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Home My WebLink About010-1075-10-000~ f7 f/1 O n N O -s 'Q C'1 "J O ct F O y_ ~ O 3 ~ O n r+ ~ 1 O O m 3 A ~ ~j ~ v y ~• ~ v ~ ,~ . ~ m ~ .a # c .D ~ ~ 9 ' ° 3 m = ~ ~ r: ~ ~ ~ ~ A ~ .. .. ~ ... O to z ~ v', a n cn ~ ~ c~ o o n m w _o .c . m' m m m ~ °~ a ~° ? C\ a m m N m ~ A o S m ~ ° O J R r i W o ' Q. ~ N ~ ~ ~ ~ ~ = 7 (A W ' A ( J1 ~ , ~ ~ ~ ~ ~ _, ~ o o ~~ ~ ~ ~ ~ o ~ ~ `~ o ~ ~ q ~ !n ~ o m o ~ r,; ~ ~ N to Ro ~ .. ~ o o p ~ ~ ~ Z D Of S O a W o v -< D d m c a ca !r rn o m a ' ~ m ~' a o_ C o < !^ 3 ~- rn rn ~ -= n c a ~ l./ ffi ~ ~ ~ v ` `_ Q Q ~ ~ ~ ~ ~ `+ O C N N W V' 0o OD ~ ~ ;'! a O ~ O _ ''' • O O O < O O ~ ~ ~ ~ U) fp lA m ~ ~ to Ul N p not ~ ~ v o g m 41 m ~ v _q o " O CD ~ <D y N ' ~ O (p ~ A N ~ ~ ~ 7 .. O ' ~ d L N lV W » .. N 7 W ~ ., N 3 ~ ~ < j ~ `~ ~ A ~ .+ N ° ~ Z Z ~ o D D o O N :. D D S ~ O O ~ a ~ a lr ro o m o (~ ~~ I c ~ i c ~ ! ro o m o 3 m ~ m i m ~, m N -' -i y I= N C ~ Vi C ~ A Z f) ~ ~ ~ ~ "~, 6 Q p 2 O CD (D ~ .. 7 I O NO _. _. Z ~ W 0 a ~ a '~ ~ Z o ~ r: 'o ~ " A Z ~ O O m rn ~ f/1 ~ 1/1 ( D N ? W n j W ~ d ~ O Z 7 O Q d ~ O~ o~ O~ a C1 ~ p ~ j ~ ~ O 3 =, ~ ~ N Q S 7r ~ ~ C O) to O~ G ~ C () v - C CD = ~, ~ N~ O O. O ~ @ f7 ~ ~ i C ~ d ~ ~ ~ Q N N O O ' cj fl_ O N N ~ A . : I 7 '. ~ ~ I S ` ~ N Oo ~ I O ? fD x ~ ~ . ~. O K ' ? n v O x y 6 A C ~ ~ ~ t ~ ~ O "O N C ; .I O O ~ O 7 ~. 0 O V fA ~ ~ ~ -^. li m m b N O O I o O ' r .+. i I a ~ 00 ~. ~~ 00 : i r y ~' Parcel #: 010-1075-10-000 11/06/2007 11:39 AM PAGE 1 OF 1 Alt. Parcel #: 31.30.16.455 010 -TOWN OF EMERALD Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O - CLOUGH, BRUCE E BRUCE E CLOUGH C - CLOUGH, BONNIE M BONNIE M CLOUGH 2187 130TH AVE BALDWIN WI 54002-8011 Districts: SC =School SP =Special Property Address(es): ` =Primary Type Dist # Description " 2187 130TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABL E SEC 31 T30N R16W 40A NE NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 31-30N-16W Notes: Parcel History: Date Doc # Vol/Page Type 02/09/2006 818258 OC 12/03/1999 614956 1476/028 OC 01/08/1998 570968 1287/064 WD 07/23/1997 426/180 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Description Class RESIDENTIAL G1 AGRICULTURAL G4 PRODUCTIVE FORST LANDS G6 Totals for 2007: General Property Woodland Totals for 2006: General Property Woodland Last Changed: 10/19/2004 Acres Land Improve Total State Reason 2.000 15,000 188,700 203,700 NO 22.000 3,300 0 3,300 NO 16.000 16,000 0 16,000 NO 40. 000 34,300 188,700 223,000 0. 000 0 0 40. 000 34,300 188,700 223,000 0. 000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 131 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin i~epartment of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village x Township Bechel, Bonnie Emerald Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION Dosing TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number ' TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well county: St. Croix Sanitary Permit No: 40 State Plan ID No: Parcel Tax No: 010-1075-10-000 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only zx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No i Yes '- i No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /. Location: 2187 130th Avenue Baldwin, WI 54002 (NE 1/4 NE 1/4 31 T30N R16W) NA Lot 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = 3.) Contour = Plan revision Required? ~'?I Yes 11 No ~~~ Use other side for additional information. ~_ _ _ __ __ SBD-6710 (R.3/97) Date Insepctor's Signature Inspection #2: / / Parcel No: 31.30.16.455 ~~ J Cert. No. 0~l:02i01 HON 12:38 F.aIC 715 38d ~d8d ST CR% CO ZUr~ING 0001 County Sanitary Permit Application ST. GROIX COUNTY WISCONSIN In dOCOrd wit11 15.04 St. Croix County Sanitary Ordinance zaNING OFFiCP Personal information ypu provide may tie used for secand8ry purposes 37. CftOIX Ct7lJNTY GQVERNMENT CF~1TF~i jPrivacy law. 5. 