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HomeMy WebLinkAbout018-1083-09-000~soonsirt Department of C.ortunerce 1Cafety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Croix Personal intomiation you provlce may oe used for secondary purposes (Privacy Law, s.15.04 (1)(m)] Permit Holdei s Name: City ^ Vi lage Q own of: onte, Ron Hammond Township CST BM E ev.: Insp. BM E ev.: BM Description: ' too • ~ r ~+ s-E-~- CST $d-,t~1 TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ ~~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic > WSJ ~. 3g r _-- NA Dosing NA Aeration A Holding PUMP /SIPHON INFORMATION Manuf urer emend Model Num GP TDH Lift ~ction System TDH Forc In Length Fi e t SOIL ABSORPTION SYSTEM (Ig)~A,,,,,,,~,5 ord. -~,rekc,~ 8EB• ENCH width , Length N O Trenches PIT No.Of Pits Inside Dia. Liquid Depth I 2•~ D1MEN 1 N SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manu adurer: ~~R I iN INFORMATION ~ ~ 5~ r ~ ' - ~' CHAMBER OR UNIT m r : M e Nub r ^ System: ph. • ^" Os ~ L ~ - t-+a7!t DISTRIBUTION SYSTEM Header / 11Aani old t/ u / Distribution Pipe(s) x Hole Size x Spacing Vent To Air Intake l Length leG 5 Dia. T ~ Leng Dia. Spacing ~' (aU 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 I Bed /Trench Center ~ Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COM M ANTS' Iln~clude cod~e,,,d~i~s~crepan~ie~ persons present, etc.) -~~~~-`'~~~'~Sr"""~'" ~ ~'~'rt'G~"~ ~~1lq~ Inspection #1: °I/ 1/0/ ~~ Inspection #2:---~-'-t-• Location: 1735 96th Avenue ~o~~ 54015 ~SE 1/4 NW 1/4 16 T29N R17W - 162917581 Phe nt illy,-~.pt Q 1.) Alt BM Description = ~r~~~~"'^•`~`~ ~'t'~ over (aQ, •S,eta,2,,r. .S~ ~Q /~--I~b ~y ~~r"~ S 2.) Bldg sewer length = 3 8 ` -amount of cover = > `'(Z ~ Q,+ -~'"~ ~.~- a as ~" ~:ts""`~v i~`l1 ~~.L( Sr.~u~j ~- 3~ F i~a~ J{,! ,,a a~ otx~ ~ w ~ t,l ~ a. > IZ u~ ~ e,cx,err cue Pte" Plan r~visioN~ n~ wired? Yes No ~ ^ ~ 6 her si a for additional infor a ion. Dz, o ~ 01 Cert. No. -~ D~ t~ t em p t Inspector s Signature 3r 018-1083-09-000 STATION 85 HI FS ELEV. Benchmark ~., Zd o}. ZO (~ , p ` A1t.BM _ D.go pb• Dr BIdg.Sewer S.5'S' o1.l,Sr St / Ht Inlet ~ ~ ,~ ~p ,Sp' St/ Ht Outlet , o ~ • 20' Dt Inlet -~ ---~ Dt Bottom Header/Man. T • ~ y6.2sC3) Dist. Pipe s~ g•8a ~' g8•`/`1U Bot. System to ~ Io. ~ R4.5o(t ~3 Final Grade ~ Sr ~.sS 94. r.S St cover '~~4¢.40E- ELEVATION DATA / F Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. ~~~~ See reverse side for instructions for completing this application PO Box 7302 Madison Wt 53707-7302 F]ept~rtment rsF Cgmmerce Personal information you provid~be.used for secondary purposes [Privac -(::awy s. I5.04(1)(m)] , (Submit completed form to county if not state owned. Attach com fete Tans to the coon c for the stem, on a r of less than 8-1/2 x 11 inches in size. County State Sanitary Permit N S ~' ^ C14ack iftevision to pre us application State Plan I. D. Num er I. A lication Information -Please Print all Inf4r 'tion , , Location: Property Owner Name Property Location `~.''il R~~ or S /` T ~ °f ~1/4 1~ 1/4 N D _~ ~~~ , o , , , - , Property Owner`s Mailing Address ,F Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number ® ~ D/ S ~s 7~G Sa~O l~eQsa.