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HomeMy WebLinkAbout032-1065-40-100 t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNERS %~,1~ L-o~- ADDRESS 7 2- 210 +4- ~w-C - o nn & r'Sc'~ J- SUBDIVISION / CSM# LOT # _ SECTION T N-R~ W, Town of 4 C, ST. CROIX CO NTY`~t1ISCON N PLAN VIEW sue' SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Jar X5 J -5/~scr~ o Z211- 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• I SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location 'SOIL ABSORPTION SYSTEM Width: / Length ,75- Number of trenches Distance & Direction to nearest prop. line: Setback from: well House Other ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold/ 9 Bottom of system SS ,7 Existing Grade 9_s Final grade 9_f DATE OF INSTALLATION: -_S PLUMBER ON JOB: r/ LICENSE NUMBER: INSPECTOR: 3/93:jt /kc# i i~ iertr>r I trTy, 24 . 31.19 A YV S &VAT& SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 193377 Permit Holder's Name: El City El Village [Town of: State Plan ID No.: BEI SOMERSET ST BM E V7 Insp. E1 6v.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300034 7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S ~Y2 , Benchmark 3' Go, Dosing ® ,.6 93- 5 Aeration Bldg. Sewer 9.3,17' Holding St/* Inlet 97 / .3 /o ' i TANK SETBACK INFORMATION St/ Outlet 3 %Z 7 TANKTO P/ L WELL BLDG. ventto ROAD Dt ~Aet Air Intake Septic NA Dt Bottom i Dosing NA Header. X.3? Aeration NA Dist. Pipe Holding Bot. System (o$ PUMP/ SIPHON INFORMATION Final Grade Manu acture Demand JC 9 , v Model Number GPM TDH Lift Friction Sys TDH Loss Hyea Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width-/ Len th i No. Of enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z DIMEN N fa SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anucturer: SETBACK CHAMBER INFORMATION Type Of /7 44-? 1-60. a / . Model ber: System: 2 ~c c0 OR UNIT DISTRIBUTION SYSTEM oF' Z/o AY/e• Header r/ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Length Dia. S~ Spacing Fes' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over y xx Depth Of xx Seeded / Sodded xx Mulched Bed /T*eoEh Center C Z Bed /T4@o6k Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 24.31.19,NW,NW, 210TH Plan revision required? ❑ Yes o Use other side for additional information. 7 3 SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 4 SANITARY PERMIT APPLICATION COUNTY 7DILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERM _!T -Attach complete plans (to the county copy only) for the system, on paper not less than 3307 -7 8% x 11 inches in size. ❑ check If revi~i5n to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY LOCATION N, R E (or PROPERTY OWNER'S MAI LIN%ADDRESS LOT # BLOCK # 7 CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) El State Owned VILLLLAGE NEAREST ROAD "Of ❑ Public kAj 1 or 2 Fam. Dwelling-# of bedrooms 3 PA EL X NUM III. BUILDING USE: (If building type is public, check all that apply) , lli~~• ~Q _ a„ 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 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. ❑ Replacement of 4.0 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 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.) (Mind ch) ELEVATION ? Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber Fj F1 El I EL I-] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans. Plumb 's Nam (Print):i Plu77~_ atur : (N s) MP/MPRSW No.: Business Phone Number: A111 1 r S' i 9 : : P um i s ddress (Street, City, State, Zip Code) J,- IX. C NTY/DEPARTMENT USE ONLY Disapproved witary Permit Fee (Includes Groundwater at I ue Issuing Ag it Slgna Sta ;Approved El Owner Given Initial 021- Surcharge Fee) 2 ~7v,P~ Adverse De rmin tin X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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. 