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HomeMy WebLinkAbout020-1321-50-000 3: C5 o 0 ti a) c ry O tl C~ O O I ~ I ti O i I Y O V C 'SS O I J7 N I o ° c z L m LL C O T3 Q 3 Cl) v ~ 2i Z N W Z O £ 0 z u, z d m c 0 C7 ~ m o Z v c o fA FZ- ° N Z c N E -O 0 m ` m N Q N N d L L O c o C U O w Z z F- Z o N z N ~ y }Ny co CL M (D (,0 m a Q I ~ °o °o a O N N N U C7 l!') N N ° O 0 C) 0~ LO aaa zoo !~i g c cD t- fA J U N _m rn } N co O r` O S N N O O O N N _0 E ° co m a) CN w Q } O 0 ~ N C gyp` O tq C O c c = N U) W ~O L 30 O v N N CL O O O V Dj ~ N E E N I~ •w M CO C/1 N - L t~ r tom(, ,o N O H H d • = ) i~> 7 00 C3 rn E U ~~II yy O 2 N O N t!I f 4t d d a' 0 4) w E U C C ;7 7 ,*At; w G r A LO) a 2 0 rn U STC - 104 AS BUILT SANITARY SYSTEM REPORT L E OWNER -5 A-V 1 4- ADDRESS & ID r L Z..- Re-Nl~ ff dP 0 ►-r W I I ~0 ~b SUBDIVISION / CSM#x44.0 i5 ✓AL( f7 LOT # SECTIONT 7_9 N-R 19 W Town ofj y y ' ST. CROIX COUNTY, WISCONSIN g. t"{~IPF PLAN VIEW 0 SHO EVERYTHING WITHIN 100 FEET OF SYSTEM ps.,rf"~ WE lL f'Nw i ~4 ak`t r' i ~o G INDICATE NORT ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: To ~ or eOeN k 4P 89 /GCe1. o~ s ALTERNATE BM: 7-.0 f o B IDc l- 1rDrr0i7/0N / y per- 9 I SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:LdElSF-l2. Liquid Capacity: (acne Setback from: Well 7S, House 3 ,Sri Other ra ficCA(r-# Pump: Manufacturer Model# Size Float seperation Gallons/cycle: ' Alarm Location SOIL ABSORPTION SYSTEM Width: q5" Length ~A Number of trenches Distance & Direction to nearest prop. line: jjo .tea Gt./a4~.4 Setback from: well: 11r House C, C* Other r® Z,'', ELEVATIONS i Building Sewer - ST Inlet: /Q, Z4 ST outlet:/j0•, * Z9 PC inlet PC bottom Pump Off ~H X1,9 ~/=9L.9'3 ~./,r{, ~ ~~,~~y&= X0.39 <1_ /S. •v~ = s~'y~ Header/Manifold(; /ua(, c: Bottom of system c=rs ss gq.1z Existing Grade /0. Final grade ~G7, 9~ - ~3 g Z i DATE OF INSTALLATION: PLUMBER ON JOB: %/~'l~p~^,. f► LICENSE NUMBER: INSPECTOR: 3/93:jt Wiscdnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labpr and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitar PermitNo.: GENERAL INFORMATION 84212 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600466 ? TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1k)(-15e_r Q e Benchmark AGO, CZ ~ Dosing , Aeration Bldg. Sewer ~e Holdi St/)A Inlet TANK SETBACK INFORMATION St/ 1yt Outlet 16)"s TANK TO P / L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic y 5U NA Dt Bottom Dosing NA Headed: 9d Aeration NA Dist. Pipe i Hol g Bot. System ~S V6 s 2 PUMP/ SIPHON INFORMATION Final Grade 617' Manufacturer Demand G, 90 !272~ Model Number GPM TDH Lift Iction tem TDH L Force In Length Dist. To wed SOIL ABSORPTION SYSTEM BED/TRENCH Widths f Length(~ ^a / No. Ofrenches PDIT No. Of Pits Inside Dia. i uid Depth DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE / STREAM LE nu adurer: SETBACK CHA INFORMATION Type O Ntc,Y ~ Mo el Nu System: !rIh (p O NIT DISTRIBUTION SYSTEM Header/ M44r+0o d Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length -Z~ Dia.. Length -6-7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr ystems F h Over Depth Over xx Depth O xx Seeded/ Sodded xx Mulched y "'d 1 ,9 / Trench Edges 3~-r 3 Topsoil ❑ Yes ❑ No ❑ Yes E] No Trench Center 3 9 COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.15.29.19W NW, NW, GRANGE ROAD /r,_ ~~R,+.,w. a ~ ~J->7 ~ ~ ' c7D-C-4'-G ~ f : t , ~ ate. +CR ~s rt.r / t . 0,-'",.'