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STC - 104
AS BUILT SANITARY SYSTEM REPORT
0WNER_ -7 e- -4 ~ c <7
ADDRESS
SUBDIVISION / CSM# LOT
SECTION.,--;2. ~ T N-RZ< W, Town of
ST. CROIX COUNTY, WISCONSIN
VIEW
SHOW EVERYTHING lq~THIN 100 FEET OF SYSTEM
n
A~f
e-
t
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: LAG- ' A> Liquid Capacity:
Setback from: Well Jr,~House C' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: l1-2- Length 5 c Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS J~<-Z
Building Sewer ST Inlet, ST outlet z5a cF-A-
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system z-
Existing Grade ~L Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: '
LICENSE NUMBER:`
INSPECTOR:
3/93:jt
I
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
'Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
PeF it H§Idq N MANE ❑ City Village [ Town of: State Plan ID No.:
star prairip 038-1,112-30-0
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.
/00''7 160 A94nn127
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic J, S Benchmark /00,
Dosing
Aeration Bldg. Sewer 5^ 0 18
Holding St/Ht Inlet /by/4
TANK SETBACK INFORMATION St/ Ht Outlet L's3 0
Vent
TANK TO P / L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Se tic ? 0 >SU` NA Dt Bottom
p cJ n o
Dosing NA Header/ Man. q. off /c1
Aeration NA Dist. Pipe q o) 7 /b /
Holding Bot. System /0,Zc/ /00, /y
PUMP/ SIPHON INFORMATION _ Final Grade 102i3
,S~,-
Manufacturer Demand C''d„t,,. 3,31-
Model Number GPM
TDH Lift Lric 'on System TDH Ft
Forcemain Leng Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~a a ~ DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer.
SETBACK
INFORMATION Type O 0 CHAMBER / Moe Number:
System: --,.._,Q t4,t u r -1 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 ll xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center !`r Y Bed /Trench Edges tYo Topsoil E] Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 28.31.18.476A,NW,SW,LOT 5,192ND AVE.
,
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 2-
SBD-6710 (R 05/91) Date Inip ctor's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code
CouNTY~~ . CIAO 1
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than d A ql ?
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 O PROPERTY
WN LOCATION
rot et /2 4 yt cz '/a U-)/4, S T N, R l E (or)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/yz 2W _5A 5 -
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Cr G~~. 0.•2 ! S3'~
E3 TY
II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE : NEAREST ROAD
❑ Public V4 or 2 Fam. Dwelling-# of bedrooms PAR EL TAX NUMBER(S)
III, BUILDING USE: (If building type is public, check all that apply) 3 /l 4j v O ~O
1 ❑ Apt/Condo < O~
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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
11 0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 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) l ELEVATION
6 V(~D 7 Feet eet
VII.' TANK CAPACITY Site
in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank 0 t4it~j/L
Lift Pump Tank/Si hon Chamber F1 F-1 R Fj 171 El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum s gnature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plum s Address (Stre t, Ci , State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si s)
' ?d Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination - -
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & 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.
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.
IL 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)
PLOT PLAN
PROJECT Duane Faqman ADDRESS 1976 93rd St. Somerset Wi 54025
NW 1/4 SW 1/4S 28 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
~ c
MPRS BYRON BIRD JR. 3318 / DATE8/3/94 BEDROOM 3
CONVENTIONAL XXX IN-GRO PRESSURE
CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X54'
BENCHMARK V.R.P. Top of P.L. Corner Stake ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 101.2
12" GRADE
TYPAR COVERING
12" 6' Q3'
' SEWER R K
12'
90' 369' P.L.
5'
NB.M.
B-2 15' -1
6% Slo
0'
120'
Rep A
B-3
N
C!~
Vent Pri A o
~d
r I a.
60 I I 12'X 54'
10% Slope I
B-5 30' 30
15' S
B-4
Pro 3
Bedroom
House
349' P.L.
Wivonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labqr acrd Human Relations _
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 5*• V t
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
a n GOVT. LOT W 1/4 SW 1/4,Spy#- T N,R J jf E (or)
PROPERTY OWNER':S M ACING ADDR LQZ# BLOCK # SUBD. NAME OR CSM #
173 9Z Xe, S L
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE JgOWN NEAREST ROAD
New Construction Use K) Residential / Number of bedrooms [ J Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow 7~0 gpd Recommended design loading rate . 2 ed, gpd/ft2_,trench, gpo1ft2
Absorption area required 4-y 3 bed, ft25~ 7 trench, ft2 Maximum design loading rate '7 bed, gpd/ft2 . 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 140%.2 ft (as referred to site plan benchmark)
Additional design / site considerations 4Q 99 9
Parent material Flood plain elevation, if applicable It
S = Suitable for system qgNVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE Sv5TEM IN FILL HOLDING TANK
U= Unsuitable fors stem S❑ U 5d" ❑ U 2l S❑ U S❑ U - S jgJJ ❑ S X U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou day Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmrch
0- i Cs •5
r G v
Ground
0-1-t 144W
e1e1
Depth to
limiting
factor-
27?
,3
Remarks:
Boring #
01
Ground
elev.
Depth to
limiting
for
~-T
Remarks:
CST Name:-Please Print Phone:
Address:
Signature: G~ w G~ Date: CST Number:
7
f
PROPERTY OWNER 24-L AX-Qda,4-- SOIL DESCRIPTION REPORT Page 6f
z'
PARCEL I.D. #t or C/
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
O 3
A.4, Ad
Ground
elev.
A-Uft.
Depth to
limiting
fact~in
ll i
f- S
Remarks:
Boring # 6
3n' /
Z
.y. C S lit. S
IV,
3 v-o 4ry w , X
Ground
elev.
/osaft.
Depth to
limiting
factor
S'-3 Remarks:
Boring #
4:ri r
i~.}:v'•n tip:. y
Ground - rc. -cam ~'S A/
elev.
/o1tt.
Depth to
limiting
fact
7
r
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Rn-arks'
Soil Test Plot Plan
Project Name Ray Fagnan Byron B' d Jr.
Address 973 192nd St.
New Richmond Wi 54017 C 479
Lot 5 Subdivision Date 7/13/94
NW 1 /4 SW 1/4S28 T 31 N/R 18 W
Township Star Prairie
Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of P.L. Corner Stake
System Elevation 101.2 * H R P Same as Benchmark
90' 369' P.L.
B-2 15' -1
6 O Slope
0'
120'
Pri A
B-3
N ~
O
ro
a
0' a
Rep A
M-4
B-5 Pro 3
Bedroom
House
349' P.L.
F FILED
Z A U G 3 0 1994 i. 8
JAMES 0 CONNELL
Register of Deeds
St Croix Co., WI O
520780 CERTIFIED SURVEY MAP
LOCATED IN THE NW 1/4 OF THE SW l Z4 OF SECTION 28, T31 N, R 18W, TOWN 0
STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN.
W 1/4 CORNER
SECTION 28 OWNER & SUBDIVIDER
T31N, R18W RAY FAGNAN
973 192ND .
NEW R C MOND,EWI. 54017
N 0
rn
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rn
U N P L A T T E D L A N D S
N
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o S 89°04' 34" E S 89°04' 34" E
° 66 I
250.64' 250.85' LO
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1 2.126 AC. f _ M °1 2.127 AC. t M
w :°n 92,606 S.F. t 92,646 S.F. t o ~ -
~I ,t INCLUDING TOWN ROAD w w a,
3 I of INCLUDING TOWN ROAD 3
ql O N 2.008 AC. f M N 1 N 2.017 AC. 1O Q
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- N 88°49' 19" W 250.68'
250.64' 66.00' f7 250.65'
N 89°04' 34" W 567.29'
POIN I OF BEGINNING SOUTH LINE OF THE NW-SW CENTERLINE OF ROAD ~
- - -192ND AVENUE
~ W
of 9411
~2 En II SCALE IN FEET
I W I xII
1 0' 25' 50' 100' 200'
N °II LEGEND
o COUNTY SECTION CORNER
z & MONUMENT FOUND.
SW CORNER • 1" IRON PIPE, FOUND.
