HomeMy WebLinkAbout020-1337-60-000
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT RFur[E IVE0 v
Owner ~e ST,s .N :f E P.1 ! 1? fq~ }
Address 9 8G , ,r./eri ¢ Tit , f 5T CROIX
City/State COUNTY
ZONINGOFFICE
Legal Description:
Lot 41< Block Subdivision/CSM #
Arla
''/4&a) %4 &,e, Sec. L2, T 29N-RZ_? W, Town of
soA
s PIN #,09,4 - IS,?7 -a
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC lap Setback from: House & "Well S4r; P/L 5-6 ,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: Call Width 3'" Length S"7 Number of Trenches Z
Setback from: House 3a ' Well 757'--. P/L Vent to fresh air intake '
ELEVATIONS:
Description of benchmark L o T s ip Elevation /dg"
Description of alternate benchmark ZA ~ ElevationTF-? 7
01 V
Building Sewer 16 2 3,Y ST/HT Inlet 6 Z. Q ST Outlet- /,0/, 7 S- PC Inlet
PC Bottom Header/Manifold /,d 1-~ y Top of ST/PC Manhole Cover l D 5i • 77
Distribution Lines 1,4'1, -r ( ) l If
Bottom of System ( ) 460 , S`
Final Grade / 6 S. r y ( )
Date of installation 3 //Q/ Permit number 2g9/34; State plan number
Plumber's signature License number 4?9? f fY Date //r/ rte'
Inspector We "It
complete plot plan or
r Z
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
s
Jl a
c
n
~s
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT •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)). V71?I' I
Permit Holder's Name: ❑ City ❑ Village IN Town of: State Plan ID No.:
_17% 0 04 95 G-ihn tP.IC vl
CST BM Elev.: Insp. BM Elev.: BM Description: . 0t ~t A~ Gs~($ Parcel Tax No.:
(b0' topes o~' 420 -133?-(o+D-A~o
TANK INFORMATION ELEVATION DATA 4g7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic AAW to Benchmar 1,974 140
Dosing RI f, Z
Aeration Bldg. Sewer !OL•
Holding V46 Inlet sw dOZ..OS
TANK SETBACK INFORMATION 5~,/'~4bOutlet ,g.741 p1.7
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 18'~ Lam' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe Z
4.98 lpp.S/
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade oS fs
Manufacturer Demand 2.7 to •7
Model Num GPM
TDH Li Friction ystem TDH Ft
Forcemai L Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED EN Width i Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM c7 S~ Z- DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu turer:
SETBACK
INFORMATION CHAM ER M mb01%.
Type O r
Syste OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold q Distribution Pipe(s) ~ x Hole Size x Hole Spacing Vent To Air Intake
Length 17' Dia. Length 5~' Dia. T Spacing ~o AS'TM }4 Z72i41
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over th Of xx ded / Sodded xx Mulched
oil s No ❑ Yes ❑ No
Bed /Tench Center Bed /Trench Edges ~~e
COMMENTS: (Include code discrepancies, persons present, etc.) 5sl~ Prove,- 'r.-&;
Gwt - ~aN t - / o P .9f 7 f
l c. F auA &M need & Gc az> Ukal 4V 3 4. , V"• . T ke W V- .e WaII6
yrlaV , ~ro/ttwq ~ t ~"ta~ Stij 5~wt p(a,G~t2(~t .
Plan revisi ~`g116d? ❑ Yes ®No
Use other side for additional information. 3 In 1q61 /
SBD-6710 (R.3/97) Date Inspector's gnature ert. N
ADDITIONAL COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER:
Visconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce 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* 7e- Yw
• See reverse side for instructions for completing this application State Sanitary Permit Nu ber
The information you provide maybe used b other overnment agency
Y Y programs Check if revision to previo s application
[Privacy Law, s. 15.04 (1) (m)]"
q Ce Drovier True ~ State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
W-, OL f 1/4 ~ 1/4, S j2 T , N, R / E (or
Property Owner's Mailing Address Lot Number/ Block Number
® 4P
City, State Zip Code Phone Number Subdivision Name or CSM Ntrber
Of (7.(6 _9
II. TYPE F BUILDING: (check one) ❑ State Owned !t Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms M Towan of u efa re-he
III. BUILDING USE: (If buildinng type is public, check all tthhat apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo N. `7 " aQ ~~3n l0
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. New 2. ❑ Replacement 3. ❑ Replacement of 4. I] Reconnection of 5, ❑ Repair of an
System 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
1 Ijoeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 FU Seepage Trench 22 E] In-Ground Pressure 42 E] 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./inch) Elevation
S 3 $ 6 CL fdl~ 94 Feet Feet
VII. TANK Cap city
gallons Total # of Site Fiber- Manufacturer's Name Prefab" Con- Steel Plastic Aper"
New Existin Gallons Tanks Concrete structed glass App"
Tanks Tanks
Septic Tank or Holding Tank O I WO ! ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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 Signature: (No Stamps) P/ PRSW No.: Business Phone Number:
Plumber's Ac dress (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
(Approved ❑ Owner Given Initial Surcharge Fee) /
Adverse Determination tarPermit /0107/
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R 11196) 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.
