HomeMy WebLinkAbout020-1437-16-000Wist:onsin Dzpartment 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
As en Develo ment, Inc. Hudson, Town of
CST BM Elev: Insp. BM Elev: BM De i 'on: ' n
. rp ~ ~ . ~ ~ ~? Nl- (~T i h.v
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing _
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/L W~ BLDG. Vent to Air Intake ROAD
Septic
.. ~
ZS' f
Dosing ~/
Aeration
Holding
PIIMP/SIPHON INFORMATION ~G~-~'V I
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss Syste ad TDH Ft
Forcemain Le Dia. Dist. to well
ELEVATION DATA
county: St. Croix
Sanitary Permit No'.
506132 0
State Plan ID No:
Parcel Tax No:
020-1437-16-000
Section/Town/Range/Map No:
22.29.19.2721
STATION BS HI FS ELEV.
Benchm
- pos r
/•~
/DI•
/D~,-6
Alt. B ~ t //„
tvT ! ~}
-l~Ot/A•
2. ~
Bldg. Sewer ~
s ~
o
-~
y• 8
St/Ht Inlet SC~~a ~~ ~ ~ / ~I~
SUHt Outlet /~ ~ ~S. -7 r
Dt Inlet ~ ~~
Dt Bottom ~~ ~
Hea er/Man.
H ~ SI ~ ~dY VI.. S
~-
~
y •
Dis e
e~ _ /
liVL~-~'»
Bo~System '
D 1
at.~a~,S
-
v
Fina`I Grade + ~ /!~
~
t
•p(R.
~ p
y(`O• /
St Cover! ~ ~~ S ~ Z ~ ~•
//- ,,,_
~/ ~`-
r
~~ i ~ ~
c /111 AQCl1QQT1/lAl CVCTGM / /_ / ~w // // 1 A.. J An w v
BEDITRENCH
DIMENSIONS Width ~ ~ Len ~
!_ ~ No. O ref T nches
y PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
V
SETBACK SYSTEM TO P/L BL WE E/ TREAM CHAMBER O Manyfe¢~Nrj,,/ / '/
~ 17 7~ 'i
INFORMATION Type System: ~ ~ tl ~ ~~ ~ ~ ~ U ,
Model Number:
is. / .
1'11CT~IQI ITIl1N1 CVCTGIIA
Header/Ma ifold
/ Distribution p~ ~
e(s) h 1 "'~~
Pi x Hole Size x Hole Spacing Vent to Air Intake
~-~
/' /
M
~ p
th Dia cin
L ~
_ Dia
Length g
eng
~... n
e~~u ~~•i~o ..______.__ •.___._~_ ~_~.. .... •a.......~ ri. n~_r_r~.•o cvcmmc nnw ~...-~---
Depth Over ~y
n
h Center
d/T
B
' ~
" Depth Over
Bed/Trench Edges xx Depth of
Topsoil xx Seeded/Sodded
;
< N
Y xx Mulched
Yes ,; No
~
re
c
e
1 .
es ;
o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / SL/_.,~ Inspection #2: / /
Location: 804 Heritage/C,o'urt H~~ud,,s~o/n., WI 54016/(~S~E~1~/4 SE 1/4 22 T29N R19W) Kelly Estates Lot 16 1~~~ Parcel No: 22.29.19.2721
1.) Alt BM Description = Wa~~1'U/YN ^~~}/ 7 k//l.
2.) Bldg sewer length =3D' f~
- amount of cover =
7 Z/
Plan revision Required? ~~ Yes ~ ~ 2~ ~ /~~~/~~ ~(p S V
Use other side for additional information. l (,
Date Insepctor's Signa ure Cert. No.
SBD-6710 (R.3/97)
9k
-~'v ' f l,~,e ~lt~,(. f 3N( ~~,nnin .x ct.ar~-~ .~.~ ~ 7..' ~ Q tt.Y'h r~-v--
1
~'_.
.tlYl,gt1V Buildings Division Co~Y
~ ~
• 201 W. Washington Ave., P.O: Box 7162 b
,
~ Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
~ 5o(o13Z
Sanitary Permit Application Stan transaction Number
~~
mission of this form to the appropriate governmental
Code
suf
Viri
Ad
1
2
,
p
m
(
),
s.