SECTION 28
T31N, R18W 0 1"x 24" IRON PIPE,
a~ ; z WEIGHING 1.68#/LINEAL
of
FOOT, SET.
m 100' HIGHWAY
SETBACK LINE
AUG 2 9 '941
ST. CROIX COUNTY
Cw: y,rehensive Plarutiir
Zoning and
Fa,ks Committee THIS INSTRUMENT DRAFTED BY DARIN PLATER PAGE 1 OF 2
If not rocorded
within 30 days of VOLUME 10 PAGE 2811
400rnva►t date
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
i%R_ u
~a a h, le
MAILING ADDRESS
PROPERTY ADDRESS
(location of sceptic system) Please obtain from the Planning Dept.
CITY/STATE /Y"'a Ir" G/717~~zty ~!/r LS°°/
PROPERTY LOCATION /UW 1/4, 1/4, Section, T~N-R ,~W
TOWN OFf~ ST. CROIX COUNTY, WI
SUBDIVISION 33 LOT NUMBER S
CERTIFIEDSURVEYMAP ! 78~~VOLUME PAGE,~02 LOT NUMBER 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.
i
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: l cry
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 4a L / 92 a- 47
Location of property "1/4~114, Sectiorw!:,T-3/N-R,/ ;3' W
Township er / i'ac^t Mailing address',4y76
Address of site oe
Subdivision name Lot no. 5r
Other homes on property? Yes No
Previous owner of property
Total size of property 2?. ~,ZG
Total size of parcel Z2 5-0 Date parcel was created
Are all corners and lot lines identifiable? )(0 Yes No
Is this property being developed for (spec house)? Yes No
Volume -/Otl and Page Number 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. 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
th office of the County Register of Deeds as Document No. Signature of Applicant Co-Applicant
C G~
Date of Signature Date of Signature
DOCUMENT •NO. STATE BAR OC WISCONSIN -1982' THIS SPACE RESERYEU Von RICORDING DATA
DOC r1 OF c~ r. FORM > 3
QUIT CLAIM DEED ii I
520835
3- ,
- - - - - ~j [AUG r%o
CR41X C4., Wl
Raymond E. Fagran, a/k/a Raymond Fagnan, and Pauline I. !i
Fagnana)k)a Fagnanhusband and wife ec'dforRv.Ord
-
Duane - 3 0 1994
quit-claims to A Fagnan - i 00 P• M
(I Resteror0vedt ;I
I~ -
the following described real estate in St._-Croix County,
-
State of Wisconsin: AETFar TO
I
i ~
Tax Parcel No :
Lot 5 of Certified Survey Map filed August 30, 1994 in Volume 10 of I~
Certified Survey Maps, page 2811 as Document No. 520780, being
part of the Northwest Quarter of the Southwest Quarter (NW} of SW})
of Section Twenty-eight (28), Township Thirty-ore (31) North, II
I Range Eighteen (18) West.
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This i8 nOt homestead property.
I~ Dated this W(is not)
h day of - --August 19_.94...
--(SEAL) . ~ SEAL)
• o d E. Fagnan II
(SEAL) - ._(SEAL)
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• ,Pauline J.--Fagnan . _ -
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AUTHBNTICATION ACKNOWLEDGMENT II
i
Signature( s) STATE OF WISCONSIN '
St. Croix
_.County.
authenticated this day of-------- 19 Personally came before me this 3D-th.___-day of
- August---- 1944---- the above named
Raymond- E -Fagnan_.and- _Pauline--Z-•--Fagnala N
{
TITLE: MEMBER SPATE BAR OF WISCONSIN
~ (If not,
authorized by § 706.06, Wis. Stats.) to me known to .b$ttjw pajs&-}*.S---------- who executed the ~
fore ng instrut~ent• difd ackud'~dge the same. I
9
THIS INSTRUMENT WAS DRAFTED BY
.
Reinstrat-Van Dyk S Needham, S. C.
201 South Knowles Avenue, Box 127 •Ruth.A.._J#hn _--t-C
Notary Public - - -~-~~~~.7~->- ------County, W:Z.
New- Rich-mondi ---W ----54017
(Signatures may be authenticated or acknowledged. Both My Commission 1g permbnept'.,(jf tot, state expiration
are not necessary.) / t 1-Ir:f 19
date: -------1-2 ,
~I K'~sc~.n,in it
it QUIT CLAIM DEED STATE MAR OF 1WISCONSIN I.-%.I RI-k Co. I-
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