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STC - 104
AS BUILT SANITARY SYSTEM REPORT
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OWNER__aSe9A~G4 JhIaKC~1~ Ker~yerJ
ADDRESS U R41 mG HA s A1,I)Q
SUBDIVISION / CSM# 1NG, R04 LAW LOT
SECT Q
ION T, 0 N-R W, Town of- 105w,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
L) ~el7Kr
Home
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✓il
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 4 1 pa s l,' C(ey, 10 O" 0
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Weeks- Liquid Capacity:
Setback from: Well sit House 1 13' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
6
Width: I Length ~~Ij Number of trenches
Distance & Direction to nearest prop. line: 103~
Setback from: well: ~a House Other
ELEVATIONS
{
Building Sewer ST Inlet, ST outlet
PC inlet PC bottom Pump Offy
Header/Manifold Bottom of system 9t
Existing Grade Final grade )ill-)
DATE OF INSTALLATION: 13th f `j
T-T
PLUMBER ON JOB:
'1t'i Y
LICENSE NUMBER:
INSPECTOR:
3/93:jt
consin Dppartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Laf, ei Human Relations INSPECTION REPORT ST. CROIX
Safes d Ruildfngs Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Per jtH4~ r,'NNam&RALD/SHARON City ❑ Village Town of: State Plan I No.:
A, -qt Josieph I
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic zl_~ IA O 0 Benchmark 1o7.a6 /OV
Dosing -1,41 66'
1yGLV
Aeration Bldg. Sewer
Holding St/ Ht Inlet 7, 0(o Qs y9
TANK SETBACK INFORMATION St/ Ht Outlet ?"/s' Cj'S >U
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ~~v ~l / 5 / is l NA Dt Bottom
Dosing NA Header/Man. qSd
Aeration NA Dist. Pipe q
Holding Bot. System f ~,a S cJ~/,C~ /
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer and a9d'*0` 99"
Model Number GPM
TDH Lift Friction System TDH Ft
oss
Forcemain Length Dia. HH Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /I-,- DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type of Model Number:
fteW,
OR UNIT
/b37 ?7' /a6 14-)IA
System:
/ ISTRIBUTION SYSTEM
Head=Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air IntLengDia- Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 4 , 1 W xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges It, ~`t Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)-Ai/-
LOCATION: St. Joseph,32.30.19W, NW, SW, Lot 7, Rolling Hills Lane
U I\4 ~ 1~ I ` '
Plan revision required? ❑ Yes No ,t
Use other side for additional information. ' t 't,
SBD-6710 (R 05/91) Date nspector's Signature Cert. No.
"-on%-Depa"i-ortof Irduslry,
Labor and human Relations EVIL Utblhlf IIVr• Itw vn l
• (Attach Soil Profile Location Map To Scale . On A Se arate, Signed Sheet) Madison. ' a 9or • • ' StParatt. Signed Sheet) Madison. *.I
Page
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LOT BLOCK SUBDIVISION
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In Mvntell St. Cont. Color lecture Gr. SSt`. /h. C nuttence R of o n ar 00p1h trench p•d
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(3 _ Mprrton Depth Dominant Color mottles Structure Lrrrvung iactorr Loaang GPdso n.
In Munsell u St. Cont. Color T It r Gr. St. Sh. Consistence Roots Boundary Oepl11 Trench p•d
Elev a
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itce Roots Boundary Oeolh trench Bed
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In M nte11 u, . Con . Color lecture cif. t. h. Consistence Roott Boundary OOP )h Tgnch Bed
Elev a
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Additional Remarks:
RECOMMENDEDrYSTEM TYPE: '
i
Other Sue Features:
r nalvr - ? -62z
System Elevation v alt runt elT eohoneNo. C s.
L2 - /,,t, z~zezz A )z :zz~l-
CST Name (PrIM) City state tip
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ix w
SANITARY PERMIT APPLICATION
v~R COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
5L D
STATE SANIT Y ERMIT #
-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 t..D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
//W'/a 512) '/4, S ,,-1 T j,/~ , N, R / E (or) W
PROPERTY OW 'S MAILING ADDRESS LOT # BLOCK # l
7
CITY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAM CSM NUMBER
J,0- j, J~ t~ hf Taw,ialav
11. TYPE OF BUILDING: Check one CITY N REST ROAD l
( ) ❑ State Owned ❑ VILLAGE 4 O A ' 1 AN
❑ Public 2'1 or 2 Fam. Dwelling- # of bedrooms PAR LTAX NUMBER(S) -so
III. BUILDING USE: (If building type is public, check all that apply) 3a _30 _ I I -1 8 J COD
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 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._T ~ New 2.E1 Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E] 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
119 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
„ RE UIREDAsq. ft.) PROPOSED s ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet 916 MV Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concre Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank / b
Lift Pump Tank/Si hon Chamber El I El El 1. 11 El
Vlll. 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:
Plumber's Address (Skeet City, State, Zip Code).
