HomeMy WebLinkAbout040-1005-95-100
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STC - 104 ` ~[r^ 1 6 1997 r~
AS BUILT SANITARY SYSTEM REPORT ST C;R01X
ZONING0 'r
OWNER ~F%(f~N
r~
ADDRESS ~Sl Ae&WOOD
SUBDIVISION / CSM# Sq/ 2-'Id PLY LOT # Z
SECTION .3 T '200 N-R W, Town of T'edlv
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ORIGINAL
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i ~
o a~= cs 7-' - 314( /-o r--
/400.0
BENCHMARK:
ALTERNATE BM: -r q or N-eew ,--ewca j~e- si~tvCt.2~
SEPTIC TANK / PUMT-CHIOMR / ROL
Manufacturer: Liquid Capacity:
Setback from: Well } SO House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL GAJBSORPTION SYSTEM
Width: Length / O Number of trenches Z'
Distance & Direction to nearest prop. line: ZO , - WAS T '
Setback from: well: 7 00 House 3 Other
-r6p oyc 14,,~44e~ e6w, j~/ AIP7, V
ELEVATIONS
l~'7
Building Sewer 1(~ a -ys► ST Inlet: cj Qp• 0Z- / ST outlet: 7e
PC inlet PC bottom Pump Off
Header/Manifold = a ottom of system Ste- 4O7`
Existing Grade Final grade
DATE OF INSTALLATION: 54A [I
PLUMBER ON JOB: RORER-1- 2C L f3iQ~ C-47-
LICENSE NUMBER: -3307
INSPECTOR: 3/93:jt
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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
4abor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division Sanitary Permit No.:
GENERAL INFORMATION (ATTACH TO PERMIT) 289325
Permit Holder's Name: ❑ City Village Town of: State Plan ID No.:
FRANK, KEITH TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
040-1005-95-100
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
" Benchmark
Septic f
Dosing r~✓
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe z~
y ,
Holding Bot. System ' q
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 4 j 3
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
No. Of Pits Inside Dia. Liquid Depth
BED/TRENCH =dl Length No. Of Trenches PIT
DIMENSION DIMEN I N Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING
SETBACK CHAMBER Mode Number:
INFORMATION TypeO OR UNIT
System:
DISTRIBUTION SYSTEM
Header /Manifold 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-Grade Systems Only
Depth Over Depth Over I xx Depth Of xx Seeded / Sffe xx Mulched
❑ No
Bed lTrench Center 9es Topsoil ❑ Yes ❑ Yes
Bed /Trench Ed
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 3.288.19,NW,NE 651 DEERWOOD DRIVE LOT 2
l 3 f i (Jy{n f D,fL. :A -'..I:_,Qd(.C,~1 ,r.t..) 'j Y
Plan revision required? ❑ Yes ❑ No gn
Use other side for additional information.
Date Inspector's Signature Cert. No.
SBD-6710 (R 05/91)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: t
5 "ev s
Safety and Buildings Division
~~■~r■r. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. ST 6e0t'
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs 97
❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]- State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION ti
Property Owner Name Property Location
~Cc / rk, eAA.., AIW 114 #,F 1/4, S 1j T N, R IT E (or)0
Property Owner's Mailing Address Lot Number Block Number
Cs3 vt.v2w 2-
City, State Code Phone Number ubdivisi n Name or CSM Number
vC)S0,~ I 1 yot~ 1('7L93WPj'03,;" C~t Yq-72.q,9 !/o/ F7 3/37
II. TYPE OF BUILDING: (check one) El State Owned Cit ,-'R Nearest Road
Public or 2 Family Dwelling - No. of bedrooms; ~ 0 vows of j~GJ00~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Nuumber(s)`
1 E] Apartment/ Condo ®v`v
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. lew 2. ~ Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] 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.
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 eepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill ~c Ie~S S [
VI. ABSORPTION SYSTEM INFORMATION: qs. 6 z~ • O
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
qSD Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) r Elevation
~ " Feet /00.OFeet
VII. TANK Capaci y
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site - Fiber- Plastic Exper.
New Exist in Gallons Tanks Concrete Con steel glass App.
strutted
Tanks Tanks
Septic Tank or Holding Tank ~djf7, l ❑ ❑ ❑ 1:1 0 4A 40- Lift Pump Tank /Siphon Chamber 0&0. El 11 1:1 11 ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) PI ber's Si nature: (No Stamps) WFWMPRSW No.: Business Phone Number:
o&~~T 14140C1iT- 3307 s. 3g~ - S!8 S
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
~Approvecl E] Surcharge fee)
Owner Given Initial
Adverse Determination -Rq a -
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS t
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.
1 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 havetquestions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and-Buildings Division, 608-266-3815 -
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-
Il. 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 curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; f) 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.