~ ~ f~.'l!s ~ a a II. Type of Building: (check one) ~ 1 or 2 Family Dwelling - No. of Bedrooms : 3' ~~~ ~Y~S ~~- "" ^ C'ty ^ Village ' C~I own of ^ Public/Commercial (describe use):_ ^ State-Owned R- m 't"` 6 Nearest Road d ~~ S ,S~ j C ~D ns,`j ~ S/ S Pazcel Tax Num r(s) 0 (a "/D8 -~- III. T e of Permit: Check onl one box on line A. Check box on line B if a lica le ! .0~9• /7. ~' p) 1. ew 2. ^ Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to 5 stem S stem Tank Onl Existin S stem B) Permit Number Date Issued ^ A Sanit Permit was reviousl issued IV. Type of POWT System: (Check all that apply) Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At- de ^ Aerobic Treatment Unit ^ Recirculatin ^ Other: V. Dis ersal/Treatment Area Information: ! - ~ 1. Design Flow (gpd) 2. Dispersal 3. Dispersal Area ~ 4. Soi Applicahon ft ) / G 1 J R 5. ercolation Rate /inch) (Min 6. SXstem Elevation 1S. 1~ 7. Final Grade Elev tion Required M Proposed ~,/~,.' . . ate ( a s y . ~ VII. Tank Capacity in Total # of M nufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks ^ ^ ^ ^ L ^ ^ ^ ^ ^ VIII. Responsibility Statement I, the undersi ed, assume res onsibili for installation of the POWTS sho the attached fans. Plumber's Name (print) Plumber's Signature (no stamps): RS No. Business Phone Number `~(~ot~ S~iax.6 ea o'lR?QY i3~3~G- 31a? Plumber's Address (Street, City, State, Zip Code) IX. County/Department Use Only - -- ~sapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) ~ Approved ^ Owner Given Initial Adverse Surcharge Fee) D "S ~o/ n ~ ~ _I ~ _t C~ Determination r O v~ / X. Conditions of Approval /Reasons for Disapproval: Q, /~,l,.Y,1ti.«„~ ~k u'(~uamA. ~4.1a (1-t~ti ~^'~~'~°"`'"`' ~.~ . mot, _.pg. ~ ~ , ,. lrc~.~. c~-~ ~o-~-s~ . ~ ~to PlaTn' W ~ G~ ~ f .~, 3-bCclroe ., ~t%5 s ys~m. ,..R s G1 ~ s~s~neG{ S nlOO/ +~ (nw«~e . ~adi~ cetef~tew btc~mw,,. ~~ reSn (+ ~ ~ s ySfrw. bel nr~ ~e..k Fl.~-+^L{{~ SVIf4, WPi w\nq w.{u-l~t~ YNG .1~ f"S 'T ice. ~~~i..--~ e~ s~s~-~ bv~eel t~Lt, o..r~tornmeNd~d '~Oa~~a'r~f! o~ tso ~ 3 s ~So 1 P•~ /,~ ~ °o X G .'L~% ~ t'L .j ~e,c.~ t~QU~ tv'tsfo~~n a~ / t~ •t `~ = S 3 ~ ~~,,....,1~-~ ~.S SS G ~ ~'S P /~O ~ oS~~C ~`,~'.~ 7~ -~ ~I~a"f/ Nrl.~~' S.~~~I,~~G~ Sl'6 ~°1'~ ~/7!J ~PJ~ ~~/1Bo a,v~~ //fS/axsksa -~_ ` -`_ -,-~ -~. --__ i ~_ 'L ~~ ~ SGlo'~ t l ~~=1t4 ` ~ ,/~ t t gca4( ~,oE - G ~ ' ~ Od Q all a ~fo,~ (ol'G $ ~ z `>' l ~~ 0 ~~. 6 0 ~bpq~ c a ~~ r~ ~-_/ aJ,~ ~ ~S ~a' q~ B~ • ~~, . gs~( ~~~ i+~a~ ~ ~.<<-I -CkZ i l °~ 8 TZ~ `~ ~ ~~~~~~~ r ,g ~ '? 1 ~-- .