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 sakes; 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 pecifications 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) Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Z Labor and Human Relations .Divisi3?0&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 not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARC L I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPER ER: PROPERTY LOCATION GOVT. LOT 114 1/4 T ,N,R C E (oc' PROPERTY WNER':S MAILING APPRESS LOT. # BLOC SUBD. NA WO CSM # CI TATE 77 ZIP CODE PHONE NUMBER ❑ I ]VIL GE OWN NEAREST ROJ~RV New Construction Use p(] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2_,_7trench, gpd/ft2 Absorption area required 7S22 bed, ft2 Z:51~ trench, ft2 Maximum design loading rate _,__7 bed, gpd/ft2_trench, gpd/ft2 Recommended infiltration surface elevation(s) Ss-~, 7 It (as referred to site plan benchmark) Additional design / site considerations Parent material 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 [AS ❑ U [as ❑ U As ❑ U ❑ S JA U El S 19U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. C nt. Color Texture Gr. Sz. Sh. Consistence Botxtdaly Roots Bed Trench Ground- so( , elev. ft. Depth to limiting factor Remarks: Boring # Fly f~J \•ii•iv'::••••:: w 0e) _JZ, 64,w5 Ground elev. 9&:: 2 ft. - Depth to limiting D factor > q «0 IIEC Remarks: CST Name:-Please Print j GOFF/GE Phone: Address: Signature: Date: CST Number. G ~2 _j PROPERTY OWNER SOIL DESCRIPTION REPORT Page--,~-,cf PARCEL I.D. # • Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fh " in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Thanch 27 ?c. 4X Ground - r lev. YQ ft. Depth to limiting factor _ Remarks: Boring # E 4?? Z /I 74 s gr Ground ev. 2S2 ft. Depth to limiting factor y 1/ Remarks: Boring # kLI s Ground ' elev. ' ft. Depth to limiting factor 1 ~ Remarks: Boring # (L J k-0-4~ &Z Ground elev. _ 45- Z4 f ~~'~ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) , I IF ' I I + T -t j I j j ( j I I l I I I ' ~ - I I I :I I i i t ! I i I~ - Y r i - - i - I , I I I r ~ i - - - - - 14 I ` t-- - - -1---t-..-y.._T- -1-_ -T r t7r ~ I ~ uSk,' ' I ~ I I I ( i , i j ~I ~ I I I I I I I I I - r r 1 L ~ r I I ' I r I j I~ ' I- + ' I I, -1- • ~ I =-t - - - - r - - - } - - I _ _ _ _ _ _ - - _ _ _ _ „ i - _1. ~ ~ i t i I i I ~ ~ ' ~ ~ ~ f i i ~ ~I' ~ I j i . _ ' I I i I i I I i ~ i i I. r-_~___ I I ~ ~ I ~ ~ I -l i i r i i i i i ~ t ~ _ ' i ' 1 - - I ~-ter I - t-A- 1 - j-.i I 1 i , i , ~ J I I I 1 , I ~ - i I ! i i ~ i I ~ I_ I I 1 I i I I A I I ~ , i , 1 I f I 1 1 i i Auto" I , _jaT 1 , i I d8 ~ - - - --T- - ~ - _ _ _ _ _ _ , , _ _ _ 1- _ - _ _ - - ~ 1 i - - _ j j _ _ . - 1 - j I i . _ ; _ _ - - . t - ~ . _ _ _ . _ - - - - i - i _ _ i - _ _ . _ _ r i - - - - _ - i I _ j - - _ _.r , ' i N1G t or ~Cross` . y MP flesh Air ihitli, Mlt 96661t41144 pipe V461 got • flail ofellop .I 0 4' cosl 1104 48" Abe* i• 11.46 0+•4• v..l py • wsh (NV 0/ i1011Mlk C••alav i r • . W AtM.•HI• OvN PIP + a+l. L.IIssZ,., » e' Atp•t46~ ~ r • 0••••1• III• • pwlw46•• pipe below " • C•yn•t 1006"46141 AI 00 ••ll•* 01 i I+Hw Pro 0 c o IA•.~ 9 fh e#`~ - - 9~0- _ SOIL rILL; OISTIt1ouno I p I ~ E • AppRO`/Cp S.j)JTN[71C Cove ,Z"OF -i'"'"ce . • ~'/'1ATEIZl~1• OR 1« OF STRAM /~4 GR C~ 111i: OR MAR00 NAy ELEV. oFFeET •^b4` r.~O~JS-tl/; LGGItCGATC ~p , dim. OISTRIAUTICTo1 plPt •TV riv t, T 4CAtiT INCNCS 6CLdw ORiG'IIJA1, .•'IwOE AUV AT L SAST LO Ii.I4b1GL SUT LIO MOKC THAN 41 I►JCIICS DELOW FINAL. CIIAGL 1WIMUA DSPN.OF F-XC.AVATIOIJ FKoM OWWAL 61AD WILL, DE IuCHCS tvHlmvM ©EPnt OFT,1<•EAVAT109 FROM 0~I4111qL CRAPE WILL. SC INCHCS ~1G►JCC+ C uGCuSC uumocki.,,. VIP ogTC: - lJ- ~ lia . r CERTIFIED SURVEY MAP Located in-part of the NW's of the NA of Section 24, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. N= d OWNER LEGEND o N Roland Belisle 2" Iron Pipe Found 719 - 210th Avenue 1" Iron Pipe Found i; Somerset, WI 54025 z W Existing Fenceline L - N N 3 100! Roadway Setback L M M O O O L (M A N 00 C fn N . Of .4 L. L C u~1~~aTTEV ~AN`Q co r_ -W TNorth line of the NW S890334411E S8903314411E S89033' 44 "E 500.00 © 79 01 250.00' 210TH AVENUE 250.00' M 129-40' 250.00' 250.00' NW Corner of g - S8903314411E c 500.00' - o N} Corner of Section 24 Section 24 M M M M M ® HOUSE O ~f) O U) WELL I GARAGE SEPTIC& _ o _ I c~ I VENT °o to 4 u-. 1 I N <i `n LOT I LOT 2 ^ 3 []I W CD° Including R/W: Including'R/W: CD 3 s C]I LIJI N o 3.01 Acres C 3.01 Acres c N L1J1 131,250 Sq. Ft. o 131,250 Sq. Ft., - ° -I !