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HomeMy WebLinkAbout026-1077-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER T2& -Rf- 0 W r--/ ADDRESS, V 6 I SUBDIVISION / CSM# ~t LOT # SECTION __T 30 N-R) 0 W, Town of 2 ► YV.p t~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW Ja t SHOW EVERYTHING WITHIN 7.00 FEE OP-SYSTEM -Cr 5f c i ?ra INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: EPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House s Other Pump: Manufacturer Model# - Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM s Width: !2 Length y Number of trenches Distance & Direction to ne est prop. line: dr / Setback from: well: ouse -3S Other G~ ELEVATIONS Building Sewe 3 ST Inlet: ! , ST outlet: . PC inlet PC bottom Pump Off Header/ManifoldjE2 Bottom of system,?,, Existing Grade .1 Final grade DATE OF INSTALLATION: /O PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin'Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor e.nd Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299059 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BROWN, PATRICK RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 026-1077-40-000 /GU !iv , a j TANK INFORMATION ELEVATION DATA A9700376 oY TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark SGo2 Dosing- Aeration Bldg. Sewer Holding - St/~t Inlet Off- aa' TANK SETBACK INFORMATION St/XOutlet (iS' Off, I'LL Verit irIto ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Septic NA Dt Bottom n Dosing NA Header S po/ ' ~pJ.( Aeration NA Dist. Pipe Holding Bot. System 3~ PUMP FORMATION Final Grade Manufacturer De nd Model Num GP TDH Li Friction Ft oss ea eEerfe'm Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT o.Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS I- SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI -Manufacturer: SETBACK CH BER Num INFORMATION Type Of Model System: UNIT DISTRIBUTION SYSTEM Header J Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grad s 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.y LOCATION: RICHMOND 26.30.18.405,NW,SE 1364 130TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I I Safety and Buildings Division 06consin 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 6-1-.4- than 8112 x 11 inches in size. GY'd • See reverse side for instructions for completing this application State Sanitary Permit Number a ~qos~ The information you provide may be used by other government agency programs ❑ Check if revision to previous pplication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner e Pr pe Location lrf c~)- .eV&-> Z i t/a, S T p, N, R ,E (06W Property Owner's Mailing Address Lot Number Block Number 4"ev lec/ Cit ate Zip Code one Number Subdivision Name orCSM Number 17 fl. TYPE F BUILDING: (check one) ❑ State Owned ❑ City I crest Road G VII age G~p Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) IC9 1 ❑ Apartment/ Condo 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 . jjj~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 i ASeepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 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.) Propose q. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation . Feet - Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper- g Manufacturers Name Con- Steel Plastic INFORMATION Gallons Tanks concrete glass APP- New Existin structed Tank Tanks Septic Tank or Holding Tank ze"fee ! ❑ El [1 1 11 Lift Pump Tank /Siphon Chamber VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plums Name: (Print) Plum ignature: ( Stam 7MY~,r Business Phone Number: ~v Y s CIS Plu er's dr ss (Street, City, tate, Zip Code): G!e st / ov IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue issuing Agent Signature (No Stamps) j- C? 7 Coe Approved ❑ Owner Given Initial Surcharge Fee) T Adverse Determination V X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R 11/96) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Plumber i INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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: 1. 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 13 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 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. o PLU I PLAN ~ -~,r~ POJECT ADDRESS~~ 1/4/ /T N/R/W TOWN ~ ~ COUNTY MPRS Byron Bird Jr. 318 DATE BEDROOM- CLASS PERC CONVENTIONAL- IN-GROUND ESSURE CONVENTIONAL LIFT- MOUND- HOLDING TANK SEPTIC TANK SIZES LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA ~ PERC RATE BED SIZE S"- Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. 