HomeMy WebLinkAbout040-1160-10-100
STC - 10 4 t/
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# G~°ht LOT
SECTION _T -,9F N-Ra,:~P W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
u
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h
n t5
196 0
fs
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a!I' ~,r
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: e!91 Liquid Capacity:
_/tea ~
Setback from: Well SAO House
Other
Pump: Manufacturer Model#
Size
Float seperation Gallons/cycle:
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width•.~ Length
Number of trenches ~
Distance & Direction to nearest prop, line:
Setback from: well:.,_t;-e' ~ House Other
ELEVATIONS
Building Sewer ST Inlet.
ST outlet
PC inlet PC bottom
Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: `jam
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Au man Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
PebrW tI XIN E] City El Village Town of: State Plan No.: rrROV CST BIV Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septicn GCLS Benchmark o?, S19
Dosi ?s G
Aeration Bldg. Sewer
Ing St/kA Inlet .36 ~ IP 1
TANK SETBACK INFORMATION St/A4t' Outlet 3 78 ,
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic -1 A NA Dt Bottom
Dosl ntj NA Header / IOU=-
Aeration Dist. Pipe
Hol g Bot. System 7b~
PUMP / SIPHON INFORMATION Final Grade
Ma Demand
Model Number M
TDH Lift L Iction Syestem TDH Ft
Forcemain ength Dia. FFii Dist.Towell
SOI SORPTION SYSTEM
BED/TRENCH Width 5 7 Length 7 No. Of Tenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS o<
LEACHING anu r:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type O itc CHAMB - Model Number:
System: *_-e OR UfMT
DISTRIBUTION SYSTEM
Header /Mwmi:dd i, Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Dia. Spacing
Length Dia Length V J_/
SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems Only
Depth Over - Depth Over xx Depth Of xx Seeded/ Sodded xx Mulche
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ` n
LOCA'T'ION; TROY, 25.28.20W, SE, NE, SKYLAN
o Oh D D VE '10~
Plan revision required? ❑ Yes 2-19-0
Use other side for additional information. l~
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System-
.
In accord with ILHR 83.05 201 E. Washington Ave
, 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 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit
The information you provide may be used by other government agency programs ❑ Checlal/is pNur6vious 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
u 5"t-1 1/4 jeF 1/4, S S T o? , N, Ra E (or)N
Property Owner's Mailing Address Lot Number Block Number
s f l m
City, State Zip Code Phone Number Subdivision Name or CSM Number ,vGa/ CS /Yl 4(7,Vf,(
G v ( ) II ewwi,
II. -TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
C] Village
Public 1 or 2 Family Dwelling -No. of bedrooms YVJownOF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
t? q®- tl6o - ~Q-ram
1 E] 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. PNew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
------System System Tank Only Existing System Existing System
B) Q 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 410 Holding Tank
12 [j§ 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
A-mo- (`Ob plani _40W) ro 3 Feet 9r9: , Feet
VII. TANK Capacity Site
in gallons Total # Of Prefab. Fiber- Plastic
INFORMATION Exper.
Gallons Tanks Manufacturer ' s Name Concrete Con- Steel glass App-
New Existing structed
Tanks Tanks
Septic Tank or'Holding Tank D~ El El El Lift Pump Tank /Siphon Chamber ❑ 1 r-.! ❑ ❑ ❑ 11
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/ PRSW No.: T,, ess Phone Number:
Plumber's Address (Street, City, State, Zip Code):
~G
1,07,6 SSG a 10A) 41011
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa?n tary Permit Fee (Includes Groundwater Date Issue Issuing Age Signature (No Sta p
Approved ❑ Owner Given Initial Surcharge Fee) h2r
5-1,011 17P
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) _ DISTRIBUTION: Original to County, One copy To: Safety & Ruildings 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.
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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
,INDUSTRY; DIVISION
LABOR BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: ITOWNSHIP/4111 LOT NO.:BLK. N(.: S DIVISION NAME:
U 1/4 Nk '/a 25 /T2% N/RZ6E (or) W "TROY Z CS
C UNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
Cf26N AN)EL4L6#►o4 ~t1gnTSOIV /4 / J-mod NLr RivIre A tnj) 5442.2.
