HomeMy WebLinkAbout020-1374-02-000 F — L"...i-Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division , Permit No: 420629 0
' INSPECTION REPORT
f. GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
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 Parcel Tax No: - 7 Westlund, John & Michele Hudson Township 020 - 1374 -02 -000
CST BM Elev: Insp. BM Elev: BM Description:
6 11,5 - b 1 `b ✓j P ' h %Y--
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark -7,,Z5 /06 y l �
12 Sze
Dosing Alt. BM.
Aeration Bldg. Sewer /a 03 )/ �a
Holding ` S tlnlet ql - / 1 3
SGK Din. cxt-
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P//L WELL BLDG. vent Air Intake ROAD Dt Inlet FT
ale
Septic �/ / f / Dt m
Dosing Header /Man.
! H o ldi tng eraion D' t� P 2 t 's ,
n
Bot. System C
Final Grade
PUMP /SIPHON INFORMATION Oa•SY 7
Manufacturer Demand St Cover t Z /
GPM /0. / 16 3 6 1 Mix
Model Num r T T , 13,0 / / 3 , 71 & OD, - 7�
TDH Lift do ss System Head T Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM /D / 0
BED/TRENCH Width / ILength INo'OfTrenches . PIT DIMENSIONS Of Pits Inside Dia. Liquid Depth
DIMENSIONS /
SETBACK SYSTEM TO U/ P/L BLDG IWE LL LAKE /STREAM EACHING Manufacturer:
INFORMATION // HA Type f System: , UN
O
I `' � > Model Number:
DISTRIBUTION SYSTE 16 _ J � S csx -Sau d
Header /Manifold i tribution / / Q I x Hole Size I x Hole Spacing ent o Air Intake
p p Pipes) U !
Length I � Dia Length lL Dia Spacing Afi, Loy
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only d
Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center , / � Bed/Trench Edges Topsoil
"r //-- Yes No Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / V / Inspection #2:
Location: 208 Starrwoodd Hudson, WI 54016 (NE 1/4 SW 1/412 T29N R1 9W) Starr Wood Lot 7 � Parcel No: 12.29..20.2240
1.) Alt BM Description= r s e' G�7
2.) Bldg sewer length = .3v <v /�„ ` ys �Q '�;4 dX fxx 1O�Y
- amount of cover - 77 U
Plan revision Required? �!, Yes *
Use other side for additional information. A Date Insepctor's Sign ture Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 ��
5consin Madison, WI 53707 - 7162 Site Address
De artment of Commerce /d — L S` d S
Sanitary Permit Application
Sanitary Permit Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide D ��
may be used for sect purposes Privacy Law, s15. 1 m ❑ Check if Revision / I
I. Application Information - Please Print All Information RECEIVEp State Plan I.D. Number
Property Owner's Name Parcel Number
o - - DEC 19 -i -
Property Owner's Mailing Address Location l
ST. CROIX COUNTY Property
17 P 1-1 C X ZONING % ii; S , .A T A N, R :kO
City, State Zip C odb Lot Number Block Number
i
Subdivision Name CSM Number
j
H. Type of Building (check all that apply) w/ ❑City
I
f R 1 or 2 Family Dwelling - Number of Bedrooms � � 3 Q �� {
❑ Public/Commercial - Describe Use ®Township
❑ State Owned 3 — a lA1 /0 Y X (0 2. S Nearest Road
I,-) so oo
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
1 ® New 2 ❑ Re lacement For County use ,
p System 3 ❑Replacement of 6 ❑Addition to
stem Ta�Onl Exis ' stem
❑ Check if Sanitary Permit Previously Issued ber Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) Y f
44 ❑ Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 9 Constructed Wetland
22 ❑Pressurized In Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerob Treatment Unit 49 ❑ Rec"
trmIating 30 ❑ Other
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required ✓ Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation CJ
,!!�'v c) �s7. 9v ? ✓ — 9q --� s o Z. a
7
y,�;sv /ov. 00
VI. Tank Info Capacity in Total Number Manufacturer p Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks va Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Sv
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
