HomeMy WebLinkAbout040-1199-40-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER_ D ~IkZ (`off C
ADDRESS
yr
SUBDIVISION / CSM# SLA%4do coo 141115 LOT #
SECTION. s G T H E N-R_Z_2q_W, Town of --r,^,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 F E YSTEM
qz `
Z ~
1 /
N
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
R
7 / -147 2
~aSC' Ll
BENCHMARK: D-4'
ALTERNATE BM: oil l 27it,
EPTIC TAN PUMP CHAMBER / HOLDING.TANK INFbRMATION
Manufacturer: L'J e_e._ Liquid Capacity: 0dO
Setback from: Well Nam House Other
Pump: tser ac u er Model# Size
Floati n Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
4 Width: j Length Number of trenches 2
i
Distance & Direction to nearest prop. line: ~ bar t ~ 7
Setback from: well: ryawP_ House Other
I
ELEVATIONS
Building Sewer ST Inlet: ('!,Z) ST outlet~35k')
PC inl PC bottom Pump Off
He
ader/Manifold 6_eO Bottom of syste K
Existing Grade Final grad
DATE OF INSTALLATION: 4/26~4~'''.4
PLUMBER ON JOB: r
LICENSE NUMBER: RSA 3 zt2
INSPECTOR:
3/93:jt
ZOOMW"rPrtTR®i561n 4UY28.19.911 A#VAN,NSEWG$ b QW LANE County:
Labor and HLman Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitar;3Tr_initlQR0IX
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
X
~mey
Parcel Tax No.:
Insp. BM Elev.: BM Descriptio
040-
TANK INFORMATION ELEVATION DATA A9300179 Z_2
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 6 i
Dosi 9
Aeration Bldg. Sewer
d f
Holding _ St/ Inlet 99,_!5 6'
TANK SETBACK INFORMATION St /,P( Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Headert Y'/ 38 c/ ;
Aeration A Dist. Pipe ~F, 3 jif! 9,9,43 .4
Holding Bot. System 17
PUMP / SIPHON INFORMATION Final Grade
Manufa Demand 10!?.96
Model Number GPM
TDH Lift I Friction em Ft
Loss ea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Len tM No. Ofd renches WI No. Of Pits Inside Dia. Liquid Depth
S I `J DIM
DIMENSION
SYSTEM TO P / L BLDG WELL LAKE / STREAM HING Man urer
SETBACK : INFORMATION Type O rtT.u CHAMB r
System: 3 :
~~u5 OR UNIT
DISTRIBUTION SYSTEM
Header / Mani j d Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length~~ Dia. Spacing
-41 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems On
Depth Over „ Depth Over P ~r xx Depth Of xx See ed xx
B9*/Trench Center Jg ,8od / Trench Edges /1 L `f Topsoil - ❑ Yes El No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 28.28.19.911,SE, NE, LOT 4,SYKORA LANE
Plan revision required? ❑ Yes Q•t416
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signa ure Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
3
f s
SANITARY PERMIT APPLICATION COUNTY
D1LHR In accord with ILHR 83.05, Wis. Adm. Code
_ COY Z %4
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /J,~~
8% x 11 inches in size. c eck revis on to pr sous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
S Sa % tjM%, S Zla TZd , N, R 19 E (o a
PRO RTY OWNER'S MA G ADDRESS LOT # BLOCK #
K*Z B'¢N s'e.aQ f- L.a..-.~..
C TY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
'4(276$ S~ 11 s
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
State Owned VILLAGE Tr
C1 NOF y
_j
❑
Public ®1 or 2 Fam. Dwelling-# of bedrooms -3 PAR EL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) O q 0 ` ( Qn (3
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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. ~9 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 300 Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 220 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.) (Min./inch) %I el ELEVATION
LIA
7U ARML
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Plastic Exper.
t App.
INFORMATION New lExisting Gallons Tanks oncre strutte
Septic Tank or Holdin Tank Tanks O Tanks iftt Lift Pump Tank/Si hon Chamber
VIII. 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/ PRS Business Phone Number:
3- 2-
30 -a
Plumber's Address (Stre ity, State, Zip Code)
1thlil2
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ue Issuing Agent atur )
❑ Approved ❑ Owner Given Initial Surcharge Fee) a,rLr
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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. t
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.
