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AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS,r ~ Z r 2-
SUBDIVISION / CSM ►y T~ t 1~ G
SECTION / Z LOT Z 1
T__~ZN-R__Z2,_6[I Town o f - c~ D S o
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FE-ET---OF S
7SHOW EVERYTHING IN
- YSTEM
Z- AAF-
IPE F- I:: t00,60" 14
5
L. p1' - Z/
/YoT/-= i To ~,L ~JHDE
f w ~ FgQA~
Lod.z v ; LLJ
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T-'F - -3-~ WEct
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_,coT -lrrF_ ~1TJ~_` JC~C?R1~
PVNT E 2 INDICATE NORTH ARROt~
Provide setback and elevation information on
reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
~N d
BENCHMARK: T o F (R- n j P
ALTERNATE BM: 1 L L kMI-/C gdT .Lerk
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: f~l,l>c / `F2 Liquid Capacity:
S UJ ce c Q15E
Setback from: Well House Other
Pump: Manufacturer Modell - Size
Float seperation Gallons/cycle:
Alarm Location -
SOIL ABSORPTION SYSTEM .r;
Width: Length Ln 0 Number of trenches G
Distance & Direction to nearest prop. line: Ef: To N.7i~?tl !~7= LINE
Setback from: well: House s Other
ELEVATIONS
Building Sewer-- ST Inlet. (p•S Y ST outlet
PC inlet 7 PC bottom - Pump Off
Header/Manifold Bottom of system ? -
Existinq Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: GL
J rc ~
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wiscorisin Department of Industry,
Labor and Human Relations PRIVATE SEWAGE SYSTEM County:
Safetynd Buildings Division INSPECTION REPORT -ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
7Pe m it Holder's Name:
AM miLLER ❑ City ❑ Village ❑ Town of: State PI
CST BM Elev.: Ins BM Elev.: X
p BM Description:
c t/ Parcel Tax No.:
TANK INFORMATION
ELEVATION DATA
TYPE MANUFACTURER
CAPACITY STATION
Septic Gc> ✓ ~F~C BS HI FS ELEV.
Dosin Benchmark
Aeration Ui4 t( , 6,1t,
,
Holding Bldg. Sewer
TANK SETBACK INFORMATION St / liilk inlet
St/F t Outlet
TANK TO P/ L WELL BLDG. ventto 020. 17
Septic Air Intake ROAD Dt Inlet
NA Dt Bottom
Dosi
Aeration NA Header/man. -739'
p9'
NA Dist. Pipe y
H ng
Bot. System
PUMP/ SIPHON INFORMATION
Final Grade
2 ZS Manufacturer ~Sl S~
Demand fah
Model Numbe
GPM
TDH Lift ctio 36
L S stem TD Ft O.
Force Length Dia. Dist- To well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length
DIMEN 1 N 75 i No. Of Trenches PIT No- O f Pits
DI N ia. id Depth
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREA A Manuacturer:
INFORMATION Type o
CHAMBER Mode Number:
//Q f/( OR UNIT
DISTRIBUTION SYSTEM
Header/ Ma~ ifold Distribution Pipe(s)
Length pia_ Length 57~ Dia. _l/ x HoleSize Spacing x Hole Spacin vent To Air Intake
SOIL COVER x Pressure Systems only xx Mound Or At-Grade Sy m
=Trench Depth Over
nter ® xx Depth Of x eeded /Sodded xx Mulched
Bed/ Trench Edges 11, c Topsoil
COMMENTS: (Include code discrepancies, persons present, etc.) ❑ Yes ❑ No ❑ Yes ❑ :No
LOCATION : HUDSON , 12.2 .19w,
} NW, SW, I'ANNEY NE
n~
Plan revision required? ❑ Yes 0-140
Use other side for additional information.
SBD-6710(R 05/91)
Date Inspector's Signatur
\ Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
Safety and Buildings Division
In accord with ILHR 83.05, Wis. Adm. Code B201 ureau Building Water Syster
Washington Ave.