PI s Address (Street, City, State, Zip Code) IV
Alf
County /De artment Use Onl
Approved ❑ Disappfoved Sanitary Permit Fee (includes Groundwater Date Issued Issuing nt Sig== Stamps)
Surcharge Fee)
11 Owner!Given Initial Adverse 1 ✓, � l �} D
Determination
t EK. Conditions of ApprIval/Reasons fpr Disa roval
u��wy -�he- ->�� � a�.a/u�e%t.� d'�.�- O�•�ted. a �- frz� -a! irz f�e�do� 3' Gc.� / acb c=P PLqns (to the Coupty only) for the sy paper 6k on pap ala
x 11 is size
2
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SBD -6398 (R. OS /ql) 3
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qL �. ZAPPA sRM RXCAVATM
Wif1
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s JS � y PIS sows
V� � EfFatia+rl,.wrr
Atr P,--PtV r
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er"k H po"wze NOAK fra kLev. % /00 .cv
OATS: / • //'
/► +�kK i,N G,+t 'i /46d J� l/ `Al t Se Jet io �•QE
The Standard I Ilb stor Chamber "
V Overlap at Latching m
T E�3t �t o'Re.w 4V A4 ri,,J s �a,c'T
I
7 2'
SrCE View
7V
Effective Length
O1'1 PLOT &, CPA"
ZAPPA DRM EXCAVATM
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DATE: ! !/•
,rr+hil �G °�6dd£ L/`AlC �rk�D�+�f
G�ir�f.>EQ TEETNrQ iY:
The Standard In 11ti stor Chamber
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V Overlap at Latching han m 1�
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_.._ ' - - - -{ -_ . _ _ . � T ESC rt $ 07�•.� ��y,cn- �i4'�o
12' ;n
slot VICLJ
75
Effective Length
Wisconsih'Department of Commerce SOIL AND SITE EVALUATION 3
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance wit rrl 64. r Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in we Ian st� Co> ty
include, but not limited to: vertical and horizontal reference point (B ectionr ST C I x
percent slope, scale or dimensions, north arrow, and location and a to nearest road. - P .1:eI .D. #
3 71 0'7 -
APPLICANT INFORMATION - Please print all in 406n. R 0. x R d b Date
Personal information you provide may be used for secondary purposes (Privac aw,'s. 15;40
Property Owner �. Property Loc ti
LZ 600 .\ .Co It0T` 1/4.6W1/4,S �Z T Z p 1 ,N,R ZO E (or) W
Property Owner's Mailing Address Lo ck# Subd. Name or CSM#
Lv a ST4 R RW 60 h,
City State Zip Code Phone Number ❑ City ❑ [r Town Nearest Road
o /s >.3�6 - s� N U - i N ?5
New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow �pOU gpd Recommended design loading rate bed, gpd/fi trench, gpd/ft
Absorption area required d, ft trench, ft 2 Maximum design loading rate bed, gpd/ft trench, gpd/ft
Recommended infiltration surface elevation(s) it (as referred to site plan benchmark)
Additional design/site considerations EyAwA T io1J Aot�c 7bk p A-r APPOVA
Parent material l. si � LAe.141. 7 LL Flood plain elevation, if applicable It
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Ta k
U = Unsuitable for system S❑ U AS ❑ U S❑ U S❑ U S❑ U ID S JU
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure D /tt
g Texture Consistence Boundary Roots
- -- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1,eA 4 m /h 1 cs o 1;
Ground
elev
Depth to
limiting
f a ctor
in.
Remarks:
Boring # _6 3 I �- V►'1 C� f5 p �.S
;:....
l ee
,... `it24 SG m5 n, C3 —° %
( Ground g 7 - 1 k � S rh S — ,Z ,6,1
!! A
Depth to
limiting
fa ct or
/ 7 in. Remarks:
CST N me (Please Qrint) Si a e Telephone No.
A ss Date CST Number
1 ts�,, ��� b 6��� -oa zzz�s�
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page "Z of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
O -5 /Ul /R I c t n► C 5 Z
-ZA ooyq 4 ? _' Sl n, I cs 1 0.g
Ground �Z - 76 � A - Yje 4 -- SG $ r1t Q ��
elev
/ '
Depth to y 9 d Sih
limiting
in.
Remarks:
Bo ng # M <f 1'1'► CS 2 ,4
4 3 r"5 /h GS 6 , - t 6 a�
Ground 8 � •`� jQ� ,` 7" J`� / 17s 1 � 0, ;� g
elev.
/ .O ft.
