated x 1.5) 60 gal/day Pump Manufacturer D NA
Soil Application state . 7 and - ne Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average` " Pretreatment Unit tr NA
Fats, ON & Grease (FOG) 530 dig/L ❑ Sand/Gravel Filter ❑ Peat Filter
Moc hemicai Oxygen Denand (BODJ 5220 mg/L NA D Mechanical Aeration D Wetland
Total Suspended Solids (TSS) 5150 mg/L E3 Du fec>aiom ❑ Otis:
Pretreated Effluent OuaRW Monthly average Dispersai Cell(s) ❑ NA
Biochennicai Oxygen Demand (BODJ 5930 mg/L 0 In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS1 530 mg/L ❑ NA D At-Grade ❑ Mound
Fecal conform (geonetric mean) 510`_dull 00m1 . ❑"Drip-Line ❑ Other:
Maximum Effluent-Particle Size la in dia. - ❑ NA: Other 0 NA
Other D NA Other. DNA
`Vak" typical for domestic wastewater and septic tank effluent. ❑ NA
MAMiT1R11ANCE SCHEDULE
Serdoe Evetrt : - . - Service Frequency
month(s)
Inspect condition of tank(s) At least once every: 3 ear(s) (Mwdn-- ru 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one-third.%) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
3.0 year(s)
/ month(s) ❑ NA
Clean efflaentfiiter At least once every: _ D year(s)
controls & alarm At least once every: ❑ month(s) ~(NA
Inspect pump. pump C7 Year(s)
Flush laterals and pressure test At least once every: ❑ month(s) - ❑ NA
❑ year(s)
Other At least once every;. ❑ month(s) D NA
❑ year(s) _
Other D NA
MAINTEMANCE VMTRUCTKM
inspections of tanks, and dispersal cab shall be made by an individual carrying we of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank
inspections must Include a visual inspection of the tank(s) to identify any mussing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scorn and to check for any back up or ponding of effluent on the ground surface.
The dispersal cep(s) shall be vissuaty inspected to check the effluent levels in the observation pipes and to check for any ping
of effluent on the ground surface. The pond'Ing of effluent on the ground surface may Indicate a failing condition and "regdres the
immediate nodfication of the local regulatory authority.
When the combined accurnlaton of sludge and scorn in any tank equals one-third (Y3) or more of the tank volume. the entire
contents of the tank shag be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
AN other services, wwkK trng but not Clruited to the servicing of effluent filters, mechanical or pressurized components, Pretreatment
units. and any servicing at intervals of 512 months, shall be perfumed by a certified POWTS Maintainer.
A service report shag be provided to the local regulatory authority within 10 days of completion of any service event.
START UP ANb OPERATION p of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of palming- products or other chemicals
that may impede the treatment process and/or damage the dispersal ceg(s). tf high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up Shall not occur when soil conditions are frozen at the Wiltrative surface.
During power outages pump tanks miry fillabove nonmaf highwader levels. When power is restored the excess wastewater wilt be
discharged to the dope sal ceff(s) In one law dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servrgng Operator prior to restoring
power to the effluent pump or contact a'Plumber or POWTS 'Maurtainer to assist in manually operating the pump controls to
restore norntial levels within the pump tank,
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise- disturb or compact, the area
within It feet down slope of any mound or at-grade soil absorption area.
Reduction or efirnination of the following from the wastewater stream may improve the performance and prolong the We of the
POINTS: antibiotKM baby wipes; cigarette butts; condoms, cotton swabs; degreasers; dental floss: diaparm, disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline. grease; herbicides; meat scraps; "rr~edicatiorns; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
When the POINTS fags and/or is pmmwm* t Ow n out of service the following steps shall be taken to insure that the system is
properly and safely abadoned In compliance with chapter Comm 83.33. Wisconsin Admi ntstrad" Code:
• AN piping to tanks and pits shah be disconnected and the abandoned pipe openings sealed.
• The contents of -all tanks and p>ts shall be removed and Property disposed of by a Septage Servicing Operator.
• After purring, all tanks and pits shall be excavated-and removed or their covers removed and the void space filled with
soil, gravel or another inert solid rnatedal.
t~A[t711IGElI1CY PLAN
If the POWTS fags and cannot be repaired the following "have, been, or must-lie taken, to provide a cede complaint
reptacementsysterrn: - - _ . - _ -
A suitable replacement anew hays been evaluated and MY be utilized for the location of a replacement song absorption
dyttem,= The replacement area should be protected from disturbance and compaction and should not be Infringed upon by
required setbacks from witting and =proposed structure, lot lines and wells. Failure to protect' the replacement area will .
result ire the need for a now soil and site evaluation to a suitable replacement area. Replacement systems must
comply with the rules kk effecf at that tine.