15.04(1)(m)) 1701 Carmichael Road T+" T+' ~ ~ - ~' ~/ ~- L}~' 3/ r ~ Hudson, WI 5401b-7710 /a S -- S / {715)386-4680 Fax 715 388-4686 Attach GOm let9 lan4 for he s s em on a er f tt1 n 8.112 x 11 Inches in tliz2. Ccun anlta Permlt# ty S Ch~r~ous Ilratlon / ~ ~ ~D6.J i. A Iication Information -Please P'rtnt all Information t_ocatlon: Rroperty Owner Name NE 1/4 NE 114, sec 31 BONNIE BECHEL & BRUCE CLOUGH ST. CROIX COUNTY 30 N, R 16 Property owners Mailing Addross Lot Number 81odc Number 2187 130TH AVENUE N/A ht/A City, State Zip Code Phone Numer Subdivision Name or CSM Number BALDWIN WI 54002 715/684-5333 N/A 1 pe o Brliltling: (olleok or1r:) [,Pity ^ Vula~e Town of ~ 7 or 2 Ram;ly Dwelling - No. of Bedrooms: 3 EMERALD G PublidCommerciel (describe use): C~ 3tate•owned Neargsi Road Type of Permit: (Check only one box on line A. Check bcbc on Gne B H applied, e) II 130TH AVENUE . Parcel Tax Numtxr(s) A) t.Q Repair . ^ Reconnection Non-plumbing 4. ^Rejuvenation 010-1075-10 ,pod Sanllatlon B) Permli Number Date Issued Q StateSanlta Pennitwas reviousl issued 076 4 - - N. Type of POWT System: (Check all:that apply) C Non-pressurized In-ground (~ Mound ^ Sand Filter Q Constructed Wedsnd U Pressurized In~round ^ Holding Tank ^ Sinele Pass ^ Crip Line At rode ^ A9rgbIC Treatment Unit ^ RACtfCWddng ^ p((t~ V. Dis ereaUTreatment Ares Infomtatioe: 1, Design Flow Igpd) 2, Dispersal Ards 3. Oaperaal Area 4. Soil Application Rate 5, Perada0an Rats E. System Elevation 7, Fin o Required Proposed (Gals.7day/sq.it) (Minfnt~J Elevation 450 375 375 1.2 N/A 101.3 103.55 V do n armat on p f n a ons ~ a # of ManufaCtUr81' Prefab Site Con- Steel Fiber l Plastic New Existing Gallons Tanks Concrete structed ass g Tanks Tanks 1000 ^ ^ ~ 650 650 1 MIDWESTERN PRE ASD X ^ ^ ~ ^ Y11. Responslbulty Statement I, thG undnrtignod, asituno rospanslbfllty for rspalrlreconnenctioNrejuvenationlin5tdtlatla~ of non•plumbing for the POWTS shown on fhe attached plans. A license is not re fired for terralitt re dir or th9 Installation of non-plumbl sanitation s item. Plumber's Hama (print) Plumb ignature (nos` B - MP/MPRS Na. Business Phone Number BENNIE HELGESON 292 71 772- 2 Plumber's Address (Street, City, State, Zip Code) W1229 770TH AVENUE, SPRING VALLEY, WI 54767 VI11. county use only Disapproved SgniYary' Parmit Fse Date Ir;eued issuing Agent Signaturo (No sumps) Approved Ovmer Given Initial Adverse cf~ I ZS . ~~l~ ?,QR~2 t ~ Dotarmination ,, , IX. Conditlorta of ApproveUReesons for DiSAppr4vat: M~ r,.u.t„~-- v,,~-- ~ ~.~~tq ~.,t. re.~.v~ec.'~tS,,. ~" ~°a- ~X~'`Q • ' n ~ a°'~ ~°'QtQ'2 C~°~i~tMO+t~S Q,Q ~ ~ d. _ __ 1 ~~ iQ~'I o -t IJ I a n '• Leh ~~ e ~•e 1 c eso~ a~ o~ 9 a 13o7N A~~ ~oacJ G~1au /~f e a r ~ st P~'o Q ~~c' -I-~ Li V1 e.. L3- M- d- V. R.P loo, oG ~c?~-^1-a m o~ ~-~ X (o~ ~ ~O6C~ S ld l r) /" Ov~~- c JCa.I e. I "-4 Q• $~ ~ ~__-- ~ / - I i ~c~o l~ I ~ ~ ~ i it ~--~~. lt)~l 1 ~ ~s~~ c o~ +~:~~ t< Eia~. i T _~ L .^ lr J~ ~ !`Onr.~ // ,,// p I ' ~.Prop~~ ~ta-t- Plan L~~' ; ~. e n n i e_-c~ e ~ ~ ~ . ~ ~ ~ I ~_~ M l~~r ~. ~ ~ ~~ ~1 ~ e. o~ a ~ 0 ~? q a l3v TN A~~ _ Ro e~.d Cc~au Al~u~~s+ Prdp~r~ z.~~ d ~- M. a- V, f~.F? Wabd~ ~~1r L w~~ ~ XC ~~~cr n avert- ~ c on +ok~- e ~'i s ~y ~~o ~ j S~-t-'~ i-- / 1~ E I ev . ~Ga~e I `~_~a~ i ga / , __- ~- _ - ~ ` ~ i~ ° " ~' ~a ~~,~ / ~o~ I I A ~ v~ ~-- - - /V cab ~ I ~ Namc. ~o ,8'~ .~.'~'° f ~ JUN-03-02 08:51 AM ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address C'/~~~ ~~~ ~~ Property Address ~~~~ ~~~'1~ G!~ (Verification required from Plattning Department for new consavctio,~) City/State i~!