Loading...
HomeMy WebLinkAbout020-1072-70-000 'o 0 -0 0 3 0 o p O ri c (1) ry 4 ° ~ c 3 N LO o c~ O L N NO c v d a~ y O 3 L L L N C C CD .p O O «O «p C O « O Y 0) N co co LL C O U O m ti O O a O ~ O O N ~ N 3 ~ m m o Z Z o m = CL 3 m LL O (o C C U. C _ O N 'C N n I co 3 M 3 ~ a z 4i z E o o O z y y a s co a m IN w a m N F Z c O C z C U O Z ~ 4= Q z d c z N H CD ~ ~ ~ E M ca O 'D 0) O U) O O N IV CL Q1 N d (D all C 7 47 ) N (n E U) U) n :3 W1 2 • a c CSI 0- c ~ CO O Q o O Q d z h z z z N o ~ ~ ~ I N N W O N ' 04 l6 Y l0 Y N CL H •w d N N O O O D D CL o G G It 0 U N EI E z > co H H H a m U) U) ° O or +v is a N co co N Mi. o N c rn p c m rn u) N U o rn Z w co cfl w U -0 .0 0 0 .O O j N r ~ j tlY N N 0 CD 0 m In r- 00 In V 4) m d is m 10 O 'II Y N N Y N H O O O N C co W C C) 0 f.- 0 _0 0 C: E C14 (D 0) O O 0 N C C N N Q G a 0 0 0 l' Er- E L. N N~ O C 2 C O 0 N N O Q co ~y O N FL- r r co Z3, -0 r..l N X x 00 : ~ U • J~ O N = N O 'n z N O ,n m CL \ £ E L 3 a L IL L a ttw~. a a _ c m U O (A U ` A U a 2 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /1 ' /L C ADDRESS /30 Y'2 t! SUBDIVISION / CSM# '`t LOT # SECTIO N-R l Town of -:f) ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM WC-LL ri, 4. No 'r serf L mL' 4 (C g 51' t !7E~ NH 7E d ~ ~ ~Vo7E: M~4y ~/ECo 7~ -y Aj,T6- slog oN hf hF o tIVE/C .~o e n(! INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. it r BENCHMARK: ~D P ,D. 4 SS E M I /VT /per AP f / /D 7 C) ALTERNATE BM: dz / /y f _ S~PTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Est /Z Liquid capacity: © /nc 6 L ~ Setback from: Well- o!L ' House 2_ o ' Other 4-1 G, 76 Al. X f/ T ,ch </f Pump: Manufacturer Model# - Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: S Length ~S Number of trenches Distance & Direction to nearest prop. line: / S_ y~ Setback from: well: House ^ Other r- -rv ELEVATIONS /'f`" a• yb Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off P,A _ /3-os pow by- Yz- Header/Manifold Bottom of system ~-°w 4611 Existing Grade/ Q , /.5 Final grade /0, /3 DATE OF INSTALLATION: -PLUMBER ON _JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Humao Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division Sanitary Permit No.: GENERAL INFORMATION (ATTACH TO PERMIT) 268657 Permit Holder's Name: Lit Village Town of: State Plan ID No.: WAXON, GLENN/SAM MILLER -HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / 1 l6 7. 7' ' TANK INFORMATION ELEVATION DATA A9600363 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark i a .05 T, D 7 11 Dosing Aeration Bldg. Sewer Holding St/Ht inlet /03 TANK SETBACK INFORMATION St/ Ht outlet 302 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > a0 NA Dt Bottom NA Header/Man. q y , Dosing 93-83' /5,20/ -02 EHI ati on NA Dist. Pipe r'/, 74( yading Bot. System PUMP/ SIPHON INFORMATION Final Grade Q/S g, i3' Demand 105,9" Manufacturer ~r J Model Number GPM TDH Lift I Friction System TDH Ft L Fie Forcemain Length Dist. To well SOIL ABSORPTION SYSTEM IMEN I N No. Of Pits Inside Dia. Liquid Depth BED/TRENCH Width Length No. Of Trenches DPIT DIMENSIONS