111. 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 required by the county; E) soil test data on a 115_fortn; 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)
p roi e- ct C -Pv I e R/ v ~l!-G/V V GJ~ v"\ • 1
Sc,,~ uj.j~ 14 GL s
--7-6w,, o-e -7~o j &Y. C-(-6'i x Ca d
PAM-A 6e-,- a
'7/Z,(o 1i3
r^ e /
aa~
~~D~ • J~ s5. aej ` la ,6
a„l~ ~S (ape r~
O= pe.crc . ho
P~~r So: /s~- asQ9`
s~(A
Go vet
/ )00
6„ A n V
~ 98 Cuross ~e- c+, 0
I
Page 0` -
Per ipe Oetoil
End View
Perforates /
End Cap \e jT PVC Pipe
`l(as, Holes Located On Bottom,
S Are Equally Spaced
e
PVC Force Main
-PVC
Manifold Pipe
/y Alternate PDe,ition Of
Distribution Force
Main
Lost Hole Should Be
Next To End Cap
End Cap Distributi ipe Layout P Ft.
R
S
X Inches
Y Inches
Signed: Hole Diameter Inch
Lateral-- " Inch(es)
License Number: - Manifold Inches
Date: Force Main Inches
_ # of holes /piip-
Invert Elevation of Laterals Ft.
i
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
' INDUSTRY, DIVISION
LABOR
BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
4 NE Y44 Z8 /Tz8N/R/9E (o )W
'7r L4 o Suadowl~ t~;~~s
COUNTY: n MAIL G ADDRESS: 1 ) ,/_,2,
J Grof x F~,+ e, lr` ~ o ~`q R44 Z B ~ elr~ s T Qd 4 Iri e M ✓P,r 1'~S w," sj
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~I (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 'J? n)/A KalNew ❑Replace I 7/Z3 193 WZ4193
RATING: S= Site suitable for system U= Site unsuitable for system II
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
ms ❑U us ❑U ®S [_]U ❑S ®U ❑S ®U 'hr*,►Gn
If Percolation Tests are NOT required DESIGN RATE:
I If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/
B- 98ror, ou-'', c&/ 3t r Irs, 7 aar B N s j 1, Z0132t/ 8%
~3 no~~ y63 sc./ 32//- GZ" 9*/ z'^63" s ISR
B- 3 616 Co$ ! 5 o" 3oN-68" R sl rob"Gs
> 9 0"- VA sal Ts"VL "ZY"Sn s, / 24= S/`` kc N69 Tor
l
B- 5 96 9910" >8(0 ! 20!r_ sy 'f'
%/I ER 4-141A310-- ?
B- 61 t7 r0 95'8 >Sfo t!, 7,,jSj S,'/ tt~Z2a i/ zt` .I tj l S3 (,"L.
13-1 49 Wo 10 11 - -
/ rr R 7N81 s i/ Ts 7"~ Z 2 "~k z Z' = 3 0't Y s o t
B- 9 SO
yr"' ~O .S / W 4.1 inga. 76' ~ 96"4-V 0"11
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD 3 PER[ CH
P- Z@~ nok, 2 30 40
P- Z 2 0 r) 0 (A-4P- Z
P- h C) CAP_ 30
P
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATIO 73"2'' erJ's~➢~e. a/c~~-er 9G/o
~,dlt .►~~I~°
~ ~ t ~culv<t~ ~eC"d ~ ri
E ;
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1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
7/Z4 Z9 3
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
K*Z $a 7S Blca , LA,r 6472 2-3- Z7 1-715 569-JO
CST SI NATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
,t
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
6. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Boll Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
•s - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sI - Loamy Sand < - Less Than
•1 - Loam Bn - Brown
'sit - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic - Silty Clay fff - few, fine, faint
'c - Clay cc - common, coarse
pt - Peat" mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER BUYER_ -S~.1G
ADDRESS ~Z FIRE NUMBER
CITY/STATE tfiJe.,r T~ s , (A-)( . ZIP_,5''~C) Z'z
PROPERTY LOCATION : vS FL 114 , I E 1/4, SECTION 02~ , TZi4 -N-R 1 4 W
TOWN OF / u'd!, , St. 6roix County,
SUBDIVISION_ 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 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 bee maintained must be
completed and returned to the St. Cr x o. on' g Officer within
30 days of the three year expiratio d
SIGNED:
DATE
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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 record' i)
-
Owner of property
Location of property SE 1/4 tJF 1/4, Section Ze T 26 N-R_W
Township 126 L
Mailing address Z. keAr.T. JV ,y' a .
