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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safet~cr+d Fsui{ding 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
Wri ht, Rea an Hudson Townshi
CST BM Elev: ~ Insp. BM Elev: BM Description:
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic . `~
l~ -e.rl, '.L~
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic ' ~ t< ~~ ~ t ~_-
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
GPM
Model Numbe
TDH Fri n Loss System Head H Ft
rcemain Lenath Dia. Dist. to well
SOIL AB ORPTION SYSTEM
REN Width Leng1
DIME ONS 3/ q3
•
SETBACK SYSTEM TO
INFORMATION
Type Of System:
Co Inv
DISTRIBUTION SYSTEM
ELEVATION DATA
county: St. Croix
Sanitary Permit No:
399483
State Plan ID No:
~-----^
Parcel Tax No:
020-1376-05-000
I `~ ~ z,9 , l.°I, 2'Lto ~
STATION BS HI FS ELEV.
Alt. BM '~• 3~ [~ ~r
[
Bldg. Sewer ~~ ~
• r
9Y•ro
St/Ht Inlet
f'.~
SUHt Outlet r,+
+J ~'• `S, r
Dt Inlet
Dt Bottom
Head r/Man.
~
F~
~r
Dist.Piy
`` ~~ ~ ,~ Q~j
System
Bot. t { .D '} ~ ,
• 30
Final Grade ~
St Cover
s~` { 3z ~ Cam)
CHAMBER OR
UNIT
Dia.
Header/M~ ~ Distribution
Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake
.~,. ~~ }
Length ~' Dia Length Dia Spacing
SOIL COVER re sure Systems Only xx Mound Or At-Grade Systems Only
Depth Over • epth er xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center ,*. ~l ~ Bed/Tre ch Edges
4 Topsoil
Yes No
Yes No
COMM T (Include code di r enc s, persons resent, etc.) Inspection #1: 12-/ ~Z- / d ~ Inspection #2: /` % -~
Location: 968 LaBarge Hudson, WI 54016 (S 1/4 NW 1/4 14 T29N R19W) Sweet Grass Faun Lot 5 Parcel No: 14.29.19.2266
1 J Alt BM Description = ~~' ~~ s1 ~t ~ _ `__ ''~~ S~~'~ ~~~'owK - "
2.) Bldg sewer length = ~„fl ~ 1 J lw~+~+'r n - .~,~~ ~ ~ ~ n
31 5amol unt of cover = n ?(c~,~~~• ~~~'~~~ ~,` s,,;~ £o~~'. .IOW
Y~ CovNCox. '~ ~~,
1 ~ ~ -- ` ((~ --~
Plan revision Required? Ye CJ No Q?, f 7~p'~ ~~ YI
Use other side for additiona m ormation. ~ ~._
SBD-6710 (R.3/97) tom, Date Insepctor's Signature Cert. No.
~ ~~/9f~'g L~.a~ova~.•. ~Sanitaty Permit Application
In accord with Comm 83.21, Wis. Adm. Code
`~SCOIISin See reverse side for instructions for completing this application
Department or Commerce Personal information you provide may be used for secondary purposes
[Privacy Law, s. 15.04(I)(m))
Attach tom lete la t th
Safety & Buildings D~
201 W Washington
PO Boy
Madison. WI 5370"
(Submit completed form to count
state o~
ns (o a count co onl )for th m,, op papet not less than 8-I/2 x I I inches in ci~e
--•••~ - atate aannary P umber O
~ k~ii!rtvision4o pt•i:v(otis~pplication State Plan I. D. Number
~h
I. A lication Information -Please Print all Information
`
Propeny caner Name ~~ Location:
a ,..'~~ •-..~-
~: Proptny Loc Lion
Proptny O
w
n
er's ailing Address r, n
~ ~ I/4 /~~/4, S Tp~ .N, l
~///
''~
~~
• -
~y~ --
.. Lot Number Block Nup
v i
.S ~'~
Ciry, State Zip Code .
o
~, Subdivision Name or CSM Number
_ ~ ~~'
f ~.. ~.-- -$"7OO
~ ~0.