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TE TS:
Residence UNIX - gNew ❑Replace I s - /oJ IQQI PTi2,19 1
J4) LS Z G ~y~ -
RATING: S= Site suitable for system U= Site unsuitable for syst m 11C 2,- K4AQV-
C 1VVENTIONAL: M ~.❑u INGNS P❑URE:SS AlTANK:IRF_COMM
0QVSNT/QN/QL:(}~tional) ?ArW_-l*5
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
tV4
under s. ILHR 83.09(5)(b), indicate: c./vJJ Floodplain, indicate Floodplain elevation:
. PROFILE DESCRIPTIONS
c
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHAM ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- Zf q?.
~Z 16"&4-15 614,4L 19"R 7AI-Ska Ms
B- Z q56 9_7.%_7 pM Lr > 9. Sa /Zr&_'S l'-,e 24 "$ftNSL 80"LT8Qv Al:S
B- .-53 3-L if o4r > ?.S-3 ,A cSOS / : 8 ,aSL 2?'*AA191S T MOT Le 141927" ~
B- 4 A-7 Notai >8.&'7 s"$LSc-rs 23` Slt /2"9[1Wfi'vS44 MS
B_ 9 14"&-S M 20"&,o SQL IS" R& a, MS
$AZ .04 ~IaNt 8AZ 4VC- MGT e1"r&1kFx4er 45[TBa), Ms
B- b ")AZ 101.8 MJo E > 9.4-a /1'' sg S M ` NSL 68 MS
e-f-r PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER V40Is0W AFTER SW LLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER1003 PER INCH
P_ Z x.10 LIC 97.46 > > > <3
P- S. v Eta 161-76 >2 > >2.
P-
P I.W T1 -T ~C
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 elevati n reference points and show their tion on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 4'S.86
a
3
E E
r
t
< F
l
N
3
P
3
LpTI~N z /100 b
INSTRUCTIONS FOR COMPLETING . 1 115 - SBD - 6595
To tar; a comr)k m(.1 accurate soil test, your report MUS't iW'JUde:
1. Compie iption;
2. The use sec i<: List cleady indir~te whether this is a residence or eomntert;ial project;
1 MAXIMUM rWMber of bedroorns or commercial use planned;
4. Is -this a new or replacement system;
5. Complete the suitabi.ity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here fo€writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scaie is preferred. A
separate sheet may be used if desired;
S, Make sure your benchmark and vertical elevation reference point. are clearly shaver, and are permanent;
9. Complete all appropiiat:e boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10. If the intorrnation (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible, copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 36 DAYS OF COMPLETION.
ABBREVIATION FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st: Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Sandstone
3") LS - Limestone
yr' gavel (under '"s - Sa?)d I Hlgh Groundwater
es - Goa se; Sand Pi- c Peicolaiioin Rate
med s Medium Sand affil Well
fs - r a.acl I idc, Builc'nq
is y wand > Greater Trlan
'sl - idy Loam ~ Less Than
i., ; Far, - Brovvn
sil - arr€ Bi Black
Vµ Gy Gray
a, y Loan) y - Yellow
sc, ly 0a y ' R Red
sici :y Clay Loa: "root Mottles
sc Sandy Clay w/ - with
sic - Silty Clay fff _ few, fine, fait-it
kc - Clay cc common, coarse
pt Peat nrm - Many, mediUrTa
€fa - Muck cl cfistinc;t
p prorn;
~I
HWL - High,
Six genera! soil tesxtures surfac titer
for liquid waste disposal BM Bench Mark
VRP Vertical Reference point.
c9 ~
SEP 271991 ~
JAMES O'(%ONNEU.
W1s owe
4 74018 . aLa
CEP T I E.I ED SUP VE Y MA P
Located in the SE1/4 of the NE1/4 of Section 25, T28N, R20W, Town of
Troy, being Lot 2 of that Certified Survey Map recorded in Volume 7,
Page 1992, St. Croix County, Wisconsin.
NE COR.
