HomeMy WebLinkAbout020-1308-40-000
ti ^
-0 0
y ° 3 o
O
Ci
O~ flO
N O
y: ~ I
n
O
O
N
r
O
L
y
•o i
0
v
O
y i
a z°
G
3
76
I
I
U. C
O
O
Q
z
Q, w E
U) o
Z y
cfl ~ d m
c ~
0
c o
o z :!t i L
Z c
dz
Y, a) N f- z
c y E •o
a m CI
N a o
c: a)
(D y
N C
0 a o
~i ~ c O U II
w
O o
Z z
~ Z o
N _ Z
E N
3 O R E I
N ~ R
> L
0 co
N > _N m 2 N O O
0 G a p~ N
N o
N y M fA M O m .
v o f 2 o
IL
= O O O Z °
•W1a m caaa (n I
CL J
~y g c_ co cfl
i O y v'
N U E rn rn y
(6 } -0 Cl) CO
0 0
m o p 00 = m N
O O C N O
O N N y n
Q } r)
A
N 0)
O O O N C
C c
° o c y a a a 0 0 °o °o
r Ci r y N N N
V O C6 F- > c 'n E E (D
O O 7 N
c O 3 N
` S"r r O N 0 00 y H F- y r ^ O
r]A1♦)1 O 7 N E E U
• L> O = > N O N -7 Cn
r
V ~ Ed
~k C. CL
• a d 2 m ~
~V E o c c
t ~a~'I,''omcOi
c1 A c °
~Sf`1
STC - 104 9 ~1Q
AS BUILT SANITARY SYSTEM REPORT
I / ' / p nLa
OWNER V eQ2 lJ {'1 U14 )lo l4EC, i;t
ADDRESS
1-44 ds'G h G/, S s" y G G :.ruMPt(10'F~C~ ~1;
SUBDIVISION / CSM# LOT #
SECTION / T P.) q N-R ~j W, Town of t~ S u YL
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• g `n
L
to
P~k
~s 3
R
J
t
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK' ~G a l ~j CJ
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: /ye dw Est cr Liquid Capacity: G U
Setback from: Well 7S~ House 3 V I
Other
Pump: Manufacturer Model#_ Size
Float seperation Gallons/cycle:
Alarm Location
":SOIL ABSORPTION SYSTEM
Width: S Length 7 ~ Number of trenches 2
Distance & Direction to nearest prop. line: Z/O
Setback from: well: House Other
ELEVATIONS
Building Sewer GU, ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system q i )1
Existing Grade Final grade
DATE OF INSTALLATIO
PLUMBER ON JOB:
LICENSE NUMBER: G G c
INSPECTOR:
3/93:jt
%VisccnsirlDepartment ofindustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations ST, CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Perrmiitt polder's Na ems: ON E ❑ City Village Town of: State Plan o.:
WO,
CST BM Elev.: / Insp. BM Elev.: BM Description: Parcel Tax No.:
I__J / /,j, G - QS
TANK INFORMATION ELEVATION DATA 6A
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_
Septic ~wcv Ern r f~,`~ 2Gc1c'~ Benchmark (p t' '
Dosin 1 v✓f ~.v~~ /d S~.3f~,
Aeration Bldg. Sewer UZj,d~ r
Holdin St /I Inlet 05- 17'
TANK SETBACK INFORMATION St//t Outlet /
7 Gal
Vent
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic Sd ~a5'~ ~5 NA Dt Bottom
Dosing NA Header-r:
Aeration NA Dist. Pipe
Holdi Bot. System 7-2,~ 93.73
s,72
PUMP/ SIPHON INFORMATION Final Grade
lvarrtr /Y7 r ::J and o ~
v
Model Number GP
TDH Lift F ' ion System TDH Ft oss _-rL ad
Forcemain ' Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length i No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 7S o~ DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC Manu act
SETBACK
INFORMATION Type O /7c,,,, {r~* CHAMBER Mo a Num er.
