HomeMy WebLinkAbout020-1365-23-000`Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and 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 ^ T41~vn of:
P.C. Collova Builders, Hudson Township
CST BM Elev-:- Insp. BM Elev.: BM Description:
L-3~ L~33 Z ii
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic ~ ~ o ~,~ ~ ~
Do `
Aeration
Holdin
TANK SETBACK INFORMATION.
TANK TO P/ L WELL BLDG. vent to
Airlntake ROAD
Septic 7 "~~~ ~ / ~ ~r NA
NA
tion
Holding
PUMP /SIPHON INFORMATION
Manufacturer nd
Model Nu GP
T Lift Lrictl System TDH
Forcemain Length Dia. Fi Dist. Tow
SOIL ABSORPTION SYSTEM
tLEVATION DATA
county:
St. Croix
Sanitary Permit No-:
363857
State Plan ID No.:
Parcel Tax No.:
020-1365-23-000
STATION BS HI FS ELEV.
Benchmark Z ~ ~ 9G . 3
Alt. BM q ~.
Bldg. Sewer ,S; ~ J(o - ~S~
I Ht Inlet ~; ~ 9S,
' ! Ht Outlet L - 9~ • ~Z
Header /Man.
Dist. Pipe T (
z ~ •
~'• 3 9 3~. Z 3
Bot. System ~ c 7-~
~' Z ' 6 ~
L L-~
~
Final Grade d.Y9 9S z~
St cover S. (, q ,/S
BED / T ENC Width Length No. Of Trenches PIT No- Of Pits Inside Dia. Liquid Depth
DIMEN ~ ~ Z DI
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LE Manufacturer:
SETBACK H
INFORMATION
TypeO -Z
AMBER
Mo el r:
System: ~ ~ G ~ ~ % OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold rr
r Distribution Pipe(s) ~
~ x Hole Size x Hole Spacing Vent To Air Intake
~
Length ~ / ~
Dia. ~ Length ~(Z Dia. ~ Spacing Z ~ Z I Z ~ Z 7 ~S
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 Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: ~"J I j /DUInspection #2: I I
Location: 660 Laurie Lane, Hudson, WI 54016 (SW 1/4 SW 1/4 15 T29N R19W) - 15.29.19.2183 Riverpark Meadows -Lot
23
1.) A1tBMDescription=6S~w7 ~vr' `~•~ 7 Z ~~ ~ 1'a ~aur,'r /~{ a~r~..~ °Sf i°"~~i~
i;.~~
2.) Bldg sewer length = Zo
/~
-amount/of cover = >/
Plan revision required? ^ Yes [y~ No
Use other side for additional infor atlon.
SBD-6710 (R.3/97)
x
~~ paTlti ~UI~Gf.GS Q~G ~~Q'a~~OI (~ / J~t~ /ov6Pr~"
L• - t
D
Da a Inspector's Si ature /~ Cert. No.
s~~ des ~-- ~~ ,
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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~~isconsin
Department of Commerce
.SANITARY PERMIT ILL ,~(TI,C1 ,
In accord with Comm 83 s~`ioY`'~e:"Adm. C n~'
11 rrr-a rf ~
Safety and Buildings Division
201 W. Washington Avenue
POBox7162
Madison, WI 53707-7162
• Attach complete plans (to the county copy only) for the s~slen, on ~~~rlr~~less boa ty
than 8 v2 x 11 inches in size. ~ _.,~
~ ~~
_~ ~ ` x
~ ~ ~
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'
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• See reverse side for instructions for completing this appllration ~ ` ` ~' r
Mate Sanitary Permit Numbe
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t•y1
.JT Vi \a~ /('~~,r`
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Personal information you provide may be used for secondary purposes ' - C{3UNN
Gp~NGE
~
,`s eck if revision to previous applica[ion
,
Z01tiiN
[Privacy Law, s. 15.04 (1) (m)].