Manu acturer* SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING SETBACK CHAMBER Model Number: INFORMATION Type0 OR UNIT 7G System: Qz~ DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) I 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 I I 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.) LOCATION: HUDSON.26.29.19, NE, SE, LOT 1, KALY ROAD lC7U o~ GcX~l Plan revision required? ❑ Yes El No - Use other side for additional information. 7 9>0 SBD-6710 (R 05/91) Date I pe or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: Safety and Buildings Division w■~r■r,t 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 8112 x11 inches in size. 4--. Cr'rOj • See reverse side for instructions for completing this application State Sanitary Permit Number `*3(05-7 The information you provide may be used by other government agency programs Check it r ision to prev ous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope' y Owner Name ~~11 Property Location NN IV,+koN :%4,011 /G E114,5 1/4,S .2(o T N,R / E( W Property Owner's Mailing Addr s Lot Number Block Number O Z `rs Z- City, State Zip Code Phone Number Subdivision Name or CSM Number U So I s (3 > Z7~. C tSy/Y! Vol- 17 /D4-4 Z ZO II. TYPE F BUILDING: (check one) ❑ State Owned o vfl(age Nearest Road p Public 1 or 2 Family Dwelling - No. of bedrooms -3 Town OF #L )D50 ~A Ley R D, III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo Z d - /d 7 -Z 7 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 Be if applicable) A) 1. ~ New 2. E] Replacement 3. E] Replacement of 4. Reconnection of 5. E] Repair of an /C System System Tank Only Existing System Existin System B) A Sanitary Permit was previously issued. Permit Number 759cl 7r 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) 9 z.-010 L oLO Elevation L/ ,SO -:5-0 -2 5-0 ~ 93-5 N 4afeet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existin strutted glass App. Tanks Tanks Septic Tank or Holding Tank /Doo U) E / S G 2 ❑ ❑ ❑ ❑ ❑ 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: 1#14,655- 11-7CAb0XE4(._,1 a?* 3~' - G9 L Plumber's Address (Street, City, State, Zip Code): 42 _70 2Y aA(7,64 I/ pzo )4 L4J IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanl ry Pe it Feg (Includes Groundwater Date Issue Issuing Ag t Signature roved urcharge Fee) pp ❑ Owner Given initial. le p Adverse Determination UU 7 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) DISTRIBUTION: Original to Coumy, One copy To: Safety & Buildings Dive-,ion, Owner, Plumber A INSTRUCTIONS i 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. 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 experimenta! 