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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
r r p a ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Please specify desired test(s) & remit appropriate fee with
application. Outside water lines are often turned off during
winter months, making access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
❑ Water VOC's
( ) $185.00 ❑ Septic $50.00
0 Water (Nitrate & Bacteria) 45.00 0 N'
Z retest~$15.00
Owner: ~Av` ^ Requested
. EkD~V by: G2Egatl WOOD E/J'r. ING.
Address : c I>u}R.nn UN [)p-4 ✓e Address : G, 5-+-
,L{ o w1 ZIP S¢v/6 V N Z I P /{o
Telephone W: ( ) Telephone N°: (zto 386--3e-74
v~ LOT .3 Sv u ~oc~
Property address (Fire IT & Street) . L-o? (.2 SvNiLI Ge
Location: $ie A)W Sec. z¢ , T'L9 N, R_1_9_W, Town of kpso j
Sz
Realty firm: f,. Lock Box Combo: R.A. Closing Date:
TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
LOT
Water sample tap location: L o-r (oZ = W~c.~
Is the dwelling currently occupied? J8f Yes ❑ No
If vacant, date last occupied: /A.A
Age of septic system:
Septic tank last pumped by: Date:
Previous Owner's Name(s):
Have any of the following been observed?
❑Y N Slow drainage from house.
❑Y N Sewage Back-up into dwelling.
❑Y N Sewage discharge to ground surface or road ditch.
❑Y N Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:----,-
1/94
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? []Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: OBelow grd ❑At-Grd OMound
Approx. size ex []Gravity ODose []Pressurized
Ft.2 OBed OTrench []Dry Well
[]Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: ❑House OWell ❑Prop. line []Other
Dose tank
Setbacks: ❑House OWell ❑Prop. line []Other
[]Locking cover OWarning label []Pump/Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: OHouse []Well ❑Prop. line []Other
OPonding: []Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
i
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Inspector
Title
AS BUILT SANSTC - ITARY 104
SYSTEM REPORT
OWNER
ADDRESS
I
SUBDIVISION / CSMJ LOT
SECTION 'Y T N-R_& W, Town of
Odra ,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
h J
6 4r D
t~-90
INDICATE NORTH A.RROF"
r
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cOver-
a
BENCHMARK: SaWt_e_ ACS ~~J
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Man u facturer-
•,/1Z<,✓ecl`ey;vl Liquid Capacity: >&®d
Setback from: Well O -~A House Other
Pump: Manufacturer Modell Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length e6 Number of trenches.
Distance & Direction to nearest prop. line: v2,5-/ ~asf'
Setback from well: •4- House few 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:
~~~o►
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR: ~
3/93:jt
WisconsinVepartmeritof lndustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
TJADEN, PAUL X
CST BM Elev.: Insp. BM Elev.: BM Description: UdSan Parcel Tax No.:
/bbl (60' /~iivYtO ~y r, 0L
____6090
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic G`10 1_e~4 Ij e', o Benchmark 1050 Od, b
Dosing 104 0
Aeration Bldg. Sewer
Holding St/ Ht Inlet ~,Sy • 6
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 70S' 5o i 7 /w l NA Dt Bottom
Dosing NA Header/Man. 7•09 oz,
rua,z~'
Aeration NA Dist. Pipe Say 94 is
,zo ic, r. ~ 9
Holding Bot. System: d a6;Y a
i .q7
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
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 $co 3 DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O ^ ^ n CHAMBER Moe Number:
9r^ 7 1(3 5-a OR UNIT
System: oC
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 o a' Topsoil ❑ Yes No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
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LOCATION: Hudson.24.29.19W, SW, NW, Lot 36, MCDirmidDrive
3 P - ~ o (D
00 51
~f i s J
1 J
as
Plan revision required? ❑ Yes ❑ No t -2- 0
Use other side for additional information.
SBD-6710 (R 05/91) Date I p"r's Signature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
II
I
Safety and Buildings Division
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 Q~
than 8112 x 11 inches in size. J/
• See reverse side for instructions for completing this application State San~itarryy Peerm~it Number
The information you provide may be used by other government agency programs ❑ Chec oif'revision to previ s 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. a 4 1/4 114, S ;Z A( T Zet , N, R 47 E (ore
Pro erty Owner's Mailing Address Lot Number Block Number
3.2, 3.-V r G
City, State Zip Code Phone Number Subdivision Name or CSM Number
A-t .J ,'41 a ( a )XI .2 ~;17.~ W
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ~t~age Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms VII Town OF /Q . el
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
B a0-
1 ❑ 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. [g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System
--System Tank Only______________ Existing System ExlstingSystem
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: /D~•S
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Eley. 7. Final Grade
.r.~a Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) /a! 0 49. Elevation /0®.0
Feet 103.$'0 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 Existing strutted glass App.