0 Borehole Q Well Scale = Feet O Perc Hole System Elevation Vent 12" Grndp TYPAR COVERING 2- 12- 3' 4 6' O 3' I Sewer Rock i 6 " 12' r V ~ Lo r\ i l ~ Wisconsin Departmentof Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 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 1-ia es in size. Plan must include, but St . Croix not limited to vertical and horizontal referen ~(df'r ctio and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location a ce to eare3 .rbA 026-1077-40 APPLICANT INFORMATION-PLE RIN~u, 0RMAt N REVIEWED BY DATE 9°L PROPERTY OWNER: PROPERTY LOCATION s _A GOVT. LOT NW 1/4 SE 1/4,S 26 T 30 AR 18 Fx(or) W Pat. 'Rrown PROPERTY OWNERS MAILING ADDRES < LOT # BLOCK# SUBD. NAME OR CSM # 2 na na na 11T11 CITY, STATE ZIP C E M ❑CITY ❑VILLAGE ]TOWN NEAREST ROAD 1V J71 4 _ Richmond 1140th. St. (:4 New Construction Use [x] Residential / Num Brooms 2 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 300 gpd Recommended design loading rate • 4 bed, gpd/ft2 •5 trench, gpd/ft2 Absorption area required 750 bed, ft2 600 trench, ft2 Maximum design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2 Recommended infiltration surface elevation(s) 99.60 It (as referred to site plan benchmark) Additional design / site considerations trenches spaced to code 3 25 , below surface P-1 Parent material pi ttPd g1 ar-i al r1ri ft Flood plain elevation, if applicable ;a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ®S ❑U ®S ❑U RIS ❑U ®S ❑U ❑S ®U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Botzzxiaty Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 1 0-15 10yr 3/3 none 1 2msbk mfr cm 2f .6 2 15-31 10 r 4 4 none Ground 3 31-80 7. elev. 103.1 ft. Depth to limiting factor +80" Remarks: Boring # L2 2 12-26 7.5yr 4/4 none scl 2c 1 mfr if n .2 Ground 3 26-80 7.5 r 4/4 none sl 2m r mvfr na na .5 .6 elev. 102.115 Depth to limiting factor +80" Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200 Ave., New Ric and WI 54Q17 Signature: 6111 _r Date: 8-9-97 CST Number: m02298 PROPERTY OWNER Pat Brown SOIL DESCRIPTION REPORT Page 2 PARCEL I.D. # 026-1077-40 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw& 1 0-9 10yr 313 none 1 2msbk mfr Crw 2f .5 .6 2 9-25 7.5 r 4 4 none sici lcsbk mfr C1w if .2 .3 Ground 3 25-82 7.5 r 4/4 none fr na na .4 -5 elev. 100.8ft. Depth to limiting factor " +82 Remarks: Boring # 1 0-8 10 r 3/3 none 1 2msbk mfr 2f .5 .6 2 8-23 7.5yr 4/4 none sici lcsbk mfr 9w if .2 .3 Ground 3 23-54 7.5 r 4/4 none sl icsbk mfr if .4 .5 elev. 97.2 ft 4 54-80 7.5 r 4/6 none is os os na na .5 .6 . Depth to limiting factor +Roll Remarks: Boring # 9f -9 i-6 2 8-23 7.5 r 4/4 none Ski lcsbk mfr if .2 .3 Ground 23-80 7.5yr 4/4 none S1 lcsbk mvfr na na .4 .5 elev. 98.0 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 1 Pat Brown New Richmond, WI 54017 MPRSW 3254 NW' S26-T30N-R18w (715) 246-6200 town of Richmond f N 1"=40' BM.= nail in Ash tree C el. 100' Alt. BM. = top of 2" pvc pipe C el. 102.30, OCo 0 (001 2' I lop to B7, Gary L. Steel 8-26-97 8 T C - 100 This application form is to be completed in full owner( s of t and he si ne property d g b onl being develo ed. Y the Y p An inad result A in de y e acies will lays of the permit issuance. Should this development be intended for resale by owner/contractor, house), then a second form should be retained and completed (when the property is sold and submitted to this office with appropriate deed recording the Owner of property r I c fC o% of P -df 6rt d W A J Location of property S Township Section ,T J'U N-R 12 W Mailing address _ dc~~ C`tel./ r ~',F~ieJ /~.l( -,Pf-4 Address of site /30 t` Subdivision name l~ Other homes on w ~t no. property? Yes No Previous owner of propert 12 y 10 Total size of property Total size of parcel "h Date parcel was created ~ctc5 r oz - Are all corners and lot lines identifiable? Is this Yes No property being developed for (spec house) ? Yes Volume and Page Number C? -,y No q -/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. certified survey, if available, would be helpful so asdtol avoid delays of the reviewing references to a Certified Survey process* Map, the If the deed description shall also be required. Certified Survey Map PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to t best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this warrant information form, by virtue of a y deed recorded in the office of the County Register of Deeds as Document No. own the proposed site for the sewage 'disposal tsystem ) orr Ie(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. Signa e of Applicant ~ ' Co-Ap licant Date of Signature n ( / STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County owNER/BUYER 0tJ r- CC K T -4 n e 4 0- . F Kt} U3 r~l MAILING ADDRESS L T PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE y PROPERTY LOCATION ~o~~N4; 1/4, Section c~ T '3 N-R 1 c W TOWN OF L ST. CROIX COUNTY, WI l rta j41 Nej I c LS- //71/ 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 canaffect 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 property 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 ate. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 fly oc t DOCUMENT NO. WARRANTY DEED %5cal ' VOL 1265PAC[041 REGISTER'S OFFICE THIS DEED, made between Janice E. Brown, Paul J. Brown, Lee $ T, d Q i X~ W Reed for R99eFd R. Brown, Michael E. Brown, Rita M. Bader, Donald G. Brown, and Mary Ann Golinvaux, Grantor, and Patrick J. Brown and Linette A. S E P 19 1997 Brown, husband and wife, as survivorship marital property, Grantee, 1 ; 30 P,M WITNESSETH, That the said Grantor, for a valuable consideration of one dollar and other valuable consideration conveys to Grantee the following Register of Deeds described real estate in St. Croix County, State of Wisconsin: The North 1237.5 feet of the West 1/2 of the Southeast 1/4 of Section 26, Township 30 North, Range 18 West; TOGETHER WITH an easement RECORDING INFORMATION across the South 1633.5 feet of the West 1/2 of the Southeast 1/4 more • • • • • • • • • • . particularly described as follows: a sixty foot wide easement for ingress NAME AND RETURN ADDRESS and egress, thirty feet on either side of a line running North and South, such line being located 660 feet East of the West line of the West 1/2 of the Bakke Norman, rive Southeast 1/4 and running parallel thereto. Such easement is intended to 1200 Heritage Drive run from the South line of the West 1/2 of the Southeast 1/4 to the South New Richmond, WI 54017 line of the North 1237.5 feet of the West 1/2 of the Southeast 1/4. Parts of 026-1077-40 & 026-1077-50 T A ER (Parcel Identification Number) This is not homestead property. Together with all and singular the hereditaments and *7F ces thereunto belonging; and Grantor warrants that the title is good, an indefeasible in fee simple and free and clear of encumbrances except: Easements, highways, utility rights and reservations of record, and will warrant and defend the same. Dated this Z69 day of Se p temper , 19 97 (SEAL) (SEAL) • * Janice E. Brown (SEAL) SEE ATTACHED ADDENDUM A (SEAL) * * ACKNOWLEDGEMENT AUTHENTICATION STATE OF Signature(s) of } as. r o y( COUNTY } authenticated this _ day of 19 Personally came before me this day of Se~j f , 19 97 , the above named Janice E. Brown * TITLE MEMBER STATE BAR OF WISCONSIN 0"%S11 9411"118', to me known to be the person (If not, _"o0 C .•••e•• l~~~xlkyted the foregoing instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) •.90 • - 'r ~wk e --yy~ THIS INSTRUMENT WAS DRAFTED BY: 9 Timothy J. Scott LM, }'BAKKE NORMAN, S.C. Z P BA b,* i-0 t~ V4 County, Wisconsin NEW RICHMOND, WISCONSIN ~fa~ •''•••••c••V~~ission is permanent. (If notes to expiration date *Names of persons signing in any capacity should be typed or printed below the~ of ~l" 0 3 5 , 19 Il1~tNt signatures. VOL 1265 PAC 042 - / ADDENDUM A (SEAL) ACKNOWLEDGEMENT * Paul J. Brown STATE OF WT. } "isal"li f'op } ss. MCA n } ° eN• G r n + Y COUNTY S Personally came before me this day of 0TARr • i Z S gj1997 , the above named Paul J. ? *8rown to me known to be the person who executed the ' PUBLILregoing instrument and acknowledge the same. 1 • a Notary Public, County, &G1.T. (state) My Commission Expires: p _ 9 ? L« . tlt. (SEAL) ACKNOWLEDGEMENT * Lee R. Brown STATE OF } ss. e,~~e~•eu~~~ COUNTY } ~,1+°~c~~Sov.a•a.~:`Personally came before me this day of Ay , 1997 , the above named Lee R. 1-0 0 ~A da i 'gown o me known to be the person who executed the *16regoing instrument and acknowledge the same. %PUOLIGI' s- -V.$ ~'•••..e~•' SO * Of Public, f 1'iSC4 County, (state) My Commission Expires: (SEAL) ACKNOWLEDGEMENT * Michael E. Brown STATE OF (,V1- } } ss. ro,•C «MCA b.ai~1' 1. r v UL COUNTY} •'•~`Pehonally came before me this _L-day of ~N 0 7A R z , 1997 , the above named Michael E. .L Brawnao me known to be the person who executed the ,PU6LICfojg instrument and acknowledge the same. rdt 4 Of HIISCO Notary Public, ,,t"11411+111~ County, ~tJZ (state) My Commission Expires: y s ' VOL 1265PACE043 ADDENDUM A (page 2) AL) ACKNOWLEDGEMENT * Rita M. Bader STATE OF LA~ ) ss. COUNTY} Pers Hall came before me this `T day of °~~~t1e 1997, the above named Rita M. kly~me known to be the person who executed the 'ip •e Instrument and acknowledge the same. ` 26.41 6 i , ota blic, ~ County) (state) % 'I ~ ~Q`Pnmi~~ion Expires: Co" OPP°tr` o V f i°°tea~eoae~°6°, }J (SEAL) ACKNOWLEDGEMENT * Donald G. Brown STATE OF W IT" } ) ss. COUNTY} sonall came before me this I day 'of ti ~i 1997 , the above named Donald G. °°e'►~ , ~e°~,5~` own to be the person who executed the d'' c5 • ~oxegop•invment and acknowledge the same. Ai o R, y I~pta ublic, County, (state) `Irrc~l'bG,,',LaB°s~ b ton Expires:` ©v of Wisl' ~'~eea~aa»,° (SEAL) ACKNOWLEDGEMENT * Mary Ann Golinvaux STATE OF /~o } ) ss. COUNTY) Personally came before me this /0'w day of ° 010118 , 1997 , the above named Mary Ann g ux to me known to be the person who executed bb ~ ,~s••••►d~y~*WrNing instrument and acknowledge the same. s ag ~ ® A Gt b ~ Notary Public w County, (state w~ttssion Expires: 0' _ / - 2 o o o s °r