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10 AS BUILT SANITARY SYSTEM REPORT oa c1 r `
OWNER
ADDRESS f O y
SUBDIVISION / CSM# J 6 LOT
SECTION _3;2,_T 97 N-R M W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a, 27 I- q
~sai N.aa,
D. 30
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r
s
BENCHMARK.
9 /do
I L)
ALTERNATE BM: Al,-- ,
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: co-R-ALCA Liquid Capacity: Setback from: Well 4r8 House / D Other
Pump: Manufacturer Model# Size
Float seperation /1A Gallons/cycle:
Alarm Location /V R,
SOIL ABSORPTION SYSTEM
Width:V-4 - 6 Length E
76'
Number of trenches
Distance & Direction to nearest prop. line: '77 Eo,
Setback from: well: House ~.5 Other. /1/1q,
ELEVATIONS
Building Sewer cf'ar, 3 ST Inlet; ST outlet 91 3
PC inlet IV I'+ PC bottom Pump Off
Header/Manifold 9 3, o Bottom of system 969/2
Existing Grade 0 9 Final grade Q~.o C7( 9l0
DATE OF INSTALLATION: 1-;Z-0 " 9 6
PLUMBER ON JOB: LZ At"
r
LICENSE NUMBER: -ryI 5;- a
INSPECTOR:
3/93:jt
Veiscor)sinDepartment of Andustry, PRIVATE SEWAGE SYSTEM County: ST. CROIX
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 259477
Pe,,4,Mlft'j N
VT. CHPRD O E] City Village [R Town o : State Plan ID No.:
Marren
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
C~~ p-1" t,)Z4~~ ea.' 037
TANK INFORMATION ELEVATION DATA 3 y~
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
! Benchmark 3,37 '
Septic
Cc#c
Do
Aeration 7 Bldg. Sewer' 37
Hol St / Ht Inlet xx'
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic -~2 e,4 NA Dt Bottom
Dosing NA Header/Man. J~.3&
Aeration NA Dist. Pipe
Hol'd ing Bot. System S'
r eo
PUMP/ SIPHON INFORMATION Final Grade yEc~,o =~r•
Manu cturer Demand Ina,.A tx cam.
Model Numbe M r~ 7. 95,971
our" s!U
Friction System TDH Ft
TDH
I oss ead 7
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / I Length No. Of Tr riches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S D ( 7 DIMENSIONS
>
SYSTEM TO P / L BLDG WELL LAKE / STR LE G Manufacturer:
SETBACK
INFORMATION Type Of t-Xc .rM r BER Moe Number
System: tre,•,C 1> OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pi e x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. gth Dia. Spa
SOIL COVER X Pressure y ound Or At-Grade S s Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulche
Bed /Trenc enter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.
LOCATION: Warren.32.29.18W, E 1/2, NW, Lot 1, 65th Avenue `
Plan revision required? ❑ Yes No pr /
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ti
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
4
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY 06
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ Check if 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
1 r h a- 4 r 5 LC h E/ d & /i/10%, S% T;~ , N, R 13 (o (j 7
PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK #
soya ~s~ ,I~.,
CITY, STATE ti ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
c.~ , Syo a3 -79 8 ~ 3 ~ C? s <
11. TYPE OF BUILDING: (Check ,o ) ❑ CITY NEAREST ROAD
1~I W at caned VILLAGE : Q yw IV c- 1y. TOWN OF: t3
❑ Public I l or 2 Fam. D elling-# of bedrooms 4-- PRE TAX N BE
o~. /oq~ io
III. BUILDING USE: (If building type is public, check all that apply) y
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. ❑ New 2. ❑ Replacement 3. [2N' Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks strutted Is I
Se tic Tank or Holdin Tank / "_1 6y 5 F] Q F1 I F1
Lift Pump Tank/Si hon 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:
GJalfe,s~ /11...c.l.vr`lle Lo /5 7yg 33~~
Plumber's Address (Street, City, State, Zip Code):
9101 H L= 10 .5- p ~ - SY~ia
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sani g Permit Fee (Includes Groundwater a e slue Issuing Agent Signa a (No Stamps)
L~Q Approved ❑ Owner Given Initial / ~f T Surcharge Fee)
,q Approved
Determination a U Phi-,
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
. 31 9~ ,
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the 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. a
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 & 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.