- ,': a plan Review Transaction Number
I. APPLI ATI N INF RMATION -PLEASE PRINT ALL I ATI °`< ~'
Property Owner Name
~ `~ pt p rt ion
N
R E (or~
t/a
S T
g g
G C l ~ ,
,
,
Property Owner's Mailing Address Lot Number Block Number
. d - ~,~ ~-
City, State Zip Code Phone Number Subdivision Name or CSM Number
` ~ d / ( S >~' Y- 977 . `u er QI / ~ u1 S
. TY F B 1 DING: (check one) ^ State Owned
3 ° Ity
° Nearest Road
Public 1 or 2 famil Dwellin - No. of bedrooms . ToWg of 1~ cl- ,~ h21~r r'-e- ~ av
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ? ~ V f . ~ (~ ~f 1 S3
!/!
r
v
(
~D
~ 2
5 _
~
,. ~,~ ~ ~ 1
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 5. ^ Repair of an
______System ________System _____________ TankOniy______________ Existing System ________ Existin~System
B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Preswrized Distribution Pressurized Distribution Experimental Other.
11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank
12 Seepage Trench 22 ^ In-Ground Pressure ~~ ,,,~I I n 42 ^ Pit Privy
~ ~' `~'z'2ut
~
~
~
-
S 43 ^ Vault Privy
13
j Seepage Pit ~
,L~
14 ^ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft:) (Min.finch) O ~Q Elevation
~sa
9
~ Feet ~. ~ Feet
~ J`- ~ 0
VII. TANK
INFORMATION Ca aclt
in allons
g
Total
ll
# of
k
Manufacturer s Name
Prefab.
Site
Con-
el
St
Fiber-
Plastic
Exper.
E
i
i Ga
ons Tan
s concrete e glass App
New x
n
st strutted
Tank Tank
Septic Tank or Holding Tank ;/~ l ~Yli 2 $'~' ti.r/ ^ ^ ^ ^ ^
Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ ^
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature' (No Sta ) P PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
r
s0 -~
IX. COUNTY /DEPARTMENT USE ONLY
^ Disapproved Sanitary Permit Fee (Includes Groundwater
Surcharge Fee) ate ssue Issuing Agent Signature (No Stamps)
A roved
~1 pp
(-
^ Owner Given Initial
~~
~ _
S ~ ~U ~
Adverse Determination t
•
X. CONDITIONS O APPROVAL REASONS FO DISAPPROV L: ~~
~~~ ~ ~
_ ~_-t _ ~ __ _ _. _
SBD-6398 (R.12/99) 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 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 Qe 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 on 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 for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every newlor 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.
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' Wiscv~-'~sin Department of Commerce SOIL AND SITE EVALUATION 2
Division of Safety and Buildings Page ~ of 3
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 County
include, but not limited to: vertical and horizontal reference point (BM), direction and ~ . C
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION -Please print all information. R viewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ S $_n .e.n^1
Property Owner Property Location ~-w V
,.~ CO ~ ~d Govt. Lot ~ W 1/4S~ 1/4,S r U T Z C( ,N,R i q E (or~
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
""l05 Qcl _ ~ ~~ ) ~ irk I~'xc~ow
City State Zip Code Phone Number Nearest Road
5 LS ( ]J ) ^ City ^ Village [~ Town
5`-Ki-5977 ~ r~ Gum lance
New Construction Use: ~ Residential / Number of bedrooms 3 - y Addition to existiny building
^ Replacement Public or commercial -Describe:
Code derived daily flow ~_ gpd Recommended design loading rate • ~ bed, gpdffl2 • ~ trench, gpd/ft2
Absorption area required g5~ _bed, ft2 ~S trench, ft2 Maximum desi n loadin rate
p g g bed, gpd/fit • $ trench, gpd/ft2
Recommended infiltration surface elevation(s) ~ (~U U ft (as referred to site plan benchmark)
Additional design/site considerations ;4/r{ . e (~ y- q/.S'O
Parent material (1U'~'t~Li Sh 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 C7. S ^ u l~ s ^ u ^ s ®- u ^ s ~] u
SOIL DESCRIPTION REPORT
Boring #
Ground
elev.
gsv~ft.
Depth to
limiting
factor
~in.
Boring #
Z
Ground
elev.
~/~ SZ~ ft.
Depth to
limiting
factor
12.1. in.
Horizon Depth Dominant Color Mottles T
xt
re Structure Consistence nda
Bo Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color e
u Gr. Sz. Sh. u
ry Bed ,Trench
t U--z /0 r 313 ~ ~'~"~ L ~S l v~ ~.$
Z ~2-- IU r y Icy - rnS Us Im ~. c _ ' . $
,~' ,
~ ~ ~ ~~ a. ;
Remarks:
f ~.. ;
i
(
t ~
,
Remarks:
SST Name (Please Print) Signature Teleph'on/e No.