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 8 112 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. ~ r rn .r Z C. - J ~.a s ~d Z A. NN LA) O b tics 00 \ cn d1 "i n t~ J ~ ~ ~ ~ II J p ~ i~ 6v ~u ~ p ZIT Q I a~ E i %T1 u d ~b ilk - E.4~ coy ~~X m ~I 'Alt Cl I I I I ~ O I r I ~ ~ Ir O c\ \ I I n 0 I , UN fl I ' I I 2 ~ w I Z I _ ['1 n I ~ k o ti < ~J J m g o µ F h ~ ~ - minGoz Wisditsin Departrront of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 Labor aAd Human Relations 4,DivisionofSafety &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 PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION [REVIEWED BY DATE PROPERTY OW ER: PROPERTY LOCATION p L( &4 GOVT. LOT t4j~ 1/46 E 1/4,S Z6 T Z9 N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBDD. NAME O CS # z4-2n CITY, STATE ZIP CODE PHONE NUMBER []CITY VILLAGE OWN N EST ROA ( ) Sd s >4~Y .81 A6 KNew Construction Use ( Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ j Public or commercial describe Code derived daily flow gpd Recommended design loading rate ®•S bed, gpd/ft2 L).6 trench, gpo1ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate .C bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) `0E:Ac-u rj - ft (as referred to site plan benchmark) Additional design / site considerations ° 2.6 Parent material Flood plain elevation, if applicable ft S = Suitable for system cO,NVENTIONAL MOUND IN-GROUND PRESSURE gT~GFADE SYSTEM IN FILL HOLDING TIK U=Unsuitable fors stem LOS ❑U 0S ❑U 9S ❑U ®S ❑U 41S ❑U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench rh Cr d . 141 Ground -82 "7. S ye - 'S L r- tij-j~ CS C> A elev. jbf.c:bft. 4 / YR 4 4 S r~ O;? 61 Depth to limiting d fact r X 2-3 JOYR4 •3 5 cr C'S - U Ca Remarks: x1,44-L L9yf--25 ©7 7N -k>6C y 9 3 6 iq I i t6" Boring # L 2 n, C rh r Z-T O.S d_ 6 .:.r A a z3 ~y>~ _ z $ , 23..39 Y g 3 <s' 3L rh b r~ r~ v r 1 ~ a .3 $2 -S? -7SYR 4 4 S?_ - ter n,v~~ GS O.A .S Ground elev. ; $3 )-/31 16Y 4/4-- 0 Depth to limiting 3'' Idy►e 4 ~yr- ~h 1 GS a.5 fact > iOZ Sth n~ Y..d~~5 r~' JC•~ i N Q6 1~~ Remarks: CST Name:-Please Print Phone: Address: Po .8,C 7/ t b ~54 A 3 i ~4d) Signatur Date: ! _ ` CST Number: S4s64 PROPERNOWNER th /~Ictktk SOIL DESCRIPTION REPORT Page of PXRCELI.AA CS14'tO'T I ' ~QL l T Z426 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mr& r!~ J (J t~ •S' Ground 39~- s5 7, -S-/P0, 414- SL jr elev Depth to limiting factor X Z -3 7 /67<~ .~r' %c(p tJ I Z GQ Remarks: 5AML 'd-'''t-~qs of Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # all, Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) M 1 r r w 3s ~6 x n r N od 1 c p ~ Ulf 4n w ~ S R Wisconsin Dep'artrriefitof Industry, Labor and Hyman Relations PRIVATE SEWAGE SYSTEM County: Safety•ancJ Buildings Division INSPECTION REPORT St. CROTX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Per1,t} 6yT','s N~~n~ /SAM MILLER ❑ City ❑ Village Q Town of: State Pla AX(JN Cihr;N CST BM Elev.: Insp. BM Elev.: BM Description: W11 - Parcel Tax No.: A 600U38 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet Verit TANK TO P / L WELL BLDG. A ir Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM riction System TDH Ft TDH Lift F Loss ead Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu acturer: SETBACK INFORMATION Type Of CHAMBER Mode Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distributiin Pipe(s) x Hole Size x Hole Spacing Vent To Air Intae Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 