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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER GQ NK COLA 1 to
ADDRESS CI' K 4 (4 G Kc lP
SUBDIVISION / CSM# TAr- Y' V., 9 W ~ pfieS LOT # 3a
SECTION I ~ T 7 N-R- 17 W, Town of I~U PNM
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
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3 9DROOM HOMIE
IND LATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK : ~o o 1 S U (zU P VI Ko Q ~ ~ e jI ; 1 0 0. 0
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W Ke vs Liquid Capacity: VU
Setback from: Well6'4'ZR So House QW Other a~
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM l'
Width: Length Number of trenches
i
Distance & Direction to nearest prop. line: V
Setback from: well: yAvg56 House Other 3a
V, )Uo
-CWD T~•~~ 53.85 ELEVATIONS C09 C,
r u~
Building Sewer ST Inlet: ST outlet: ~v.
PC inlet PC bottom Pump QOff
Header/Manifold Bottom of system
~a
Existing Grade Final grade
DATE OF INSTALLATION: 1011119
Y• IJ~W►~-D
PLUMBER ON JOB:
LICENSE NUMBER: 3YU~I
INSPECTOR:
3/93:jt
Wisc6nsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
` Labor and Human Relations
Safety and Buildings Division INSPECTION REPORT ST CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
• GENERAL INFORMATION 262396
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
COULTER EUGENE & AMY HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: ~t Parcel Tax No.:
-_me GIS -tom` -
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 5 c-r,,C " c J~< Benchmark
Dosing x"16 D-11 7a i
Aeration., Bldg. Sewer
Holding St/ Inlet 93, ;ZS-
TANK SETBACK INFORMATION St/ IX Outlet g a~ ,3 ()X,
TANK TO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 50 C3) NA Dt Bottom
Dosing_ NA Headers-- 77`T 9a•yy'
Aeration NA Dist. Pipe
Holding Bot. System 02 CYp
PUMPL_INFORMATION Final Grade
Manufacturer Demand 370 97. 5~(
odel Num GPM
TDH Li Friction stem TDH Ft
oss
F emain Length I Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width O Lengt s No. Of Trenches No. Of Pits inside Liquid Depth
DIMENSIONS DIMERStGU-S
I u acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type Of =RUNIT Num er.
..W .
System: ,
DISTRIBUTION SYSTEM
Header Id- i/ Distribution Pipe(s) i/ x Hole Size x Hole Spacin Vent To Air Intake
Length Dia. Length Dia. `F Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems Only.
Depth Over Depth Over xx Depth Of- xx Seeded / Sodded J;~ Mulched
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSO~N/.17. 29.19AW,, SW, , LOT 1 ,32, CARTER CIRCLE
~,p ~ t- Q~ ~ t
!l/l/~llL'✓~ f ~ ~ , r
0/
Plan revision required? ❑ Yes p-lo
Use other side for additional information.
SB -6710 (R 05/91) Date Inspector's Signatu Cert. No.
ADDITIONAL COMMENTS AND SKETCH
F
SANITARY PERMIT NUMBER:
e
r
SANITARY PERMIT APPLICATION BureauoBuilding WaterlSystems
In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave.
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 81/2 x 11 inches in size. ~~p n I 'y
• See reverse side for instructions for completing this application State sanitary Permit Numb
The information you provide may be used by other government agency programs E] Chec~Uog i6
[Privacy Law, s. 15.04 (1) (m)j. v us application
State Plan I.D. Number
L APPLI ATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prot~l ty Owner Name Property Location
LL r_'Ynu 1<e f~ ~ /4 ~ 1/4, S /'7 T N, R I E (or
Proper
tOwner's Mailin Addr ss Lot Number Block Number
a4, -j9 P_
City, St to tip Code Phone Number S division Name or CSM Number
t5/ ('J/J" )J . e
II. FY FE BUILDING: (check one) ❑ State Owneda ❑ ity Ne est Road
Public 1 or 2 Family Dwelling - No. of bedrooms ~ ° village
Town OF ~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo t ~~®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.ew 2. L] Replacement 3 Re lacement of
stem E] p 4- ❑ Reconnection of 5. E] Repair of an
y____________System_ _ Tank Onl
y______________ 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
Requ'r `d(sq. ft.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Mi /inch) EI ation
V 3 • ~ ~ U Feet 74.y o Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per.