11. 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
w9LnQ , s `
o oZ WaterPro Supplies Corporation
a'~iQ^o s`~ 15801 W. 78th Street
Eden Prairie, MN 55344-1894
WaterPro Telephone: 612-937-9666
6 800-752-8112
Fax:
Fax: 612-937-8065 i
PROJECT DATE C;
/o 2 loS- c~ y a a~
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t K
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
1" r r r"r N i ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 540 1 6-771 0
(715) 386-4680
EMERGENCY TANK REPLACEMENT APPLICATION
STATE OF WISCONSIN )
) ss.
COUNTY OF ST. CROIX )
CITY, TOWN, OR VILLAGE OF: M/►~'vv 40o PROPERTY ADDRESS : %D'4/;4 !O 4,.9 a-3
i
LOCATION:_.'-,, 1l Sec. :;?2, , T_2'LN, R~W, Town of
I, R 1 C* 9,4r Q O L- 4 J S&110Jb the undersigned do hereby
acknowledge that I am receiving a sanitary permit to QP a.
-t".a.,...Ds- without a soil and site evaluat on, or
existing system evaluation, and private sewage system plan review due to
inclement weather and health or safety emergency. Further, I
acknowledge that a soil and site evaluation, or existing system
evaluation, and private sewage system plan review will be conducted by
the deadline stipulated by the permit issuing agent, or as soon as
weather conditions or circumstances permit. If the private sewage
system is found to be failing as defined in s. ILHR 83.02(18), Wis. Adm.
Code, corrective measures will be taken such that the private sewage
system complies with all application requirements of chapter ILHR 83,
Wis. Adm. Code.
Dated: AA~
PROPERTY OWNER
Subscribed and sworn to before me q Owl-
this / day of %
this
~a~.e 19 CP . ~~.~~\~~•~.....,.~•1S'J~
- • fir.
otary Public U~~,C
St. Croix County, Wisconsin •
My commission expires /-r)~ - 00
`rra °O~~'~,o,'
saeramur'a~"
COMMENTS:
~c 4
PLEASE RETURN TO ZONING OFFICE, 1101 Carmichael Road, Hudson, Wisconsin
r
Wisconsin Departrnent of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
k. Division of Safety & Buildings in accord with ILHR 83.05, WrisAd
NTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan _ C Q X
not limited to vertical and horizontal reference point (BM), direction and % of sloPA . #
dimensioned, north arrow, and location and distance to nearest road. - I I- /p
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION p~VIE BDATE
PROPER WNE PR TYLOCAT~~NrR~X V
/ G'~ .Sl1f?U GO 1/4,S a9 N.R / -8* W
PROPERTY OWNER':S MAjLING ADDRESS LOT M #
U S 1 y ~~.~02
d _
CITY, S E ZIP CODE PHONE NUMBER ❑CITY NEAREST ROAD
, j am"
[yC[ New Construction Use [A Residential / Number of bedrooms Addition to existing building / htr/rcnn?
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 606 gpd Recommended design loading rate-,? bed, gpd/ft2--±~trench, gpd/ft2
Absorption area required 860 bed, ft2 7~ y trench, ft2 Maximum design loading rate -,2-bed, gpd/ft2$trench, gpolft2
Recommended infiltration surface elevation(s)5c'& 5'i k- a/65W 4Cl / ft (as referred to site plan benchmark)
Additional design / site considerations :%Ysteow7l u cros .
Parent material L~~d(? 1D/L~ IrlCt ~.fl^i~% Flood plain elevation, if applicable - ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ®S ❑ U ®S ❑ U ® S ❑ U ❑ S I ❑ 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
v iz 2/a S L 2 m sbk Ek C S 3 F es , to
\ ~?!o !d iz 3La :5,1 L .Z m Sbk M FR C u.~ •2 f o 5 .
Ground CL 3 5bk ~1'~~ /~,S Z f' . s
e-lev
9s.4ft. 9:~ ~s. s/(v S t7 rn m 2 VF
Depth to
limiting
factor
rv/R
Remarks:
Box¢ g # 3/~ m Sbk I~ Fa C S &F Ground
elev~
ft.
Depth to
limiting
factor
Remarks:
CST Name: Please Print ~O L __r J IS.E Phone: .21S / pOo, ~0
Address: ,5/l d C.rC' ~PL ~7 S LLIcYYI L~S~a. ~Od
Signature: Date: 1-z y CST Number:
h
PROPERTY OWNER SOIL DESCRIPTION REPORT Page _of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barxby Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
rLC
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
t
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
kv QQS
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
1 A C
D v V
O
MAILING ADDRESS AA
PROPERTY ADDRESS /1 W S y 0 °2 3
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE R bD "
PROPERTY LOCATION IV C) 1/4, Section T,Af N-R W
TOWN OF (O %-kA-2-g ~ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 3b 3 ~TS~o VOLUME I , PAGE 9 3 2; 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 ye xpiration date.
