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HomeMy WebLinkAbout042-1078-60-120 00 0 6q N O b Oq ~ I O Q` U ti C O N © L ~ c ~ o O LO x in o ° l~ Y 'n U o a C N a) i 7 m LL C <0 O O> a ° I Cl) w z a 00 z o v z m z d m o I O zv' c fn t- c CD m N E a w N a ~.W N (n U) I .N 2 0 c C O 0 Z H Z Z N 04 c O d C C LO V V E > N N ~ co O d CL An w C° O ° V O O a °o °o N N IL U) th~v a~ 0 0 0 ZOO Mrv a a a I Q> (~1 co co N J U o rn rn > 00 7 :7 O a) 0 o O O N 1 O 7 n m I (D 0 _ N N ~V N Cy ° C U) C p E O d (0 3 0 v, u, o rn o M N C C C: u IL O N 11 :2 12 -0 7 CO O W C C m m Q) C2 4) M 0 O O C i M 04 V 01 N C~ can c9 m U 0 N Q N O N Cn r i ~J dt n. Ln CL (D CL Z E i c c (D t A V i ' in 0 a 0 ~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER _T6 i ADDRESS SUBDIVISION / CSM LOT ~ SECTION__a?_~ T_';Z_~ N-R_L(f_W, Town of A/ A / .L~/+ ~ ~ rte{ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 79 Q ,qo f l /O0 GAt, -S 7, a'Sk5o % eP~iv'cy~s' so. et- INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provides ? ; .4=f BENCHMARK: V p /RDAs A(A 6 9 4 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: .e ~ Liquid Capacity: ~apb Setback from: WellHouse Other NO CUEC"L ye--T, Manufacturer Model Size Float seperation Gallon Alarm :SOIL ABSORPTION SYSTEM Width: Length , Number of trenches Distance & Direction to nearest prop. line- Al Setback from: well: House-,21- Other AO wEL~ ~~T ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet_ " PC bottom - - A14 Pump Off , Header/Manifold _ Bottom of system C5 Existing Grade Final grade. Q DATE OF INSTALLATION • ! Q PLUMBER ON JOB: LICENSE NUMBER: 3 INSPECTOR: 3/93:jt SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUN ~/+.~ueawnn~w,es STAT SANITARY PER LIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. I"J cOlf revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ' UIY4 %4, S TX9 , N, R 8 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # OTC` VE 1 NA CITY, STATE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER B 0 ] 11. TYPE OF BUILDING: (Check one) ❑ State Owned 0 CITTLYi4GE NEAREST ROAD 8a7.4 v~ ❑ Public ~1 or 2 Fam. Dwelling-# of bedrooms AR N Ill. BUILDING USE: (If building type is public, check all that apply) G O r ~0 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 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 in line A. Check line B if applicable) A) 1. DC New 2.E1 Replacement 3. ❑ Replacement of 411 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) El A Sanitary Permit was previously issued. Permit # Z Cab A? a 3 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 N Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 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 ® Jr 6-00 12 _9Xr. 3 Feet 3Pf Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Q~ Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb s ignature: (No Stamps MP P W No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 6 t IX. COUNTY/DEPARTMENT USE ONLY ED Disapproved Sanitary Permit Fee uses Groundwater Date Issued Issuing Agent Sin a (No Stampfg) Approved ❑ Owner Given Initial Surcharge Fee) Advers Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: 61 VC/ SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber 1 -Ab INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the tirnc- C rerErv-31 an•i new criteria in the Wisconsin Administrative Code will be appiicable. 