T 1 ~
_ ~Qf ~o
QV rn 1 G 41k Soti Lai o~ 1St
IX. C NTY/DEPARTMENT USE ONLY
s
)
❑ Disapproved Saary Permit Fee (includes Groundwater Date Issued Issuing em Sig ure (~ta
Surcharge Fee) Q
Approved ❑ Owner Given Initial
Adverse Determination c0
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber
a
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.
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.
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 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
jequired 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)
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OT H I I AN
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FRESH 1tlAND pr.'?ERVA`r10tr-PI.pE
CROSS SECTION
Approved Vent Gap
,Na, 6Rn
Minimum 12" Above
Fi na r~aSle_.-
fn A.,x
A" Cast Iron
Above Pipe Vent Pipe
To Final Gradr.
Marsh Iiay Or ~Synthetic Coveri.ng_ r
Min. 2" Aggrc(j'I111 _ , .
Over Pipe 1V
Tee
Distributio~~
Pipe
Aggregate Per•f.orat:ed Pipe Deloar
1) neath Pipe --Coupling Terminat;incj
Rot• tom: of - Sys tem.
I
wwonl.^ Deoa•tr^.rtollroustry
Uoot and Human Relations 5Vll Ut:)lhlrllvr• nil vnl
: 0 9Qx
(Attach Soil Profile Location Map • To Scale • On A Separate, Signed Sheet) Madison. 41 SJ: C'
Page
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TOT BLOCK AlleL SUBDIVISIONwtw _ atrLacl
D • Horton Depth Dominant Color Molllts Slrutture Limiting Faclerr 1.486n9 VPD sp n.
In Mansell t. onl. Color Texture Gr. St. h• Consistence Root 0 n ar Depth Trench 0a1
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In Munsell v t, onl. Color Texture Or. St. h. Consistent R oil lovndar Depth Trench sec
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In. Mun ell . S . ont. Color Tetrturt Gr. St. Sh. Con h once Roots Bounds Depth Trench Bea
Elev = J/' U A11,31
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In Mun II .Con , of r T x r Gr.utt. h, n t me Roost eo ndar 0 "tn Trench Bed
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Additional Remarks: REC MMENDED SYSTEM TYPE:
Other $Ite Featurts:
ST s
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Sys(= Elevation
CST Ntune (Print) City ~iE C State Zip
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S T C - 100
this application form is to be completed in full and signed by
t!:e 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.
of property 6c Y'a~ 0.v ~1 _v o n ~~e rV 2
Location of property-tw-1/4 1/4, Section
3a . T,3L_N-R_]I_W
'i0 ship 30Sf D
i,a i 1 i ng address 6 ~Wti Q
Address of site ..V1 j S an-e so VA ~=Sycl
Subdivision name
arI,--, via Lot no.
Other homes on property? _yes -K No
Previous owner of property J erv (,L~d ~l ~Q b ~ky
Total size of parcel - Ckc res
44 L LL&Z( br- Ve f o peVS J:od.)
Date parcel was created 9 q
Are all corners and lot lines identifiable?
K Yes No
Is this property being developed for (spec house)? Yes X
jV 7(P S77 No
volume and page Number
of Dee s. - as recorded with the Register
INCLUDE WITH THIS APPLICATION THE FOLLOWING: - -
l, WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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
('-,e) certify that all statements on this form are true to the
'_lest of my (our) knowledge that I (we) am (are) the owner()
t`1e property described in this information form, by virtue sof oa
'.arranty deed recorded in the office of the County Register of
:.eeds as Document No. (p
^n the proposed site for the sewage d~ p salt system) orr I e(we)
L'tained an easement, to run the above described
the construction of said system, and the same has been duly
o
recorded in the office of county Register of deeds as Document
No.
Signature of ap-licant v-~
Co-applicant
Late of Signature'
Date of Signature
I
L
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~ r c`(1 S ha. ro el '3K -e r V ~ Vn
MAILING ADDRESS D 0 C4c a
PROPERTY ADDRESS lO YOLVIA S L6 r1 e ~t~S1S ~`~4~ So
(location of septic sysleff~ Please obtain from the /Planning Dept.