Depth to
limiting
> f c r in. Remarks: ll/xGt� ✓`�� �C11 Q S C(C1� G%�h/:P.r c{•
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. l Bed , Trench
Boring# 6_6 n1
=, g -3C IDS ,� � — SC, r►•s rn CS �? .�
Ground 10YR 4 P� n'S '6 4
elev
Depth to
limiting
f arlar
} Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
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Ir` y POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page -I/— of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner - Septic Tank Capacity al ❑ NA LA"Vty N
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ® NA Pump Tank Capacity al ® NA
Estimated flow (average) pp gal /day Pump Tank Manufacturer ® NA
Design flow (peak), (Estimated x 1.5) 0 gal /day Pump Manufacturer 9 NA
Soil Application Rate al /day /ft' Pump Model 2 NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ® NA
Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :_150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD :_ 30 mg /L ® In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /1 OOMI ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ® NA
Other: ID NA Other: X NA
*Values typical for domestic wastewater and septic tank effluent. Other: ® NA
TMANTNNCIEAE SCHEDULE
e Event Service Frequency
nspect condition of tank(s) At least once every: ❑ m year(s) (Maximum 3 years) ❑ NA
® earls►
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ® Yeast )(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
KI year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month ❑ yeaarr (s) (s) ► 9 N
Flush laterals and pressure test At least once eve ❑ month(s) ®NA
P every: ❑ year(s)
Other: At least once every: ❑ month(s) ® NA
❑ year(s)
Other: ® NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority. %
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
Ali other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of :512 months, shall be performed'by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
START UP AND OPERATION Page of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
® A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure 6f the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name T Name _
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name ?' _ Name —
Phone 6 _ Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)ld► &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer L , .��Li iv fl
Mailing Address
Property Address c 'b� S ua::�L
(Verification required from Planning Department for new construction)
City /State J »�, �Z Parcel Identification Number p2o /. - o7 -o00
LEGAL DESCRIPTION
Property Location , vs '/,, S►-✓ %,, Sec. /A,, T o29 N -R A0 W, Town of �u �
Subdivision csrAe2 u)��L , Lot # _ 7 _ .
Certified Survey Map # , Volume , Page # -
Warranty Deed # �iJ�o�Oo�e , Volume I /73F5 , Page # 19/
Spec house ❑ yes 9 no Lot lines identifiable IN 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 years 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, journeyman plumber, restrictedplumber 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 Zoning Office within 30
days of the three year a piration date.
SI NATURE OF PLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
/ e property descri d above, by virtue of a warranty deed recorded in Register of Deeds Office.
JS
�NA OF APPLICANT 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
` VOL 1738 PASE 497 659202 WALSH
Document Number WARRANTY DEED REGIS H. EGISTER OF DEEDS
ST. CROIX CO., WI
This Deed made between LANDSTED HOMES INC. RECEIVED FOR RECORD
10 -16 -2001 10:00 AM
a Wisconsin corporation Grantor,
WARRANTY DEED
AND JOHN G WESTL,LTND and MICHELE R WESTLUND EXEMPT I
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: • 477.00
husband and wife, as survivorship marital property Grantee, RECORDING FEE: 11 .00
Witnesseth, That the said Grantor, for a valuable consideration of one PAGES: I
dollar and other valuable consideration, conveys to Grantee the following
described real estate in St. Croix County, State of Wisconsin:
ReGordinq Area
This is not homestead property. Name and Return Address
Together with all and singular the hereditaments and appurtenances ''?'
thereunto belonging: And Grantor warrants that the title is good, 3..e? 3,2-
indefeasible in fee simple and free and clear of all encumbrances except
- asements, covenants, and restrictions of record,
an will warrant and defend the same.
L01 7, PLAT OF STARR WOOD IN THE "TOWN OF HUDSON, ST.
CROI COUNTY. WISCONSIN. (Parcel Identification Number)
020 - 1374 -07 -000
Should Buyer and Seller not enter into a construction contract for a home to be built on this property by 4/12/03,
Buyer may sell subject property with the condition that Landsted Homes, Inc. remains the exclusive builder on
this property.
Dated this / day of c?c7a6Ee 2001 .
Yom___.
V�tr M. � nc - on, President
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
COUNTY OF ST. CROIX L
Personally came before me this /?4I day of 06 Pub�2001
authenticated this _ day of the above named Mark M. Erickson, President
to me known to be t e person(s) who executed the foregoing
signature instrument and ack wl ge the same.
type or print name 7 1 ' I
e signature 7be 113. /YMAAk°#--
TITLE MEMBER STATE BAR OF WISCONSIN iype'or print name
(If not,
authorized by §706.06, Wis. Stats.) j Public „ST. CROIX County, (.aIS.C�VS /'
com rtissioti is permanent. (if not, state expiration date:
THIS INSTRUMENT WAS DRAFTED BY T
Robert F. Wall ' ` P U
,•ames gFperiitlns signing in any capacity should be typed or
4
''d�y�;•.,, printed, eir signatures.
` 0 < . '
8tate otVVkcoraki .
county of St, Crl*
I hereby 0r* #* thN N a turf;
true and oorrect copy of the document on
' No and of mord In my ollim and has been
Aomi t�.�-
lkt Wal , gister of Dee
VOL—