In accordance with s. Comm. 83.2
unit is required prior to obtainiag a sanitary permit. NQQ'u: Application forms for state-owned POWTS aro
a be used for sewn
' Project Address (if different than mailing address)
m
submitted to the Department of Commerce. Personal information you pro
in accordance with the Priv Law, s. 15. 1 m', Stars. ~ co ~ )` -! Ce
L A lfcation Information -Please Print All Infogmatioa P 1 #
Property Owner's Name
APR 1 3 2007
~
~- 1'~ ~~' ~b ~" ~
~
5 ~ r~
Property Owner' - ing Addtees
' ~ ~, Z 7 Z f'
(l
LINTY
S'L in~n~ ST. c~~C G vc.Lot
.
~+P '/~ y., Section
City, Stan J
Jp leo~'~
T ~N; E qF r'~'
l
h
- - s _ - -
~ _. _ `/
hc. ~
y) -
app
at
II. Type-of BuildYng Ycheck afit ~~ Subdivision Name
or 2 Family Dwelling - Nrunber of Bedrooms
~
~
~
b Pl
n G/
s,.
~, y
t
e., #
^ Public/Commercial -Describe Use ^ City of
~ CSM Number ^ Village of
^ Stau Owned -Describe Use
Town of _,._, -
Z Q :a~- w ~-l ' `~
III. Type of Permit: (Check only one box on line .~. Complete lin e B if applicable)
A' New System ^ Replacement Sysum ^ Treatment/Holding Tank Replacement Only ^ Other Modific~tioa to Existing System (explain)
List Previous Permit Number and Dau Issued
^ Permit Renewal ^ Permit Revision ~ ^ Change of Plumber ^ Permit Transfer to New
B
.
Before Expiration ~ Owner ~ (~-(`
IV. of POWTS S stemlCom onent/Device: Check all that a t ~~-~
of suitable soil G G'
d < 24 i
^ M
s
oun
'ion-Pressurized In-Gmund ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil
^ Holding Tank ^ Other Dispersal Component (explai;t) ^ pretreaunent Device (explain)
V. Dts rsaUTreatment Area Information: ! ~ S 3Q t.
Design Flow (gpd)/ Design Soil Application Dispersal Area Requirod~sf) Dispersal Area Propo~Cd (sf1 System Elev n 1-
~ J
VL Tank Info Capacity in
Gallons
~ Total
Gallons # of
Units Manufacturer
_
New Tanks Existing T
nlcs /~ ~
~ /~X ~~~ ~ ~ to ~ ~ ~ P+
Septic or Holding Tank ./
l~
Dosing Chamber
VII. Regponsibili Statement- T, the nndersigned, r ponsibility for installation of the POWTS shown ot- the attached plena.
Number Business Phone Number
RS
P
MP/M
Plum 's Name (Print) Plum tore
~
J
~
~~~-Lt,ti~ ~ ~ G-V ~ ~J~~~ ~
Plumber's Address (Street, City, Stan, Zi C
/ ~~
p
~
'
-
~-~J
L~ ~
VIII. Conn /De ant Use Oni
perout Fee Dau sued Issuing nt Si
^
rsapprove
pproved
i$ ~~D • ~ ~ , ~ f~ ~
^ iven Reason for ial
lX. ConditisYS7 ApprovaUlteasons for Disapprgval ~~ Q~ ~ ~~ ~ 1JCJe1 c~ct.~ -~ ~o% d t~.~•.-~--
~
Ela DWNER:
a
V nn t,~, P~
1. Septic taMt, effluent finer and ~(,a,~~~„~,,,~„~ tYa.
dispersal cell must all be services /,maintained
as per management plan provided lby plumber. ~\ ~vo Pam O~ !J ~g~~ ~ ~ :,~., ~~ •~.,~
J w•
7 All e:n"tt~arlr rnn~~irnmante m~~st hrt rriaintained i _.. -
system and submit to the County only on paper not kse the 8 t/2 x Il blebs fa sixe
SBD-6398 (R 01/07) Valid thru 01/09
' PLOT PLAN
PROJECT Asoen Development ~ ADDRESS 511 Second St. Suite 202 Hudson Wi 54016
SE 1/4 SE 1/4S 22 /T N/ 19 W TOWN Hudson COUNTY ST.CROIX
4/10/07 BEDROOM 3
MPRS Shaun Bird 226900 _ ~~ `~ .DATE
CONVENTIONAL XXX IN-GROUN PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
,BENCHMARK V.R.P. TOp Of 1/2" pvc pipe ASSUME ELEVATION 100' Filter BEST Filter
^BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 90.5/91.5 4.5' below grade
Well is to meet all
setbacks required by
WDNR Heritage Ct.
Plans Designed Using
Conventional Powts
Manual Version 2.0
Pro 3
Bedroom
House 265' Property Line
~- 3 ~'
Vent ~~~i~-~dlaf' ~y
>6„ Quick4 Standard-W ~°~ S' ~ S
Leaching Chamber q9' kr~
of Cover with 20.0 ft2 of Area
12 5.8ft^2/pair of end caps (~ ~
4' Long ~~
34" Grade at System Elevation
14% Slope
B-3
2-3' X 66' Cells w h >3' Spacing ~~
sy~~~
-1
` ~ ~~ '" Alt. B.
~T~xa
~~
h
B-2 B.M.* 11~" 95~
~~ ~
b 36' 110'
Line ~ i~ 46' ~~ 9'
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PLOT PLAN
PROJECT Asoen Develooment ' ' ADDRESS 511 Second St. Suite 202 Hudson Wi 54016
SE 1/4 SE 1/4S 22 /T N/ 19 W TOWN Hudson COUNTY ST.CROIX
~~ > r
4/10/07 BEDROOM 3
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN-GROUN PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
,BENCHMARK V.R.P. TOp Of 1/2" pvc pipe ASSUME ELEVATION 100' Filter BEST Filter
^ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 90.5/91.5 4.5' below grade
Well is to meet all
setbacks required by
WDNR Heritage Ct.
Plans Designed Using
Conventional Powts
Manual Version 2.0
Pro 3
Bedroom
House 265' Property Line
Vent
ST
>6„ Quick4 Standard-W
of Cover Leaching Chamber
with 20.0 ft2 of Area
12" 5.8ft^2/pair of end caps
ng 3 4„ Grade at System Elevation 14% Sloe 80
p B-3
2-3' X 66' Cells with >3' Spacing
B-2 B.M.*
110'
36'
B-1
Alt. B.M.
95'
207' Property Line • _ 46' _ • 19'
5 ~..,.~.x, ~ . _.... _ .... ... .. ..... .~.
E 1222
~ °~~ ~°~~~ ~ ~'~'EVALUATIUN REPC3R~T ~5 ~ ~ ~, ~ 1 of 3
Wisconsin Depattrr~rtof Commerce ~,; ~ , , , , (,,:i ~-
Division aF Safety and Buildings in accordance with Gomm 85, Wis. Adm. Cade i Sted Sal Servrce
Attach complete site plan an paper not less than 8!: x 1 i inches in size. Plan must C t my ~ C~:roDc
include, brrt rbf IimAed to: dert~ and tnrizoNal referer>ce poa~ (BM), direction and °'~
percent slope, scale w dimems~ns, north arraar, arnt location and distarx;e to nearest road. Parcel t.D.
Pending
P/e$S8 ~ftitlf ~3/Jj l/Jf0/Ii-aibO~fl.