• P.O
Attach complete plans (to the count P.O. E- Box 7969
than 8112 x 11 inches in size. y copy only) for the system, on paper not less county C/ Madison, WI 53707-7969
• See reverse side for instructions for completing this application • ~~O/y
State Sanitary Permit Numbe^
The information you provide may be used by other government agency programs
[Privacy Law, s- 15-04 you (o (m)j. ~0/
I• APPLI ATION INFORMATION -PLEASE PRINT ALL INFORMATIO ❑ Check revision to to previous application
Property Owner Name State Plan I.D. Number
f all, C L Property Location
Property Owner's Mailing Address
NW O 1( 2 Z_ ~ 14 $G(J t /4, S / 2 T 27 , N, R / E (or~
Lot Number
City, State ZIP Z. / Block Number
v As'o ~ Code Phone Number
If. TYP i a/ (j86i z Subdivision Nam or SM Number
F BUILDING: (check one) 76' 7A NNZ /D 6~
Public 1 or 2 Famil Dwellin ~ State Owned ❑ It
111. BUILDIN - No. of bedrooms ❑ village
Jj- JD Nearest Rooafd~
USE: (If building type is public, check all that apply) Pace Tax ONumber SO T~~~F! L~ ~'L~
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall ~ / 3~C~ ' ~ U OQ
3 ❑ Campground 6 El Medical Facility/ Nursing Home
4 El Church / School 7 ❑ Merchandise: Sales/ Repairs 10 El Outdoor Recreational Facility
5 ❑ Hotel /Motel 8 ❑ Mobile Home Park 11 El Restaurant/ Bar/ Dining
9 ❑ Office/ Factory 12 ❑ Service Station / Car Wash
IV. TYPE O 13 ❑ Other:
F specity
PERMIT: (Check only one box on line A. Check box on line B, if a li
A) 1. New 2. E] Replacement 3E] Rep pp cable)
System System . lacement of 4. ❑ Reconnection of
B) Tank Only tingSystem 5. ❑ Repair of an
❑ A Sanitary Permit was previously issued. Permit Number Existin S stem
Exis-- -
V. TYPEOFSYSTEM: -----9-y_-_-
(Check only one) Date Issued
Non-Pressurized Distribution
Pressurized Distribution
1 1 El Seepage Bed Experimental Other
12 Seepage Trench 21 El Mound 30 El Specif T
13] Seepage Pit 22 El In-Ground Pressure y ype 41 ❑ Holding Tank
14 El System-In-Fill 42 ❑ Pit Privy
43 ❑ Vault Privy
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. R
Required (sq. ft.) Proposed (sq. ft.) (Gals/da h ft ate 6. System Elev. 7. Final Grade
77 .S d y q ) (Min./inch)
Elevation
VII. TANK Capacity SD
Feet / Z/, Feet
INFORMATION
in gallons Total # of
New Existin Gallons Tanks Manufacturer's Name Prefab. Site
Tanks Tanks Concrete Con- Steel gFiber- lass Plastic Exper.
Septic Tank or Holding Tank strutted glass App
Lift Pump Tank /Siphon Chamber / w;7 S .L ❑ n
VIII. RESPONSIBILITY STATEMENT ❑ ❑ ❑ ❑ ❑
I, the undersigned, assume responsibility for installation of the onsite sew ❑ ❑
Plumber's Name: (Print) age system shown on the attached plans.
' K~ )VI-5 Plumber's Signature.: (No Stamps) 111111111111111 1
~ Q Ltd A MP//MJPRSS~W No.: Business Phone Number:
Plumber's- Adress (Street,
City, State, Zip Code):
0,4/ 011111111111101/Z_4 e4111'llillIll~l~l r
IX. COUNTY/DEPART ENTUSE ONLY
Ill
❑ Disapproved 11 Approved ❑ Owner Given Initial Sanitary Permit Fee (Includes Groundwater
Surcharge Fee) ate slue Issuing A ent Signat re (No S mps
Adverse Determinatio din.1 14-1,
X. CONDITIONS OF APPROVAL/ EASONO D~
ISAPPROVAL:
BD-6398 (R. 05/94)
DISTRIBUTION: Original ro County. One copy To: Surety & BuilJings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
i ma be renewed before the expiration date, and at a time of renewal any new criteria in -the
2. Your sanitary perm t y
Wisconsin Administrative Code will be applicable-
3. All revisions to this permit must be approved by the permit issuing authority-
. or lumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
4. Changesinowners p p
county prior to installation licensed pumper whenever
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a
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, E608-266-3815.