3. All revisions to t'lis permit must be approved by the permit .;suing authority 4. Changes in ownership or plumber requires a Sanitary Permit ransfe•/Ren• wai Forrrr '`i 639:)) to be submitted to the county prior. to installation. a' c°rinseti ' Onsite sew,fie systems be proper), rnainfairteo. The . tar=k(s) n; t be J. pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your oval code a(t-inistrator or the-- State of Wisconsin, §afety & Buildings Division, 608-266-3816. To be complete and accurate this sanitary.permit application must include, Al 1. Property owner's name and mailing address. Provide the legal description and parcel tax rum er(s) of where the system is to be installed. IL Type of building -being served. C11eck oniy.on4a and complete # of bedrooms .f 1 or 2 I=~:rmih Dwelling. III. Building use. If building type is Public, check all appropriate boxes that appl IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacenier,t recor nection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorp 'cn system information. Provide all information requested in ##1 -7 VII. Tank 1;ofo.;-ration. Fill in the capacity urf every new EM/or exi, silk, i -,t t f )gun _ r of tanks and i1nanufacturer's name. Indwate prefab or site cons,, w, J and lank.. rr.t:. ~ j,; =te for all scp •c cL.;np/siphon and holding tanks o- Iihis system. Cf,eck • eriment.i '.ankt. received exoerrrr.er;jai product approval from DI►,,R Vlll. Responsibility statement installing plum/-6r is to fil l in name 't--se no!i be, wltn E 3ie pr e,ix (e.g. MP, etc.), address and phone number. Pidmiber must sign ap, :1cation form IX. County/Department Use Only. X. County/Dep;-_rt,ment Use Ortiy. ^on t_,i..,ns and spec &f ations not _,.malier than 8Y, t" inches m;.; r t c,o!-rity. The o inc'ude "he fo `iw; .lg: A) pl.. '.an, drawn tu, rir with c.1;:-. } i :X:"11 -i of septic tz other' r,. t. tal'•I AAVt. . w ;E`:. ,;Fitt ! >erVlCe; St~erlrll< a.."• iah.F?ti f7Llr+.+ -,!.j 'ion tan"4, 1-1 ll`L10n t " . o!; att-t, w •±~1!~i'n areas. a~~ . - 'c'n7~'E-••. SySte+Tl r ;sic location of tiul~~ iding 74 !lQ(1 ..,'kd verlica C) complete specificatiof;s f-Jr pumps and c:o::iro;s; dose voiume; elevation c.tfe iun Icss; pump performance curve; purrip model and pump manufacturer; D) cross section of the soil ,gib=,ci,ption system, if. required by the county; E 3est data on a`1T5 form; and F) all siZingi infor,aiation: - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 4 dry include=d the creation of surd i~:..a} f, i ~rur-1 b"r c v re;lll-ated practices which carp ffi ct groundwatec The r:ronies collected through these surcharges < r s€ ° r lc ; c; d ;a'° q r water contamination investigations and establishment tit starv)aros. SBD-6398 (R.11/88) 1 = ~0' Y" /RUC ~nrT f !!►~1,0, t.2 y., l411,PWvve" c ove& ZY 5r a ~r .J ® Tf1 57-, o PRoPostr cueL c ° ~ousE bl f uv J Evc q~ s clla * g. ,4 CT s ! Tc= N Is v, ~l '1 f$a_W-1 - t_-'i.Rv. qS.%I' oti Lu T 1 LuT ~~1 x 'Ly w oeU SThk.~ w! t_c~•nl 9?i 4w.a3• ~eh -~t.~t1V.gt.9V' oti 18.97.61 e►1- L=L~V. 96.96 oti \'~~Z"WUOp S111Ytt oea lN>< Z." t" 1 Rav P, pL, W / L t~'ll) t~~op0 SMR~ W /1.11111 WT y Lur3 Wisconsit4epartment of Industry, PRIVATE SEWAGE SYSTEM County: .Labor and Human Relations + INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) 5anita1 68623 Permit Holder's ame: p City Village Town o : State Plan ID No.: ANDERSON, JOHN WARREN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600325 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 6, 96' Dosing Aeration Bldg. Sewer 2- 0 IS 7 ' Holding St/ Ht Inlet _ 55 4$36 TANK SETBACK INFORMATION St/ Ht Outlet 79 / Vent TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet Septic Rio /770 ,av NA Dt Bottom Dosing NA Header / Man. %36 c/F,ss Aeration NA Dist. Pipe S F .SG ' Holding Bot. System 8 ~s q s, 46 ~ 95.3 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain Length Dia. f 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 Manufacturer: SETBACK INFORMATION Type of CHAMBER Model Number: System: /D a5 a -v~it- OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) 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 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: WARREN.29.29.18W, NW, NE, 80TH AVE s Za h; -n, Plan revision required? 65/Yes ❑ No QI Use other side for additional information. b SBD-6710 (R 05/91) Date n ctor's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH ~ r SANITARY PERMIT NUMBER: F stems Bureau ofB ilding WaterlSy 201 E P.O. ox shington Ave. SANITARY PERMIT APPLICATION o 796 53707 7969 Code In accord with ILHR 83-05, - Adm- County / • /r]1 on paper not less for the system, ~/1 v State Sanitary Permt N. m~ 3 ber to the county copy only) (o/ (O h complete plans ( plication previous aPPlication • an 11 inches in size. this ap Check than 8 112 x for completing if revision to • See reverse side for InStCUCt10n5 agency programs State Plan I.D.Number provide may be used by other government The information you pT10N r N, R i8 E (or~ Law, s. 1 5.()A (1) PLEASE PRINT ALL INFORMproperty Location T (Privacy W 114 r~ 114,S Z INFORMATION - Block Number I, ION APPLICAT Lot Number . A lip, III Ili ir Property Owner Name Subdivision Name or CSM Number Property Owner's Mailing Address phone Number Nearest Road /0 ~0 7 Zip code ( ) 0 ityage 0 CIt , State State owned ❑ vill 0 ~ ~S check one) ❑ Town OF OF BUILD No. of bedrooms Parcel Tax Number(s) O Dwellin _/0 f II, TYPE oNGanvil ing Public type is Public, check all that apply) © y BUILDING USE- (If build 0 ❑ Outdoor Recreational Facility Home 11 ❑ Restaurant/ Bar / Dining 1 ❑ Apartment /Condo (i ❑ Medical Facility I Nursinpairs 12 ❑ Service Station I Car Wash 2 ❑ Assembly Hall 7 C1 Merchandise: Sales/ Rep 13 ❑ Other: specify 3 ❑ Campground 8 ❑ Mobile Home Park 4 ❑ Church / school 9 ❑ office/ Factory if applicable) Repair of an ❑ Hotel / Motel Check box online B, S Existing _Y one box on line A. 4 ❑ Reconnection of - -S s_tem_ Syste----------- Check only Replacement of Existi ng m- 5 V. TYPE OF PERMIT: ( 3 0 n I----- 1. New 2 ❑ system Replacement -------Tank-- O ly Date Issued A) System previously issued. Permit Number ether B) [3 A Sanitary Permit was p one) Experimental 410 Holding Tank F SYSTEM: (Check only V. TYPE O Pressurized Distribution 30 ❑ Specify Type 42 ❑ Pit Privy 43 ❑ Vault Privy Non-Pressurized Distribution 210 Mound 22 ❑ in-Ground Pressure 11 ❑ Seepage Bed 12 %Seepage Trench 13 ❑ Seepage Pit System Elev. 7. Final Gray In-Fill S. Perc. Rate 6 Sy Elevation 14 ❑ System- TION: Rate Area 4. Loading ft_) (Min.linch) O Feet /AO'4 FE VI. ABSORPTION SYSTEM INFORM 3 Absorp. ft) (Galslday/sq. 2. Absorp- ft) Proposed (sq 7 E 1. Gallons Per Day Required (sq- 3.~ site Fiber- plastic prefab. con_ Steel glass Y~o Capacity Total # of . Manufacturer's Name concrete strutted it. TANK in gallons Gallons Tanks ❑ ❑ ❑ INFORMATION New E)(istin _ ❑ ❑ ❑ ❑ Tanks Tanks ❑ /ODU Septic Tank or Holding Tank plans. on the attached STATEMEN Business Phone Number: Oft Pump Tank /siphon Chamber stem shown VIII. RESPO NSIBILITY onsibility for installation of the oll s MwIMpRSW No. / ned, assume resp r,ssignature : (NoSta 1, the undersig Plu Plumber's Name: (Print) _ t C Code): I n9 Agent Signature (No Stamp Street, City, State, ZIP plumber's Add ress ( ONLY ate sue ARTMENT USE Fee pncludeaGroundwater IX. COUNTY I D sanitarypermit Surcharge Fee) ❑ Disapproved CUc7La~O ❑ Owner Given Initial Approved Adverse Determinat ion pROVAL 1 REASONS FOR DISAPPROVAL: X. CONDITIONS OF AP Owner, Plummer on inal to county, One urPY T°: Safety & Buildings Dive ion. ra1rRIBUT10N'. 