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STC - 104
AS BUILT SANITARY SYSTEM REPORT i+ rtgt ;y 1985
~ `+l~ yLF~t,•cn
OWNERA f/~ zf~,O12a~,1 f rtNO C
y n~~
ADDRESS
SUBDIVISION / CSM# ~~~-cam LOT
SECTION," T ~N-R~q_W, Town of ~1asF
i2~
ST. CR COUNTY, WISCONSIN
II ~
PLAN VIEW
SHOWJVERYTHING WITHIN 100 FEET OF SYSTEM
3s
INDICATE NORTH ARROW
L~E1/ /~'vacs.~
Provide setback an elevation information on reverse of this form.
C.X.ev.}
Provide 2 dimensions t center of septic tank manhole cover.
r ~
3 _
BENCHMARK: 2 r0
ALTERNATE BM:„ 9<741
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer Liquid Capacity:
n•
Setback from: Well 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: "aj
Setback from: well: House Other
ELEVATIONS
Building Sewer S, Z/ ST Inlet: 9-1,78 ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system_
Existing Grade % Final grade
DATE OF INSTALLATION: - C
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: L<y
3/93:jt /
vuisr~^ in Derpartment of Industry, PRIVATE SEWAGE SYSTEM County:
o a, d 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 of: State PIA o.:
GERMAIN, MICHELE X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TOSEPH
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV-
Septic~ Benchmark 3 /e®''
Dosing S U G_W
Aeration Bldg. Sewer ' S5, 7y
Holding St/ Ht Inlet G' ~y 79
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Air
Septic >SO y S' J5, 11-5, ' NA Dt Bottom (3 %y G, ~w~ / gv,
Dosing ~ o ,T ? 35' -_2 NA Header / Man. 95-15- '
Aeration NA Dist. Pipe C111_. ✓
Holding Bot. System 5-'
PUMP/ SIPHON INFORMATION Final Grade 3_ ggs
Manufacturer Demand
Model Number GPM
TDH Lift ,A Friction a~j System ~ TDH ((j.1A'5Ft
Loss 1 Head I
Forcemain Length //S ' Dia., Dist. ToWelly,,7a'
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No_ Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Sytem: C" ~L' i✓~~ '`oo" OR UNIT Model Number.
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 y 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: ST. JOSEPH.26.30.19W, NW, SW, LOT 9, AWATUKEE TRAIL
L, jt 61 ~.¢4
Plan revisi`dn re ti ed? ❑ Yes ❑ No
Use other side for additional information. ,t' f let<c.
/ / q5 C~/~ < I<-
SBD-6710 (R 05/91) Date ' Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
i
r, Safety and Buildings Division
vi~■,~ SANITARY PERMIT APPLICATION Bureau of Building water system:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than _8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Saanitaa y Permit Num er
The information you provide may be used by other government agency programs ❑ Check if r~visiion to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property wner N e Property Location
1/4 ) 1/4, S T , N, R ~(or~
-A _Q
/19 Property Owners Mail g Ad es Lot Number Block Number
City, St to Zip Code Phone Number Subdivisio ame o2CS Number
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cityage Neare t Roa
Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Vll Town of
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
03 0 - I -Irv-aao
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 _ New 2. ❑ Replacement 3. ❑ Replacement of 4_ E] Reconnection of 5. E] Repair of an
-----System --------System _ Tank Only______________ Existing System sting System
❑ 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:
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/da /sq. ft.) (Min./inch) Elevation
S- _ Feet Feet
VII. TANK Ca
in alloacitns Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete co" steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank Q IppLsJ~~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber`1 ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, t undersigned, assume responsibility for ins allation of the onsite sewage system shown on the attached plans.
VPIube s Nam : (P t Plumber' Si at e- to ps) rP/MPRSW No.: Business Phone Number:
_I _91
P umber's ddr Street City, S e, Zip e):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved S4nitary Permit Fee (Includes Groundwater ate Issued l Iss ing Agent Signatur No Stamps)
liQ(J 7~ Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. OW94) DISTRIBUTION: Original to County, One copy To: Sdfety & 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 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 wi th 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.
C_~rnlete p!,3ns and specifications not smaller than 8 1/2 x 11 inches must be sub-°iitted to the county The plans must
M(Jude the foilovving: A) plot plan, drawn to scale or with complete dimer,son,s, locati , - < f ~')o ding tank(s), septic
r .~`s r' er IreatrtM-nt tanks; building sewers; wells; water mains/watc_= ce; stre_- lakes; pump or siphon
r ~ s ~u ion boxes, soil a5sorption systems; replacement system area,,,- the lot-tio, c the building served;
N; hor~c rid vertical elevation, reference points; C) complete specification `or pumps a-~C -ontrols; uose volume;
elevation differences, friction loss, pump performance curve; pump model a --mp m,:<~ r-ct,~rer~ D) cross section
of the sof! ai sorption system if required by the county; E) soil .est data, oi, <a 1 :_)rn,; a 1a al= 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.