System: LrercktsS /C 1J OR.UNIT
DISTRIBUTION SYSTEM
Header Wamifo+d Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length _Z 0 Dia. 7 Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S
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.)~S {3/ ~~¢z ,~~7
LOCATION : HUDSON.16.29.19W , SW. SE BENJAMIN ( r ,
67
(I nC , m ph ` ern 10,E c~ ~f /
021 LO a c Y 1 G'~lfi~ ~Q/6 ~r 1~, c~s r1 Cc . G t , r !s rh ~ZZ,U /,CtL dP G 13+~ Q tie ~G
Plan revision required? ❑ Yes SIN"o Q _
Use other side for additional information. /T
SBD-6710(R 05/91) Date Inspedor'sSignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureau safety anofd Bildi uildining Water Systems
gs ter 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. :5:,(- • CrQlX
• See reverse side for instructions for completing this application State Sanitary P'57ermiitVNuummber
The information you provide may be used by other government agency programs ❑ Check itrevision 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 Propert Location
Veron E. Waxen SL9 1/4 Sh 1/4, S 10 T 29 , N, R 19 E (or) W
Property Owner's Mailing Address Lot Number Block Number
549 Ct Rd. A 4
City, State Zip Code Phone Number Subdivision Name or CSM Number
Hudson, WI. 54016 (715) 386-3438 Pleasant view
II. TYPE F B ILDING: (check one) ❑ State Owned city Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No_ of bedrooms 4 Town OF Hiid.-,on -Qty Rd. A
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) / QD
1 ❑ Apartment/Condo O.P-O ~w q o
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. M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System SystemTank 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 ❑ 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.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
600 750 750 .8 ~ 4.0 96. (feet 98 Feet
VII. TANK Ca
in gdlloac(tns Total # of . Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank X 1200 1 Midwestern ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility r installatio of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum is Signature: ( o t s) /MPRSW No.: Business Phone Number:
Joe Stan MP Mp 6646 1-715-698-2266
Plumber's Address (Street, City, State, Zip Code):
506 Willow DR. Woodvil e WI. 54028
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issuing A nt Sig ture (N to
d Surcharge Fee)
pprove ❑ Owner Given Initial
10 1 Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05194) 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 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 pamper 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.
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; 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.
V~'r n o n t. L/axon
S- el _ Cry
Js L,1, k. s g i G
A l3 . M. l 101-P ~ /UU
16,22
Dley ~u.t~iF~ q~3~' ►3-3
16-4
7 a-
S'
v
v U '
42, ?z
1
NokSt:
r
9G U •
L__49q,o
Wisconsin Oepartrnent of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY S~„. G R O 1' 1L
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
(IE,eAlOv 5. 4V A)(O A) GOVT. LOT WEST -5F 1/4,S Ko T 2 9 ,N,R.17 E (o W~
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # .
S 9 ELY. EL). A y PIE6SAh3T L)(G v
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST gqppgqpp
vpSoZ eutS • .51/a /G (7/5) 96 - 3'138 HUOSoj cry. 0o +
[ New Construction Use [ Residential / Number of bedrooms 3 40 Addition to existing building
j I Replacement f50- ( I Public or commercial describe
Code derived daily flow &cy gpd Recommended design loading rate • ? bed, gpx trench, gP~
Absorption area required bed, h2 trench, ft2 Maximum design loading rate • ? bed, gpd/ft2 trench, WW
Recommended infiltration surface elevation(s) 5-W- h • 3 ft (as referred to site plan benchmark) SEE to o
Additional design / site considerations 4E1.0
Parent material ScS Fl? - P+ 1 I o T 56. Flood plain elevation, if applicable Al- • ft
S - Suitable for system LOO ION MOUND C] U IN-G UND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING Tint
U = Unsuitable fors stem • L7 5 ❑ L75 O's ❑ U B", ❑ U 03 Li- ❑ S 130
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence B9e5 Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tench
I 0-10 /0 YR 3/z 2 , Sfk W fie 3 t ..5 . C.
8, o-2/ /0 YR /f 5A& V-I%X /vI~ . .5
Ground C 9 /oy~ y s o, s
elev.
`If q 2- I
Depth to
limiting
factor
Remarks:
Boring # ^ 0-/7 /6 YR 311- si~ 2.w< '4& ito~►fR G' S r F
• S } .
El 0 71,5 5'1 74,3* 4" IU-f
(3 z F0 - y /a R 31 /s ,e 'Mvf~P 5 • 7 •R
Ground
elev. C, O /d f - C S U, S 7
-72 5 '7- -ft
Depth to
limiting
factor
Remarks:
T Name:-Please Print 12c) 8 E e r -u L e R i c k r Phone: 715-3-?(,- ?18 S
Address: O' N t_ i L 'RD. ~{-U OSo ej to IS . 5q01 (P cSvi 2y 8L
Signature: Date: _ CST Number:
PROPERTYOWNER URN w~X 0~J SOIL DESCRIPTION REPORT p 2 t •3
PARCEL I.D. i
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rend
3 A 0-1 AO yW -2-/2- 5777 2 sri& n~ f' e s Z~F . s . ~
R► V- i.(o /o ye 312-
s./ /f s6~ s / ~f .