9 INSTRUCTIONS 1. A sanitary permit is valid for two 2- Your sanitary (2) Years. Wisconsin y permit maybe renew Administrative Code will be applic the expiration date, 3. All revisions to this Pplicable. and at a time of renewal any permit must be Y new criteria it, 4. Changes in ownership approved by the permit issuin or P on lumber requires a SanitarY P g authority county prior to installati er 5- Onsite sewage systems mit Transfer/ Renewal Form necessar must be (SBD-6399) to be submitted to the y, Usually every 2 to 3 properly maintained. These 6. If you have Years. septic tank(s) must be Wisconsin questions concerning Pumped by a licensed Safety and Buildin Y°sionsitesewa pumperwheflever Buildings Divison, 608-266_ sewage system, contact your local code administrator To be complete an or the State of d accurate this sanitary permit application must include: I- Property owner's name and mailin system is to be installed. g address. Provide the le II. Type of buildin gal description and parcel tax number (s) being served. Check only one and complete building t plete # of bedrooms if 1 IV. T ype is public, check all a or 2 Famil p ype of permit Check onl Ppropriate boxes that apply. Y welling. only one on line A. Complete line B if V. Type of system. Check a permit is for tank replaceme VI. Absorption system information. pending on system t nt, reconnection Provide all information requested e or repair- VII. Tank information- Fill in the capacity of ever bers 1 throw manufacturer's name, indicate prefab or site constructed for numbers y new/or existin gh u- holdin tanks for this system: Check experimental approva 9 tank, list the total ucted and tank material. gallons, numberse nks and a/1 of ta holding l only if tanks rece ved experimental Complete for product VIII. Responsibility statement. Installing plumber is to fill in name, approval from phone number. Plumber IX. County/ Department Use Onl must sign application formense number with appropriate X- Count y' Prefix (e.g. MP, etc.), County/ etc.), y/ Department Use Only. Complete plans and specifications not smaller than 8 1/2x I include the following: A) Plot Ian tank(s) or other treatment specifications drawn to scale or with I inches complete county. tanks; distribution the The dimensions, location of holding and vertical soil ab absorption systems; ns/water elevation differences; friction loss; PUMP systems; replacement mstem areas service tank s ytem areas; streams and lakes; pum)'P or septic points; C) completes and the location of the building siphon absorption system if re P Performance curve; peodelations for of the soil r quired by the count Pump model and pumps and controls; dose g served; y% E) soil testdata on a 115Pformp manufacturer; p volume , and F) all sizing ) cross section - g information. 33 Wisconsin Act 410 included the cre GROUNDWATER SURCHARGE °ct groundwater. anon of surcharges (fees) for a number of regulated practices which can es ablishment of s a dards_ monies collected through these surcharges are used for monitoring groundwater contamination investigations r 1 x 2422ox _ a Y' fpUc 1101%f rl- IAIV? G" . s YS~trr ~t ~ ~7,d ~ o _ 5~ - 6 ' 5 g© T# /4vt V 1~ N p~aPas ~ 0 waci- C O pRopase~ ~ Q ~aus~ b O /OD© GAL• q S,7. t3 t - - - 9/1 7 pp /jPo/v pipe v ~ A~T Rc 9~• 9~ © 9P 3y 63 LoT W/ L a T R a3 Go T 6~ _ %cp N/Ra.v /Pt L or U/T•4u>~ivG foR 8 a 1=96 D?ACUf(~~K)~ f3}, /D(o 7 80 Tip ~UE SS !