Owned by: SEC. 25
Daniel & Lenore I I
Knudtson I I PLAIN__VIE_W ACRE_S_
_ m
169 Delander Drive LO-i- 4 r- ti
River Falls, Wi. I ( S 87° 07' 46"E
425-7491 355.82)
S 87'038281AE 355.90•
t66. 0'
APPROVED i I
SEP 2 7 1991 1 (LOT 7
Sr CROIX COUMY I Septic 111,420 Square Feet
OOM % PARKS PLAIW4IIi1 I vent
AND2bNNdG COAMA~fEE 1 (2.56 Acres)
-1 I iv \
1 Septic tank - W
W1 I a z
01 I I HOUSE m z
QI m o F-
CLI I Q W w
LO z_ o
(D J GARAGE Z (f)
1 CY) v O R _j iI
J, 1 iA -Q 0) ZI
co LO
O; I w; W 3
N QI
-4 W
N 01 1 I XI `T s
a r ~i C1 01 N 88'40'05"W 3.88'
55
L 01
W N c1 1 1~ • WI
~o 3 VI I QI O
W I zi z ILO T 8 o al
100,432 Square Feet _J1
W a 1 _J1 QI1 (2.31 Acres) N a'I
W~c I wj ° N ~I
rn 1
z W V) I co
W z 1 N Ln
LL N
W W Q I 07
0 1L W I
E0 o C I Centerline of road
w
W z W I as traveled.
N 87'27'06"W 355.96'
901.90' O
65.96' ! 355.78)
- - - 355_97'
1323.83'... - - -
EAST - WEST /e o...~. _
S'I'C-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER
~'~.7~~ .~~~elYl~
MAILING ADDRESS Clae-
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
a
CITY/STATE /(S ca `J
PROPERTY LOCATION 1/4, WA:r. 1/4, Section 1 T a N-R ?D W
TOWN OF %y ST. CROIX COUNTY, WI
SUBDIVISION , LOT NUMBER
CERTIFIED SURVEY MAI'VOLUME-4. PAGE W:t 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 expirati i date.
SIGNED:
DATE: 2 7 ,A AIL- q/6
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hodson, 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 jz„
Location of property-5 /r = 1/4, Section T_aZEN-R_,;Z,:~_W
Township TI~a Mailingaddress ~S-11 /.6 / oc
Address of site
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel,
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes k_No
Volume /170 and Page Number h 12 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'y / 79 ;s , 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.
S Tatur of Applicant CO-A plicant
Date of Signature Date of ignature
+ i 554 .'793 STATE BAR OF \161SCIONSIN FORM 2 - 1982
WARP-%.NTY DEED -
DOCUMENT NO.
VOL 11 iOPa,_ ILU9 v
ri-f., t
SE .CROIX,
# _Daniel Knudtson and Lenore Knudtscn, husband I a 1996
and wife, APR
8:00 A. ,1 _
Rolf L Onjukka and Dori L. Onjukka,
I, conveys and warrants to %
r, I husband and wife, as survivorship marital property, t
THIS SPACE RESERVED FOR RECORDING DATA _
NAME AND RETURN ADDRESS/~ ,R
St. Croix County,
x the following described real estate in
State of Wisconsin:
4 I
40-1160-t0
PARCEL IDENTIFICATION NUMBER
Part of SE 1/4 of NE 1/4 of Section 25, Township 28 North,
Range 20 West, St. Croix County, Wisconsin described as
follows: Lot 8 of Certified Survey teap filed September 27,
1991 in Volume "9", Page 2404, as Doc-=ent Number 474018.
TRA FE
t A
This is not homestead property r
(is) (is not)
Exception to warranties:
Subject to easements, reservations and restrictions of record.
9
Dated this ST// day of A ril A.D., 19 96
£ r~. 'x
(SEAL) (SEAL)
DANIEL KNUDT ON
(SEAL)
(SEAL)
• LENORE KNUDTSON
i
AUTHENTICATION ` ,.-KNOWLEDGMENT
z
State of Wisconsin,
Signature(s) ss.
_ St. Croix Count .
authenticated this day of 'ejtw~ Personally came before me thisT day of
A prit 19 96 , the above named
Daniel Knudtson and Lenore Knudtson.
TITLE: MEMBER STATE BAR OF WISCONI ft S ~O ~G
(if not, ~Ni s o "
authorized by §706.06, Wis. Slats.) Q•. J..rf'~~~`•~ to me known to be the person s who executed the foregoing
' 0\ instrume d acknowledge the same. ,
•
2 THIS INSTRUMENT WAS DRAFTED BY peM~$t3~E
STEPHEN J. DUNLAP
, , " i a Cmmw ~%Vi,