I1 Type of Building; (check one) ,A `:._._a_._~-- city
I or 2 Family Dwelling - No. of Bedrooms:~
O `
~~'/` ^ Village
Public/Commercial (describe use): j~Town of
O State-owned ~
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest oad
A) 1. New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Tax Nu er(s)
S stem
B) Tank Onl Existin S stem ~ Q y~ ~ d L
^ A Sanita Permit was reviousl issued Permit Number
~~ ~ q . ~ g Date Issued
~ ~ ~
• >>t.~ ~r rv.., ~ysiem: (l;heck all that apply)
'Non-pressurized In-ground ^ Mound
^ Pressurized In-ground ^ Holding
^ At-grade erobic
V Dis ersaV'1'reatment Area Information:
1 Design Flow (gpd) 2. DispersalArea 3. Dispersal ,
Required Proposed
~~
VI Tank Capacity in Total
Information Gallons Gallons
New Existing
Tanks Tanks
fir-
r '~~ d "~ ~r~~'~
^ Sand Filter ^ Constructed Wetland
^ Single Pass D Drip Line
rrient Unit ^ Recirculating O Other:
i~ _ f~
i 4. Soil Application 5. Percolation Rate 6. System Flevp~~~n 7. Final Grade
Rate (Gals.lday/sq. ft.) (Min.tinch)• //~ T ~ '9~;1 Elevation
/! ~ • /\ 6
>Y of Manufacturer Prefab Site' Steel Fiber• Plastic
Tanks Con- Con- glass
Crete strutted
VII Responsibility Statement
1, the undersi ned, assume res onsibilit for installatio of the P S show n the attached tans.
Plums Nam print) r ~ Plumber' gnatu (no stam~s): P/ PRS No. Business Phone Number
~ - ' ~ ~~ Q_
Plumber's Addr (Street, C y, fate, ip ode ~ ~`' ~~
VIII CountyrDepartment Use Only
^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued su Agent Sign ure (No stamps)
Approved ^ Owner Given Initial Adverse Surchar a Fec)
Determination '~~ ~ ~ ~ ( ~
IX. Conditions of Approval /Reasons for Disa proval: ~
~- ~~ lam' - v.~-.....~'- ~. ~.~,~ ~ ~, ~-- ~. r`... a~a-a.. ~ ~ ~ ~ ,v~ ~ ~l,,~ ~,
SBD-6398 (R. 07/00)
C
(~ r _ t~
1 r
~ ~~
RECEIVED
ad ~ ~`~ MAY O 1 2003
~.,~ D ST, CROIX COUNTY
~~~r~ ZONING OFFICE
a -ice T
L5 7, ~'
~,l
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Irk
~a35~
FARM
W1 /4, PART OF THE NE1 /4 OF THE SW1 /4, IN THE SW1 /4
11 /4 OF THE NW1 /4 AND PART OF THE NE1 /4 OF THE
NSIN.
N1/4 CORNER
I SECTION 14
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IoN ~a ~ ---N89°64'',51 "E 2641.38' _ _ ~ _
_ - - -
~ NS9.48'8o'E 821.19' McCUTCHEON _______
4
J
_OT 8
2.23 ACRES
17088 80 FT
ILDINO N89'48'80"E
030.0
~Q
R
$ LOT 7 i
~ N
Q . 1. A
~
m
2.04 ACRES Q
~ R
A ses34 s0 Fr
Q .-.-. ~ .
871.20'
418.14' I
LOT 6
2.04 ACRES
88849 SO FT
MIN BUILDING
ELEV. = 918.0
N89'48'80'E 871.20'
MIN BUILDING
ELEV. = 018.0
LOT 5
4 90823 SO FT
W
4
438.80'
~_._.1~~
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'r?iiscon~),zt Department of Commerce SOIL AND SITE EVALUATION
Division`of Sa!ety and Buildings
Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
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 '~"`
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. #
..q'°'. ~ ! ;+ ''may
.k
Page ! of
APPLICANT INFORMATION -Please pr~>~ ell ~~rfdrmafidnlr" ° ~ Reviewed by Date
Personal information you provide may be used for secondQ~rY"pi~oses~(Privet~r Law, s. 13.94 (~1) (m)). 'Z,?
Property Owner ~-` ;~ ~ • _• . _ P'rgp rty Location
~~~ Govt' of Sr 1/~f v 1/4,S/G~ T~ `~ ,N,R ~~ E (or) ~
Property Owner's Mailing Address _. ~ ., .J : Lqt # Block# Subd. Name or CSM#
13 -(~ ~~~r ~~,~~x ~We- -rr
City State Zip Code ~~'Pf~one p,pF~;~,c \ . ~ City ^ Village Town Nearest Road
!-~~ er(Snn I /. ~ f 15~--~//„ i~F;7l~ ) ~,~t~i-(~~ ~1 ~ ~-~v~tlSor~ i ~c~C-~our
[~} New Construction Use: Residential /Number of bedrooms ~ ~~ Addition to existing building
^ Replacement ^ Public or commercial -Describe:
Code derived daily flow ~zQb gpd Recommended design loading rate - ? bed, gpd/fl2 "~ trench, gpd/fi2
Absorption area required ~' s? bed, ft2 7 ~~ trench, ft2 Maximum design loading rate bed, gpd/ft~~_trench, gpd/ft2
Recommended infiltration surface elevation(s) r~/~-~ +- ~ Z • ~ ~ ~/ --t~'" `jb' `~ ~ ft (as referred to site plan benchmark)
Additional designlsite considerations ~~-~_~/T~1.~-~~- ~/ 3 `~ 7 l~• u-~` r' y Z P 7
Parent material ~ y"~-[~ ~- 5 ~1 Flood plain elevation, if applicable .~~ ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
u = Unsuitable for system ®s ^ u C~ s ^ u l~ s ^ u ~l s ^ u ^ s C~ ^ s ~ u
CAII r1FCCRIPTIAN RFPl7RT
Boring #
~~
Ground
ele_y
93.`1' ft.