Tanks Tanks
Septic Tank or.Holding Tank 4 (,ZQU ~ ~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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) MPPRSSW No.: Business Phone Number:
Ail V16:4 I" A, I r~,JF. q t
Plumber's Address (Street, City, State, Zip Code).
-4-) W 0/ 4
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issu ng Agent Signature (No Stamps)
41Aroved Surcharge fee)
pp ❑ Owner Given Initial ,iY
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SRD-6398 (R. 015/94) DISTRIBUTION: Original to Couniy, One copy To: Safety & Ruildings Division, Owner, Plumber A
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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.
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 on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7-
V11. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, num;)E:r 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 c(:.inty The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, locati :)n of 'u,ldincl tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water serece, strea•r.s n _l lakes; pump or siphon
tanks, distribution boxes; soil absorption systems; replacement system areas; an( the lo::. t.ior ( f the building served;
B) horizontal and vertical elevation reference points; C) complete specification, for pumps a ,,c (ontrols, dose volume;
elevation differences; triction loss; pump performance curve; pump model and rump rnanuf, c .ire; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; a id F) _iil sizing information.
- - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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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i ~,f 131-131- 3 Su/'rm4/ ,~ol/w2 _6,e_ _.47-Wisconsin Department Relations Industry, SOIL AND SITE EVALUATION R'E P O` Page of
Hu
Labor and man Relati
Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST ~,POi}C
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PAR D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
BE I D BY DATE
PROPERTY OWNER:
ER -h
11L T TrF~~'v f3~y~~P GOVoc N
GOVT. T=~l~? ,1%4 y~'4y%t'14,S ;YT 2 /r
3z 3 3 N,R E (or `W
PROPERTY OWNER':S MAILING ADDRESS LOT # BL t -SUED. NAME OR CSM #
//P~QG~ dam' 3Cr Slirl/iPil>~~-
CITY, STATE ZIP CODE PHONE NUMBER QCITY []VILLAGE ]VILLAGE &OWN NEAREST ROAD
~fl ~r 11ei,i v.✓. Ss~1/ (G~i) yS~-37540 rf U P o")
W 1 5 MG 1'71f}R M
( 6ew Construction Use [ Residential / Number of bedrooms Addition to existing building
Replacement Public or commercial describe
Code derived dally flow oD AJe ~A- 3 3 y S
lY gpd Recommended design loading rate gpd$ ~trench, gpd/ft2
Absorption area required ,gibed, ft2 2ov trench, 112 Maximum design loading rate bed,
9Pd/II2 . $-trench, gpd#t2
Recommended infiltration surface elevation(s) -s-e- P . 3 ft (as referred to site plan benchmark)
Additional design / site considerations __~t= P IAcl=n~,~ htSEj1- 5X411 4C O y vp 7 Y,,OC- S ST
Parent material JX_' Flood plain elevation, if applicable it
Lc= Suitable for System ~~Cl U L MOUI~p 0 U 4GR9iJtdD U ESSURE ATT-GR&DE SYSTEM IN FIL FOLDING TUnsuitable for s stem 01 U ~ 0,5 O U ❑ S
[ ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourtay Roots GPD/ft
E3 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rerldi
F/ 0-J` /D 312- 2 f s4,Z- fit? CS 3-~ , S
Z S- /9 10 lie 31S/. f s e ~An,5;e e5- 2`f• • S
Ground If- 3 /D " 31 ~ /015/f,_ Off f,P `f"S , 5
elev.
ft. q
Depth to 5 G- 15 31a , . S
limiting AK!
fac 11 (e ex 70~v
ASS ~
:
Remarks:
Boring #
lam .?/Z- s / z f s~ Cs 3 ~ , S
2 z y> JO yle sX 1 , f Ae 40e C
s s j. G
V
Ground % - ~o~ `3 S J,~J.C ~+r► f~ °f S
T '
elev. ft. G/ 7d 1701D i tiG~o '
Depth to
limiting
fact
Remarks:
CST Name:-Please Print p LQR / GGt Phone: 7/5' -JojeS
Address: &55 0/ N y~ L
Signature: Date: CST Number:
ORIGINAL
IF
3
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # G0 T 3 ~0 sV'y Jj?I
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boux'fa y Roots GPD/ft
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench
1,0-/0 /D 3/~- - /Wrl;< C s . S
S~/, L ~~sd,~ .~►~-Fie as / s G
3 2 0- z ~o ,e 31
Ground /O i 1~`✓/ S ~n
elev.
ft.