/ALLY t//EW Tie O &E.4 TS Wl . Syo,2 3 cS0 me FR serl a-)/` Yoh ~P2.Sw 320 DEPARTiMEAT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN'DUSTRX, DIVISION P.O. BO HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W 7969 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNS UNICIPALITY: :~rT NO.:BLK. NO.: SUBDIVISION NAME: Nsu3l/ NE 1/ -n /Tz9 N/R )gE (o) w~P_R.`r.~ -L - ~r.,~pus~ csM COUNTY: MAILING ADDRESS: -7(4 O 1) z'" S-r. ST.Cj~1X ~ZOI~RL17 R. S 7NAFZT 1~oB TS L j SKO-6 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: I TESTS: Residence 3 A- O New ❑ Replace l 1- Z6_ 90 N OZL : L/ I F 111- GZiivtivD 2~SSUR~ Sy s-rem L- j,/ Li ')c S Z_' $~D l 5 ) ^ll S RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) QS ❑U ❑S ©U ES ❑U 0S ❑U ❑S EJU ~Z'x Sz' CWU~N'T)Wj~ L C3 En # IbUE S L0T>t?S lull 1I'E1kR1%\ ►IV If Percolation Tests are NOT required DESIGN RATE: If an C L..~S S \ any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ,V PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 918 loz-3 t-uNoL ? 4g s 1~RG~ 3 of 3 B- Z $ 44-~ If B- 3 $D B- C1Cl B- S 100, p 7 $ g B_ PERCOLATION TESTS } EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I PERIOD2 PERIOD PER INCH P- Iv. - P- P- 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. Gtr 6 7 E~1? ~,~T SYSTEM ELEVATION -PA 6,C- 0,F 3 { 3 5 -t cod T 0-op-R1 ~'Z-Z o TH( tvw U u N a0lm hu:a r ` s~ a INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability 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 for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soll Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand < - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point 2 1 v; Q 0 k a bl a r \o\ ~ lpo ~ r~2 , ~ B Z ~►v~T~PL OE-D - E~, A1.o f 014 BLb - eL. q 6. o I N CIS f-v p- s•4 A C 3S ` $'3 f' q 0 L.uT 1 l.oT KZ~ t..ooD STltkk w/ LVA-N 8M fft,,.a7.61 ~ Bh- ~tL~v. x6.96 o~v ~12c~. 83. Bah -~sv. a2,9V' o~i l \ l~0►V 'P~ P~? wood ST'RR~ w/ ~-~~TN w/ L P, TA wT 4 wr3 SOIL DESCRIPTION FORM Attach 50 I Prof o Cd 'o Me On a Su Brats Sheetl gLIENT, EAR IN TE: 8 ' ~z5 SAIL "Sp"PW SYST91 SLOPE, • q °1b PURPOSE: ~V~LV ~E ~R gurlIPTION BY F~RT?-}UR L we-S n-nECT• rCI2~ S Z6, 1970 CU REN LAND US : woo t Sot' Not 42~ 22 DATE: S`r ~K CpUIU TY i LV VEGETATIVE COVER ~I ruC -S - cz w S COUNTY/STATE ,T Z OF PFzopose-b C-9" LOT DESCRIPTION:" 'Pr- OF -Z9, 1.~W-1JL SEsC. Z9►J, R I81v DRATIM, CL SS' 4r**C eTS I U e Llf DRNNJSD p.-1Z L TION: 'Tpl~. II GALLONS-PER S . FT. PER DAY: SENT MATERIAL(S)/DEPTH SOIL SERIES: El~l~'lt~~T S HY! all HORIZON DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS P11 .BOUNDARY REMARKS ;n. :01st Gr Sz• Sh COATINGS ~o~ G I O-l l l~`CR 313 - s I 1S ~k 17► uc S 2 11_zb ~O`C[z y/ - S~ ZT3 rS1'F~ as 3 ?.6-y$ lp~tt~ s/(, s I l~sbk m~i cs 4$-qg ~,S yR Sly - S , O S T11) - ~ o -S l0 31 s I ~'~Sbk my ~S - 1s t~s~k rn I c`" 3 Zg -Vi o s M ~3. vQ1 G 3 -W te`t(~~ f3 - 1S Sbk )1IQ 5S ly _ So \Q-j R y 16 S 0 S 'M l 021 6 o --7 l0`C R- 3 l3 - s ) S ~h yn F!, c S Z-3~ 1o~t(Z y/ - si 1 1 Sbk c S 3o N G S 1 0-10 1~~t1~ 3 13 - s l Z~s~k mu'f+- _ ~S Z 10 - 8 K~-`1 ti y l S o S ^n TRVIENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR HUMAN AND PERCOLATION TESTS (115) MADISON, W1 53707 P.O. BOX 76 HbMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: NW V4 MC- V4 Zq /T?