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.) LOCATION: HUDSON.26.29.19W, NE, SE, KALY ROAD Plan revision required? ❑ Yes ❑ No Use other side for additional information. Ll I SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System: 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 1/2 x 11 inches in size. .57 • See reverse side for instructions for completing this application State Sanitary Permit Number 496'01 Al '7o`~" 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 11 Property Owner Name roperty Location GI k 1i K SA* Al I UIFA- ~1/4 5F, 1/4,5 Z(, T 49,N,RE( )W Property Owner's Mailing Addr ss Lot Number Block Number City, State Zip Code Phone Number ame or CSM r JD-so w r S-o 1 (0 ( ) .5 2- 9a L II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City ha rest Road V-Al- y' ❑ Village Public l or 2 Family Dwelling - No. of bedrooms -3 Town OF t~D.so III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O 7Z-- 70 1❑ Apartment/ Condo OW i/ 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. rl New 2. E] Replacement 3_ ❑ Replacement of 4:T] 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 'Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13] Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: Alp X00, r 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) tp= q(. - o Elevation S~ CP~n l . Z_ ,93, 5 Feet S,,Vf) Feet VII. TANK Capant in gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App- New Existin strutted Tanks Tanks C C Septic Tank or Holding Tank 10~~ GO 1- S E ❑ ❑ 1:1 11 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1:1 ❑ 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 Signat : (No Stamps) MP/MPRSW No.. rBuisiniess Phone Number: Plumber's Address (Street, City, State, Zip Code): / r C~~e Fh/ 1 / L L 0r>D SO At IX. COUNTY/DEPARTMENT USE ONLY E] Disapproved Sani ary Permit Fee (Includes Groundwater ate Issued Issui Agent Signature (No Stamm Surcharge Fee) ly [Approved ❑ Owner Given Initial ~p Adverse Determination 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 , Y 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. a 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. _ W F,: T COT L//S( J'~ e; ire) CE rn m z v T ~ ~ m ! N- - ti to m ~ ~ ii-rzi ~ ~ T I C 1 r ~laPE -n o ~ r n A n 1 ~ 0 Q 3 ok 3 f v U fi r ro ~ ~ l_ t'1 w ' TT 3s ell ' v` ~ ro a / l L T~l Q E ISr lo? l/l~~ b r~ co r-I '6 r~ i I a~ ~ < 1 ^ T I , ( , 1~ O cu m I ~ , ~ rn I nj U/ m i I W o I ro i C; I Z - - w 4 i cu N I m -o b -100 ~ 0 2 0 4 tA 1-7_ 1, z n T Y, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 HUMAN RELATIONS N WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATIO : SECTION: TOWNSHIPHwdfttetPAt+T-Y: OT NO.:BLK- NO.: SUBDIVISION NAME: /.3G- ~1,E 1/ sE V/ '2 z (-o /T29 N/R 0 E (or) W H U VSO j / C- ~ H f &ff M>~Ano~s~ COUNTY: MAILING ADDRESS: CROr x G~ZZ~4j "/v/9X0.L) 7Z- (o C'00.1-31y T-o. A) , ti U D so,J w IS Svc)/ USE - -'22 S DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: r~ I1OFILE DESCRIPTIONS: PERCOLATION TS: Residence 3 op- 4- IV, 4, MNe. ❑Replace 10A..5E ( ( d, l5 Iq q) fU~~ l S ~ f Ca 9 ~ I 5c ~ a0 k ~A RD-r- RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) os ❑u ©s ❑u ®s ❑u as ©u as au TPEjG~t,S - w,f. V00P pox - If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), i 7- ndicate: C /i4SS Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. 