New Existin Gallons Tanks Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank b 0 O , I ❑ ❑ ❑ ❑ ❑
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) P bep Si ture: (No Sta ps) MP/MPRSW No.: Business Phone Number:
: J6
Plumber's Address treet, City, State, Zip Code)
IX. COUNTY / DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Ag nt Si nature (No S m )
Approved E] Owner Given Initial ` 60 Surcharge Fee)
Adverse Determination 7d
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County,. One copy To: Safety s 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.
VI. Absorption system information. Provide all information requested for numbers 1 through 7-
V11. 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; ELI 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.
B.E.: 67 PLOTA 1-11 c.: R0S5_ SI
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FRESH All' low.-Ts AND OBSERVATIOW-VIRE
C11OSS SCCTION
Approved Vent Cap
I...,~ F) P)
n p
Minimum 12" Above
Einar ?rle___~ s-('
ya Mix ,
4" Cast Iron
Above Pipe Vent Pipe
To Final Grade-
Wisconsin Department of Industry, SOIL AND SITE EVALUATION 3 4 e of _
LaboY "and Human Relations in accordance with s. ILHR 83.09, WIs•
DMsioh of Safety and Buildings County RICEIVE0 hes Attach complete site plan on paper not less than 8 1 /2 x 11 in0, 1 _inaired on ands - C V
,
.cam
include, but not limited to: vertical and horizontal reference point (BM) arest
percent slope, scale or dimensions, north arrow, and location and distance to ne road. Parcel 1. 1 4 1996
0 O
COUNTY D
Reviewed
1
nPOrma~tion• ZONING OFFICE
APPLICANT INFORMATION -Please print all
15 ~ (t) (m)) ~ a
Personal information you provide may be used for secondary purposes
Location E
Govt. Lot ~11 1 /4 &F 1/4,S
Property Owner
/ FW5 Lot # Block# St, . Name or CSM# A
Property Owners Mailing Address X32
~ N Nearest Road
Z :2. / M State Zip Code Phone Number City El Village 0 Town T L
city (38G) 7 0
0
Addition to existing building
New Construction Use: ~ Residential /Number of bedrooms
Replacement ❑ Public or commercial - Describe: trench, gpdt~
Recommended design loading rate ~7_bed g _ _ trench, gpd/ft2
Code derived daily flow 9Pd bed, 9P _
rench, ft2 ~ Maximum design loading rate
3 bed, ft'-5-4- -3t ft (as referred to site plan benchmark)
Absorption area required s.~
Recommended infiltration surface elevation(s) -AQYAK"
It
Additional design/site considerations Flood plain elevation, if applicable Holdin Tank
Parent material AT-Grade System in Fill 9
In-Ground Pressure ❑ S ZU cis oU 11 g 11 U
Mound oS ClU
C
S Suitable for system onventional 0S ClU ED S Q U
U Unsuitable for system
SOIL DESCRIPTION REPORT GPD/4
Mottles Structure Consistence Boundary Roots Bed , Trench
Dominant Color Texture Gr. Sz. Sh. ,
Boring # Horizon De in. Munsell Qu. Sz. Cont. Color
.2'
m. 2
2 3
M
Ground Z -2 S
elev.
ft.
s o s~
Depth to
limiting
factor
in.
Remarks: ~ . 2 3
Boring # 0 O -2
Z S _ Z AA
V 2.
Ground O 6:-
elev. 3
fL. 3-ft'
Depth to
limiting
factor - ks: Telephone No.
in. Remar Signature _~(S(
CST Name lease Print) L CST Number
Date
3
00
6 T
Address
Page Z of _.31--
t . SOIL DESCRIPTION REPORT
%~(O[1 L 7E
PROPERTY OWNER
2
PARCEL I.D.# Roots
Structure Consistence Boundary Bed Trench
Mottles Texture
Boring # Horizon Depth DomMuns color Qu Sz Cont. Color Gr. Sz. Sh. ell , in.
fy. 3 L S
Ground 2 / - • 8
et v. L
Depth to
limiting
factor
. in.
R7-rc a rzv
/ - S Z , • 3
Remarks: L
Boring # 2 -
2 _ S-- 3 3 o sG L S
s
~'/9 ~.s- -y 6 c L c~ F~ r
Ground J- y 3 S S
~elev. _
Depth to
limiting
factor
~n Remarks:
Mottles GPDIft2
Structure Consistence Boundary Rooms Bed 1 Trench
in Texture
Depth Dominant Color Gr.