/~1~,i?~ ~.~ Parcel Identification Number alp 105 =~a LECAL D < SCRIPTION Property Location ~ '/., I~_ '/., Sec, ~, T„~,~, N-R,1~W, Town of ~h~~ r~~ ~c.~ Subdivision ,Lot # ~.. 1 Certlfled Survey Map # ,Volume ,Page # Warranty Decd # 5~0~~3 ,Volume ~~7 ,Page # ~~' y Spec house ^ yes ~ no Lot lines idcntifiable~ yes ^ no P. 01 SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failt:ie to handle wastos. Proper tnsintetteat:e consists of pumping out the septic tank every three yearn or aooaer, if needed by a licensed ;atttnper. What you put 1t3t0 the iyB:em can afftet the function of the septic tank as a treatment stage in the waste disposal system. The propctty owner agrees to submit to St, Croix Zoning Department a certification form, signed by the owner and by a master plumber, jotuneymau pltunbcr, rastrictedpltunber or a LiceASedpumper verifyin,gthat (1) tho on-silo waatewaterdisposal system is in proper operating condition and/or (Z) after inspection and plunging (if necessary), the se;~tic tattle is less than 1/3 full otsludge. Uwe, the undersigned have read the above requirenteats and agree to maintain the private aeu~age disposal system with the staaderds set forth, herein, as set by the Department of Commerce sad the Department of Natural Resottrces,State of Wisconsin. CertiEleatioa stating that yotu septic system has beeA maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. i~~;~~ ~G.~~~ ~ ~ ~~ SIGNATURE OF APPLICANT DATE OWNER CERTIFIC~~'~ON I (we) certify that all statements on this form are true to the best of my otu lmowledge. I (we) am (are) the owner(s) of the property described/above, 6y v~irtu~e of a warranty deed recorded in Register o cede Of.:ice. i'LJ~L~%C ~ / y l ~~ SIGNATURE OF APPLICANT DATE '•`••' Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ••~••• •' Include with this applieatlott: a stamped warranty deed from the Register of Deods office: a copy of the certified survey map if refecence is made in the warranty deed ~~~V~ZDV STATE DAR OF WISCONSIN FORM 3 - 1982 WARRAtJTY DrE[ED DOC:'~~FNT NO. Y1! ~'H i ~Ait[0~~ REUBEN M. CARSON and LOIN Ai t_ARSON, husband and wife. conveys,and warrants to BRUCE E. CLOUGH dnd BONNIE M MOULT011, as point tenants. [he following described real estate m _ St. CrDix County, St.te o[ Wisconsin: /o REGIST~R'S OFFICE ST. CR IX CO., WI ~•c'd br ~setxr JAN ~ 8 1998 9:30 AM -s~.~c~.~,-~ r,~~,.a.~ N~ I~frr of D~~d~ TNIS SPACE RESERVED FOR RECORDING DATA NAME ANO RETURN ADDRESS T. M. Abstract & Title Services 63 S. Third St. Barron, WI 54812 010-1075-10 PARCEL IDENTIFICATION NUMBER The North^ast Quarter of the Northeast Quarter of Section 31, Township 30 North, Range 16 West (in tiie Township of Emerald). TRP NSFER OfI This 15 not homestead pr~peny. (is! its nut) Exceptiuntuw•arranties: $Ubject t0 highways, easements, restrictions, and reservations of record. rd rratPa this ~ day of January . A.D.. 199$- n STATE BAR OF WISCONSIN FORM 3 - 1982 614956 QUIT CLAIM DEED KATNLEEN H. WALSN DOCUMENT NO. ~(1~ 147UPAGE 20 _ REGISTEk OF DEEDS ST. CROIX CO., WI , _ : ,- ; RECEIVED FOR RECORD Bruce E. Clou h and Bonnie M. Moulton as , ioint tenants 12-03-1999 ~:15 PM QUIT CLAIM DEED quit-claims to Bruce E, Clou¢h and Bonnie M Bechel fka Bon M - EREMpT D 3 T FEE: T nie . Moulton as oint tenants ~ CHI ' FEE TRANSFER FEE; C DIN6 FEE: 0.00 ~ ~S 1 the following dexribed real estate in St. Croix State of Wisconsin: County, THIS SPACE RESERVED FOR RECORDING DATq quarter of the NE quarter Of SeCC. 31, NAME AND RETURN ADDRESS Twnshp 30 N, Range 16 W, in the township f E .2`j%'.~; rX l ~~~' o merald. t-~~ e~/~7 ~,.~{~ ~Qre~~L¢ .