Gyp
~G
A~p
3y~
SAFETY & BUILDINGS
R1 MENT OF REPORT ON SOIL BORINGS AND DIVISION96
as ~ ~ P.O. BOX 7T AN PERCOLATION TESTS (115) ~qM DI ON, WI 53707
R AND
aN RELATIONS (H63.09(1) & Chapter 145.045) _
TOWNSHIP/MUNICIPALITY: LIT N9.:1 n/a O.: S~asSISLake South
. /
ION:
"PION: SEC
26 /T30 N/R19x1°rlW St. Joseph
MAILING ADDRESS:
VTY: OWNER'S BUYER'S NAME: 1353 Awatukee Trl. , Hudson, (~i. 54016
CrOlX Richard Stout DATES OBSERVATIONS MADE
PROFILED S RIPTIONS: R O ATION TESTS:
NO. BEDRMS :COMMERCIAL DESCRIPTION: New Replace (y_2 x_97 n/a
Zesidence 3 n/a
rING: S= Site suitable for system U= Site unsuitable for system
NVENTIONAL MOUND: INGRO'UND-PRESSUR.: S STEM-IN{FILLHO^LDING~fVK: RECOMMENDED SYSTEM:Ioptional eV 1 trench
s au is ❑u o s ou a s S U U
DESIGN RATE: FFlo0 any portion of the tested area is in the
°ercolation Tests are NOT required dp lain, indicate Floodplain elevation: n/a
der s.H63.09151(b), indicate: CLASS 2
PROFILE DESCRIPTIONS page 42 11
deciaml' P HT R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
ON BACKI•' 1 • 17 , 7 • 5 -
)RING TOTAL ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRVM
JMBEROEPTHQC .67 10 r4/2, 1., 1.42., 10;_ 1 7.01 98.10 none >7.01 4/4, s,!., 3.50, 7.5yr5/6, - - .75, 10yr4/2, 1., 1.17, 10.
5.33, 7.5-
c 2 7.25 08.30 none >7.25 r4 4 co.s. ?..00, 10yr
.75, 10yr4/3, J--,
7..y / , r
15 r4 6 J-• 3 3 7.42 97.10 none >7.42 /4, co.s. .75, 7.5 rLI/4,
.58, 10yr[,/3, l., .83,7.5., 2.00, 10y
[1 6.91 94.0none >6.91
1 5n 53=311k, , 1., .75, 7.l., 5.25,
B -
.67, 10yr4/3
3- 5 6.67 94.20 none >6.67
B
PERCOLATION TESTS RATE MINUTES
DROP IN WATER LEVEL INCHES PER PER INCH
-LEST DEPTH WATER IN HOLE TEST TIME p RI D 2
NUMBER INCHES AFTER SWELLING INTERVAL•MIN. PEitIOD 1 -
~P-
P
1 _
IP see desi rate
P-
P-
hori-
P =
PLOT PLAN: Show locations of percolation tests, soil borings the on di the plot mensions of plan. Show suitable the soil areas. surface Indicate elevation at scale all or di
borings stances. and the direction whatrection are and the percent
zontal and vertical elevation reference points and show their
of land slope. 94.10= upper trench
SYSTEM ELEVATION 93.10= lower trench
f
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the location this form awere re correct by me be tcoord r with the pro lures an . methods specified in the Wisconsin of the tests Administrative Code, and that the data
recorded and to the my knowledge a belief
I, the undersigned, hereby certify that the soil tests
TESTS WERE COMPLETED ON:
NAME (print) _
4-23-92 tioi,all:
Garv L. Steel CERTIFICATION NUMBER: PITON MUE of BERI°p
nliDrTFSS: ?20 2~`h-62 0•
live • . '1 TeF7 )'v1C}]P.tOn.d. T'):l . 511017 CST SI UR E: ~=-~-=K----
Hlq, UTlO Pt°ptrtY Owner n
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PAGE OF
s PUMP CHAMBER CROSS SECTION AMD SPECIFICATIOXIS
VENT CAP 4* C,I. VENT PIPE
T WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MAWHOLE COVER
2.5' FRQM DOOR,
WIWDOW OR FRESH I2"MIU.
AIR INTAKE I
GRADE
ti" MItJ.