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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwe''Eing-
e is ublic, check all appropriate boxes that apply.
III. Building use. If building typ p
Check only one on line A. Complete line F. if permit is for tank replacement, reconnection, or repair.
IV. Type of permit.
V Type of system. Check appropriate box depending on system type.
V I. Absorption system information. Provide all information requested for numbers 1 tahroug number of tanks and
VII. Tank the capacity of every new/or ex7-
Ming manufacturer's name, indicate cate prefab or site constructed and tank tank, material. total g ompfete for all septic, Pump/siphon and
information. Fill in
tem. Check experimental approval only if tanks received experimental ;product approval from
holding tanks for this system.
DILHR. appropriate prefix (e.g- MP, etc.),
VIII. Responsibility statement. Installing plumber is to fill in name, license number with address and phone number. Plumber must sign application form.
IX. County / Department Use Only.
X. County / Department Use Only.
The fans must the
cou
nty include ete the plans followiandng: specifications not smaller than 8 1/2 x 11 inches dimensions,'location of hold ng tank(), o PS ~chon
C P lot plan, drawn to scale or with comp
the locatistreamsoand lakes; pump
of f the building served;
areas; and service;
replacement wells; watermains/water
or other treatment tanks; building sewers; systems;
tank(s)
tanks; distribution boxes; soil absorption snce points; C) complete specifications for pumps and
B) horizontal and s volume;
curve; pump model and pump manufacturer; D) cross section
vertical elevation reference
county; E) soil test data on a 115 form; and F) all sizing information.
elevation differences; friction loss; Pump performance
of the soil absorption system if required by
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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W1soi a Department Industry
,
Labor and Human Relations SOIL AND SITE EVALUATION REPORT
Division of Safety & Buildings Page ~ Of
in accord with ILHR 83.05, Wis. Adm. Code 13
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but COUNTY t x
not limited to vertical and horizontal reference poin o ~1R6
ction and /a of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and d'
~etetto~nejr t d.
APPLICANT INFORMATION-PLEA AI I ~
TALL IN ON REVIEWED BY DATE
PROPERTY OWN R:
«L~~ ~ o-~~~'~ PROPERTY LOCATION
PROPERTY OWN MAILING DRE GOVT. LOT NW 1/4 1/4,S 12 T Zq Q
) BOUT ift 13 J LOT N,R / E (or) W
k lkl L BLOCK# SUTAME OR CS
CIT)',nST T/~ E / l A N N try ~1 ~ SC
L) PHON WWER ❑CITY EVVC GE OWN
( "Gt .7t= ~ N REST ROAD/
New Construction Use Residen ~~~14u~
j) Replacement [)Addition to existin buildin
[ j Public or comme P g 9
albe
Code derived daily flow gpd
Recommended design loading rate " bed, gpd/ft20- 2
Absorption area required bed ft2 2 _7trench, gpd/ft
Recommended infiltration surface elevation(s) trench, ft Maximum design loading rate bed
9Pd/ft2.Q1trench, gpd/ft2
Additional design / site considerations E1~~02 vQ°;1 p~, ft (as refer d to site plan benchmark)
Parent material 0D120V44,.
Flood plain elevation, if applicable ft
S=Suitable for system CONVENTIONAL MO S D Q U
U =Unsuitable fors stem
I IV S ❑ U IN• SOUN❑D U ESSURES DO U
S SEM Lj ULL HOLDING A K
SOIL DESCRIPTION REPORT O S
Boring # Horizon Depth Dominant Color Mottles
in. Munsell Qu. Sz. Cont. Color Texture Structure
Gr. Sz. Sh. Consistence Botuiclary Roots GPD/ft
z> Bed Trench
! nt sb K
Ground
01-7
elev
1 r~ ~s3 ft.