-j r o r° I-- I Q I 0 Excluding R/W: Z Excluding R/W: <I LL CD 31 0 O 2.82 Acres 2.82 Acres oo y ~I z 123,000 Sq. Ft. 123,000 Sq. Ft. cn w I D -)I 250.00' 250.00' N89033'44W 500.00' UN PL_ATTE~ LANDS PREVIOUSLY RECORDED Line Bearing Length QA S8801213011E 794.37 < S8801213011E 500.00' © S0103810511W 525.00' ® a t, 9 N N88°12' 30"W 500.00' < ° ® N0103810511E 525.001 SCALE IN FEET Z ° 0 50 100 200 SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify that by the direction of Roland Belisle, I have surveyed, mapped and described the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel.surveyed and mapped is described as follows: A parcel of land located in part of the NW1/4 of the NW1/4 of Section 24, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin; further described as follows: Commencing at the NW corner of said Section 24; thence S89u33'44"E,,along the north line of the NW1/4 of said section, 794.40 feet to the point of beginning; thence continuing S891,33'44"E, along said north line, 500.00 feet; thence S00v17'25"W, along the east line of the NW1/4 of the,NW1/4 of said section, 5,25.00 feet; thence N89033'44"W, 500.00 feet; thence N00017'25"E, 525.00 feet to the point of beginning. V. Above described parcel is subject to right-of-way for town road (210th Street) and all easements of record. I, also certify that this Certified Survey Map is a correct representation,to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the Wisconsin Statutes and the Land subdivision ordinance of the County of St.-Croix in surveying and mapping same. ti S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS FIRE NUMBER CITY/STATE .(Y~P~~`~~' ZIP ~~1TO PROPERTY LOCATION: ~,M/4, 1/4, SECTION-, T- N-RJ„~_W TOWN OF SOf(`(~Qf CS? , St. Croix County, SUBDIVISIONLt A )0'[. 9.01. 667 , LOT NUMBER Q.. I C/ 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 a 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 Co. Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix co. Zoning office 911 4th St. Hudson, WI 54016 4 STC-loo This application form is to be completed in full and signed by fthe 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), thenia 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 ofproperty 1/4 t1/4, Section (7~q T_N-RqW Township ,ry Mailing address t(bh(-~j Address of site Subdivision name__ (?,5M . Lot no. other homes on property? yes-- No Previous owner of property Total size of parcel A C 1-es Date parcel -was created _ . Ili ) C/ Are all corners and lot lines identifiable? .._._Yes No Is this property being developed for (spec house)? Yes )~,No Volume_ and.Page Number <_Q~-as recorded with the Register of Deeds. qa9 567 INCLUDE WITH THIS APPLICATION THE FOLLOWING: A 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 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 fbr/the 2-V 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 County Register of deeds as Document No. Signature of applicant Co-applicant ICJ L lS(. ~ ff 'lo Date of Signature Date 0 f Si nature 9$9PAGE CJs 1 VOI. DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA 494034 QUIT CLAIM DEED II REGISTER S OFFICE ST. CROIX CO., VA j Waensl_ J,--_Belisle_ and__ Janet R. Beli ----sle- husband- and Reed for Record II - JAN 1 4 1993 f M quit-claims to __Lisa Ann Belisle and Susan Marie Belisle,-as.- at 8.30 A, tenants in common - - - - - r. _ - - - - - Register of Deeds the following described real estate in St.__CrOl------------------- County, - - State of Wisconsin: RETURN To Heywood & Cari A parcel of land located in part of the NW1/4 of P.O. Box 229 Hudson, WI the NW1/4 of Section 24, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin; further described as Lot 2 of the Certified Survey Map filed in the office of the Register of Deeds in St. Croix Tax Parcel No:._.__..-.. County Vol. 9 Page 2579, subject to the right of way for the town road as shown on survey map. EX VMPT- This is not homestead property. (is) (is not) / Dated this day of January 1993..... - - - (SEAL) -------------(SEAL) * Roland J~ nns- - (SEAL) J - - - - - - - - (SEAL) GGGGGG"'''' I~ * * Janet R. Belisle - AUTHENTICATION ACKNOWLEDGMENT Signature (s) __of both_Zrantors STATE OF WISCONSIN ss. y -January 93 ST January CROI------- County. authenticated this _.._V.d of 19_.-_•- Personally came before'm9 938 the above named ~i Ta/-°-]------------ 6 MEMBER STAVE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the III foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BYI I i Heywood••& Cari -2.2.9.. __1~_.__H~y Hud_s_on Notary Public County rWis My Commission is (If not stateex n (Signatures may be authenticated or acknowledged. Both permanent. p are not necessary.) date- 19.---•--••) i it - - i I'i I I l QUIT CLAIM DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 3-1982 Milwaukee. Wis.