-9N/RisE(o► w~RtzL►~ Z - ~r~pus~ cs~-I COUNTY: MAILING ADDRESS: -7 4 O f) Z`T"Tf ST. S~ . c 1x ~o~R~~ R. S~'EwART 1~o~ TS w svoZ' USE DATES OBSERVATIONS MADE NO. BEDRNZ CO R IAL DESCRIPTION: Residence ®New ❑Replace ROFILE DESCRIPTIONS: PERCOLATION TESTS: 3 N •A- 11 - z6- Qo ►v A. NOS: L/ IF 1N4-G1_0Av>`1D kIX-LESSUR.e SLJS'~ W/LZ')C SZ' $~D 1Z 1~VS~gL, . RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL OLD ING TANK: RECOMMENDED SYSTEM: (optional) ~S Du Ds DU ~S Chu .®s ❑u Ejs Ell 1Z'x Sz'Co>JQN-nWJ~L Qi # SUE S ~-oPt?S tip ~l'~R~ ►►v F rcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the \ r s. ILHR 83.09(5)(b), indicate: C ` kS S ` iFloodplain, indicate Floodplain elevation: I v ' PROFILE DESCRIPTIONS BORING TOTAL DEPTH GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION _OBSERVED_ TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B- l 9S loZ_3 iU~L 7 q8 s n>~~~ 3 of 3 > $ B- Z $ 4 q - I( B-3 81D 7.2 i~ 7 8 D ~i B- 9 9'- Z B- S -7 $ S ~i B- PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP I WATER L V L-IN H S RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p I D 1 P RI D PERIOD PER INCH P N- 1-"-\ - P- P- 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. Ce ( _7 EY`'11~ T S SYSTEM ELEVATION sew p~ 6c z ~f= 3 E I I _0-1..-'..._1 't"^=-~1-~/-~54 y".-~'~'t.. I I _-F I _ _ L c -Tt li kae - 4 - 'T- F O 00 L4. d. a ~ lo\ ? po J t 52 ' a •Z 10 iN~T~PI C3ffb - Wit, A1.0 ~ ~ of I r~L`~-Rr.~ATe-. e~U - tt. 9 6. o'er ~ t g.y $_3 Vol RZ.9y' orv ol.i Z" 1'~ 11Z0►v pe oop STRRke L w w/►~Ct1 W/ LPt M i .ter u Lur3 SOIL DESCRIPTION FORM Ri l .'5'Tew T" (Attach Sod P. u LoCatiOn s Oi a Su er s Sheet) LINEAR LOADING RATE' 8 6S f~l~tENT PU : EvPcW TE FnR S61L R$SORPT~01.1 S`tST191 q °1b rr SQV`1L~f ~TrrloN BY: ~4Z"T}~UR. , W EG nsr: DATI Nc V Z6 i 1990 CURRENT LAN USE WOOat;-D SO►t 6t OPT- kIZ>`n S 1 N C - G S COUNT STA : CP_c~ \x ovi7U "rl LV I VEGETATIVE OCOVERI •Z of PF-opose'b a-s;" LOT DESCRIPTION pT OF D U[= SI?G Z9, 1-2^3, R. 18w DRAINAGE CLASS' t:'')cC~SlU~LY D~flub"D LOCATION: "1 D1~11J T~ l /ERR = iV GALLONS' PER SO- FT. PER DAY I I PARENT MATERIAL(s)/DEPTH _ SOIL SERIES$ EM ,1 emT L s Y~TCWA 14Y! _sQLL= 1101=. HORIZON DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PII BOUNDARY REMARKS in. foist G Sz. Shp COATINGS $oRl G I 0-1( ►o~ct~ 313 - s( 1 Sbk muJ~. cS 2 11-~b ~o~t[z y/ - s1) 2~sbk n~~h ~S 3 ?6-y$ 1~~tR SI(, S I l~sbk ~i es 4~_g$ -)~S `!R IN - _S O S m 1 ~oRl 2 s Z ~'Sbk M v 0-s 1 0 -a 10 3 z _z,g ~o~~ t b - 1 s ~ s~k I c~ 3 Zg-8~ ~o~R 416 - S ass- eQ1 6 3 i 1 lb`tR 3 I 1S l.. Sbk yltv'f sS I o-114 Z 1y-So 1o,tR. 4/6 S o g MI 021 G s i ) Soh 1n ~R es ~ o --1 lO~i 3 l3 - 2 x_31 ~o~il~ yl - Si( l Sbk ~aS o~ N ~ 5 1 010 10`~1~ 3 /3 S ~ Z.~Sbk !nv'f►- cs z i o- g lU l ti 4/ - S Io s hn 1 PIT M E 1`4 T(' REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS It jUSTR~', , DIVISION LABOR AND ' PERCOLATION TESTS (115) MADISOP.O. BOX 7969 HUMANRELATIONS N WI 53707 (ILHR 83.09(1) & Chapter 145) LOCAT O SECTION: TOWNS UNICIPALITY: LOT NO.: RLK. NO.: SUBDIVISION NAME: NW 4 ME f/4 z9 /T2911/11 i 8 E (o , wry R.9-Q- 1-,3 1 z - ~r~pus~ csM COUNTY: MAIL G ADDRESS: -7 L1 O 11 z"I 5T. \x ~c~rJ~`~ R. S~Nr~2T' ~oB S w svoL~ USE DATES OBSERVATIONS MADE NO.8 DRMS.: [UMMERUIAL DESCRIPTION: PROFILE DESCRI >s RCOLAT S: ®Residence 3 A• ®New ❑Replace ( NN - -L6 - 9 t- oT - L/ I r I eo.Av>uD ~R t~ssuRr s~ Sriat•1 w/ lZ' ~c s Z' L3tzD I z 1 Av S' m L.LL~ . RATINGi S- Site stiltabte for system Ue Site unsuitable for system CONVENT ONAL: MOUND: IN-GROUN IR S -F L I-DiNG TANK: RECOMMENDED SYSTEM: (optional) Zs E] U 10SRU1 Qs OU .