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Wisconsin -Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page l of 3
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
Toy
include, but not limited to: vertical and horizontal reference point (BM), direction and «w
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parke-ft. #
APPLICANT INFORMATION - Please print all information. R by to
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ST L 'K
r'
Property Owner PropertyLocation1 Kai' fNGi ICE -PON
Govt. Lot /1/(n/ 1/4/•; (q
i E (or W
Property Owner's Mailing Address Lot # Block# Subd. Narn ei_ 3
&53 'DE Rw003> Z) R • ~EN~,~ CS,~J
City State Zip Code Phone Number X15 - Nearest Road
kfuDSo 13 1 w t . 5~{OfCo (3) L4038 El City . O vo e ❑ own DCEQwoo7 7{Z .
New Construction Use: Residential / Number of bedrooms 3 ^ 7 Addition to existing building
❑Replacement ^ ❑Publicorcommercial-Describe: A107- /Pe~ 5;0,AfA4evl~~Z7
Code derived daily flow y O 0 gpd Recommended design loading rate bed, gpd/fig trench, gpd/ft2
Absorption area requiredbed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/fit trench, gpd/ft2
Recommended infiltration surface elevation(s) S'@e~ ft (as referred to site plan benchmark)
Additional design/site cons' a tions 7,(5E- Lave-1V9WAPW 7 ~'E~,c t.lc~S - 3 IuE$ S X R~et~,.
Parent material SG5 7 P~ QT S/1 Flood plain elevation, if applicable N ft
I Conve onal Mou
In-Grou Pressure SAT,-G5 a System in Fill/ Holding Tank
S = Suitable for system
U = Unsuitable for system S ❑ U E S ❑ U ✓J S 1:1 U L5'S El U El S E] S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
/ 0-12 foYR ~1Z /oA, 2-Fskk ,w,-rp- es 3~ S ;
Z /2 -/q /oyA 3/3 Si/ 2f s,6,~ die CS 3f S
Ground 3 _ Z.a,
io 31 S. s,6 G
elev. ~ ye / e f.P s / f s eul io lD,/Y~. ~y//3gv9F ~ . S, Cll. S hX ~c S ~ -_7
•8
Depth to /Q r % s /7 SApC iWl f . S
limiting
factor
77 in.
7 Remarks:
Boring #
fshf` ,-,,-6P es 3 f . s C,
2 Z -/7 D Yee 3 S-11 1 f5he r&) 17` • Z •3
3 to X3//3 S/ /7~sh~ die e4J L1 • s
Ground 7 ~P NDEI~ Jr Q~s 7
elev.
Depth to
limiting
factor
7 f_Q_In. Remarks:
CST Name (Please Print) Signature Telephone No.
RoQER-r 2(~R r'c ~i 4 27/5 = 3R6 Address Date CST Number
csT,y 2 ~8 L
n.h.-a- Q--_ /`..-ItaMe
• r
PROPERTY OWNER X4 SOIL DESCRIPTION REPORT Pa 6 Z of 3
n 9
PARCEL I.D.# Cs~ PF~Oi~t1(~
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
3 0-14 toy,eZ/Z e,e ,fv,G -,fiw P s 3-F z --3
Ground 3 if- 31~_ s S~T ~W 7
elev.
fo--ft. S• OS ~r -'1 :.,9
Depth to L a S l S
limiting
factor
77- ;
>,611 in.
Remarks:
Boring #
o-i 3 /o Le _ 2 z a,e RA1iG S, / /I-"shr' 3 -F 2- 3
z- 3 / 100? 3 z- 51 2 fShe 6 c4r,' /U , S-; . 6
3 / S./ Z-FShe A,lo `Uf . S .Co
Ground Z /o 13f}AuIA~ •S . 00 S . iLvt~ S
elev.
oft. /o 5 /fs9 "o
Depth to
limiting
factor
7 in.
Remarks:
Horizon I Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD f
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # / p 21/2- OW64,vi•c 511- A/ 5ht - ie S' 3 2 3
Z -l0 3 Sl/. 2 fS her s" 6e 64v /uf . s ' ~
Ground O S iy►1 4-5 elev.
01
Depth to /o O s • O
limiting
factor
7 7t;o
/ l-
_ Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
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7
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P'S I I
•
Fresh Air Inlets And Observation Pipe
'L C"~) Approved Vent Cap
p G iT Minimum 12".Above
Final Grade
#A/•~ ,
7
; Above Pipe 4" Cost Iron
'to Final Grade Vent 'Pipe'
Synihelic Covering
Min. 2" Aggregol6
Over Pipe
Distribution Tee
pipe 0 0 0 0 0 ,
Aggregate Perfbroled Pipe Below
Beneoth Pipe o Coupling Terminating At
S1ST' 2-=--~ Bottom Of System
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above ~~~visff~D
EiU Final Grade yt
2!~ 4" Cost Iron
70-
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Ale wank
ADDRESS ~~r bvcro
d dr~ FIRE NUMHE
CITY/STATE_ ~ ~Snn, 1/✓~r ZIP_ VOM
PROPERTY LOCXTION:Nw114l 1/4, SECTION , T N-R~W
TOWN OF__ Trov St. Croix County,
SUBDIVISION , LOT NUMBER Z
CsM sy'72y 8 va t ~ P5 13-
Improper use and maintenance of your septic system could
result in its premature failure to handle waste:;. Proper
maintenance consists of pumping out the septic tank every three
years or sooner, if needed by a 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 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/Ile, 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 Co. Zoning officer within
30 days of the three year expiration date..