Depth to
limiting
~ ~cYrZ
Remarks:
Boring #
A
f cS z d,4;
o X24 4-
z4 s , C J,,'Sk (h- Cs ~ o •z 0,3
,,pp
Ground 6 4 41 16y ~ 4
O r
0.7 elev.
►14A!L~15ft.
Depth to
limiting
>t. -1z
Remarks:
CST Name.-Please Print
Q ~~N N($~hW Phone:
Address: o SOU / ~ ~
Signatur •
Date: 9 5~ CST Number:
34~9-
Page
PROPERTY OWNER ~4/h I at'-Q, SOIL DESCRIPTION REPORT
PARCEL I.D. # LOT 2.1
Mottles Structure Consistence Baxcbry Roots GPD/ft
ed Trench
Depth Dominant Color Texture Gr. Sz. Sh. Bed
Boring # Horizon in Munsell Cu. Sz. Cont Color rn C S 2 ~ b
p-za d~~~3 s~ m s
17 /01 1+ 0 ~j
Ground
elev.
1ZL 6~ ft.
Depth to
limiting
> ct 7 s
Remarks:
Boring # ` ~ S~ 1 n, SDK ~ ~ GS 2~ 0 ,q 'O,S
s~ I vii, sbY, 1 cs 2 o.~
r 677 0.'
Ground
elev.
I .49 ft.
Depth to
limiting
f t0 -
Remarks:
5 l m sb~ rh 1 ~s Z~ o ,4 S
Boring # 3A !bL f~3
Ground
elev.
IZ3 zS ft.
Depth to
limiting
'factor~
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
gon,_o~onl4 ncrM~
y
M
A) L .
1 0 rb
r 14 ~
1 ' 1
y
1
K ~ 1
1 /
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S T C - 100
This application form is to be completed in full and signed b t
owner(s) of the property being developed. Any inade y he
only result in delays of the permit quacies will
development be intended for resale by owne/ contractor I issuance. Should this
house), then a second form should be r tai edr and compl ted(when
the property is sold and submitted to this office with n
appropriate deed recording. the
owner of property 5 / tjj Gu L
Location of property N W 1/4 $ Lo 1/4, Section / Z
Township T Z 9 N-R / 9 W
Mailing address ~px Z
t S y 0
Address of site 4-
Subdivision name A, I p
Other homes on property? Yes Lot no. L /
.~_No
Previous owner of property 0 N
lip t
Total size of property 2, z -7 Fqe L V
Total size of parcel 2. L L
Date parcel was created 9-/
Are all corners and lot lines identifiable?
Is this Yes No
property being developed for (spec house)? X Yes
Volume /0 and Page Number S/ No
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 asdtolavoid
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 the
best of my (our) knowledge that I
property described in this information(aform, owner(s) of the
warranty deed recorded in the by virtue of a
Deeds as Document No. -1-6 y .FS office of the County Register of
own the proposed site for the sewage ~disposaltsystem) orr I ent )
obtained an easement, to run the above described property, for the
construction of said system (we)
the office , and the same has been duly recorded in
_ S~ yg S
of the County Register of Deeds as Document No.
Z ature f Applicant
Co-Applicant
Date of Signature
Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 5 A 411 IU (L L
MAE L NG ADDRESS I p x Z r
PROPERTY ADDRESS b ' T 4
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE -l~y D S O W I c- p/L
PROPERTY LOCATION N W 114, S U-i 1/4, Section / Z.
- • TAN-R
TOWN OF P L2 L) 0 N
ST. CROIX COUNTY, WI
SUBDIVISION T A k kf Y t D ~c
LOT NUMBER 2.
CERTIFIED SURVEY MAP S3 / syZ . VOLUME , PAGE LOT NUMBER Z
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 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.
1/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
DOCUMENT NO. STATE BA F WISCONSi ORM I-1882 THIS 94C[ R[a[RV[D,oR R[CORDiND o,r,
_ AARRRANTY D ~+0
504855 VIOL 10 31PAGE 456
r- j
OFFICE
This Deed, made between ' r =C'ST"4' G
5
Randall _W. Synan and Patricia E. Synan, ! 0•.~~
husband and wife ^ec'd'brReeu~ .