Depth to
limiting
factor
1 D0 in.
Boring #
Ground
elev.
9~:1? ft.
Depth to
limiting
factor
/d8 in. Remarks:
CST Name (Please Print) ,~,, ^ I , Signature _~/`~ Telephone No.
~'C~+'CiCYl Schi:C'(~ G'"~" C'li5) 2~t?'`f0p~
Address Date CST Number
Zi ! ~ ~~ ~• ~~s~-~ ~ (~ i- - 5 `fy ~ `t-~ oy 25 3309
Horizon Depth Dominant Color Mottles Structure t
C
i B
d Roots GPDlft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ence
ons
s oun
ary Bed ,Trench
~ a-z o 3 --° ~ I w•s ~~ cs l „~ ~- ~ ~
z. r2- «~ n ~- w, ~ S ~.-,- ~ ~ ~- ~ • ~
wF Ro.`t ~'~ .~' 8'$'. ~' ,
3(r / 2. S
Remarks:
1 0-i3 p y ~-- j_ ~.~ c ~~ ~ ' . ~
Z ' j (~ ~ (~ t~ ~J ~ ~V ~~ ~ r _,
PROPERTY OWNER S ~`~
PARCEL I.D.#
Boring #
3~
Ground
elev.
~'.(p~t.
Depth to
limiting
factor
/p3 in.
Boring #
y
Ground
elev.
~LZn.
Depth to
limiting
factor
~lQin.
Boring #
~~
Ground
elev.
93.9 7 n.
Depth to
limiting
factor
1111 in.
Boring #
Ground
elev.
ft.
SOIL DESCRIPTION REPORT
i
Page ~' of
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed .Trench
o- ~~ 10 ,-- LS 1 Fn ~-5 ~ ~ F , ~ ~ .~
a7f"'
3~ ~ z ~~
~S-, u~.
4-
Remarks:
-- ~ r+~ bk ~Q L v ~ •~
Zy ~ a 6 - ~ cs -- „} ~ Ff"
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
Z ~Z`I ~ - S ~ ~ Zvr.a-b ~ ~-; ~s ~, ~- ,
~D.~iQ' /
v ~~Z
Depth to
limiting
factor
in.
Remarks:
Remarks:
SBD-8330 (R.9/98)
'~ ~ i
PAGE .~ OF
NAME S fCsy -f-- LOT# ~5 LEGAL DESCRIPTION~G ~~4~tJ1~4,S ly T Z4,N,R IQE (or~W~
SCALE: 1"= I ~~
BM 1 ELEVATION ~ DU ~ ~
BM 1 DESCRIPTION ~ o~ I ~uG~~~. ~la a
t~ q ~
BM 2 ELEVATION ~ t. I Z'
BM 2 DESCRIPTION +opa ~ (s~ e~~ p~Ti, IuYf~. ~( F=/ate
SYSTEM ELEVATIONvtO{ r ~~• ~~ (,.~,~,,,~~ q0,q r/
ALTERNATE ELEVATION~~ a ~~~~ ~ 9a+:9 7
CONTOUR ELEVATION ~j/~}
i
+- -
I ~
y t3~
at ~3 a5
f1Lt'
O'~
~J^'' ~' 1 1 ~/~
^~_
D,
Private Onslte 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
Number of Bedrooms
Design Flow -Peak (gpd)
Estimated Flow -Average (gpd) ~
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft2) i_ _ ~,
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
Septic Tank Component Soil Absor ti n Component
Design Flow -Peak (gpd) z -
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 se ti and outlet filter shall be assessed at least
once every 3 years by inspection. Th outlet filter hall be cleaned as necessary to ensure
proper operation. The filter cartridge shou not be remove un ess provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Pn,,,.«A.e„
' Management Plan for a Septic Tank and Soil Absorption Component
i ,
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 pertormed 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 atmosphere within the septic or other
treatment of holding tank may contain 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 leirels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface 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
1 ',
e
Management Plan foc a Septic Tank and Soil gbsocption Component
Plantings of deep-cued trees and shrubs direc~fy oveC a min ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
a~ So-~-~ .~~i. ,C3E ~s~
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, ST CROIX COUNTY
SEPTIC TANK MAII~ITENANCB AGRSEMBNT
.AND
OWNERSHIP CERTIFICATION FORM
OarnerBuyer
Mailing Address l70/ /ir/~i's~2aP~ ~'~, ~`~ ~~~svr% G-~ ~S~`O,
~ n
Property Address ~ ' i `~ '"
(Verification required from Planning errt for near
City/State y Parcel Identification Number U Z.o -' ~ 3 ~` - ~ s - ~d
~~r~; nrcc7tlPTION
~~. t/<, ~ `/<, Sec. ~ ~ . T~N R~w~ Town of ~j~d,~___. "~-
property Location ____._
~ ~.~r~_../1~-,S~.s ~i9~i1~ .Lot # _~,,.