1 HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 0/o ye 31z 5 owed ' /z - i0" Y'e 3, 3 S:/1f ,Q B- I I15 qY,( >fcS fR;10-3~cS 5 K,n.,Ic,'~ 4-/~s o /Dyx 912 s p owed; " /oY 3/3 2~ N B- Z IID Ifo•SO > t/O '+~~P ; G r N/o y.P 312 P-16 -:0t,0 ' Is-/(o "/0 yA° 3/3 S/ z f bra, B- I ~D2 /r~ > R j /G -Zo f//? S`i /c 5 0-t ufle 20 9 //.P L!K c _ /o S r „ / o y2 3 / z S/, /o -64 S/, B- 1/4 /00'/0 ~U ;W60 2fsb)e, i'/e; ly'_ 2- y"/o yt % s,./, z41, F 4'.i/ - I 2 N• 3 V/ O y R 5/y Cou~PtE v c y,P 3,f 6- lv yP 3/y c s Gj O-/o " /0 ye 312- 5717,_p owa /7 "/o me 313 s,'/ 24 p /w Fi i g_5 102 q r / l ~ ~~d8 I~"-2Q''/o V'e 514 5 13,k, A,fR~ z~/G"/o `/it'4 ¢ ~~12C ~lEZ,4T roaS PERCOLATION TESTS siy/ 2 f sbk, , 1' y~ "-/off" /oVx s/y e, 5' } TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEE-INCHES RATE MINUTES f NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD PE R 100 P PER INCH P_ I 3- /o 2_ o Z / P- 5 9 0 2 61 3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. t+ 7 P E Aj 0 ~ M I'DDLE 7.eji v I, c~+ SYSTEM ELEVATION. Low, i e- ,uc = 93, So I I - E7, } I I I i j`, NNC y LA J DS RPflRox. No. LvT Li.uE.._____.._.._~____.,~....___.._ PLOT PLAX3 LOT GOi l CS,y Ao 7 1 i 5c/F ~E ~ ~ ' 3 O I X - /~i~ C Si'TE$ 'L3.M. SS'T'. o S'tf E L C O,u 0 L) r P I' PEI, x P, N P X 20' i 61EVA-rloo-j- /00.0, sysrEM Go Fu ~y k .3 s PEPLACEHEn)r rd 5 z B, x STC-105 SEPTIC TANK MAINTENANCE AGREEMENT //St. Croix County OWNERBUYER C F /Y ~)x 0 N elzz_~V' MAILING ADDRESS E6 Z' Z-- PROPERTY ADDRESS 7 7 SAL RDAy (location of septic system) Please obtain from the Planning Dept. - CITY/STATE /71yDS O lA 1 J '(C) ((A PROPERTY LOCATION 1/4,- SE-- 1/4, Section 2 T N-R / ?W TOWN OF ~ 0 _Z 0 ST. CROIX COUNTY, WI SUBDIVISION C- A-) LOT NUMBER SM~ CERTIFIEDSURVEY MAP S2 O , VOLUME , PAGE2 y2 v, 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: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo ThA.s 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 G I L N 1V /L L sr Location of property_&,C_1/4 Ste- 1/4, Section , T2~1 y N-R / q Township Ry l7 S 5q Mailing address BoX -;t le- P L Address of site-,;? Subdivision name Lot no. $ Other homes on property? Yes No , Previous owner of property Qd w ; A); u K Q r ~F Total size of property 3, 9 11 C Total size of parcel > , S 7 { L,. Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume 3 sY and Page Number./3 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. a 24y , 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. as47( Signature of Applicant Co-Applicant Date of Signature Date of Signature azo Alf V 40 Duo 1,47SY0 boa ' S It 4e&,& >zQ,~ ,e If /a r iris Novo is9r . 1 , o i~'9 ~.S/!7 Q%zy 2, d.2 aG, t7 ,LAMES 4t ~IVNEL ( ~ r i00 Z .G3a< tt 1 =.aO Iltt~ IKW, 'k G Aethln° s*'`ar`."r'e e 6 the : @ast-r+est t ce ~ Sectaon` 26, ~assume'~d' to ~b'ear co O a r r .0 . 