CITY/STATE H-kL 6 Vl L~ ~T D
PROPERTY LOCATION ~l 1/4, 50 1/4, Section c) T N-R___L! W
TOWN OF S-, S e v) r\ ST. CROIX COUNTY, WI
SUBDIVISION ~~O Vl 11S o v~ Y, LOT NUMBER _7
CERTIFIED SURVEY MAP 7"P~7 VOLUME 4 PAGE/ L3 , LOT NUMBER_ r~
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:
St. Croix County Zoning Office
Government Center
1101 Car►nichael Road
Hudson, W1 54016 11/93
• ` WARRANTY DEED THIS arACa REy ERVaO FOR RECORDING DATA
DOCUMENT NO. STATE OF WISCONSIN • FORM 2 't
516189 Y,;;1 076PA,t 5 -1 7 _
:c -
r
l
2nd
day of
indenture, Made this. i`'laV
neC'J IbY f:y~xlJ
This I
J L Lae Deve~or~ers, Inc.
. . cr
.
A. D., 19-9.1., between &
a Corporation duly organi•_ed and exi flog under and by MAY 3 1994
virtue of the laws of the Sta- of Wisconsin, located at..._Hq n-......
Wisconsin, party of the first part, and Gerald R.- Slceryen and•-Sharon- V_-.•••, nC 11:4 . A.
Skeryen~•. huslxzncl.eod--wife-r•, as-_suryiwrs.h marital
pro r _ -
part... of the second part , D
Witnesseth, That the said party of the first part, for and in considerationo` the sum
of..._. rty-one Thousand aitid rb/10Q..Lbl ars _ RlcTt„N To
to it paid by the said part-12S. of the second part, the receipt whereof is hereby confessed and
acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and con. A
firmcA, and by these presents does give, grant, bargain, sell, remise, alien, convey, and confirm unto
the saA parL.1e of the second part............their heirs and assigns forever, the following described real estate, situated in
the County of -St co.lX State of Wisconsin, to-wit:
:.r
Lot 7, Johnson Parkway in the Town of St. Joseph, St. Croix County, Wisconsin.
`O0 Yr,
I S-'- .
L
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE) 'S
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the a:r
estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or
expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. A`
To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said parLleS,~ _
of the second part, and to .........their......... heirs and assigns FOREVER.
And the said aT_.&_..L.-Lal1d..IeMe1QA2XS.,....I1'1C......._....
party of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said parties of they
second part, t7eir........._ heirs and assigns, that at the time of the ensealing and delivery of these presents it is well ~
seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple. M
and that the same are free and clear from all encumbrances whatever
i RR
i
and that the above bargained premises in the quiet and peaceable possession of the said part.. e$ of the second part, ._._._thair- .
heirs, and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and ~r
DEFEND.
J & L Land Developers, Inc.
In Witness Whereof, the said
party of the first part, has caused these presents to be signed by... C'erdld -A.-•. J011T1SOn__....._...._......-._ i
x
Linda D. Johnson - its Secretary.
its President, and countersigned by......... _
Hudson Wisconsin, anr}-rtrexgrnsir stah~m~edtt-reanto-a$ixed: this
-Z•Fld..... day of......... PY A. D., 19.....94
J & L Land Developers, Inc.
..........................................A.............._......_......._............__.._-.....--
SIGNED AND SEALED IN PRESENCE OF
ril~rste %'a--
Co
Pesident '
0-rald A. I.
Jo n `
COUNTERSIGNED:
:Uiv..._ ` Secretary Linda D. To STATE OF WISCONSIN
St. CrOlX County. } ss.
. .
A D., 19...9...., !
N1a
Personally came before me, this day of ....................y.
Linda Johnson
Gerald A. Johnson President and , Secretary
of the above named Corporation, to me known to be the persons who executed the foregoing Instrument and to me known to be such
President sad Secretary of said Corporation, and acknowledged that they uteri t e going instrument as such officers as the deed of +
said Corporation, by its authority. . .
~V~iz
.
to , k Zia. (~•IT ~
THIS INSTRUMENT WAS DRAFTED BY St. O1X
1' Q 7 AG''1C~fl~'il(r o.ry Public, County, Wis.
Attorney Hugh H. Gwln try commission (cr.Pires) Statutes (e riam of of the Wisconsin witnesses provides
notary. Section ~59.11t5 similarly requires shall that a the plainly y of r`}eed or npeho or 8 vettw
the names s of tha e , grantors. granteentees. ry t ppcc
mental agency whichi.h draafted such instrument, shall bSTATF.h 4 WISCONSIN F~ °r written tnereun in a legbl•'smor in • Leg Rl B:ar.k Cn. Ire.
WARRAN'I.1• DEED-By Corporation FOR.'[ No. t ?lilwnd,r+. W..