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 curie; 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.
--------------------------------7-------------------------------------------------------------------
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.
Ao,
~j 100,
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~ Y4
cal
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OeIMOIJ
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of __3__
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Crr)ix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 020-1020-90
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT NW 1/4 NE 1/4,S 12 T 29 N,R 19 f(or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
na Grass Range Addn.
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE SOWN NEAREST ROAD
Hudson McCutcheon Rd.
[ New Construction Use k ] Residential / Number of bedrooms 3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 -8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 101.80 ft (as referred to site plan benchmark)
Additional design/ site considerations alt. system el.= 101.30' & 100.10'
Parent material nI I twaGh Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U RIS ❑U ®S ❑U ®S ❑U NIS ❑U ❑S ®U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 -
Ground 3 17-80 7.
elev.
105.46 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 0-12 10 r3 3 none sl 2m r mvfr Cs 9f -9 .6
,2....<< 2 12-26 10 r4/4 none is os mvfr
if .7 .8
QIW
Ground 3 26-82 7.5 r4/6 none cos os ml na na .7 .8
elev.
103.2 ft.
Depth to
limiting
+ " 1
factor
ST .,RO%X
Remarks: tt
CST Name:--Please Print Gary L. Steel Phone: 715-246-6204
Address: 1554 200th. New Richm WI 4017
Signature: Date: 5-1-97 CS')I' Number 402298
PROPERTYOWNER- KPrnon Ragf. SOIL DESCRIPTION REPORT Page? -of _3
PARCEL I.D. # 020-1020-90
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Boundary Bed Trench
nnne S1 2mar mfr CIN 2f -5 .6
0-19 10yr3/3
2 12-2 10 r4/4 none is os mvfr if .7 .8
Ground 3 28-8 7.5 r4 6 none s os m1 na na .7 .8
elev.
104.8 ft.
Depth to
limiting
factor
+82"
Remarks:
Boring #
mvfr ?f .5i.6
2mar
4...:: 2 8-14 10Y-r4/4
na .7:.8
1448 7.5vr4/6 none MR Osa Mi CM
Ground 3
-
elev.
105.46ft. -
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 in
ncme ?mqbk mfr 9w
-12 -1nVr1/2
.6
2 12-20 10 r4 4 none sil 2msbk mfr if .5
Cfw
Ground 3 20-30 1 r 4 none is osa mvfr if .7 :.8
elev. 4 .30-80 7. 4 4 e ml na na .7 .8 non Cos 0sa
103.1ft.
Depth to
limiting
factor
+8011
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Kernon Bast 1554 200th Ave.
CSTM2298 NW4NE4 S12-T29N-R19w New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
lot #6-Grass Range Addn.
N
1"=40'
BM.= top of NE lot stake @ el. 100'
Alt. BM.= top of section marker C el. 100.55'
,\4,vl, 016
~'I0' 1w I' 30t 33 , 00 ` A
IN C
t
-Xv
.!L F
V
F
fit, 3tf
30
Gary L. Steel
5-1-97
i,ij"A f4du%l,U"C jy~ n hjS ,i),Qd'C
1'45!6 N190293516 ww I S20003110'B
9'35'6 133059'584 z o w J N35015108-B
9'58'N N76058'1711 w H H14048155'N
8'111N S49034'30'N w L E79017121-N
4901N S25055'031N Ix z Fn N S30006138-9
4'57'6 S00022'2116 w = z N S11003'10'6
811416 N19029'35'6 u- 0 S39010155-8
9'35'9 N20023'301W z o w p N86041122'6
w Q N13001143-9
z 0
~
Ul'lFI A c LANDS
BENCHMARK
EL = 886.82
, USGS DATUM 1929 NI/4 CDR
145E 1680.21 SEC. 14 N89°04'23"E 656.31' NOR
158.39' 111.82 285.08'
0
M
LOT 6 LOT 5
Z®
n 2.02 ACRES M
1 ~y
1 \ Oo 87,991 SQ. FT. 2.16 ACRES
94,215 SO. FT
M
HWL = 886.0 j a'~ 1.53 AC. EXC. ESMT.