1:221. N to rt C) N89 •37 1.W. N Oct 2 Z :'1991 > > !2t' ST Ct701X CQi1M1/ Unplatted' Lands N N 'COMPRrEHENSIVEPArMRANfVl111G =1 _ ° o . AND IONmc to t=!M1i►Mr17EE ` West line of the SE} of Section 26 H S000181.2411E 1058.201 ' 200'.001 'NO0018124nW 858.201 N . 1"a co 10) r-j C6 zb I rt o Z'. co 0 0 t", to I c a o N Ffi O N t0 w 4.1 me N o4-' fu rr! I O. N Csi O F,y N I rt= 2 O ry ` m m 2 O?~/ a I to N - = OH ,y a cst = z ° i I r C+7 i~ O o ro ti . .A i /mtsbe° e ° y f.h p~0 ~4 ~'1 e 14 ~~I 661' , 'd 7, n /;e ~L-~a• D C,. zz N tri rt' rt rn: y ~ ~ 2: '~`8°~ i ld~. ;~a 2 O o,~i L _ ~ r > O tiM ' ~ r • ~'E ti iy r r.+~•px . Yy I•'t .A{ a s' p O ""<Q!'1r0 yQ~r~.""~'~/..ry/~/~~.t..~ {r1SO S V 11 Y 'Y 'Fh • t 6 tT ~yrc a4 t V yt t j♦ '~y~i l,, ~ f ~.;W 4''1rt~ frt-1 A~: r~ X17 t~,y .,11 t0 ABM Q~7F-V A Dd b~4 F Y 4 ~r Ml~` r,' q, i~ O toV:'t , O CN//. . kr N00°148:1;'1311 (12.1'2'' ^ 1 M. ' N ft m O N . O F • I 'ta' cv .O • V D M, :U . . N . co = m } Vj: 3 II l t~`~ t i, „ e ' N nYJI(~6i~ . ' , ~ ~ ,'''tY,'~ T.':' -n . ~ • (p ' ~ rt u 3~ o yr Ifr. II y I .i ~Cb%t~a' o b rt rt: CJ A fD v s cl~ -0 Cr ' 9 Cr N N to I w 1 yr ' ' z " A N~ i A~ 3r i(b 'A 4m (A G F . w r• Co . ta+ 4- a i .5t rt iJ~ ..J : in CJ N O i'Y• N O N 'o N H W co 0 1_~y u cn O ~p ti r V R'ruq 3 C ►ti Z b. A IC IC r 1, • N Unpla,tted Lands °f 3.ur t i4i r r fo51 N. F± h ~r~'t 3I4: 501 308.50 Wi'``t+;.G]•', Z N 66 OOI m co v r 7 r ~ t4 r ~ N1°9r(L~~ t~. t Lt4e,i t t a~TM 1h"+f+, ~'rY [T1w 5 r ~ C~ i i I i.,, ~ I' r C.:1 t1'~Z At 11~k ~dY t 1 ~ ~ri t"• ~ i M W ~ x t~ .~ti ~ `~7:+t° 'BRA 'off ~ ° a ~ ,a {Qr / j " 'N ,cb o ti °r, r ' • C> tz~dd 6 3wnlOn % i Y I `//r 1 w • awpS BUTddvw pup buTAaAans u.T ~q-oao . • qS 3.9_._. Aqunoo auq ;o 9oupuTp20 UOTSTnTpgnS puVq aqq pup sagngvqS uTSUOOSTM auk: ;0 VE'gEZ a agdpgo ;O SUOTSTnoad quaaano 9u4 u4TM paTTdwoo ATTn3 anpu I 4puq pagTaosap pup paAaAans Aavpunoq aOT294x9 9u4 3o aTpOs off. UOTgpquasaadaa pauOTsuawtp AT409aaOO p ST dpW AaAanS p9T;T4a90 STU4 qpu;, A3T4290 osTp I i •pzooaa 30 s4u9w9sp9 TTp oq goaCqns sT Taoaed ~ pagT.zOSap anoqV I 'buTuuTbaq 3o 4uTod ac;T oq g993 9t • ~LZ '4pTd pips 30 9 4OZ 30 auTT ATa94s9M auk. buoTp '.M„00 , 8tOETN 90u9144 !499; 85' LL£ 'L 4071 .pzps 3w auTT ATaag4aOu 9u4 buoTp 'S„00,ZVoT8N 90ua1474 WSZZ 'L 407 pTps 3o auTT ATz94s9M auk pup an-no pips ;O.O.zp au4 buoTp 'ATx94s9m44aou 80u9u4 :49a3 LL'9TZ seanspaw pup.M„LT,TEOTM savaq paouo asouM '„bE,9ZoSS sa~znspaw aTbup Tva4uaO asouM 'ATaegsamgqnos 'anpouoo an.zno snTpva goo; 00'EEZ p ;o axngQAano ;o 4UTod atq oq q993 OE'OLT '4pTd pips ;0 L 407 3o auzT 4s9M aul buoTp 114„00,8VoETN-90u9u4 :4993 00'99 'Avm-;o-414bTa pzps 'buoTp '2„00,ZTo9LN 9OU944 ! (anT.za Ni0pV9N) ppo2 UM04 ;0 ApM-;O-'gbT:Z AT.zau4.aou pips 04 4993 OE'OLT '8 4071 pTps ;'o 9uTT°----4spa 9144 StrOTp 'a,,00,8VoETS 9OU9,744 :A0u8buv4 3o qutod eq-4 o-4.