R I ve..tr FeL,l-s S zz
I
Address of site
Subdivision name 4,jul" 11-S Lot no.
other homes on property? yes~No
Previous owner of property Eo r / Ce-,p An ~nc}c-c s
Total size of parcel 2.22. CAC=.1YrIQ_-.S
Date parcel -was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?kYes No
Volume S11 and Page Number l3 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 & 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. 37Z 6 Qrn , 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
reco a he office of County Register of deeds as Document
No.
i
S' a re of applicant Co-applicant
A- ~
~ ~
Da e of/Signature Date of Signature
~ I r
~ DOCUMENT NO. STATE BAR OF WISCONSIN-FORM 1
WARRANTY DEED
322080 '(HIS SPACE RESERVED FOR RECORDING DATA
REGISTERS OFFICE
THIS DEED, made between Earl C6rnOliOlls. Bernard C@rnOhOL19,
Rosella Cernohous Hendrickson, Margaret Cernohous Ahrens, ST. CROIX CO., WIS.
Lilliam Cernohous Blake Rec'd for Record this-- _2$th
ana Sykora Land Grantor day y_______q.D.19?L
Inc., a W sco nain
A:, M.
Corporation FZ
Grantee, W i t n e s a e t h
, That the said Grantor for a valuable consideratiod--- Twent
pe6 ste► of Dee s
One Thousand and No/100----($21,000.00)------------Dollars
conveys to Grantee the following described real estate in. St- Croix County, RETURN TO
State of Wisconsin:
The Southeast Quarter of the Northeast Quarter (SZOV4) of
Tax Key
#
Section 28, Tomship 28 North, Range Nineteen West.
This s is s not homestead property.
i
TRANSFER
FEE
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining.
And_ said five grantors and each of them
warranMthat the title is good, indefeasible in fee simple and free and clear of encumbrances except A&°SMgmt+a Of rel!erd
and will warrant and defend the some.
Executed at Myer F l a i Wisconsin and t a 2nd day of may -1974
St. Paul, Minnesota C, Tll~l
IS
SEAL)
ous
SIGNED AND SEALED IN PRESENCE OF ®~'Yl0
erno O en C OA
9
(S
EAL)
Cernohous
4 1 •
Lillian CernOhous Blake
ICE
MArgaret Cernohous Ahrens
r
Signatures of Rarl Cernohous, and Rosella Cernohous Hendrickson
authegtie'afea thfa - /1/n day of May '19 74
y - 0 e iC.: Banta'`
-
t" Title: afffimm
.
Boom.
Other Party
Author
Minnesota ued under Sac.
706.06
STATE OF viz. Notary Public , State of Wisconsin
s s.
y~ Coamission ex ire
"J S . 6/6/76
Ramey -County p Personally came before me, this th da of ~ 1974
!
the above named Bernard Cernohous, Lillian Cernohous Blake, and ) gars Brno Ous Ahrens '
i
i
to,mf\knpwn to be the person s who executed the foregoing instrument and acknowledged the same.
;T ~trumnt was drafted by
H* a2•1 Plante
E ~fs, Ra=e Notary Public j County, Via.
RiFWisconsin
PiTE
l.A
H P
The'hse of witnesses is optional. .
b My Commission (Expire>~)
Notary :
- ._._hAY.n;uunusSiur, t.+~tn~ey Aug .
Names of persons signing in any capacity should be typed or printed below their Ve t res. A
BOOK J~ PAEE 413 ttcMi~~rca,a.h~
WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 - 1971
I