- _ .. ~){~ -/ ~ 7~ - /~1 PARCEL IDENTIFICATION NUMBER t This is not homestead ptnperty. (is) {is not) D~at~ed t~h~is 10th ~ day of Seutember A D 19 98 ~:~,~-s4 i `E`~° (SEAL) (SEAL) ,~j~~B,,ruc~e E, Clou~hj~' "~"`°'°~ ~--'«4-Jet _ (SEAL) (SEAL) Bonnie M. Moulton (a~~ka__ Bon~nie M. ,Buechel) aoc~.t:,nGl~ ~~ ~~ AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, n ss. ~' ` ~"it t k County. authenticated this day of , 19_ Personally came before me this day of 'fit' 1~7~F !~ g ~~ , 19 ~1 the above named F mH ¢ l~a;aJ E,m TITLE: MEMBER STATE BAR OF WISCONSIN ~~ (If not, authorized by §706.Oti, Wis. S[atsJ , to me known to be the person _~ d.the foregoing in ent and acknow dge the sa THIS INSTRUMENT WAS DRAFTED BY Bonnie M. Bechel (fka Bonnie M. Moulton} ~ .',` . Jo F '~, Notary Public, _ Co>t2)ty, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is rmanent. ([f ~ n at necessary) !~ ,~ ,, ~ ~ ~1(PiOuon date: ~J _ _. _.. ' Names of persons signing in any capariry should be typrd or printed below their sgnamres. ~ ~~ ~~~ - ~~~~ - ~ ~ ~- QUIT CLAIM DEED STATE BAA OF W15CONSIK Wisconsin Legal BIaNc Co., Inc. Form Na. 3 - 1982 Milwaukee, Wis. ~_ ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner r .~ c ~ Address f '1 fl City/State ~.~ Legal Description: Lot Block r-- Subdivision/CSM # '/4 ,~ %< ~ Sec. ~, TAN-R~W, Town of 4 i ,f >•~~ -. PIN # A~ ~~I-o' ~~ y~ ~ Tank manufacturer l"rf~W ~~ Size ST/Pt;/~-`~ / ~~Setback from: House ~"' Well~~ P/L~3~ Pump manufacturer. ~ ~ Model 65~ 3 3 Alarm location ~„ Coe 7r~ ~-co C-~~-~e ~~~~. (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: - Type of system: ~,~ Width ~~ - ~ Length ~ Number of Trenches Setback from: House Well (l 1 P/L ~ Vent to fresh air intake ~-- ELEVATIONS: y ~ ~ cow n ~ ~. ,~ ~, ~ ~ ~ S ~ -~Q OCR Description of benchmark ~°~'"'- ° ~ ~ k ~ s' "~ Elevation l~ Description of alternate benchmark ~ ~ ~.~' s~ ~~~ Sc,~ Elevationi~~ S ~ Building Sewer ~ ~~ ST/HT Inlet ~ ~_ ST Outlet~~ U PC Inlet O PC Bottom ~ Header/Manifold D ~~ Top of ST/PC Manhole Cover 91 ~ ~~ ~ ~D~ Distribution Lines ( ) /6/, 7S' ( ) ( ) Bottom of System () l ~ ~ ~ S ~ () ( ) Final Grade () /~ 3 • Y y () ( ) Date of installation/ /~ Permit number ~~~~~ State plan number ~ .~~ Plumber's signature icense number Date S /~ Inspector ~~cl~ Complete plot plan ~ .-~. ._.---. /3a ~~ _-_ NOTICE. Please provide the followii~ ~`~`/ • A plan view sketch showing everything within 100 feet of the sy • Two horizontal reference points to center of septic tank manhole • Show alternate benchmazk, if applicable. ~~ ~~ e~ i ~~ o ~ a~ ios %/ ~,_ ~~ c ~~ , INDICATE NORTH ARROW VIEW ~~ JI /~` ~ ~ ~~~~ ~ f~~` SQL ~~ VNiscons~n Department of Commerce PRIVATE SEWAGE SYSTEM Safety ar~tf Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ Town of: ~rut~ t/ ~o CST BM Elev.: Insp. BM Elev.: BM Description: I bd ~ SOD ~ ~s}b.,1 s ~ S col: r/v/ Lo/ Neer p'~ TANK INFORMATION TYPE MANUFACTURER CAPACITY eptic mj,~wQ,ct' ~rCc~6 f l Oot7 Dosing ~o«~ba (aSo Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic ~, ~ , NA osing NA Aeration NA Holding PUMP /SIPHON INFORMATION IyI,,,,X• GPnn y2 Manufacturer r~~c Demand Model Number ~ ~•`'~~GPM TDH Liftp-~t~, Lriction 2.35 System 2•S TDHIS,~! Ft Forcemain Length ~S' Dia. Z~ Dist. To Well SOIL ABSORPTION SYSTEM ELEVAT IUN UA 1 A County: ~~. c,ro~ r Sanitary Permit No.: 30 ~(~4 SF State Plan ID No.: 9glo~/S Parcel Tax No.: ~p/D -/07$ -/o-~GYj ~rR n~ R' 3 STATION BS HI FS ELEV. ~4 Lf. F3M'` 3.33 ~0~. 57 Bldg. Sewer /o •25l 9~ `~ St/ Ht Inlet ~p•bS -95~•2Y St/Ht Outlet ~,., .~ Dt Inlet ~.. Q.,, Dt Bottom ~jo, s Header /Man. Dist. Pipe i~~/ /V /•76 Bot. System 3.75 !o/. / S Final Grad e tt // RENCH Width ~y r Length , ~ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM I N a ~ ' DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING anu a SETBACK INFORMATION Type O m ~, 7Ce ~ N S r I ~ ~- CHAMBER OR UNIT Mo er: Syste , DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length ~ ~ Dia. Z~ Length ~ S~ Dia. (~~ Spacing ~~ !