N \ 1,38 AC. EXC.
66-0486 SO. FT Q y
K `60,314 S0. FT
NOo 1 HWL
0~~ ®1 886.4_ .
LOT 8 LOT; 7~
1
2.10 1 ,0
ACRES__-L 1 M I C~p`
♦ ♦ 91, 475 SO. FT.
\Y i I y
/ 1.86 AC. EXC. ESMT. p
O♦` 80,999 SO. FT.
G i/ I
3.61 ACRES I A9 I -mss r ; 2
OOS 157,109 SO. FT. pCP ~G i F . Ic
2.52 AC. EXC. ESMT. 190. M
109,697 SO. FT. O~
C2 NO 7 11030'
26~E
7
%
6 ♦'1 / - 885.16
-10
-Q LOT 3
C 3.19 ACRES
LOT 9 11 / 5 „ LOT 2 ~ 139, 139 SO. F
2.02 ACRES 6 1 3.. 01 AC. EXC. E
88,055 S0, FT. 2.58 ACRES 131,325 SO. F-
~
i 112,331 SO. FT ~p
% 2.42 AC. EXC. ESMT,
105,561 SQ. FT. m
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER o ho n1 QS S4a_r)e_k-
n
MAILING ADDRESS l~ irc~ d I
PROPERTY ADDRESS e i° ? C 1 i~G~~,S'd.r/~
//(~~locagtion of septic system) Please obtain from the Planning Dept.
CITY/STATE Hi Tj Cc) C". W I
PROPERTY LOCATION 1/4, 1/4, Section T-gq -N-R__L!I_W
TOWN OF Po d`c , r ST. CROIX COUNTY, WI
SUBDIVISION l 9-cz, rvo,~p LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in- operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The properly owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• 8 T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
owner of property I/ - '2 - - n S
Location of property ti W 1/4 F1/4 , Section 12 , T _N-R=W
Township _S C roi Mailing address
Cnr" (Ij
YI/~O
Address of site e(l l.~r~,1,e•~ ,`~_~"u~d~~J V~`~
Subdivision name rcu. fidde, Lot no.
other homes on property? Yes_~6 NO
Previous owner of property Lk e\ rx.(da r - 6aC ,~~rndn f s~
Total size of property
Total size of parcel -12,2- c reS
Date parcel was created dC-~- 2 ~c/q7
Are all corners and lot lines identifiable? _.csyes No
Is this property being developed for (spec house) ? Yes No
Volume j2--7Z. Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner (s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
C- signature f Applicant Co-Applicant
AL y -Y:7
Date of Signature Date of Signature
VOL 1272PAcE256 ~o~
CC ry p~+
~J6 `~ov STATE BAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO.
Donalda J. Speer-.$ast. and__Kernon _J._ -Bast REGISTER'S-OFFICE
ST. CROIX CO.. WI
--Ahyaliaad and wife) Rac'd for Record
OCT 2 4 1997
convevs and warrants to -Thomas . J. _ and Pal e-ja_--a an--k
(httGhand and wife) With survivorship marital ~ C
Property ~ Re Ister of Deeds
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,
State of Wisconsin:
MIDAMERICA BANK HUDSON
Lot #6, Grass Range Addition in the Town of 6002nd$tt d
Hudson, St. Croix County, Wisconsin Hudson W1 SIMS
PARCEL IDENTIFICATION NUMBER
TRANSFER
This i c nni- homestead property.
Exception towarrantles: Easements, restrictions and rights-of-way of record,
if any.
Dated this 23rd day of October A. D., 1997
it s~°iL~-GG t- 5;2`k~ (SEAL) (SEAL)
• Donalda J. Sheer -Bast ernon J. As-k
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
C`/ / ss.
`Lk.. (1-0 Ir ^i COu
authenticated this day of , 19 Personally came be ore me this day of