®s au cis ~u i{ ~1~~ S~PNS ti~ _reT;kR~Ifv If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: C l-ks S Floodplain, Indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED -TET-Tff,fit 1' sf- TO BEDROCK IF OBSERVED (SEE A88RV. ON BACK.) B- 98 102.3 t-'~ csu L 9~ s f~\ GC: 3 of 3 IB- Z $ 49-~ I( > 8 Y B- 3 $ 0 9 B- 9 9. 7- ? 7 B- S 8~ loo.o 88 IB- PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH P_ P- P- Pr P- P- LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ntal 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 f land slope. L-7 Eli-, r I j YSTEM ELEVATION s 6e Z of 3 - s _ '4~- - ~S v 1 N , ' TN - - - j SOIL DESCRIIIIION PORN ~~}J/~l-~ ' .~~"~ltil/(~Z-r (ltl&Sh So{) Ml110 LOCaSLon map Og e_lupPrefe Sheetl LINEM LOADING PAM S. t65 pun posi, evt\t. vim FoR sr)-)t- R<3so mnm SYSra-t ! o • q °fb nesrn ART)-1Ui~. L . {.y E6 el n~rf~t: S uv`"t I--4z 68 19 40 CunnENT Ln►1D UsE woo p~-A so►, sr ol~ hiz~~ s DAU ' No - CRU \K Covey ~V 1 VEGETATIVE- V 1 N~ - G S oT 2 of Ps~F~S~e e sh E-K CF?3 s J U E: lrY b~ll.►67D LOi DEcC•plPi[ON'F 7 01= VYLA3-►J1;• SE=C Z9. TZ~1Jr R IOL-, DRAINAGE CLAW O ' Z ON' " of= ~'cRRt_IV OALLONS• PER 32'-'fl- PER DAY 1 I PARENI MTEn1AL(t)/DEPiII ` SOIL SEn1ESi E1"1 w1 ~R-T' ` S . 1 BlL.6J.03S EIGAI1Bd• . tlonlloN OEPIII MMIRIX COLORS NOIILES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PIT .90LRIOMY nENARKS (In.l IPU{fl) ar. ShPCOA1! OTCs $oR1 G ~ _ o-I~ I(31-tR -cS 2 11-z6 \b4Cs y/ - s 2 ('s~k )h'Fh - S 3 ?6-y$ 16LIR sJ~ S 1 l~Sbk ~ i es y$-98 I's yR 3)y - S , o s9 >n - 3 X16 2 rl _n S 7231, In V TV- CS ~ ~ -~i \b `tR 3/ 3 Z ~_Lg \l~,LttL 16 S"o"M - CL t3bQl ~6 3 - . v -114 10`1 R. 13 1 S \ 5%bk ITT V 'F H s s Z N-go \o-tR Ll - S o S M1 o~Zl G o 1.0`i EL 3 13 - SO 1 f S vt hn 4 _ _c 5 2 -3~ Io~iR Y/ - Si 1 Sbh YA~~ S b~21 "G ~j 1 0~ 10 1byCZ 3 /3 S ~ Z.~S~k M v'f►- _ cS Z to-a Ib`Iti ~~/6 - S D sg_ M 1 w.. l . kit v; J O w LL 0 bl cJ J po .J 10 ~tv~T~PI Ca %b q9 I PIL~'RNA rift - L7L. 9. I ` N tow f~ o ~s~ I! L uT 1 LuT 't. ~`I 1--L,, L. 000 S1~ttke- W / Lr1T1 TR 36' 9T1 a I `a~1- t~flv. a6.9 oti ~?A.83• Bit -t'L-~sV. q2.9~/~ Oti 6 ~ 1xz wcr~p Sl'A`~t~ o►_i Or -O 1 ROrv pL WOOD 5TRltfi W/ LP% wT q Lo T'3 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER c d24,1 MAILING ADDRESS UQ'~/S_ ~1~f5. ~'~'i+''C'S~ GO T,/%~~✓ PROPERTY ADDRESS 1Q ~y ~~a~6 (location of septic system) P ase obtain from the Planning Dept. CITY/STATE j _ PROPERTY LOCA ON NZ J 1/4, 4&a 1/4, Section 4-,19, T _ay N-R_2 W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGER ±L4, LOT NUMBER - ~ ft`781 f~ 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 com leted and r ed to the S roix County Zoning Officer within 30 days of the three year ex ' do ate. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property ✓p pi Location of pr pertyy( / 1/41/4, Section ~,TN-R1~W Township Mailing address 10t;2 '-'0a777 AUK (f Ui3 RTS 602' Address of site AS? Rb Ar~06L Rt)akF,ers W1. swI73 Subdivision name Lot no. Other homes on property? Yes No Previous owner of property 75~,/~- Total size of property Total size of parcel, r Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number f 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 e office f the County Register of Deeds as Document No. and that I (we) presently own the proposed site for t e 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. 