/ ~r 3~ •c SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of ~ ~ xx Seeded /Sodded xx Mulched Bed /Trench Center ~ L~ (a Bed /Trench Edges ' .Topsoil ~ Yes ^ No ^ Yes ~ No COMMENTS: (Include code discrepancies, persons present, etc.) ~,f1gZ ~s~c,"f~ .~VG ~~• 3 r~~ - as ~ ~ i, ~ s~~ ~, -~~ sw ~~N~ ,~ ~~ r~~~ sr ~l T ~ow~j ~ ~ri~~ S~[o~AB Plan revision required? ^ Yes ~j No Use other side for additional information. ~ Z ~8 0~ S ~'' ~ SBD-6710 (R.3/97) Date In edor's Signature ~~ 'f ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~' I l ~~is~onsin Department of Commerce SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Safety and Buildings Divisiai 201 E. Washington Ave. 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 t/2 x 11 inches in size. ST CROIX • See reverse side for instructions for completing this application State Sanitary Permit Nu ber q~ ~a The information you provide may be used by other government agency programs 7 ~ ^ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number I. APPLI ATION INFORMATION -PLEA E PRINT ALL INF RMATION 98-10451 Property Owner Name Property Location BRUCE CLOUGH NE 1 /a NE 1 /a, S 31 T 30 , N, R 16 ~~(~~ W Propert Owner's Mailin Address N1C~260 171ST ~TREET Lot Number Block N tuber y N/A A N City State $OYCEVILLE WI Zip C de 5+725 Phone Number Subdivision Name or CSM Number N/A - (715 >643-2420 II. YPE B ILDING: (check one) ^ State Owned ~ ~t~ Nearest Road Public 1 or 2 Famit Dwellin - Na of bedrooms ~ ~ Town OF EMERALD 130TH AVENUE III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 010-1075-10 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on-line A. Check box on line B, if applicable) A) 1. ^ New 2. ~ Replacement 3. ^ Replacement of 4. ^ Reconnection of S_ ^ Repair of an ______System -_______System -_ Tank Only______________ Existing System ___-____ Exlstln~System B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 (~ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 103.55 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 450 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation X7'$/ 375 375 1.2 N/A 101.3 Feet X3~ Feet VII. TANK Ca aclt INFORMATION in gallons Total # of Manufacturer's Name site Con- g ass Plastic E xppr. N E i ti Gallons Tanks Concrete Steel A ew x n s struded Tanks Tanks t~ 1000 X00 1 IDWESTERN PRECAS ® ^ ^ ^ ^ ^. umpTa er 650 650 1 IDWESTERN PRECAS ® ^ ^ ^ ^ ^ .RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print} Plum is Signature: (No 5 mps) MP/MPRSW No.: Business Phone Number: BENNIE HELGESON 220292 715/772-3278 Plumber's Address (Street, City, State, Zip Code): , W1229 770TH AVENUE, SPRING VALLEY WI 54767 IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin e~]t Signature (No Stamps) ([Approved ^ Owner Given Initial n('/o Op Surcharge Fee) G' ( / ~ ~ ` ( ~7 ( %~ ~ /~~ f L Adverse Determination f0+] V ( '' 1 X. CONDITIONS OFAPPROVAL / REASONS F R DISAPPROVAL: I seas3sa ca., tiss~ astxiaunor+: o~g~:o cow.cy, oee copy ra: sari, a auildi,gs a~o~. ors. Humes. e INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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, 608-266-3151. To be complete and accurate this sanitary permit application must include: I. 