~~ ~ ~m'~ ~/ ~ ~ds~~ yyyy~ ~~ 7 994 ~~~~/GO Wiseonin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings ~R'~1t~/r~with Comm 83.05, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8'/s x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and t d d l t t d St. Croix roa o neares . is ance percent slope, scale or dimemsions, north arrow, an ocatie~-end- Parcel LD # APPLICANT INFORMATION - P/ease~Ct~t'alf informatiod:~ . . ' Q O y a y ry.p ~ ~ cy Personal information ou rovide ma be used for se nfla ur ses F~iva Law, s. 15:4 1 (m)). ~-~ viewed B Date y q /b Property Owner F ~ Property Location Bonte, Ron - Govt. L t SE 1/4 NW 114 S 16 T 29 N,R 17 W Property Owner's Mailing Address ~ ~ Lot #. Block # Subd. Name or CSM# 1011 170th St. 9 Pheasant Hills City State Zipp Code Pho~ V~b~, d WI 5 X1 =~ ' " ~O 0 3 ty ^ Village ®Town Nearest Road d 170Th St ~ H Hammon 4 5 ~b~ L 1 : S ~ - . ammon ~ Residen Numbe~ of Eye ms 3 ^Addition to existing building '~ New Construction Use: Replacement ~ Public or commer escribe Code Derived daily flow 450 gpd Recommended design loading rate •3 bed, gpd/ftZ •4 trench, gpd/ftZ Absorption area required 1500 bed, ftZ 1125 trench, ftZ Maximum des¢~n loading rate •5 bed, gpd/ftz •6 trench, gpolftZ Recommended infiltration surface elevation(s) 2a" below contours ft (as referred to site plan benchmar install 2 - 5' x 112.5' shallow trenches along contours for 3 br Additional design /site considerations Parent material till Flood lain elevation, if a licable N`4 ft S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitable for system ® ^ U ®S ^ U ®S ^ U ®S ^ U ^ S ®U ^ S ~ U JVIL L/Ga7\+Rlr I IV1~1 RGrVR 1 Boring# ,, 54 Ground elev 100.1 ft Depth to limiting factor > >o" 2 Ground elev 100.1 ft Depth to limiting factor > 60" H i Depth Dominant Color Mottles T t Structure Consisten Bounda Roots GPD/ftZ or zon in. Munsell Qu. Sz. Cont. Color ex ure Gr. Sz. Sh. ry Bed ~ Trench 1 0-4 7.SYR 2.5/1 - sl 2 m gr ds cs if .5 .6 2 4-16 7.SYR 2.5/1 - sl 2 m sbk mvfr cs if .5 .6 3 16-23 l OYR 4/3 - sl 2 m sbk mvfr gs 1 f .5 .6 23-35 l OYR 4/4 - sl 2 m sbk mfr cs - .5 .6 5 35-70 SYR 4/4 - sl 0 m mfi - - .3 .4 S,L ~ . Remarks: 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs if .5 .6 2 4-11 7.SYR 3/1 - sl 2 f sbk mvfr cs if .5 .6 3 11-35 7.SYR 3/4 - sl 2 m sbk mvfr cs if .5 .6 4 35-42 lOYR 4/6 - sl 1 m sbk mfr cs - .4 .5 5 42-60 SYR 4/4 - sl 0 m dvh - - .3 .4 ' l0 ~ Remarks: SST Name (Please Print) Signature: Telephone No, Henry F. Grote ~ 715-665-2681 4ddress ertt to of esttng ate CST Number Ref # P.O Box 57, Knapp, WI 54749 /27/2000 222774 1021 PROPERTY OWNER: Bonze, Ron SOIL DESCRIPTION REPORT 2 ~ 3 PARCEL LD.