'do iicant Co-Applicant Dat _ of SianatiirP natA r,f c;r.,ar••, ~ y CERTIFIED SURVEY MAP LOCATED IN THE NWI/4 OF THE NE1/4 OF SECTION 29, T29N, R18W, TOWN OF WARREN, ST. CROIX COUNTY, WISCONSIN LEGEND ST. CROIX COUNTY SECTION CORNER MONUMENT, FOUND. • 1" IKON PIPE, FOUND. 0 1"x24" IRON PIPE WLIGIIING 1.68i1/LINEAL FOOT, SET. IN PERCOLATION TES'T LOCATION NO'TE: THE SETBACKS OF MAIN BUILDINGS ON THESE LOTS ARE AS FOLLOWS: SIDE YARD: 10' MINIMUM AND 25' AGGREGATE REAR YARD: 25' HIGHWAY: 100' FROM RIGHT-OF-WAY LINE" ORDINARY 111GHWA•1TER MARK: 75' W rn 3 w OGN00 `"I co ~NORTH LINE OF THE- NE1/4 - 00 zo ~ o z C4 U o - - F x U N P L A T 'T E D L A N U S o ,n U F, stn 1-1 80TH AVENUE 049'21"E o z H 7 fn E-+ _ _ _ _ N88 2604.581 cn N 1302.29 1_302.29 _ N876J4'0u"L 7.18' o- 237.12' _ 20.66 - - - rk- - - - 0 237 .12' - - _o - 77 . w _ 6 i'i POINT OF 3 :o .off ' BEGINNING -I 11 N N ' { I _o of 1 it'd ` N r-4 1 0o •-I 2 r NI tnl z N to o to 1'UND I .-t , n 3~9. 5' 41.581wl o ~~d 85.40' 151.7"2' 126.53' 252.7 cr-. AI 0 a N 237.12' N87°34'(,~U' L 420. 3 \ , o zl 01 ~ Q I ,°o g N87°34'OU"E 3 p 3 1 z z FBI .I tA 4 High ko •I ~ ~1 w AI ~ H ~IW60 ~3: I ^ o Water Mark -~~~NI wl cn o w O o ) 10 N 0 . 1 ICI _ N ~I + ;I I co co o z 39.38'-;-1 11) x1 o HI " y `_V cn r 381. 61, H H I ,o.'~ ocnl.]1 S87`31i"00"1d ii_1U_ -.9-9-1 of 7 SCI t,7 o i vlal z '4 284.94' 334.38' 38.83 i j 1 x ~ a ai H co S87°34'OU"W 658.1.5' , H a1A1 ROADWAY EASEMENiv '6 1 V) zl :a z x i U N P L A 'I' '1• E D L A N ll S o' ; I ~ww ko ~Hw WI ~i HIAI ~ v 71x1 ~6' 3 - OWNER ' '39.3 M I _ & SUBDIVIDER 150.U0RONALD R. STEWAR'T 4 , I o L S111F HkR OF IS( I)NSI\ II)R" 1+rN: \VAR1RANTTI"~)FFD(j~/( _ 1)uCI1MFNTNf', YO~~I J 7QI1t7L~'lw ft-,%Ji_ _ _ 1 $T. i'.nv„t This Deed, made hctKern JUL 5 9D Dale R. Stewart and Nancy M. Stewart, husban.~ s'<' wife at 9:30 A•(!;! and John T. Anderson and Deannz M. Anderson, pd, rorot0ee husband and wife as survivorship marital proper-_.t Witnesseth, That the said Grantor, for a %aluable comtderat - r A receipt of which is hereby acknowledged %AMEANEE"v' St. Crcix MSTINA OGLAND come}'ti to Grantee the following described Dal estate in ZII7., FStft:Cl1 & Ogland County. Slate of :r'tx.insin: P, O, Box 3S9 Lot 2 (two) Certified Survey Map, recorded in '(udson~ WI 54016 Voluw:. 9, Page 2414, Document Number 474818, located in the Northwest One Quarter of the Northeast One Quarter (NW} of NE}) of Section Twenty-nine (29), Township Twenty-nine (29) North, Croix 1Paru•I Wrr.uL..u,on \um!+rr' Range Eighteen (18) West, Town of Warren, County, Wisconsin. descrihed urpose of all theconveyance Nancy M. Stewart joins this interest that she may have Wisconsin Marital Property Act. $ ZZFER This is not homestead pr,)pent 11 I t. noU Toeether such all and singular the hereditament,, and appcrtcitai helon_iine: end Grantors Harrant, that the title is good, indefeasible in fee simple and free and le. t `+•an, "2s`cpt z no exceptio s and %sill ssarrant and defend the same. 96 19 /-une Dated this da•. of J ISEALI (f ISE:U Dale R. Stewart . L ~C.u I t ISEALI S E 1 J N: ncy . . Stewart AUTHENTICATION ACKNO%LEDG%IE:N C n ~~u~wuwt tiT >TE _)F \i ISC'ONSIN Signature(,) IV~^'' ' ,!sCivsr3~'t~t' Count t~ tAI_V__ V 19 V, s. halls lame before me this das "t authenticated this Ja} of Ira the abuse namA Z Dale R. Stewart and Nancy M. Stewart TITLE: %IE\,IBER STATE BAR OF WISCONSIN (If not. s aho esciuteJ the -K , ,,.use to he the person authorized b+ §706.06, W'is Slats 1 arc ~nstrumrnt and ackno~kledgr the sa,nr 1,..1 - _ro-IrNT WAS DRAFTED By fr.n~ ~ . ~