-4;99j.: 00'TZZ '8 4071 pTps 30 auTT ATz94spatP:rOu atjq pup aAano pips ;0 022 9M4 buoTp 'AT.zagspaygnos aouauq !q9a; ZZ'SOZ seanspaw pup S„TV,ZVoTSS sspaq paogO asouM '„ZZ,6boSL seanspaui aTbup Traquao asouM 'AT -aagsemT4gnos anpouoo an.zno snTpra qoo; 00' L9T p ;o a.znq n.znb 30- quTod eq-4- 04 488; LS`EET '8 407 pTvs ;o auTT t[420u 9u4 buoTp 'S„ZZ,LEo68S aOuau+ '4VTd pTps ;0 8 40Z 3O ,zau.zOO MN 9u4 off. 499; OS'VLE 'S,IET,8To00S 90u9t-4 ~993 80 TZZT ' uOT4Oas p.vs 3O 8UT 1 PT vs b/T 4S9M-.,sp9 auk buoTp '2„ZZ,L£o68S aouauq 149a; 0Z'858 'auTT 4saM pzps buoTp 'M„bZ,8To00N aou9144 !UoTgoas pTps 3o NaS 9u4 3o auTT 4s8M 9144 04 4993 TO'909 'M„ZZ,LEo68N aouau-4 :-4993 ZT'ZTV '4vTd pTps 3o TT 407 3o auTT TsaM 9u4 buoTp 'M„ET,8To00N a0U9u4 !4a93 £0'99 'ApM-30-q.ubTl pTps buoTp '2,,00 100098N a3u9u4 :(anTzQ Moppaw) ppoa uMOq aut ;0 ApM-3o-414bTa ATzau42ou aut 04, -49a3 98'~TZ 'ZT '4071 pTps 3O auTT 4s99 aux. buoTp 'S„ET,8To00S aouauP :4993 00'0vb 'ZT 4071 PTA's 30 auTT g4aOu au'. buoTp 'a„ZZ,LEo68S 90u9144 :sMOppaW u,bTH 3O 4v Td 9u4 30 ZT 4OZ 3O .zauaOO MN 9u4 04 4993 OZ-8901 'uOT409s pTps 30 °SS auk. 3o i auTT -4s9M auk. buoTp '2„VZ,8To00S 90uau4 "4993 8Z'96LT 'auTT ~/T 4saM-'4spa pTps buoTp 'M„ZZILE068N buTnuTq.uoO a0uau4 :uoT~dTz0sap sT~;=~ 3O buTuurbaq j ;o -UTod aq-4 oq g9a3.V91806 'uOT409s pTps ;o auzT V/T 4s9M-4s99 aux. buoTp 'M„ZZ,LE068'N 90u9uP :.9Z UOT409S pzps 30 .19uaOO,h3 ate'. -4p buTOUawwOO SMOTTO3 sp p9gT.'0s9p aegq.zn; : uTSUOOSTM 'A4unOO XtOao • 4s 'uospng ;o.uMos, 'M6TH 'N6ZS '9Z UOT409S uT TTp 'hHS 9u4 3O ESN auq ;o -4.zpd uT pup haS 9q4 ;0 hMN •atj ;o ~.zpd uT paqpaoT pupT ;o TaO~pd V : SMOTTO; sp pagTabsap ST paddpw pup paAan.zns Tao--pd pupT au4 ;o Aavpunoq aoTaagxa aq4 gpuq : dpw AaAanS p9T;T4aa0 sTgq Aq paguasaadaa ST 14DTgm Tao.zvd puaT.._auq padd-ew pup pagT-OSap 'paAan.zns anpq I 'uoxvM uaTO 3o UOT4092Tp auq Aq ~pU'4 WARRANTY DEED To Husband and Wife as $91nt Tenants 'FORM3"(Revised) - f ~ a.c nnunco M *A0t[ '256764 i his IndenUre, Made this (~uy of .'&xtktayr in the year 1 ` :'of our Lord, one thousand -nine hundred and..:ft7t n~.... .-.......between Hgdwig••Wint}olff„- a/k(a.,. 1 Windolff partY........ of the first part, jt 1 Glenn Waxon and V c 1 M -Waxon husba a d wife and...... . .y--.4.. ,............_??4t....3~......................................................... . . , of H.ltda4E1:,...W;tS.C4it0xJJl.._....................................... husband and wife, as joint tenants, parties of the second {fart. r I WitAesseth, That the said party. :-ot . the first part.- for and in consideration of the sum of Six' Thousand..($kt' . to.....lier.:.........in hand paid by the said parties of the second part, the' receipt whereof is hereby confessed and acknowledged, ha..V.c..... given, granted, bargained,' sold, remised, released, aliened, conveyed anti confirmed, and by these presents do .......:..give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of iI the second part, as joint tenants, the following described real estate, situated in the County of . :.:..at.....Croix and State of Wisconsin, to-wit: The North One Half (N1/2) of the Southeast Quarter (SE1/4), the Southwest Quarter (SW 1/4) of the Southeast Quarter (SE1/4), approximately .54 acres of land located in