R By Date
Personal mfonnation Yai provde maybe roved for secondaY vU f~TM~Y Law, s. t5.Q4 (t) (m}}. ~ ~ O
Property Owner Property Location
Retiartt Developers LTD Govt. Lot SE 1 /4 SE 1 /4 S 22 T 29 N R 19 W
Property Owner's RIlaEEing Address Lot # Block # Subd. Name or CSt1A#
9900 Vary /~C~re"""ek Rd_ Suite 135 16 na Keayr Estates
City C.JdDorOctl~ State Zip Code Phone Number ~ City __! ~Ilage Tam Nearest Road
MN 55125 651-731-3174 Hudson Heritage Ct
rV New Construction Use: jj/' Residential /Number of bedrooms
__ 4 Code derived design flaw rate 600 GPD
Replacement Pubis [x carrrrrrercial -Describe:
Parent material outwash pins and stn~m terraces Flood plain ~,, if applicab~ na
Genera! corrrments
and recommendations: System elevation 95.15ft trenches spaced and depth to code 4.75ft bek>'w grade
Sorirrg # Boring
~
Pit Ground Surtace elev. 99.90 ft. pepth to limiting factor
in- Sod AQplication Rate
Horizon t~pth Daninant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
'Eff#1 'Eff#2
1 0-15 10yr3/3 none scl Zmsbk mir gw 2c .4 _6
2 15
30 4i4 none
10 l Z
bk fr 1c d~s~ ~`"
- yr s ms m
cs .
3 30-63 7.5yr4l4 none Is osg mvfr cs na _7 1.2
4 63-96 7.5yr4/6 Wane ms osg ml na na .7 1.2
,~~R 3
o B~~# ~ Boring
ry Pit
Ground Surtace elev.
99.90 ft.
pepth to limiting factor
96
in-
Soil AQpGcatan Rate
Horiaort Depttr Domir Color Redox Deter Texture Stnx:ture Consisterce Bourdary Roots GP D/ttz
'Eff#1 ~Eff#2
1 0-8 10y-3/3 none sil Zmsbk mfr cs 2e .5 .8
2 8-16 10yr4/4 none sic! Zmsbk mfr gw 1 c _4 _6
3 16-45 10yr4/4 none scl Zmsbk mfr gw na _4 .6
4 45~D 7.5yr4/4 none Is osg mvfr cs na .7 1.2
5 60-96 7.5yr4/6 none ms osg ml na na .7 12
5}~~3
trrruent ~7 = r~u 5> 30 < uu mg/L ara 1 SS >:30 < 150 mg/L • €ffluent #2 = BOD < 30 mg/~ and TSS <~p mg/L
s-
CST Name (Please Printj Signatune: CST Number
David J_ Steel ~~ 248956
Address Sterl Soil Service ~ Date Evacuation Canduded Telephone Number
1564 GR GG, New Richmond, W f 54017 10!23/2002 71x246-5Q85
6
p~{y O~ Reliant Developers LTD Parcel ID # Pending
~~ # ~~
~
~
Depth to limiting factor
ft
9ti i
~; Pit Ground Surtace elev. - - n-
Horizon Depth Dwnir~t Goior Redoz Desetn Textufe Structum Corasterx:e ~ Root
1 0-12 10yr3/3 none scl 2msbk mfr gw 1f
2 12-34 10yr4/4 none sl 2msbk mfr cs na
3 34-96 7-5yr4/4 none Is osg mvfr na na
~- ~{. ~~ (,,,Q~ y~~ ~ s}fig 3
~1 B~~ ~ --~ ~~
Page 2 of 3
Sal Applicatan Rate
GPD/f~
'Eff#1 *Eff##2
.4 6
.5 .9
.7 12
' Effluent #7 = BOD ~> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS <_30 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opgortnnify service pmvider and empinyer. If you need. as.~is~uiee to access services ar
Boring # _ !Boring
_ Page 3 of 3
STEEL'S SOIL SERVICE
David J. Steel 1564 Cty Rd GG
CST-POWTSM Reliant Developers LTD New Richmond, WI 54017
Lic. # 248956 SE1/4,SE1/4,S 20,T29,R19W (715) 246-6200
Town of Hudson, St. Croix Co. (715) 246-5085
Kelly Estates lot 16
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for
your use. The location of the test may or may not be as shown as permanent lot lines were not
established at the time the soil test was conducted. Legend ~
"
'
1
= 40
Benchmark El. 100.00Ft
'
"
op of
/z
pvc pipe
`~ Alt Benchmark E1.100.00Ft
op of/~" pvc pipe
^ =Borings
Boring Elevations
B 1 =99.90Ft
-~ r . 2 3 B2 =99.99Ft
~ B3 =94.40Ft
p~-~-
}- B4 =OO.OOFt
~.6
ti` ~.e
U-er -`~uq..~
fl
C+,
/ ~
~ Y23 ~~ ~~`?5~a~
~~
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s
~ ~~
~~
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~~~
~'~ gig" s
~~s~
.S~~c'-~ ~ ~b -E-- ~ ~~ ~
1 I' 0.C lab m Nal rar aYU t7za
° ~"~''~° KELLY ESTATES
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address
Property Address
City/State
~~
(Verification required
LEGAL DESCRIPTION
Property Location ~_ r/4 , `J ~ r/4 ,Sec. ~- ~ , T
Subdivision 11~
Certified Survey Map #
~ ,Volume '~-,Page # l
Warranty Deed # U ~~ ~ ~ ~ , 'Volume ,Page #
Spec house ye no
Lot lines identifiable ~ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
'.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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
-.The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal 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.