Depth to
limiting
factor
i
Remarks:
Boring # '
l -/0 /O yie 3/2- Si/ Z -FSk rrr'F~ s ~-F 5-
E3 Z O 12- /a X 3 511, ` / y S
Ground 3 2 ^ y3 /Q X `3 ,511 Z Nn . die ~S ' - S _ ,
rev. ft 3_ s /oYe s/ ~f -,e - = y s
Depth to
limiting
>
Remarks:
Boring # / S'/ Z f 56,E ~f' CS /f . S i - 6
D- a YX 3/z
131
- /d y ~ i1N /yy f~ Q s r 7 •
Ground ~i
elev. ,P,w y 0 . '7
60
ft
Depth to
limiting
Z, ;
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
OWN 0"^10 n[ MM
J A
1 3 Y f 'wee
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17W V
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STC-105
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SEPTIC TANK MAINTENANCE AGREEMENT i
St. Croix County
O WNER/BUYER
Y
1Y' 11 ~i~ .U ~G
MAILING ADDRESS 39. 3,3
PROPERTY ADDRESS o'Z SICiT r tr v~ t
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE a.d _57,1 61 /,J
PROPERTY LOCATION 5-AL_ 1/4, 1/4, Section o2 T Z N-R__Z W
TOWN OF ST. CROIX COUNTY, WI
s
SUBDIVISION LOT NUMBER J~_
CERTIFIED SURVEY MAP , VOLUME , PAGE , 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
j
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.
t '
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
Form - S T C 100
Owner of Property_
,Location of Property SGJ ~i, Section o2 y _,T N lt-~f-w
TownahipAle,-
Mailing Address S-233 IV
r~~ga J d} la
v
Subdivision Name_
Lot Number 26"
Previous Owner of Property
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? 'x Yes No
Include with this application one of the following:
Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
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. ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an casement, to run with 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.
SIGNATURE OF OWNER , SIGNATURE OF CO-OWNER (IF APPLICABLE)
b
DATE SIGNED DATE SIGNED
12/12/1994 20:,01 715-986-3593 LOWRY REAL ESTATE PAGE 02
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• pocuMU4T NO. WARRANTY DEED THIS SPA•:i FCSEPV ED FOR RECORDING DAT♦
i. '
'STATE BAR OF WISCONSIN FORM 2-1982;'
,524(;7:9 VoL1Q►A~E125
- _ Y._ _ -
REGISTER'S OFFICE
GrPenweod Enterprises, Inc. a Wisconsin Corporation, l ST. CROIX CO., WI
Pi
Rea'
.
I
DEC 2 8 1994
Pau. L. T aden and Therese A. TjadIs
;1 conveys and i,,'arranta to 1:00 P.M
husband and. wife as survivorship .marital-.property,.-..-
I . ew
- . .
. _ _
R ET
URN T
~
Heywood S Cari, S.C.
. _ f P.O. Box 229, Hudson, WI
w
f _ oll .
. owing _ described real . estate in -St. Croix ...Count),
State of wiscansin:
Tax Parcel No:..............................
Lot 36 of the Plat of SunRidge II filed in the Office of the Register of Deeds for
St. Croix County, Wisconsin on August 1, 1994 in Volume 6 of Plats at Page 17 as
Document Number 519728.
This is not homestead property.
--Oirt (is not)
Exception to warranties:
S' Jar ~ M i 19.
Uated this day of 94.
(SEAL) _ (SEALi
/.Jame_ E. Rusch, President Ma Rusch, Sec ary/Treasurer
-(SEAL) (SEAL) _
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) .--James E. Rusch, President STATE OF WISCONSIN
ST. CROIX _ County.
authenticat this j-l!.day of_ dlc/ 4"1( 19--94 Personall came before me this ................day of
19.94.- the above named x>
Ma - R Rusch, Secretary/Treasurer
Wa ter Hod nsk s'
TITLE: NIEMBER STATE BAR OF WISCONSIN -
z: If not. - - - - - - - -
µ authorized by $ 108.08, Wis. Stat9.) to me known to he the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Heywood 6 Cari, S.C., by Walter Hodynsky
-
k
. Croix
County, Wis.
P.O. Box 229, Hudson, WI 54016 St
I to-y Public - -
' •
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
' are not necessary.) date: _
d~• •Narn s or Persona riming in any capacity should he t)pe.i or t ted hole their slg _a :.ros.
STATE BAn OF RISCO\ci~l RI+:.,. L~cxl f In•~k t'•..
WP°iRANTT DEED b'I+llM o. t n'•.