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 online 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 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 1/2 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 contamination investigations and establishment of standards. ~1 ~..i INDEX SHEET PROPERTY OWNER: BRUCE CLOUGH RECF~VED N10260 171ST STREET MAR ' 9 BOYCEFII,LE, WI 54725 1998 SAFE ~ Y ~, BLQQS DIV. PROJECT NAME: BRUCE CLOUGH 98-10451 PROJECT LOCATION: NE 1/4, NE 1/4, S 31, T 30, N, R, 16 W MUNICII'ALITY: TOWNSHIP OF EMERALD COUNTY: ST CROIX CONTENTS Page 1: Plot Plan Page 2: Cross Section & Plan View of Mound Page 3: Distribution Pipe Detail Page 4: Pump Chamber Cross Section & Specifications Page 5: Pump Specifications Name: Bennie Helgeson Address: W 1229 770Th Avenue Spring Valley, WI 54767 Credential number: 220292 Signed. Date: March 18, 1998 f~'lo-f- ~-'I ~~. ~)cL~r~'~r~~ ~rt,.c~ Cl~c~~h i(,lw.beh~ ~, 11nIP ~ a('tSOv~ ~a~~9~ /3 t~ ?h d C~~~/ / T~•~1 F L~f~.p, tpc~.no k7o~ Ova o~ ~~~ Y ~° ~, 0 ~~~ ~'i ~' ~ ~. •~ J .~ ~1~.~) ~ f l / V C ~sfern PRIVATE SEWAGE SYSTEM Conditionally ,--__ ~~ APPS No~ b~ ~'~, DIVISION Of SAFETY AND BUILDINGS • iJs~~b ` ,F~t-cam. ~._~~._- SEE CORRESPONDENCE L- ~ ~' Ii ~ .,, ~p! C pr`"'fou r / ~ ~Itu. 10 0.3 .,, ~ro oSc c~ ~~ ~ ~~ K m.~ ~. ~~c C __ ~.. ~,~~ i~ S~ ,~~ F' ~.~~Medium ~ ~ ,~,, -~ '' Topsoil Straw, Marsh Hay, Or Synthetic Covering Sand -.J I ~~. 3 _ 1` ~G __ F e,~ ~ p E/e~. iod•3 Force Main Plowed From Pump Layer j % Slope Bed Of ?~- 2 %Z Aggregate PRIVATE SEWAGE SYSTEM Cond~~~tionally Cross Section Of A Mound System Using A Bed For The Absorption Area `~,.'~~ Df1f151~~~~~5~!~~ 13UILDIIIGS s ~: .. SEE CORE ~~~ pvc~ Force Main L _ page - Of _ ~~~ ~;~, `~ iDistribution Pipe q _~ Ft. 6 y7 Ft. K j0 Ft. L ~ Ft. ~ ~_ Ft . T -~~Ft. w ~?~-Ft . D j Ft. E j o~3 Ft . F , 75 Ft . G /.O Ft. H /.S Ft. ~ Observation Pipe-~ ~ ~-- B --- ------- ~ K A ~ --- -------------- ----------------------. w ° - -~ ---------------- ~„ ,„ Distribution Bed Of 2 - Z'2 Pipe Aggregate I Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area .. ' - )rl ~r• C Er CND c N N -~' l.act Next 7o End Cap Distribution-Pipe Layout PF~IVATE SEWAGE SYSTEM Conditionally PdP RAVE D "•~~ ~IVISION OFNSAF lIND BUILDINGS ,~ icense ~m e SEE C NDENCE t~ ~ ~ J f~~';1 ~r; ~ 't,_ Permanent End Markers Holes Located on Bottom are Equally Spaced P a a, s' R '- S ~_ 3' x Y Hole Diameter ~_ Inch Lateral ~_ Inch (es) Manifold ~ Inches Force Main " .~ Inches .~ (J~rf ~~ev. i0/. ~ Perforotnd Plps Oetoll Page Of---~ ~... COMBINATION SEPTIC TANK/PUMP CHAMBER ~`,f '~" ~-'` t ~ .'•'_ ~~~, 4"~CI VeitPipe`with (No Scale) Approved Cap, +25' ,Approved Locking Manhole Cover From Buildings With Warning Label Attached ~ • Weatherproof Approved .Warning Label Junction Box Vent Cap ~~ 12 Minimum 6" Minim m ~ 4' Minimum Final Grade-~ t 6" Maximum 4" C.I. ~ Quick . Disconnect 18" Minimum ~ Insp. Pipe `- -- ~ 1/4" Weep n ~ Hole Baffles I I L1 I . t Approved Joint ~ A w/C.I. Pipe Alarm Q~ Extending 3' g Approved Joint Onto Solid Soil On 6i w/C.I. Pipe PRIVATE S GE SYSTEM. .. ~ U ~ C Extending 3' Onto Solid Soi CU~td t•OnaLZy Off n Conc. Block APP V~® ~~ ~~avisioN oi; ~_ r < ~ •~ ~.~_- 3" of Bedding Under Tank -~ SEE CORRESPONDENCE ""~ Note: Pump and Alarm Are On Separate Circuits GallonsoPeroDay/tip-Dosesayl ./ ,S Gallons Volume of Backflow:.......+~~Gallons /~ Total Dose Volume:........=_L~~allons Tank Manufacturer: ~~ ~~+ 1`"~~ ~- Tank Size-Septic/Pump : o a ons ~~ G~1 t?.•~ r~c-^ Alarm Manufacturer: S J E!{~ ~. ~ ~ ~' ~~ -Gallons Model Number. ~ Capacities: A /7 inches or~Gallons Switch Type: ~ r + Cinches or~Gallons Pump Manufacturer: ~ + D ;o inches or~~_Gallons Model Number: allons Minimum Discharge ate: "37.~15~ Tota1....._ inches or~~; 3,~5'G Vertical Difference Between Pump•Off and Distribution Pipe:~~,Feet Minimum Required Supply Pressure. :....... ..... ......+ Feet g_~' Feet of Force Main x x.76 Friction Factor/100~Feet: + ~.3~ eet Inch Diameter Force Main ..~ Total Dynami c Head :... _ ~~-~S"`Feet Li qui d Depth 38~ ~~ {emu, C~~.rbcr Internal Tank Dimensions: Length..