SIGNED:
DATE: "774,,ei l q /
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 K;0'r" "
Location of property ~ A) L.,) 1/4, Section ,3Z ,Tv2`21 N-R l~ W
Ste`'
Township R/~A-►r Mailing address j a 'Y
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 as , 1W
Are all corners and lot, lines identifiable? vl~ Yes No /
Is this property being developed for (spec house)? Yes ✓ No
Volume IPO and Page Number 3ey 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. L' q q 3c 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.
ignature of Applic nt Co-Applicant
Date of Signature Date of Signature
i„
ly,
n
Of ID.Ods
363856
CERTIFIED SURVEY MAP
STEVE LUEPKE
Part of the Southeast 1/4 of the Northwest 1/4 and part of the Northeast
1/4 of the Northwest 1/4 of Section 320 Township 29 North, R.wge 18 West,- .
5. !y . 01 4 Town of Warren, St;. Croix County, Wisconsin.
o Indicates 1" x 24" iron pipe weighing 1.13 lbs/ft. set.
~MON'J • Indicates 1" iron pipe found.
S 6 _
SG u Tf/ /Ce~~`Y
00. 001,1
m s ,o Z
NOTE,' L C>7-
A? -1c- -IS ¢-75AG
-=-x c1 CJL7/A/ G
L O T / LOT Z 0 VI
Z- 0 7- F-1 '7 7
AGRES EXC. J AGF26 S~ ~O ACRES 1~ ~~N \
R. O W. J
0 00k
0 S7' 0 ,4L= Y m r 4
-A M E' IY^l nt
O!i/EL.C //V GN 0 \ 1Y O
00 0 0
o Q Ap
N
~3. 58 X25=-/S.'_3p'~ 625!5_ Q 0 Q
w 85 >
TO W AI .4 OA L7 S C.Q 200
DESCRIPTION:
That certain parcel of land located in the SE 1/4 of the NW 1/4 and the NE 1/4 of the NW
1/4 of Section 32, T 29 N, :R 18 W, Town of Warren, St. Croix County, Wisconsin, more fully
described as follows; Certified Survey Map filed in Volume 2, Page 491, Document # 344073,
St. Croix County Records, St. Croix County, Wisconsin.
State of Wisconsin )
County of Pierce )
T_ James L. Murnhv. Reeistered Land Survevor. do hereby certify that by direction of the
STATE BAR, OF WISCONSIN
383433 FORM 2 -1982k
VOL
661 PAGE38
_ 4TUR5 OFFICE
$T1 4010jx Co.,
Steven C_,Luepke and Jean A. Luepke, ~E Rsc'd. for R rd ift9s 23rd j~
s~8 h.L.S.. w f e__:a n d •n•_ h e r ° "'n r 1 gh t
Clpr Of MArch 4
_A.D. 1483
conveys .and warrants to Richard. -O.--Sundb_y and______________________ i at 11:55
M.
-De.bra.-K. ___S.undby, husband aXLd Wi X e_,_ a .5L
J.o.in-t-- ten_an.t.s- -
er of Do I
a
I
.
-
RETURN To Richard 0. Sundby
Rt. 1, Box 68
Hudson WI 54016
the following described real estate in 5_.___CrOlX_-______-_ ---County,
" State of Wisconsin:
Tax Parcel No: 1
Lot l of Certified Survey Map dated April 28, 1980,
recorded as Document #363856, in Vol. 4, page 932
of Certified Survey Maps in the office of the
Register of Deeds, St. Croix County, Wisconsin,
except-the:E. 5.15 feet thereof.
This- 5-:-D-Q t homestead property-
CW (is not)
Exception to warranties: Existing highways, easements, rights of way
and restrictions of record.
Dated" this day of .Ma-rcb-
(SEAL) - AL) _
`
- * t-eve-n---C - -Ell-eFk-e..........................
I:
- • ---•----(SEAL) Q.Q.1!( .d - (SEAL)
* --Je-an---A-._.L-u- ep-k e.- .
I
AUTHENTICATION ACKNOWLEDGMENT
~
Signature(s) - STATE OF WISCONSIN
iV
- C r o i x--------- ----County. ss-'.7
St
authenticated this :...day of 19 Personally came before me this Gam.. day of
-March--•-•-_-••-• , 1983••• the above named
- - - Steen -uePke and Jean A
t
- - - Luepke , husband and wife =
TTTT,F,. MRMUP.R. Qq ATF. RAP. OV WTRC0NRTN I