Grantor, ! SEf 1: 1993
Sam g_ Mil ier~ a sin le erson
and . q_p.-.................. it to:45 - A: M
L a
Grantee,. al 0eam
WitriesSeth, That the said Grantor, fqr a valuable consideration...
'r Randall. W. Synan and Patricia E. Synan
convoys to Grantee the following described real estate in St . Croi_X RaruRN ro
County. State of Wisconsin:
=f
Taz Pared No:...................................
The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2
Of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of
NW1/4 except the East 74 feet thereof, all in Section 12; all in
Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin.
' F~
AND ~
A parcel of land located in part of the NE1/4 of SE1/4 of Section
11, Township 29 North, Range 19 West, Town of ftudson, St. Croix
County, Wisconsin further described as follows: Commencing at the
E1/4 corner of said Section 11; thence
North line of the SE1/4 of said Section, 1212.32 „feetltogthee
point
~q of -eginning; thence continuing S89 30100"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8q 30100"E,
along the North line of Certified Survey Map filed in Vol. "30,
Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence
N03 58134"E, 351.07 feet to the point of beginning.
7 This .•t1Qt. homestead property.
* (is) (is not)
.14 Together with all and singular the hereditaments and appurtenances thereunto belonging;
-9 And..... Rcl.1.1da.1J_. W...... S n_an_ an_ d• t?atri.c.i-a - E. Synan_
warrants that the title is good. indefeasible in fee simple and free and clear of encumbrance except .
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
•h `
Dated this 1
day of Auq.L1S.t.................................. 18...41.
k4r
Win ' " (sEAL) u t.. f..4~
...........(SEAL)
Randall W. Synan Patricia L'. Synan
•
• -
(SEAL)
(SEAL)
' .
e' AUTHHNTICATION
ACENOWL3DaMENT
Signature(s) . STATE OF WISCONSIN
r,
'i
Croix sa.
tit County. authenticated this day of......................... 19 e~o nally •L•_ 3I..
Aug St came before me day of
18........ the above named
511 .............P........
~i Randall W Synan at i
r cis
TITLE: MEMBER STATE BAR OF WISCONSIN Synan ' "
i (If not, ;
authorized b aCt Y0~► ~OM01'J i
~ y 4 708.08, Wis. Stata.)
h
to me known to be the person - I-......N44Y= he I
).I;:
r ADDITION To TANNEY RIDGE SPECIAL ADD17
DIN PART OF THE SWIM OF THE NW I /4, IN THE NW 1/4 OF THE SWIM, AND IN PART OF THE NE I/4 OFT HE SWIM, ALL IN SE
R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN.
OWNER
1101TH IIMC O. TM 111114 O' TM NMI/., 191710N It 7AN NILLI•
•0 go.. 262
_ S89'25.46*W 984.21' ~~so .ot
r 400.00' 5 B4.21
n
'T' 6 I {O (A
N
OT 41 LO 40 'n = till PIL-1
2.44 ACRES 6 ACRES 't i
' OT /42 106,124 S0. FT. ,006 SO. FT.
'42
2.25 ACRES ly `
197,851' so. FT ,Q % 0t0 1311' 40 \ 0 2 D Z- 3 C7 0
ti/ / NV O~ z~
►os
~J;asppW tr cuL LA'Jv5
•
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10 EST -
~jt• ~i -118.33 ~ +
\LOT 43 Ne3•osooyw
.L `gA ACRES 0 0 ..............~J ~ ~
+ .592 SO. FT. , ~W/ s9 ~J► .
V 92 ~h
LOT 39
o T ! I 2.73 ACRES
b ° • , IRi cL • n:.e
"I 66.00'
I ,
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11 / i I ; 0Z6 W
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?4. p q r J7
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10 /
A~ LO 38
/ • 2.,.0 ACRES
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B
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' : ~ 811 "s'•.e~ / W M
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LOT 37..."e
y o-
101 Q b• 2.25 ACR \ /98.009 50. ~e +
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