L ~~~ 7~~"zT 7'yd0(~
Address Date CST Number
PROPERTY OWNER ~U l (c~.r cc SOIL DESCRIPTION REPORT
PARCEL I.D.#
Boring #
3
Ground
elev.
~/~ ~ft.
Depth to
limiting
factor
~_in.
Boring #
~i
Ground
elev.
Q~.
Depth to
limiting
factor
Z in.
Boring #
5,
,.
Ground
elev.
9G_~ft.
Depth to
limiting
factor
in.
Boring #
Ground
elev.
ft.
•~
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
~ ~-12 10 r 3I Z _-_. I r ~ I v~ . z~. 3
Z 12-23 l y~`I - ~ 1 irYfi ~ - • Z ' • 3
3 z3-~za l0 rat CP m~ o mi cs . ~ ~ . g
58.8 /~
Remarks:
1 o-io ! z - Si Imabk i~r ~ I~ . Z
2 ~0 28 ~ r yly S•1 ~ ~ c - . 2 '. 3
3 z$ ~ ~0 yl ms o ~s .~ ~ ,
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
I o-~2 I(~ r 31 Z -' Si I I mobl~ cs 1 v~ . 2~. 3
2 -z-z lD r y Ly - 5 i I 1 ma-bk mfr ~-S - . Z ' • 3
3 2Fr-i zy I ~ r y ~C~ - m5 v c.S ~ . ~ ~ . $
• 2 l 2~ , - f
Remarks:
Depth to
limiting
factor
in: Remarks:
SBD-8330 (R.9/98)
. ~. /-
N~iri E~ ' Pa --I-
BM1 ELEV. _
DESCRIPTION-
BM2 ELEV. _
DESCRIP2TON-
ALT. ELEV
CONTOUR E
----- ---
PAGE ~ OF 3
-- ` ~ tli
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ~. ~.. ~ I IO{~A g (~ a1 s ~n1 ~
Mailing Address wS ~`r~ • ~t d ~ /wr~su.v I,vL .~~}-v 1(0
Property Address ~~ ~ ~ ~2 (f, ~~,q-~
(Verification required from Planning Department for new
City/State tT~ ~~o N (~~ Parcel Identification Number
LEGAi, DESCRIPTION ~~
Property Location ~ '/,, $r~ y,, Ste, ~, T~N-R~W, Town of ~ct!So n6
Subdivision /~(l l6,
Lot # 23 .
CertiCed Survey Map # Volume .Page #
Warranty Deed # w0 ~ ,~-(d ~ Volume ~~ ~ Page # Z
Spec house O yes~no
Lot lines identifiable yes O no
SYSTEM MAINTENANCE
Impmpcr use and maintenance of your scptic system could result in its prematurafailure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the systcm
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 licensedpumperverifyingthat (1) the on-site wastewaterdisposal system
is in pmpcr 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. Cmix County Zoning OfSce within 30
days o e year expiration date.
SiZaOv
SI ATURE F APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge.
the pro escribed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SI NATURE F APPLICANT
I (we) am (are) the owner(s) of
.~ /~/ O~
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
SrATE DAR OF iVISC,OfJ>IN FORM 2 - t982
W'ARJtAKTY DEED
DOCUMENT N0. el~. 1',l3JPac~ ~~ ~`2
f 1
~~ ~ liar jorie 1lalernee, Frances August and Paul K.stner
ns tenants Lu cumin°n `~ a/k/a Fr~.ncia _
_--.. _ Alt R U 6 t
convr;s acd wunms tc •C. Cn__ ova Du Gera, Inc., a
Fttsi:onsin Corporaticn
G~Or6267
KATHLEEN H. uALSII
F;EGISTER OF UEEUS
ST. CkO1X CG.F UI
p.ECEIVED FDR RCCOAD
07-06-1934 9:10 AM
YriRRANTY GEED
EifCtByl tl
CERT CDPY FEE:
CDDY FEEF
TRAKSFER FEEF 1318,0
kECl11tD1FC FEE: 12.00
PAGE9: 2
bu! 5>AL'E nFS tRSFD rOn R[COnOR:6 DFTA
the IoItdU9n~ dt3e1'11Yd a'J1 Cfl'a(r .n ~,', ro n County, cAV'i ' J, F~STRE~:'~
Slma o(I,t'iseensin:
304 L -)GUST . 1'.
SE 1/4 vl. 1J4 Sec. l0-'f29N-RL9W excepting s.hereCrum Lot l HUUSUN, WI 540'c
of Certified Su•cvay Ctap recorded 1n Vv1,7 of Certified
Survey ttupo, pnf;e 2089 as Uoc. No. 44130), also excepting 02U-1010-20
the railrcad right of way. 0201026-90
020-1025-9~1
tiE !/s NW l/4 Sec. 15-'t29t1-R19W excepting tharel r. r•.m Lot I~~l'cEl FJtntIilGAllOV NUMBER -~
of Certified Survey P)ap recorded in Val. lU of Certified
Survey 61apc, page 2701 ac Uoc. yo. SCi;2g.
tit: 1/r NE I/4 Sec. 15-T29N-R19W
This is nor hort>c;lc•d proprrty
-.IkL- (snot)
F7ccptlon to a~aranues.
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Dated. skits _____~~ day of ,yt~~ttJune Pry 9 99
~a a ' r n ~' ~~'fS.~L7f ~;y ~!! ,( ~! ice"` (c>:AI.)
Frunaes AuSUSt B ~ ~~ Paul aatner
.~.cr~, • gin; ...+~~l~n's~ssiiu ion'
ltari(±rieQ:alernee ~ a.. ''_-~~':;;;,"?
~~~i~:
AUTf1ENT1CATION slnt`n
auth:ndcsled this Jay of , :9._
I
- (r-F.AU
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-_
ACKNOWLkDGhIENT 'I
t1 h},iin on SEE A"CTACHEDI
Stale of 1tsl~s~bTrs~F~, 1gXliIDIT "A" '~
Jr ss.
KLnR _ Courcy ~
Te~soul:y carat br(ure me sills 26th day u( ,'.
June __l9 99_,d.eaboTenan:nl
ilil`--: ~1Eh1BER;TniC UAk OF WISCJNSIN _ Irancod ugust ~ -- j
tl(nul, _ _ ~~~
' aulhorizcd by 8705.06, R'is. Set..) FD tre hnuJVr: to b he prrsen -,+fio executed she for:guirg
insl ,, l an r n wlydyit}la/sat e
'.115 W3TFUFAENI l'/45 nn0..TEn aY
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Heywood 6 Car:, S.C. b Sialtcr aodynaky
Z04 L~cuet St., P.O. Nun 125 Hu son, f(I 54015 K111q
- Notary Public. ..----... ____ Cuunty;~tb-
(Sidr.D:cres may bz nua:emica;ed or aknow:adged. H, ih eta nnl 1.1y cu.iuni-sinn fs pumanenl. ;I( ncl, acre exprrsisus dale:
nrc:ssary) Septetnbet 1, 2001
• TLvrs of pmnn, s~rniny sr. ,m' npu ~Uy,Anal! by sjMd •r paned hdnw lnnr sVgr me,a~.
~N1itRAN]Y DECD (FATE B.1t C1r SVIyCGt.51N vnsarsn ALega Cain Cu. v,;.
Farm Mn. 2 - 19P1 .uh~a,+w. Y,b.
L:A
ll~i..~'2 Ji1 P:tG~ ~~ 1~
E;~IIBIT A
ACKNOWZF,DG117ENT
State of Ohio )
ss.
F'rank~~.n County.
Personally came before me this 28 th day of Junn , 1999,
t}t_ shove named A4arjorie hlalernee to me know to be the person who executed
the foregoing instrument end acknow9edgc the snmc.
1~,...G_ ss ,~ rrz.-
2Jotary Public, Fcan6lin County, OH
T9y commission is permanent. (If not, state expiration dale:
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P~ ~~Y ~\Q~
~ Mar. 27; ZC03
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O`\, Statc of Illinois
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ACI:IYO~~'LEDG117CVT
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Personally came before me this ~.R f flay of u.--~ , 1999,
the above nazned Paul Katner to me know to be the pcrson who executed the
foregoing instrument and acl;nowledgc the same.
' ~..~1° •4sC.r ~ ~2~t
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Notary Public, ~°c.L. _ County, IL
My commission is permanent. (If not, state expiration date:
OFFICIAL SEAL
LAVERNA R SNEER
NOTARY PUDIIC. STATE OF ILItNOrE
MY COMMI1610H E><MKl:0~11tl/00
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