I B' M I IJ~
CONDUIT
IV'
A
PROVIDE I I - - -
IS71MLET
--7~ AIRTIGHT SEAL I i l I
1 I I
APPROVED JOINT A I III APPROVED JOUTS
W/ C. -1. PIPE I III W/C.I. PIPE
EXTENDIN¢ 3' I II ALARM EXTEW011JG 3'
OWTO SOLID SOIL B ONTO SOLID SOIL
1
I I GN
C
PUMP
OFF
D
L CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF .TANK MANLKACTURI`R HAS SUCH APPROVAL
SPECIFI.CATIOUS
i:PtIC AND
OSE TANKS MAWUF'ACTURER: QUMBER OF DOSES:' PER DAy
TAWK GIZE : GA LOWS DOSE VOLUME: CALLOUS
ALARM MMJUFACTURER: S J,f C CAPACITIES: As;,,~R 11JCHES OP, 1=2 GALL0U5
MODEL NUMBER: B= ,2 imr-NES OR GALLO►JS
SWITCH TYPE: C=-.INCHES OR GALLOU5
PUMP MAMUFACTLIKE R: t 0- ::Z WCHES OR CALLOUS
MODEL NUMBER: NOTE: PUMP AND ALARM ARE TO BE
bWI1CH TYPE: .#.6 y . I USTALLED ON SEPARATE CIRCUITS
PUMP DISCHARGE. RATE GPM'y /S
VERTICAL.DIFFEREWCE bETWEEW PUMP OFF AQO DISTRIBUTIOW PIPE.. FEET
♦ MINIMUM NETWORK SUPPLY PRESSURE -a-. -Er- FLET
+ - FEET OF FORCE MAIN X 39R F/00 FLFlRICTIOU FACTOR.. 1 S FEET
TOTAL OtWkMIG HEAD = ~7 FEET
IUTERNAL DIME IONS OF TANK: LENGTH ;WIDTH -;LIQUID DEPTH
91GIJE0: LICCUSE IJUMBCR. - ~ 7 DATE:
Performance
Curves Pumps
METERS FEET
90
MODEL 3885
25 80 SIZE 3/4' Solids
WE15H
70
Z 20
WE10H
60
~ - WE07H
50
15
WE05H
40
I
10 30 WE03
WE03L
20
5 i
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
0 10 20 30 m3/h
CAPACITY
MGOULDS PUMPS, INC.
sew F,I's new roan i3i"6
METERS FEET
120 MODEL 3885
35 SIZE 3/4" Solids
110 IWEISH
i
100
30
90
25 80
70
20
60
O
F-
WE05HH
50 1
15
40
10 30
20
5
10
I-
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
t i i ,
0 10 20 30 ml/h
CAPACITY
91985 Goulds Pumps, Inc. Effective July, 1985
C3885
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 'NVXN
MAILING ADDRESS _ $S Q0e, 01*-k
PROPERTY ADDRESS W) 5L{ b 1 n
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Li % t y b ) Lg PROPERTY LOCATION 1/4, 1/4, Section T 3 O N-R I_W
TOWN OF n n o ST. CROIX COUNTY, WI
SUBDIVISION 11r~-°' ~c0 LOT NUMBER
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
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year ~expiration date.
SIGNED:
DATE: 'f) J~ _ %'S
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, W1 54016 11/93
M
t x" 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 Location of property 1/4 Stw' 1/4, Section, T 30 N-RW
Township Mailingaddress 1$S aos~ au".
Address of site 135G S~ybj
Subdivision name aQt. ~,.15~ Lot no.
Other homes on property? nn 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)? JZ_Yes No
Volume and Page Number l.S 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. 5 3~3a9'-/ 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.
Signature of Applicant Co-Applicant
08/141e95 •T 16:23 $ COUNTY CLERK Z002/002
l4
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 TM IS SPACE RESERVIUDFOR RECORDING DATA
WARRANTY DEED
533294 Yoe ,1~ 3gPAG~ 158 FRE
'S OFFICE
CO., WI
f
orRsowd
Richard 0. Stout and Janet P. Stout, ~X955
bit4 11~and and wife survivorship marital
prooiler tY, at 1:30 P. M
conveys and warrants to Michelle M. Germain, a yy
married person. ~le'"`~°~•
Fie91t:~ of Desds p
- /0.00
RETI,IRNTO Q l1 R,hr
/ 9 53 I~.GV•ttLe ^j~s~".
the following described real estate In st. Croix County, A^°" `t'om'
State Of Wisconsin:
Lot #9, Plat of Bass Lake South, Town Of Tax Parcel No:
St. Joseph, except the northerly nine (9)
feet previously deeded to Vernon and Marlys Orf.
This is not homestead property,
(l8) (is not)
ExceptiontoWarranties; easements, restrictions and rights-of--way of record,
if any.
Dated this 31st day of August '19 95
(SEAL) zv:~~ LC /fvr~- \ (SEAL)
Richard 0. Stout Janet P. Stout
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEAGMENT
Signature(s) STATE OF WISCONSIN
ss.
St. Croix County.
auihendcatedlttis day of 19 PeMonally0amebef0reme this 31St day of
AtjGust .19- 95 theebovenamed
Richard 0_ stout and Janet P. Stout
TITLE: MEME1ER STATE DAR OF WISCONSIN
'I {II not, to me known to be. the persons executselpe
authorized by § 706.06, Wis. Stats.) foregoln Instrument and ackno . U .f J
II TAISINSTRUME►jfl gR IMBY
Jwill~ t"
!353 Awa*kes Tr-. W co
u
Hudson, W1 54018
'i Notary Public U•/ Ou ,,.W
I (signatures may be authenticated or acknowledged, 9oth My Commission Is permanent. { ~,{(e•M~>t~on,
are not necessary.} ~••'a.-~ i~.m•=~ri•)
date:
'Names of persems signing m any capacity should be typeo or primed below (heir sionaluree S02 NTF cov
WARRANTY DEED STATE BAR OF W ISCONSIN Nelco Tax Forms, P.O. Box 10205, Green Bay, WI5a307.pZM
Form No $ - 1982