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 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 Planning &
Zoning Department within 30 days of the three year expiration date.
I/we cerdify that all statements on this form are true to the best of my/our knowledge. Uwe amaze the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number o edr oms
SIGNA OF LICANT(S)
~~ /~
DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. ***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
~`~ N R~W, Town of ~/;17.~~ ~~
,Lot #
(REV. 08/05)
Parcel Identification NumberG~V' ~~ ~ ~ J ~~~
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4.Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
ency Plan
Option #1. If system fails, determine cause of failure, use alternate area and install new
sys em in tested replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
Option#3. No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715-246-4516
St. Croix County Zoning 715-386-4680
Pumper Tom Mondor 715-246-5148
Shaun Bird #226900
State Bar of Wisconsin Form 2-2003
WARRANTY DEED
Document Number Document Name
THIS DEED, made between LaCasse Development. Inc., a Wisconsin Corporation
("Grantor," whether one or more),
and Aspep Development Inc.
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant
interests, in St. Croix County, State of Wisconsin ("Property") (if more space is
needed, please attach addendum):
Lot 16, Plat of Kelly Estates in the Town of Hudson, St. Croix Connty, Wisconsin.
8 1 8562
KATHLEEN H. MALSH
REGISTER OF DEEDS
ST. CROIK CO., MI
RECEIVED FOR RECORD
82/14!2006 18:40AK
MARRARTY DEED
El~?PT 1
RfiC F"fiE: 11.80
T1tAI1S FEE: 332.78
COPY FEE:
CC FEE:
PAGES: i
Recording Area
Name and Return Address
RIVER VALLEY ABSTRACT & TITLE
1200 HOSFORD STREET, SUITE 201
HUDSON. Wt 54016
i'{'2687301
020-1437-16-000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated FehrnarX, 13,, 2D06
*LaCasse Development, Inc.
(SEAL) (SEAL)
« *
Signature(s) _
authenticated on
ACKNOWLEDGMENT
STATE OF Wisconsin )
ss.
St. Croix COUNTY )
*
TITLE: MEMBER STATE BAR OF VI ,~G('J~~i!~r,,~ Personally came before me on February 13, 2006 ,
(If not, ~~~ "~C '~ the above-named LaCasse Development. Inc., a Wisconsin
authorized by Wis. Stat. § 7 ' ~ • • _ p Cor ration
'Z ~ O~ ARy • ti to me kn n o be the person(s) wh xecuted the foregoing
THIS INSTRUMENT DRAFTED lj : ~ * . * instru t d acknowledge the
Attorae Kristina O land % p~1 B
Hudson WI 54016 '~ ~~~ * C nnie M. Gullixson
~~~~~r~nttttttttp~~~~` Notary Public, State of Wiscons n
My Commission (is permanent) (expires: 10-26-2009 )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY mENTIFIED.
WARRANTY DEED ®2003 STATE BAR OF WISCONSIN FORM N0.2-2003
« Type name below signa[ures. INFO-PROTM Legal Forrns 800-655-2021 www.infoprotortns.com
AUTHENTICATION
818562 1 of 1
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