~5~~ ; Width 7R,,; _~_ '~-~ , Se-c..~~o„ ~.~- ~-fi~~~~; Signature. License Number Date ---. Performance OSP33 -MAX SOLIDS 518" SPHERE - 1750 RPM 24 20 H W LL ~s Z Q x 12 J Q H 0 H 8 4 0 i eI Distributed by: Bulletin 110.3 Rev. 12/84; Supersedes 210.1 LITHO IN U.S.A. ,~ ~.,, ~~ Dimensions er. eray ¢ r„ 4}} ~, ~ ~-ski !v~~ ~~r ~" ~` ~ w :~• r x ~ d $4~ y~ s'ti"~' ~ ,rx ,'U~r t> ~ i° `ty„~)y ~N OTE,.~+GP~ST ~: ". 4 ro. THD. RY ~ 1Y8" Mwp~Er THE MARLEY PUMP COMPANY (~ HYDROMATIC PUMPS Box 927, Ashland, Ohio 44805 i4t9) 289.3042 In Canada -Marley Fluid Systems, 126 East Dr., 0ramptOn, Ontario L61' 1C2 International Sales -Mission, KS Telex 718875045 MARLY UW ~tN,~scbn~ Department of Commerce SOIL AND SITE EVALUATION 'bivision of safety and Buildings Bureau of Iritegrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Page of Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must `'"""`y include, but not limited to: vertical and horizontal reference paM (BM), direction and '~ ; ~ ~) X perc~ntslope, scale or dimensions, north arrow, and location and distance to nearest road. paw I.D. # APPLICANT INFORMATION -Please print app . R Date Personal information you provide may be used for seconds Privacy Law,; 5 t) (m)). .~~, l ~• , ' 97 Property Owner rty Location ~~ r/ ` ~~~~+~~°Y' „yL t ~~ 1/4 1/4,S~ T3v,N,R ~ E( W Properly Owner's Mailing Address L Block# Subd. Name or CSM# _, , ~ K ~ 4~~7 $~ _ ~~5~ d ~ ~ -City State Zp Code 'P ,one Numt~r,~yyr/ ^ Village 'own Nearest Road ^ New Construction Use: idential / Num ~ f ~ ty~ Addition to existing building eplacement ^ Public or commercial -Describe: Code derived daily flow O ~ gpd Recommended design loading rate bed, gpd/ft2~trerrch, gpolft2 Absorption area required bed, ft2a~/ trench, ft2 Maximum design loading rate bed, gpolYl~~-trench, gpd/ft2 Recommended infiltration surface elevation(s) / ~y ~ ft (as referred to site plan benchmark) Additional design/sit considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system ...,..........,..•.. ....,...~ ..... ...... ............. ,.. ~.,..... ..,....,.......... ...,._...,, ._... u unsuitable for system ^ s ~ u ~s ^ u ^ s ~u ^ s~ ^ s ~u ^ s ~'u SOIL DESCRIPTION REPORT Boring # I Ground Depth to li~mit~ing ~" "in. Boring # Grounrxl /~"~/ fl. Depth to limiting factor i Rnrr»r4c• CST Nam~e+(PI se Print) 'nature Telepho/ne No. .J~. ~. Gds l~'l0 ~ (~ - b/~ Address Date CST Number Horizon Depth Dominant Color Mottles T t Stticture n i C t B nd Roots GPD/fi2 in. Munsell Qu. Sz. Cont. Color ure ex Gr. Sz. Sh. ence o s s ou ary Bed ,Trench 0-8 ~ ~ ~, ' ~,~ ,-~ - 5 ; f ~ ~ ~ ~ 0~ ~,..~.~ , ~ ~ ~ ~ , 5; • ~' 3 pC"" O ~.7 r ~ ~ ~ ~ /~ ~ ~ i ~ i Remarks: - - ~ J / ~ o~ c/ r y i~ /1'1 ~ l~ ~~ ~/ f PROPERTY OWNER' -`'~1~z°~~G~rs'.1';ry,--OIL DESCRIPTION REPORT PARCEL I.D.# Boring # Ground I /G~~tt. Depth to limiting ~~in. Boring # Ground elev. ft. Depth to limiting factor in. Boring # Ground elev. tt. Depth to limiting factor in. Boring # Ground elev. ft. Depth to limiting factor in Page ~~ Y Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench ~~ s~ - - a . ~ om ,~._.. ~ ~ ~ ~' ~ ~ \Y 11/ ~/ m ~-N'! ~~ /n L ~ ~ ! S ~ 1 ~~C ~ ~ ~ ~ , Remarks: Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench Remarks: Remarks: SBD-8330 (R. 07/96) ~. : Soil Test Plot Plan Project Name Reuben Larson Sha Bird Address 2186 130th Ave ~ ' `~~~~ Baldwin Wi 54002 CSTM #3922 Lot ----- Subdivision ------- Date 10/25/97 NE 1 /4 NE 1 /4531 T 30 N/R 16 W Township Emerald Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Shed Siding System Elevation 101.3 *HRPSame as Benchmark 5' 1% Slo e 30 B-3 30 B-4 B-4 does not affect 5 ° system area and thus the soil profile was not recorded 0' 30' _2 ~ <' 5' 120' Pro 2 5' Bedroom House .. ~. ~,, ,. F~ ~, 1,.._ r~ ; ~7 ~ i-iCil;~C '~ c~u~T~r ,~ ~.,~ ell DW 20' 4,n' B.M. Pole Shed 130th Ave r Soil Test Plot Plan Project Name Reuben Larson Shaun Address 2186 130th Ave Baldwin Wi 54002 STM #3922 Lot ----- Subdivision ------- Date 10/25/97 NE 1 /4 NE 1 /4S31 T 30 N/R 16 W Township Emerald Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Shed Siding System Elevation 101.3 * Fi R P Same as Benchmark ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ i^c~G2 ~ ~~/G'~~~ o~r~ .