# ~ Page Hof • ~ g Certified Soit ems i'n 3 Ground elev 99.0 ft Depth to limiting factor > 67" 4 Ground elev 98.7 ft Depth to limiting factor 62' 5 Ground elev 98.0 ft Depth to limiting factor > 62" Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ftZ Bed Trench 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs if .5 .6 2 4-12 7.SYR 3/1 - sl 2 f sbk mvfr cs if .5 .6 3 ~ 12-3I 7.SYR 3/4 - sl 2 m sbk mvfr cs if .5 .6 4 31-48 7.SYR 4/6 - sl 2 m sbk mfr cs if .5 .6 5 48-67 7.SYR 4/4 - sl 0 m mfr - if .3 .4 0~ Remarks: ~~~~~.,~,a~ ~~ ~,~~~u~~~~~~ ,,, ~~~, «.,«~ Y ~.., 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs lm .5 .6 2 4-15 7.SYR 3/1 - sl 2 f sbk mvfr gs lm .5 .6 3 15-24 7.SYR 3/4 - sl 2 m sbk mvfr cw if .5 .6 4 24-35 7.SYR 4/4 - sl 2 m sbk dh cs - .5 .6 5 35-62 SYR 4/4 - sl 0 m deh cs - .3 .4 6 62-65 SYR 4/4 f2f 7.SYR 6/3 sl 0 m deh - - .3 .4 KemarKS: 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs if .5 .6 2 4-9 7.SYR 3/1 - sl 2 f sbk mvfr cs if .5 .6 3 9-24 7.SYR 3/4 - sl 2 m sbk mvfr cs if .5 .6 4 24-50 SYR 4/4 - sl 1 m sbk dvh cw - .4 .5 5 50-62 SYR 4/4 - sl 0 m mfi - - .3 .4 Kemancs: Ground elev Depth to limiting factor Remarks: S t..wl~ ~„ = ~C O 10 l00 ~~ zsa.~~4 C L w w•. ~.na, Cq ~,~t~ d ~~~~~ ~w .~ X53. ~ o sei~~oo~ck n•-a ~`~e zsb' i 57.,x.35 ' ~.t~6 d•z ~' -1-Y + IL 1_~' ° +~ ~3• ~ z."~'~ fi rc (a 8~'~S ~.81~' _ Cq~.45 I i3~-c Z7o' ~ L-u•~.a~ 3 0~ 3 ~, O Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number 3-r~iyZ Number of Bedrooms 3 Design Flow -Peak (gpd) y~v Estimated Flow -Average (gpd) Septic Tank Capacity (gal) ~ o as Soil Absorption Component Size (ftz) ~i2s Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) l ~~ R~~. 7 Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The afmosphere within the septic or other treatment of holding tank may confain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surtace seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT .-AND OWNERSHIP CERTIFICATION FORM Qwner/Buyer /L d •/ ~ia~r~C Mailing Address /0 ll lT4 ~ S T ~~ ~ ~'"1 ''~ ~ ~ `~ Properly Address City/State T EGAL DESCRIPTION Parcel Identification Number ~R°' ' /d 3 `/- ~ ~'" Property Location ~. `/a, ~ `/4, Sec. ~~., T~N-R / ~W, Town of rir m sK ~~ .~~,~ . ~ ~ s a.,r/ J` T ~ ! Lot # _~. Subdivision Certified Survey Map # ,Volume Page # Warranty Deed # ~ -~~9 3 Volume b~6_ .Page # ~ ~2- Spec house [~ yes ^ no - Lot lutes identifiable ~ yes ^ no SzYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its p ymature fail pe to hanclle~wastou Put int~the cyst m consists of pumping out the septic tank every three yeas ~: i sooner, if needed b a licensed umpe • y p caa affect the function of the septic tank as a treatment stai,e in the waste disposal system. artment a certification form, signed by the owners b em The property owner agrees to submit to St. Croi:--: Zoning Dep r ve that (1) the on site wastewaterdispo yst masterplumber, journeyinaiiplumber, r~estrictedplumber o. a licensedpumpe ~~ the s tic tank is less than 1/3 full of sludge. is in proper operating conditionand/or (2) after inspection i and pumping (if necessary), ep I/we, 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 Commerci> and the Department of