SIGNED:
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
c Q
1ti
8 FILED
JUL 2 4 1996 lo
L KATHLEEN H. WALSH
Rcai-,hrof Deeds 2
St. Croix Co., WI ~
547248
CERTIFIED SURVEY MAP
Located in part of the NWJ of the NE} of Section 3, T28N, R19W, Town
of Troy, St. Croix County, Wisconsin; being that parcel of land
described in Volume 798, Page 388 at the St. Croix County Register of
Deeds Office.
A •
OWNER VOL. 496, PG. 459 pp/~
Mary L. Frank PROVEV
653 Deerwood Drive ciAALL TRACT
Hudson, WI 54016
- - - - DEERINOOD QKII E JUL 2 4'941
s °i 8T8 { ~O~t~Y
N 8 2° 5 0' 0 0 "E (R= 2734.551) u= V toning find
78.301 I Existing (I parks Committso
cn Drive
Proposed S
Drive o p Septic If,not recorded
c within 30 days of
S approval data
Yoprovalshall be
N . - - - LOT veld
Is
rt o I T~
House & I~ Ir-
i_ Garage ~m
o LOT 2 PI)
e+ I ` I U) ~
CL r 13
m jf ID C o 1-
et itl- Wei l 0 Ip
a io
1 2.57 Acres o 101 f D
M 1. 2.50 Acres 112,130 Sq. Ft. o I-is I^
CL 1-11 108,901 Sq. Ft. 1P. _
0
Gl ib N s
Itr 1-I %D r:
~n Shed
IN
i0
r
C
o
v Shed .
U1 I
274.94' 81. 3' -
S90°00' 00"W 356.57' NE Corner i
Z Section 3 c f
N p o:
SMALL i rA(-- T F-A Co Q,
co O
Wm<& co C> VOL. 544, PG. 569 0 ov°a°-~-~
~ moo o~
H
m LEGEND
o ~ trJ v
Aluminum County Section Corner o
° cr Monument Found
t S T C - 100 If
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 kef _X / r'1nK
Location of property IVty 1/4 NE 1/4, Section T Z(?N-R W
Township -T;;& Mailing address
Address of site tk )9 t
Subdivision name e-5M 5Y1 V1 V61. It - PS ' 313'7 Lot no. Z--
Other homes on property? Yes No
Previous owner of property 4'!,4)eK 66JAX&
Total size of property 2. S G,ff
Total size of parcel 2.S' 144d S
Date parcel was created
Are all corners and lot lines identifiable? Yes No /
Is this property being developed for (spec house)? Yes No
Volume W31 and Page Number /OZ 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. ~tf-f/ and that I '(we) presently
L 4'4 I
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.
Signature of Applicant Co-Applicant
Date of Signature Da of Signature
.
.
TN,S SPACE QCSERNEDr OR RECORDING OAT
M • OOCUMEVT NO. STATE BAR OF WISCONSIN FORM 2-1982 -
• ' WARRANTY EEO
YOl ~.1~ t PAGE1~ fim.-TET80r wfi
_ $LCi~IXCtY.YYI
641
_ . Il~lllirlrmld
^7Q 1 L u l r r~ s .r, . AU6 1996
&t 12:40. P. M
convey$ and warrants to MCI - acr w - _ i
I
P t -1'il2tL ~ , ~ ~ ~RETURN TO /vi t4.. r ~ J K / ~u J7
/S3 .mac-c-rwood ~r• I
5 1' C r o
the following described real estate In ;x county.
State of Wisconsin:
Tax Parcel No:
oc. „
II ry7c1Zoca re-d 1'n 0-;"t 0 -it sin. - 4_ be
I!I J rY r)
I
II
~ T ~ER
_
This homestead property. `
(is) (is not)
Exception to Warranties:
G~ 19
Dated this .-day of ,
J
(SEAL) ~~-L (SEAL)
14 Lou `roh
(SEAL)
(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature{s) STATE OF WISCONSIN
ss.
Sr- o ~ -County.
19 pTpsonally came before me this S day of
authenticated this day of 4 t 191Ji _ the above nomad
I ~ .
TITLE: MEMBER STATE BAR OF WISCONSIN who executed the
(II not to #"e morn to be the person -
tpr nstru entand eCknowl getne m
authorized by § 706.06. Wis.. SIMS.)
/Y!'CL h V ENL O WAS