~.~/~~ ~ /~ /`'~-'~~~ Mailing Address ~G , C?d~' 54.~ /~~~v ~~ ~ ~~y~ Property Address "_ ~ g 7 /~O ~~~~/I~ia~ .~~~~ is G~i ~'~/DD~ (Verification required from Planning Department for new construction) City/State Parcel Identification Number Ol D - / 075- /4 LEGAL DESCRIPTION Property Location .,~V~ '/4, ~Y~ '/o, Sec. .~` , T,~~N-RAW, Town of L~~.Q ~• Subdivision - ,Lot # Certified Survey Map # ,Volume Page # Warranty Deed # S7o~ifo l~ ,Volume ~ 2g 7 ,Page # ~ Spec house ^ yes C~ no Lot lines identifiable CJ yes ^ no SYSTEM MAINTENANCE 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 yeazs or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three yeaz expiration date. S GNATURE F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form aze true to the best of my (our) knowledge. I (we) am (are) the owner(s) of t/h~e property described above, by virtue of a warranty deed recorded in Register of Deeds Office. j~ ~G~~~~ ~3 ~!J/ 9~ 't'" IGNATURE OF AP ICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ~'` T ~ jr ~~ a ~' ,t ~ fi S•i - \: ~, t f~ ~- ~~~ ,,E'~ 4 ~r q- :~ ~.. ~; r~ ~_ ~, .~ .' ~.'~~' ~~ i fir, . ~ % 0`.~f)_j ST.iTE BAR OF 1~'Ix":?'~~,o FORA ' - 19g? A«iaRR~J1~I1 DEEll J~ DOC'.i~nr NT NO YOl ~<~~~M~~`i REUBEN M__LARSON a_n_d ,COI`' A,_LAR..SQN,__hu_~~tn~~ad_~ife,_. rum-rys and H~~rt~nts to _BRUCE E. CLOUGH and B +~iNIE ?~1 M0(Ij~jQ~ as~oint tenants ~c "~i~./ R~G'S7CR'S ~~FF^ CE ST. CRaiX Cp„ W; i s~'d kr R~conr JAN 0 8 1998 9:30 q~ R~ tyfs. o/ O~sda ~ ~~~ ,,, _--- --- -_-__ *~i~S SPACE aE~Ea'-!ED EGA REi:JHDMG UA!A the following described real estate in ---- ----- "A""E ^''D aE•ua" A~eatas St. Croix _ counry; T. M. Abstract & Title Services Mate of Wisconsin: 63 S. Third St. Barron, WI 54812 010-?075-10 _ ?aaCEt_ ~DEN?~r.CAr.JV vuMdE~ The Northeast Quarter of the Northeast Quarter of Section 31, Township 30 North, Range 16 West (in the Township of Emerald). TRANSFER oy E~- Phis _ 1 S not homestead propem tir~) !"r; nut) [xceptiontow'arr.mnes $ubJect LO highways, easements, restrictions, and reservations of record. a r\d Datrdthis _-__-- d,;;,,r___ Januar - -x-------- --- --- - -~ .~ n . } y_4~_ -- _. _ iSFAI ~) ' ~ ~ / ~°~"~'-=~----___ (SEAL! - • REUBEN_M_LARSON _ '~~----_____ i~EA~) • _ LOIS A. CARSON __ __ _ _ Signature(s) AL`"fHENTICAT[ON autht nucatrd th+s dac ul -- -- -- mr n ,\t ' __ ___ he the f, ,< ~ ' r~,.e~t~utrd ;rgon:g .~trwx ,ind a Ln,+' i' ~ i - -- • ter," ;~_,~ _ ~. ..'tar(' PU})ll. , ~ f-~ F ~~. J •1~~~~ nu~,;l~;, t,. ra .y,t _ I --1--- ' _ ~ _. - __ ~ _ l I) `- ` . 11.1RAVAlY nI.FD tiCVri 9l> ~~F - „l~.iA h,ra ~: _ - .aCKNOWIEDG'-iENT ___.__________ State of ~~'Isconsitt, ---- ~ . 19 --~~`~ _ Count r - Personally .ame F:lore rae :~:; _ ~~ _ - da;~ of Jan~x_-_- -----. Id~B_-. the afxn'e named - ~EUBE___IV _M _~ARSON _3[l~-.LOL4 A~_L~RSO~_-_ ------- -h~s_ban~_~ad~tife~__-__---- ----- _ --- authorized h 1 1 -ti -- _ ~,a"N •• r - --- y' 37t 6 t C, Wis. tats.) :1 _ e,~ ., f ~. ' .G THIS JStR~FtE;T ~+;Aj pgAF(ED 9Y ~ '~ ~~~ 1 ,'••~ David _P ~ ` ':~'= Cusick, Attorne~at law 44 S. Fourth St. -- - - --- ;-~. ththt:ah:ri ^i,l\- be ;ltlt ht'lll tl:llrl! Ur l h::U\\ii _- ttt Sia ry 1 ` - ; err" n u. y,.,,. (111L \fEh1BER S LEI [BAR OF ~~ I tlf rut,