Natural Resources, State of WisconsO ~ ~tli h30 that our septic system has been maintained mu->t be completed and returned to the St. Croix County Zoning stating Y ~ y piration date. Ys ~r~ia° - ~J'Z"~ DATE S GNATURE OF APPLICANT OWNER CERTIFICATION our laiowted e I we am (are) the owner(s) of I (we) certify that all statement, on tW. fc~~m are true to the best of my ( ) g • ~ ) pr rty des above, by virtue of a ,qty deed recorded in Register of Deeds Office. 3 ~ d ~~ / DATE SIGNATURE OF APPLICANT artment. ****** s««**• pny information that is mis-represented sa:iay result in the sanitary permit being revoked by the Zoning Dep (Verification required from Planning Department for new •* Include with this application: a stamped wa~•,>anty deed from the Register of Deeds office a copy of the ~c,cttified survey map if reference is made in the warranty deed v~.1.15~1PAGE3 !~ 6a0'3b3 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CkOIX CO., WI RECEIVED FDR RECBRD Dine M. Bonte, as Trustee and Ronald C. Bonte, first alternative 0~-10-2000 10:30 AN Trustee of the Karl M. Ulferts and Katharina G. Ulferts Family Trust, for a valuable consideration conveys without warranty to TRUSTEES DEED Ronald C. Bonte and Dine M. Bonte, husband and wife, Grantee, EzEMPT N CERT COPY FEE: the following described real estate in St. Croix County, State of COPT FEE: Wisconsin: iR(WSFER FEE: 20.00 RECORDING FEE: 10.00 PAGES: 1 Thomas A. McConnadc 102010'" Ave. Baldwin, WI 54002 018-1034-60, -70 (Parcel Identification Number) The North Half of the Northwest Quarter (N ~ of NW %) of Section Sixteen (1Fi), Township Twenty-nine (29) North, Range Seventeen (17) West. Dated this 24thday of March , 2000. Dine M. Bonte Trustee 'Ronald C. Bonte Trustee AUTHENTICATION Signature(s) authenticated this -day of , signature type or print name TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DR~ ;~ ~ Thomas A. McCo a ! '' ~' = t Baldwin, WI 540t7~.' O ~ ~ ' : ~. q r ,: ~.. O .~~ ,• ACKNOWLEDGMENT STATE OF WISCONSIN ST. CROIX COUNTY Personally came before me this 24t:tbay of ~~ 2000 the above named Dine M. Bonte, Trustee and Ronald C. Bonte, as first alternative Trustee of Karl M. Ulferts and Katharina G. Ulferts Family Trust, to me known to be the person(s) who executed the foregoing instrument end acknowlgQge the same. signature type or print name Dele I~ Jensen Notary Public St. Croix County, Wisconsin. MyOc~m~is~Qn is permanent. (Ii not, state expiration date 11 j3 •) 'Names of persons signing In any capacity ahoukl be typed or printed below their signatures. IrAormation Orofssaional, Cattperry FoM du Lac- Wi,canain i100-655- _ - _ __ _ 1y .. ~ ~ , QTTE~ LANDS 13 %~ a } ~~'_ . I A ;- Y- lt <l J ' N ~ vi't W ~ ~~ NE ('Q^ . f ~ A T) EAST L tN~ OF THE Yw 1~4 i _ --,~-,9 ' ' 2605. 77 03' (TH ~ ~ $ SkEE T) 486.96' . 350.00' 1 1 66 OS' ; ' -. 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