[7 A suitable replacement Wes is-not available due to setback and/or soli 6mrtadions. Bamng advances in POWTS
"olmology a holding tank may be installed-as a fast resort to replace the failed POWTS.
E3 - The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performied to.locaRe a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the famed POWTS.
CI Mouaid and at-grade MV absorption systems may be reconstructed in place following removal of the biomat at the
infltrative surface._- ReMmorug ions of such wistems.,must comply with the rules In effect at that tine.
SEPTIC, PUMP AND OTHEVt TREATMENT TANKS MAY CONTAIN LETHAL SASSES ANDIOR OXYGM. DO NOT
EITER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY DANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DN ILT OR McPOSSIBLE.
ADDITIONAL COMMENTS
POINTS INSTALLER POWTS MAINTAINER-
Name- ,f oN~✓ Edll - a73l 3 ,'G Name J_o L,rE ~El rE Lur16~~6
Phone G7.? - S,?G4 . Phone
SErTAGE SWIG OPERATOR (PUMPER) - 441X,, d4W LOCAL REGULATORY AUTHORITY
Name Name j- -.cello/ Zo.Ji•~?~ tJF,
Phone E Phone 386 - yG o
,W,a documem wee drafted in compeance with chapter Caram 83.2212)(b)(t lid) I) and 83.5QI).1Z & (3). Wisconsin A(10*486112We code.
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Wisconsin Depwknent of Coinmeme IL EVALUATION REPORT Page Z of 9
Division of Saw and Buk#n-qs ~ `ih aoooraanae vAh 85, Wm Ad n 46
A txx oft she plan not less 11 • in size. Plan must County include, taut nat lini ted Uac and din and 1
peroentslaW scale or distaance to nearest A 6 2Z z16 -
rN~ by Date
Peru bdbnavAmr you wee w.poses (Pri~eg+~ aye , s ,s o4 c,) c~3)- . /0 /
Pmpertyowner Property Lor~tion
Se o rr- L C A ,p a Govt Lot s~- 114 s-4/ U4 S /,?0 T ,7 N R/ 9 A( w
PropertyowmeshlaftAddiess Lot4 Bl)dc# Subd NanrearQ
7 a?8 rr ~dE /g ~E Z"
Ci[y Subs Zip Code Phone Munbw ELY [age O Town Nearest Road
~r✓se,a I SY,:W ( ✓1-5) 7e0 - a/~ uosati~ ~rri,~ Qo.
W Mew C *ucWn Use:® ResWenW / Nurntw of bedrooms H Code derived design flow rate `OD GPD
❑ Replacment p r a coo nerd l - Descrbe--
Parent malerW DGt TA/,y S.Y Flood Plain elevation if appkablo ~/,p ft
General oomBrrer b z
and remmiendaftw. 1A)411to4.,0 1"I0W rSJ . 9i°°/~Fr ,Ga,/oi✓C ~l.v rE Ile 1A) s rip 1ZdW 4!FX ° lj-rrAl"A✓
5
171 B-'
30 ® Pit Ground sudaoe elev 99 2L ft Depth to kniterg fac6or 'I/0 in.
Sal Ap*mim Rate
Horizon Depth Dom color Redox De. r Texture Skuckm Corsisterim Boundary Roots GPOW
eL tflunsell QLL SZ Corot Cotes- Qr. Sz. Sh. 'ER1 'EH#2
/ o -,22 io M ?/,2 - - / iv y c s - v 6 v
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fn 1-1
a l# ❑ aft
® P;t Qoundsrufaoeelev ?73 ft. Deter to 116 in.