•~",, Plan revision required? ❑ Yes to Use other side for additional information. a ` SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: S i I I r~~ipiilh Safety o and Building Water Division System: ~•■~r■ri SANITARY PERMIT APPLICATION Bureau 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 -SL . than 8 112 x 11 inches in size. I • See reverse side for instructions for completing this application State Sanitary Pe~r/n)it Number The information you provide may be used by other government agency programs ❑ 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 Property Owner Name Property Location _ A-M 4A/4 X1/4, S / S T Z;F , N,R /I" E (or(D Property Owner's Mailing Address Lot Number Block Number o -'W- Z V 2= City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city Nearest Road p village /ZAN6 E I~O/5►~ Public % 1 or 2 Family Dwelling - No. of bedrooms Town of ff CJQ 5 0 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________System_---------- __TankOnly- Existing System _________ExistingSystem 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 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c Elevation 4/5_ S 3 Co C a _ Feet 3- 7 Feet VII. TANK Capacity acctns Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ 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) MP/MPRSW NO.: Business Phone Number: Mllf 6 #1`-fQ0Y5L1- I -,k~/, ~i~ Plumber's Address (Street, City, State, Zip Code): % j0 *Tr__,C- Z / D < Rorl- D X 0 J0,S C, A( w / S (ID /L IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing gent Signature (N S) ,$/Approved Surcharge Fee) ❑ Owner Given Initial '1_0 A'/r~j~ - Adverse Determination QC/ / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County, One copy To: Safety a 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, 608-266-3815. 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 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. Vl. 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; 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. - 5 ~ ~ ~ t J/~ ~ = /o' D~.~ ltil fir/ 1?•t ~ ~ S - 0 3S a ~ f i ~2 E !p o S' i o4JO I, T R, vlt, Z / ►e o N ~z /~T N LAJ oT ~o NEB lv y ~S" Z8 Xj° a ~10 20 n ^10 j oft ~O a \ G , ~S 14 e V Of I ~ I i cm~ I o ~ j A~ t I I z ~ r I ~ u rnW ~ ~ W ~ o I ~ M, b I ~ rn i I ~ ~ 0 i ~ I r I z -Ti I r I w m I N 0 I N VA z m L4 I ~ I ~ Q ~l ~ -o U} 04 go µ i o ~o z r~ 1 . - ! - ~lILL~W RIV[R ,TTaTE fsaRK SErMi. .1wE cr Trt bw ..a AEOKir[c E N89.54'9'E 1320.96' r«E K 19s?^' Ss200' -26...92'- •IwS..Y I SCI Mw I[5i 16700' . s. ` •10aT -121Edl i.B6'- a •9198 13.1'1~ `ra a: o LO'f~2 -LOT I ; -33 9210&5 SO r/ tl KCS W z ! 9"_.2,9 sfi ET I_ YlK Q 1f i o I I er, 110 so fT 4 ~t. vJIFS EM FSVT / !77 h ' Q © I ID N,..a U, fr - M~.. t$ n LOT 4 LOT 3 NOTE cA~ E r. °r1c..r°•. , CNE• • ]!D 9E3 yM1~ ~t - wO " C:: '.•fF b_u 'e K •69G SC r•'.~~. 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TUGUT UM, C~a SCALE IN FEET ' 711..1• Isels.n. 1f707S's 3^E 73.17' 71.70' o 1 PLAT 1OCATbN ye Nf tl'1f•t 1St IT7J•1 TM SECTICN.S ' S~• a 2~cc X.X~, T29~:R9w ll • . .5 ~ d L ~w1N Calm pi - ' lc _I 3EETOY O I _SW SSE Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations _ Division oiSafety & 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 46 tX not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL 1. D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PRO ERTY OWNER: PROPERTY LOCATION q Q i & GOVT. LOT NLA) 1/4 A j;,j 1/4,S1 S_ T Z9 AR 1 E (or) W PROPERTY OWNER':S MAILING ADDRESS L0J,# BLOCK # SUED. A E OR CSM # Alva u t CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE MOWN NEAREST ROAD c ),U -rte A ] New Construction Use [Residential /Number of bedrooms ChJ'y', [ ] Addition to existing building j j Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate C> bed, gpd/ft2 ~ trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0,7 bed, gpd/ft20 .Z trench, gpd/ft2 Recommended infiltration surface elevation(s) ft ( referred t site plan benchmark) Additional design / site considerations I L 004 LL)A i t -j AO)Aj& l'&2 PLP I P t A L Parent material Flood plain elevation, if applicable ft S = Suitable for system ONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING,~wK U= Unsuitable fors stem S ❑ U If S❑ U 91 S El U S❑ U MS ❑ 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 Q-~ ~Dyt23 I l A7sbK n, L tr 2 s o . Ground -I i' lr@ S r- /h 1 .7 elev. C . ft. Depth to limiting Remarks: Boring # _ /h rte r_~ m~r /,f7 o-Z 1 L l y ~.4 6 .'S A4 _~7 6 -'Z 6 Ground $ -~S 7.S7 4/4 S r r Y,~ O elev g~ ft. D I +2 S r /st 7 Depth to limiting factor Remarks: CST Name:-Please Print APWLy 0,9M22N Phone: 31~~ r 46 gb Address: Signature: Date: V CST Number: 2r 9~~s4 PROPERTYOWNER'SAA M)LLk'Z- SOIL DESCRIPTION REPORT Page Z of 3 t PARCEL I.D. # Boring # Ho Depth Dominant Color Mottles Texture Structure Consistence Bourx3aty Roots GPD/ft rizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer~ -i 3 L /lam <r M f 'r (S 1 0.4. r3-ZS 4 J,L 1 tfih, SbK Vy C-w I a.z 3 Ground 7.2/ 4 S r /k 1 C 3-7 b.Z elev.. S y., M 7 €O Ci s ft. ./24 /me4 Depth to limiting f ctor > ~o. Remarks: } Boring # ~r _Z3 /orb s S I Co 1 r, sb~ ~~v r c ~ - 0 -Z- © 3 5 Y ~ Ground tt. d~J2 / ~ e 3 Depth to limiting factor Remarks: ' Boring # Q 13- ~ - rh cr- ' j 2~ 0 O S 1/-74 -11c~ s,4 R r- cs J.0 I . 3 Z4-4o ~.sy 4 3 S L t' a bg -fl, Tr r S - (),7-:() Ground 8ra 6.67 -7,S`/ 3 SC Q r n~ U 0 0.~ elev. ~Z ft. o /dYR43 _ 5 r, r 1 677 d-8 Depth to limiting factor 7 1~3 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: 05/92) s $~NCr~Ma~~. "r QorJ AT NW Loy Co ~uL~Q Eu~-Ykriao' JJ x 46, 9 r r , ~.3 Qr ~S r ~z STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S 4 L L 1Y MAILING ADDRESS Z(n Z-- 9- Z- PROPERTY ADDRESS Ce,0P_ Ili 6 F k_04-t) (location of septic system) Please obtain from the Planning Dept. CITY/STATE 40'0 _s o Y w ( S V <O PROPERTY LOCATION N uJ 1/4, N U-) 1/4, Section / -:T--, TAN-R_21 TOWN OF ,I O D S O ST. CROIX COUNTY, WI SUBDIVISION LM t L 67 `I LOT NUMBER CERTIFIED SURVEY MAP 2 VOLUME __L, 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 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 date. SIGNED: z", DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S 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 'A W 41) L £ Location of property J1/4 V L,(j 1/4, Section TAN-R / W Township #-u I0S o N Mailing address ~o~c Z.qZ 14- v m S a k( w k S D/ f0 Address of site-(o 0 2,4 V ,0- o 4 b Subdivision name L4L4 s/ Lot no. Other homes on property? Yes X No Previous owner of property Do u 64-4S r k- A T 4/4 /L Total size of property Z. 7 3 A c Total size of parcel z 8 04 e Date parcel was created - Z5• - 5 Are all corners and lot lines identifiable?"k' Yes No Is this property being developed for (spec house)? X Yes No Volume YZ- and Page Number /O 7 A 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.s s/c,/mv 4 , 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. .5'3 y~ao 6¢ c nature of Applicant Co-Applicant #-zc'-~(' Date of Signature Date of Signature r • State Aar of Wisconsin Form 2 1982 WARRANTY DEED l DOCUMENT NO RFG STER'S OFFICE =r Si: CROIX Co., W! Rac;`d htf Rcnoid ~o 'i Douglas C. Katner, Bernard J. Neuman, SS EP 2 9 1990 I an-d Chris P Wed an 8t 12;30 P.M Sam E;-MiIrer Rag>`lrrof - - conveys and warrants to D oda ~l sPACE RESERV711 FOR RECORDING DATA NAVE AND RETURN ADDRESS the following described real estate in St . Croix - I County, State of Wiscoasin: I RR A ~i~ 0111. (Parcel Identification Number) II F NW1/4NW1/4, Sec. 15-T29N-R19W, except Certified Survey Map recorded in Vol. 5, Puge 1418 as Doc. No. 393288, and except Certified Survey Map recorded in Vol. 6, Page 1761 as Doc. No. 420627. r This--- is not homestead property. (is) (is not) I' 3 Exception towarrantics: easements, restrictions and rights-of-way of II record, if any. September 1995 i~ Dated this day of - i lj~ --f - (SEAL.) - (SEAL)' Douglas C. Ratner Bernard J. Neuman (SEAL) --r - - (SEAL) Chris P. Neuman ~z 'I AUTHENTICATION ACKNOWLEDGMENT Signature(s) Bernard J. Neuman, STATE Of i ~ Chris P. Neuman County. authenticated this day of S_ 'p _ Rtb r- , 19 95 - '17r ca before me this x day of Y _ 19 9 q#iae ve named - - ugTas C -KafneY Ix,• ~g 1ti$ s land r. .ef. Kristine TITLE: MEMBER STATE BAR OF WISCONSIN (lf not. - - } - authorized by §706.06, Wis. S1as;J to me icncsy n to be the perwn eXc uteCthir foregoing in;Lunwnt and acknowledtfte , y. THIS INSTRUMENT WAS DRAFTED BY