the northwest corner of the Southeast Quarter (SEI/4) of the Southeast Quarter (SEI/4) described as follows: Commencing at the northwest corner of said Southeast Quarter (SEI/4) of the Southeast Quarter (SE1/4), thence East along the North line of said Southeast. Quarter (SE 1/4) of the Southeast Quarter (SEI/4) a distance of 76 feet; thence South and para- lell to the West line of said Southeast Quarter (SEI/4) of the Southeast Quar .,ter (SE1/4) a distance of 312 feet; thence West and parallel to the North line of said Southeast Quarter (SEI/4) of the Southeast Quarter (SEI/4) a distance ~ of 76 feet; thence North along the West line of said Southeast Quarter (SEI/4) of the Southeast Quarter (SEI/4) a distance of 312 feet to the point of begin- ping; all of the land described above being in Section Twenty-six (26), Town- ii y ship Twenty-nine (29) North, Range Nineteen (19) West. Also, the Northwest Quarter (NW1/4) of the Northeast Quarter (NEl/4) and all that portion of the Northeast Quarter (NE1/4) of the Northeast Quarter ~i (NE1/4) lying West of the re-located town road, all of the above being in Section Thirty-five (35),. Township Twenty-nine (29) North, Range Nineteen i (19) West. dir.. . iiledwig Wfadolff, a/k/a Hattie Windolff And the ss~id i, part-y ...---of the first part, ..heirs for...:: , her•,,, , , executors. and administrators, do-es :L.covenant, grant, bargain, and agree to and with the said parties of the second past, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing anal delivery of these presents ....A X1P is,.....•.._.,..- ..........well seized of the premise, above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that .I the same are free and clear frourall incumbrances whatever, . i j and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part, as joint tenants, his or her heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof,....... Bhe .............will forever WARRANT AND DEFEND. In Witness Whereof, the said part y.... ...of the first hart ha hereunto set.... her . ---hand......and , seal this 2nd..... day of 44144;Y A. D., 19..59 Signed, Sealed and Delivered in Presence of ` CQ~i~II.C .e t -.(sr,AL) ' Hed.-. W indolff ? cep. . ..........................(SEAL) i John W. Davison r.tau.*' .........(SEAL) I Kathleen Tobias i STATE OF WISCONSIN, Ss. . ple.rc.c ...........County. I Personally came before me, this day oL'...J.an=r-K ...-...2nd A. D., 19.59....., I the above named ..Hgdwig_Windolff, a/k/a Hattie Windolff . . z.. to me known to be the person.....who executed the foregoing instrument and ackn wl ged the same -aed A J l71) ~ • nV •'t a-wt THIS INSTRIVAUIT WAS DRAFTED fiy i ;8.,.._......... .4.... WHITE, MVISON & viullE, ATTORNEYS . J T t AT LAW. RIVER FADS, WISCO"SIN _ John W. Dab186P Notary Public,...... Fivx. 614M. is `n1y Commission e%xpirea.. .Pal.. (Section 59.51 (1) of the Wisconsin statutes provides that all Instruments to be recot ad shall have plainly printed or'tyltllii~ttafnlfiet>'op"tha names or the arantors, grantees, witnesses and notary) ` j j O b 'U M V1 i s d .0