Ground f3 z - 36, /o yR 313 S / f' si& 7,w s' /vf y . S
14.iyft 1 3 - y5 /0 Ye 3 ~'iP c's • Y , . S
Depth to C S y~ 7•S yip y/ 00
limiting
factor
}
Remarks:
Boring #
.o loyt 2-1:, 2-
13 , lo- ZS toy 342-- S~/ / f sdK ~+-~~~P s l~ `f i• 5
/3 Z S -3 7 /b 3 ~r ?,P s %f . y _ . 5
Ground
elev. /33 3 7- lo e Y13 Sr l 17C Y; k 7~ e e5 • G~ ; • S
Cf li 3
Depth to C K/0 16 7's /W s GP~ - • ?
limiting
factor N =
Remarks:
Boring # 5'11 D -30 M Ye ~Z ~ / 70- 56,E N+'~'.e S 2-F • Y i .
y0 to y)e 312- 71if ~S - • y S
y3 s~ / ~f s6.~ fie C5' . y j .S
Ground
elev. 9 ? .s-Yf cs, 01 S
ft
Depth to 6/E0,-tLI'G D 0 ~ I
limiting Sf/STe.Ar 0vj!5- r`f le O 'r %
S
factor
Or 1~ L rf0~ (r-
Remarks: 4474: o 7 45 Zfs&D
Boring # ►
i
i
13
i
Ground
elev..
ft
Depth to
limiting
factor
Remarks:
eon 0121Jn10 ncrnrn
Pg 3of 3
(EVATi'CA3 -
4 , 9y. y2 '
(3i 57.72-
16, C33 .22_ -
SCALt I 30
F6 .3 w
BS
3100 Nd LOT
LOT
S06-6Es teD Sy STE•N
(5 l1" 04- 7-aV5
l (rte T R eAJ CA", yG, D
~yo - ,
low TREAj G14,
N
D
v
/oo a3 ~
w
,416u y 500 yk
%ol r r
OF 7255T-
f-~ Z cG-•J l o~ Dw~
5v5%
P-~tT£ s 'x46
-
f? ' e. -r* q1-f A
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER Veron Waxen
MAILING ADDRESS 549 Cty. Rd. A
PROPERTY ADDRESS ~07 r a l+'t 1/(
(location of septic system) Please obtain from tite Planning Dept.
CITY/STATE Hudson, WI. 54016
PROPERTY LOCATION -3W 1/4, SE 1/4, Section 16 T 29 N-R 19 W
TOWN OF Hudson ST. CROIX COUNTY,, WI
SUBDIVISION Plesant View LOT NUMBER 7
CERTIFIED SURVEY MAP , VOLUMEr-- 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.
V\kle, 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 Croy
County Zoning Officer within 30 days of the three ye r expiration date
c -
SIGNED. W _ -
DA'rL- - -
St. Croix County Zoning Office
Government Center
1101 Cannichael Road
I iudson. \VI 54016
• 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 Veron Wmaen
Location of propertyS W 1/4 SE 1/4, Section 16 , T29 N-R 19 W
Township Hudson Mailing address 549 Cty. Rd. A
Hudson, WI. 54016
Address of site CYO? c n '0M c
Subdivision name Pleasant View Lot no. 4
other homes on property? Yes x No
Previous owner of property
Total size of property 3
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for (spec house) ? Yes No
Volume and 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.
Signature of App icant Co-Applicant
3 /1 ~ /7~
Date of Signature Date of Signature
pp `
WARRANTY DEED (Forney Statutory Form). B00TA'!<. IST.O" N SI Miller-Davis Co., Miune:uadk.,
Form No. 9 W. ...il-
259581
is Inbrnturr, Made by St. Croix County Public Welfare Depart. ,nt
grantor , of Stl..,Croix County, Wisconsin, hereby conury and uwrraot
Vernon Waxon,and Irene Waxon, husband and wife as joint
tenants and- Pot alra ~nsnoJ in common St. Croix Cwt nl't,
Wisconsin. for the su.ut of One Dollar and other good and valuable consideration
! j['i Ali ~rN J7
the followirz~ tract of land in $t. Croix CoyntJ, .Stair of
The West One-half (J) of the Southeast Quarter (SEJ)
of Section Sixteen (16), Township Twenty-nine (29),
North of Range Nineteen (19) West, excepting the
railroad right-of-way of the Chicago, ST. Paul,
Minneapolis and Omaha Railway Company and excepting
a conveyance of lands to St. Croix County for highway
purposes as shown in Volume 11336" Deeds, page 65 in
the office of the Register of Deeds for St. Croix
County, and subject to an easement to the Wisconsin
Telephone Company as shown in Volume "295" Deeds,
page 371, in the office of the Register of Deeds
for St. Croix County.
I
i
ST.
r.F<oix ct)
I 'I
[-,c( A] for R!-Iaortl to • 30t,h
II"~fI '
UC)
r r n r J Y ~.v...~..
r r f
t r
III 7 ~ 7 I' I lyl - 1nr1.. '171
I
In lUituruu I'tlttrrraf,Thesaid drantor• has hereunto set his itonfi ntl.;r,J/ hi:
28th day of September eq. n. 1l 59.
SIGNED AND SEALED IN PRESENCE OF
- - f
i ) 3t. Cr x-County Publl We 1 are Dept..
Kenneth H. Ha a Bye ~1'
Brigh , Dire 11or
-
__Mary__Ellen_Marlette_
Otate of Wisronsin,
SS.
St. Croix Cortnty
Personally came before nie, this 28th day of September
.4 n- 1959 the abore named St. Croix County Public Welfare Department