IW lication Rate
Horizon Depth Dominant Ric Description Texture Structure Consistence Bounftry Roots CPOW
irL Mansell Clu. Sz. Cant Color G r. Sz. Sh. -Eft -EW
e -a? l o >A, 3/L - S/ D
I,?/- Y7 161'it .t/a - .7 sdk ry s- - G B
3 7-70 /or< s/ sbk ,y~~ cs - G .G
y 70 /~o /a YiG s/Y s - , G
`mmmd#1 = 2w > -W :S 220 rrrglL and TSS >,m rrrgtL t 2 = BOD < Sg RIgIL and TSS < W nV&
CST MWIS (Please fto CST Number
/oi/A~'~ AssErr ~7a?y97y
Address Dale E%vM tion Conducted Teteptrone Nunber
/S43 /•~i~tGloY ..fir, ~,a~ `6AiR~ ~JI S~/7v/ 9-ao -/t /S' d3 y- 8G/~
ptopet[yomw _SGo;-r 1"K 4 o'XI/44X PlemelID# paw a7 of -3
F-31 0&ft
P8 Gr+dt<ndsnufaoedw -2-L7-,L Depth to barbs bckx uL
SolAppkefian Rade
Hoimon Depth Donninant RedaK Desc*do r TM&M Structine -Cornsbww BoudMy Rays Q'ar
fir. Munsell QLL br- Cant Cdlor Or_ Sz- Sh. 'EM -
l a -3/ r/Z Wz - I&:Y
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F-ql Q
® Fqt Gmundsuiaceelm- /oo, o $ Dep& io Bjdftjr -bL Sat Appkabm Rate
Hormon Depth _ Domiruut Redoz Desc*" Ta ta+e . Sfruckwe Ommstenm Bourg -Rools GPOR
an. Mansell Qu. Sz. Cod Color or_ ST- Sh. 'EfW 'Ef~2
/ D -.2
3 7-sS /o rat J13
y s3 &o /a rc y/y - / / F Si k sib
Bamg# Q Pik Groundstubwelev 98.3 fL Deo Da N 6c or >/ro ,i n.
ScRAppicefica Rate
Hannon Depth Damirnanf Coks Redor Descrl " TeAm Struclue Carnsienoe Boundary Roos CPOW
in. MurnseB Qu. SL Corm Color bY_ St Sh: AEM 'FM2
/ 0-14 lem fy/3 sl~/
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE; AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer -~,--J~
Mailin Address
Property Address _-Q- - - t e+!Sd-- '-c►/~--
(Verification required from Planning & Zoning Department for new construction.)
City/State _a- Parcel Identification Number
LEGAL DESCRIPTION
Property Location ~E '/4 , Sr &~t, '/4 , See. 0 , T c2 N R-/_I-_W, Town of c,
Subdivision Lot
Certified Survey MaP# Volume _ , Page #
Warranty Deed # Volume
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §C:omm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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.
I/we, 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 W isconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
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.
Number of bedrooms
CSOSIGN T(S) _ DATE
***Any informatidn that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
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Tx:4020107
STATE BAR OF WISCONSIN FORM 1 - 2000 936597
Document Number WARRANTY DEED BETH PABST
REGISTER OF DEEDS
THIS DEED, made between Dean T. Barker and Lisa L. Barker, ST. CROIX CO., WI
husband and wife, Grantor, and McCormack Classic Construction, LLC, 05/24/2011 1:44 PM
a Wisconsin limited liability company, Grantee. EXEMPT#: N/A
Grantor, for a valuable consideration, conveys to Grantee the following REC FEE: 30.00
described real estate in St. Croix County, State of Wisconsin (the TRANS FEE: 217.50
"Property"): PAGES: 1
Lot 18, Block 1, Plat of The Glen in the Town of Hudson, St. Croix County,
Wisconsin.
Recording Area
Name and Return Address:
St. Croix County Abstract and Title Co., Inc.
219 S. Knowles Ave. .
New Richmond, WI 54017 SFA8260
Together with all appurtenant rights, title and interests.
Parcel Identification Number (PIN)
020-1414-40-000
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants, and conditions of record.
, 2011
Dated this daP-'~e
r I
,
* D
ean T. Barker * Lisa L. arker
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF hk I ZON A )
COUNTY m Ag C O A ) ss.
authenticated this Personally came before me this `Z- day of M ,
2011 the above named Dean T. Barker and Lisa L. Barker to
* me known to be the person(s) who executed the foregoing
TITLE: MEMBER STATE BAR OF WISCONSIN instrument and acknowledged the same.
(If not,
authorized by § 706.06, Wis. Stats.) ~Mczt
THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Z()N(
My commission s permanent. (If not, state expiration date:
Robert L. Loberg • 10. 1 57 )
Loberg Law Office lmg/
(Signatures may be authenticated or acknowledged. Both are not necessary.) NOTARY PUBLIC
.Names of persons signing in any capacity must be typed or printed below their signature STATE OF ARIZONA
MarlCWpa County
LOUISE NAGY
WARRANTY DEED STATE BAR OF WISCONSIN ley Corrxnfas ~ FORM No.5-2000
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