Horizon Dep Munsell Qu. Sz. Cont. Color Sz. Sh.
. 1 . 3
in.
Boring #
S .s.•3
- 3
2-
-Z7
Ground
J-'ft. 3 7- •s- 6
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
-in. Remarks:
SBDW-8330 (R. 08/95)
i
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S'I'ANI( MAINTENANCE, AG12EFMI"N 1
Sl. Croix Counll
MAILING ADDRESS
PROPERTY ADDRESS o
(location of septic system) 1'Icasc obtain from the I'Ia11111ng Dept-
114, 1/4, Section
I'ROI'F,R'I•y LOCA't'!ON ~
• 'ROIX COUNTY, \\'I
I'p~'~'N OI' St. -_-tom S~ /
- v \ LOT NUMBF,R
SUBDIVISION 1V
VOLUME , PAGE ,LOT NUMBER ~
CERTIFIED SURVEY MAP _
could
Improper use and maintenance of your septic system result III
years or sooner, if heeded
wastes. Proper maintenance consists of pumping out the septic tan every
e tic tank pumper. What you put into the system can affect the function of the septic tank
by licensed s p
as a treatincnt stage in the waste disposal system.
St. Croix County residents may be eligible to receive operation a prior g a toor July a l1 lax 1978, of St. 60%o of tCou
of replacement o cost
f a failing system, which was l requirement this program in August of 1980, with the requirement that owners of all new systems agree to
accepted P
keep their system properly maintained. the ('\,jef
The prop If°lil,,;)c signed verifying that (1)
crl) 'owner agrees to submit to St. Croix "Zoning a ccrtilica';o~(
and by a mater plumber, journeyman plumber, restricted plumber or a 1Ce { 2 after inspection and
the on-site ~~'astcwatcr disposal system Is~ss than 1/3 full of sludgclan<t,scum( )
pumping (if necessary), the septic tank ►s l
c the undersigned have read the above requirements and agree to maintain the private sewage
I/\V
i l
in accordance with the standards se,t follh, herein, , cd andretilrned lto the St. C °Ix tile Cellification stating; that your septic has been mamtailled must he comp
e.t
disposal system
County /.oiling Officer within 10 days of the three Year expiratum datr
-
-
SIGNI?U
)A IT,
tit ('loix t'cnm1y %,oninl; (Mice
l invclnlni'ilt l rnlci I II`tl
1101 CaI111101:10 I:u;u1
Ilmisiin. \'11 A010
This application form is to be completed in fu l inadeggned will
. owner(s) of the property being developed. Y permit issuance. Should this
only result in delays of the P owner/contractor, (spec
be intended resale b,
development for
house), then a second form should' be retai eds notfice1 with when the
the.. property is sold and submitted to
appropriate deed recording.
owner of property ,t N_R_W
Location of property 1/4 1/ 4, Section ? T
Township Mailing address / L0? A 00
Address of site t,no.
Subdivision name J~Wk_ Lo
other homes on property? ~ Yes No
Previous owner of property ~~----p-
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? - Ye's No
Is Is this property being developed for (spec house) _Ye A
aster
Volume " and Page Number as recorded with the Re9
of Deeds. -
INCLUDE WITH THIS APPLICATION THE FOLLO 16LtTME AND PAGE
A WARRANTY DEED which includes ~GIDOOF T DEEDS R, In addition,: a
NUMBER AND THE. SEAL OF THE would be helpful so as to avoid
certified survey, if available,
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 the I we certify that all statements on this g or oare wner(s) of the
best of my, (our) knowledge that I (we) am (are) the
property described in this information form,' by virtue of a warranty deed recorded in the office of nthehat I t( e)e aster of
presently
Deeds as Document No. stem or I' tl
own the proposed site or disposal
described property, for thee:.
obtained an easement, to run
construction of said system, and the a e, has been duly eccondedNiin of Deeds as the office of the County Register,
~
Signs a of Applicant Co-Applicant
_FJ# A~
Date of Signature Date. of sxgnafu-
545124 State Bar of Wisconsin Form 2 - 1982
WARRANTY DEED
OFFICE
DOCUMENT NO. ~((lf 1183PACi 511 V Eat%~K
Darrel E. CROIX 0% W'
Wert and Beverly A. Wert
us an an wl e, In .lvl ua yan eac 6
in eir own rig A• M
conveys and warrants to Eugene T. lter. and
~
may J_Ceand e as
s urvi vor s hi A marital property
THIS SPACE RESERVED FOR RECORDING DATA
NAMEAND ETU ADDRESS the following described real estate in St. Croix GWIN LAW FIRM, S • C .