Sub~'~on
Certified Sarvey Map # ~ Vohune _~ .Page #
Volume / Page #
Warranty Deed # ~u ~ ~ ~ ~'
Spec house ^ yes~ao Lot Lines identifiable dyes ^ no
SYSTEM 1VIAIl~tTENANCE
Improper use and maint~nanr-eof your acptic 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 hcensed pumper. What you put into the system
can affxt 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 cerdf~cation form, signed by the owner and by a
mastCrplumber, journeymanplumb~ nestrictodplumber or a licensedpumper verifl-ing that (I) the on-site wastewaterdisposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than il3 full of sludge.
to maintain the private sewage disposal system with the standards
i~ the undersigned have read the above requirements and agree
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of RfisconsOffic~e ~ 30
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning
da of the three year lion date.
~ D TB
SI ~T
OWNER CERTIFICATION
I (we) certify that aII statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
virtue of a warranty deed recorded in Register of Deeds Office.
the tty described above,
/ /
DATE
I A OF APPLI
t being revoked by the Zoning impartment. `"`'`*««
«««««« ,may information that is mis-represented may result is the sanitary Pemu
«« Include with this appitcatlon: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the waaanty deed
/i.al
STATE BAR OF WISCONSIN FORM 2 - 1998 tF S6~364
WARRANTY DEED rsti;~LtEN H. wALSO
r"~~ QQ ' RFGi TER 0"r DEEDS
• Document Number ~72~,PAGG 2vU , • w~iDl,c~ dCi. , WT
VOi.. v+
HECEtVET~ FOR kECORD
This Deed, made between - - 09-1'3-8001 10:00 RM
_ 'r^NART] O STAiTT anA JANFT P RTAi1Te
_hus and and wiPp:-- -. .- NNRKNF+TY GEED
_ Grantor. ;.:~;:'~FT ~
a sing-T e person I:F.-:; LOGY FEE:
and REAGON R. WRZGHT~ i,~ii'i %'~~
- :rat95FE~~Ek: 144.60
- -l;i;r:iilu , ~.. 11.70
__ Grantee. }~A6Ls~ 1
Grantor, for a valuable conslderatlon, conveys and warrants to Grantee [he following
~~~ described real estate in St. CrOlX County. State of Wisconsin: [~
!i~ l r ,j ,:r;;i
Lot Plat of Sweet Grass Farm, Town of -
• e and Return Address
n, St, Croix County, Wisconsin.
~: j-LC
020-1376-05-000
Parcel Identification Number (PIN)
Th1s 1S riOt homestead property.
(ls) (is no[)
Excepuonstowarranues: easements, restrictions, rights-of-way and covenants
of record.
sr
Dated this ~~ / day of _A11Q115t 2001
Richard 0. Stout (SEAL)
(SEAL)
$Ignature(s) _
authenticated this
day of
,t} /Janet P(~ Stout _ (SEAL)
(SEAL)
ACKNOWLEDGMENT
State of Wisconsin,
ss.
St. Croix -County. ~
Personally came before me this ~~ f _ day of
August 2001 ,the above named
Richard 0. Stout and Janet P._
Stout _ .-
TITLE: MEMBER STATE BAR OF WISCONSIN --- to
(lf not, me known to be th~~~~~~~ecuted the foregoing
authorized by §706.06, Wls. Stats.} instrument andl®i"~JrarON~~~
KERINON J. BA8T _ __
THIS INSTRUMENT WAS DRAFTED BY ~-
Janet P. Stout
1353 Awatukee Tr ~ "_ -
HudsOri, WI 5401 6 Notary P bile, State of Wisco s'
My c rssion is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not ~-~~---- ~~~ -')
necessary.)
• Namea of perwns signing in any capaclry must be typed or printed blow their slgnauue.
STATE BAR OP WISCONSIN Wisconsin ~egai eiank Co.. inc.
WARRANTY DEED FORM No. 2 - 1996 MNwaukea. wis.
AUTHENTICATION