County, State of Wisconsin: 430 Second St.
Hudson, WI 54016
020-1300-30
(Parcel Identification Number)
Lot 132, Plat of Park View Estates Sixth Addition, in the
Town of Hudson, St. Croix County, Wisconsin
$ T FER
This is not
homestead property.
XhO (is not)
Exception to warranties: TCGE` HER WITH AND SUBJECT Tp any other ease Illents covenants,
reservations or restrictions of record, if any, but this shall not be deemed to exrn
any such other recorded encumbrances beyond the term established by law therefor.
Dated this 1 0th
day of June '1996
,
Darrel E. Wert (SEAL)
* (SEAL)
* Beverly A. Wert
* (SEAL)
(SEAL)
*
AUTHENTICATION
~ I1 • ACKNOWLEDGMENT
Signatt r~(~~ • ' !y. STATE OF WISCONSIN
St. Croix. ss.
ti altedlhi• :day of 19
t w County.
Wisconsin Department of Industry,
labor and Human Relations SOIL AND SITE EVALUATION REPORT Page 4 of
Division of Safety 3 Buildings in accord with II-HR 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 .S o t>,,
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
PROPEW OWNE PROPERTY LOCATION
GOVT. LOT LJ V 1/4 !,JZ 1/4,S T N R E or
l~ Z J W
PROPERTY OWN ':S IfAILING A DRESS LOT # BLOCK # S D. NAME OR CSM #
2z2. .3Z cr,C yle,./ ejlAl j
CITY, Sj E IP CODE PHONE NUMBER ❑CITY ❑VI lAgE WOWN NEAREST R AO
~J New Consiruclion Use Residential / Number of bedrooms (j Addition to existing building
] Replacement CJ~~ f j Public or commercial describe
Code derived daily flow gPd Recommended design loading rate _ , 7 bed
9Pd/ft2.1_ _trench, 9Pd/1112
.
Absorption area required k113 bed, ft2 G 3 trench 111:2 Maximum design loading rate _;Z_bed, gpd/tt2 . S` trench, gpd/ft2
Recommended Infiltration surfacQ elevation(s) , 5~ ft (as referred to site plan benchmark)
Additional design/ site considerations S Nj
< 60v~
tParentsmaterial Flood plain elevation, if applicable ft
uitable foDem ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ 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 Trertdl
Z' r Z 09 e G 3G 5k- M A5 Zs'.' 2- 3
Z 2 Zy 53 3 C L sbk 2
Ground 3 zy I-''Y r 'e
~f
Depth to
limiting `
Ifaclor
Remarks• 3
Boring #
o io z s e 36 5 6k A57 2
El 2 °'zz 1~ ~G 4 2 .3
Ground 3 2- IWti
7. 5' YZ 0
5
3 ft.
Depth to
limiting
7-1
Remarks:
T Name:-Please ~l Phone: •-7 f S
3~6 o2v
ress:O 3 ~d z , IN ✓9/,~
7,9
Signature: Date: O CNumber:
rte, 4~
SOIL DESCRIPTION REPORT Page of
PROPERTY OWNER Z
.
PARCEL I.D. #
D/ft
;Dt h Domin ant Color Mottles Texture Structure Consist e B Roots Bed
GPBoring # Horizon Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
l/ S~ z Z 3
-Lo
R.
-Z, 3
3
Z l/- Z s b
Ground
It LL It.
Depth to
Gmibrq
Remarks:
Boring #
Ground
elev. _
fc
Depth to
kn"
fir
Remarks:
Boring #
Noun
Ina
Ground }
elev. _
Depth ID
Nm~bng r Y..
factor
Remarks:
Boring #
1
Ground
elev.
It.
Dept 1D
b*ng
low
Remarks:
3BD-SMR.O5"
PARCEL IN VOLUME 533, PAGE 471
(DOC. NO. 331419)
36"E 1486.69 (S00°36'40"E) _
;I' wO 1 161.20' 208.80' 330.01'
=MENT _1
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