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HomeMy WebLinkAbout020-1374-16-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanit Permit No: INSPECTION REPORT ry 430128 0 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: Wag ' Mark Hudson Township 020- 1374 -16 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No: I D2 , 81 1 1 U 2 • � 1 I S i 16t 0 wK -f pal ( 6m / ) 12.29.20.2249 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark We4 SeIr bm I v, !073 Dosing Alt. BM L PWi r le "k Aeration Bldg. Sewer .J Holding St/Ht Inlet 4 1$D� 5. C q b TANK SETBACK INFORMATION St/Ht Outlet u l . U TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic �. ju4 &A I ' a Dt Bottom Dosing Header /Man. Aeration Dist. Pipe i' Holding Bot. System E -7, , PUMP /SIPHON INFORMATION Final Grad r " 1 �u 1 it J�1 Manufacturer Demand St Cover GPM Model Number b"G.t/1 TDH Lift action Loss System H d TDH ) Ft , Force n Length i Dist. Well h . SOIL ABSORPTION SYSTEM BEDITRENCH Width 7 Length No. Of Twacbes a �� /l5 PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 3 DIMENSIONS G , S / N Ch(t144 6 S pw SETBACK SYSTEM TO J P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR a (A I "fir Type Of System: VkQ,.� n y f to UNIT Model Number: I- V- (pb s; k 5 DISTRIBUTION SYSTEM Header /Manifold I Distribution x Hole Size x Hole Spacing lVent to Air Intake 9 , � l_e n s g ) Len � p g Len 7 Dia Le th � Dia S acin SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Ove r xx Depth of xx Seeded /Sodded 1xx Mulched Bed/Trench C Ed COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:10 /30/ 0_2'6� InsnP / Location: 241 Starrwood Hudson, WI 54016 (SE 1/4 SW 1/4 12/ ` Ty2�9�N��R20W) Starr Wood Lot 16 Parcel No: 12.29.20.2249 1.) Alt BM Description = �°pt �, (_ ft o i `r &— 0 Ue 41 -&d A (2.) Bldg sewer length hta (l> n } � Z � - amount of cover = d �'[ ` J vl \ r -out X2 Plan revision Required? Yes No I O — 2/ — Use other side for additional information. 10 p te Insepctors Signature I Cert. No. SBD -6710 (R.3/97) [ Safety and Buildings Division County ' 201 W . Washington Ave., P.O. Box 2 C, V111) isco si Madison, WI 53707 - 71 Sanitary Permit Number (to be filled in by Co.) Department of Com merce (608) 266-3151 30 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information z Property Owner's Na me Parcel # # Block # OHO -/37y. A r 2013 ZVE Property Owner's M ailing Address Property Location 0 N ,� 1 ..._ _ : _ AA, �S'6 'A, JA/ tk,Secrion City, State Zip Code Phone Number S- -4/0 (circle one) II. Type of Building (check 1 that apply) T _`L N; R &O E oro t14 S ® 1 or 2 Family Dwelling - Number of Bedrooms S Subdivision Name CSM Number ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use 2. x []City []Village ®Township of , 0 ek,�%rp,,1 %-..p III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. El Permit Renewal El Permit Revision El Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) ,y+� ® Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter S V'_ J 0 El Constructed Wetland El Pressurized In- Ground El Holding Tank El Peat Filter 11 Aerobic Treatment Unit 11 Recirculating Sand Filters n ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) A.I% a d V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System 4<0 1 1 -7 � /Y 4-10 1 1 9,9, S-10 ) VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel 1 p&r Plastic Gallons Gallons of Units Concrete Construct Glass New Existing Tanks Tanks Septic or Holding Tank / - Y Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature MP /MPRS Number Business Phone Number PlumbqiAs Addre ss (Street, City, State, Zip Cod VIII. Count Department Use Onl Approved Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Iss ing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial IX. Conditions of Approval /Reasons for Disapproval OA R-Re- _V^0A&AffkNM$4%t dA4,,,\ Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) .. , IX w . /3ouciu9,ek N ld Aj l4 c.sle9+PK - �JO1/f� //V /fro O.¢K --PLO 67• - PLOT i CROSS SECTION PLANS =APPA SIM. EXCAVATM INC 1 PPJ#AD tii UNIT PR"cr y y pdtr fFFuCL+�I L,,•�� L A N6e j e � > �� ` Po o �pi4yP�(4 E /J e w Co e wi Lo 3 41 gllo k *041 r^ L ,A R ��£ s ..b SCE �i �•r6�cp 1 /� Ew - D © .sAf jkvowl 0 1Z SIGNED: VEN r 4kP UCENN: Ll -S' -a N t seECi� DATE: O �rJ 1.��,,r, �c•�4�, P ewM eo P/vE .saLtES�q sY: - The Standa d Ini ilti for Chamber TtiJcN 8olrb n 'ai'vAn'00► 0 Sal Est 1r n -� s�oE V i C w 75' Effective length .•..y . O 'd � ANt� /�irff ! c'Jt.•�0? OGL w - /g�;c�fsK Or_ � . JC�eQ Pe o �i� Quo �7 45E.ucF$,vl*s?K - �'O10(.R //U ho 04K 'r47,WT t'J 4or I 7� ��OV • Ac9 ?. �l ' I s S gt PLOT & CROSS SECTION PLANS �� , �',�.�►� ®t�?� T Q ('/ ✓1 =APPA MM. EXCAVATWO WC ? � �`Sca��� 2- iu sP�c Pr ®�4 A•�I 3�f��P . PRMCT y " Pdc FFrac J, -%Ir �.tSo GAc �ar�tT.b.ir LyAG .SO I y`'Sc �? t..rboD k /a Sswc? top oj � 4 eie C4 , j B ,/ /!� Y E Ntw GP(' wt r`(if d. , Jc bF � 1 ti O E w ^4 SCALE Pt Ad ©IS'S�Q'1�14TI0� Ofd SIAId:O: VEN r 4!p uCENEE: (/2 S A 7 �iN csrFG DATE: /�5• 03 /1�A+u.naa 71G'i�6o�E n GN�kist� N Al t se M �D >Q�6 . The Stands d InI IM mtor Chamber :SO�TESNgeY. -- f 1. ove rlap at�2� . � Taw Bor.�, ��v��► P� Sa��� 7s• Effective Length ,Wisconsin Department of Commerce S OIL AND SITE EVALUATION Division f �+ o Safety and Buildings Page ` of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County 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. # APPLICANT INFORMATION - Pleas „Nt I Revi wed by Date Personal information you provide may be used for crMtdary purpose *rivacy w, ,s. ,5.04 (1) (m)). Property Owner ` ; ,�y (xf,Property Location O Oovt. Lot .$LC 1/4 1/4,S Q TZ 7 ,N,R ZO E (or) W Property Owner's Mailing Address c W , r ' Lo in Lpt # Block # Subd. Name or CSM# � b SrtA f2 C.JOO City State Zip Co 6 Pkl � ; � El city ❑ Village Town Nearest Road 7N 3s New Construction Use: ® Residential / Num er of bedrooms ' Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate f17 bed, gpd /fi y. 4� trench, gpd/ft Absorption area required e4:�'P bed, ft ?s-y trench, ft2 Maximum design loading rate _0,; bed, gpd /f1 D.1e trench, gpd/ft Recommended infiltration surface elevation(s) Y.9, ky9, Yv ft (as referred to site plan benchmark) Additional design /sitee y &�4LuA i 16 N ti6>\19 Czar A AD IQOVA C Parent material G C j��t �{ Z ! < <.� 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 a� S ❑ U 4 S ❑ U Ws U M S El U 9 S El U ❑ S 00 U SOIL DESCRIPTION REPORT 1,'6 . BO E Q Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Bou ry Roots g, in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 4 0 6 in�t- -Y l k 4 _ 54 M:5 /h d tS •'Y Ground Depth to limiting factor Remarks: Boring # 3 A AA / 3 i SC, <� 7'h c 2-V a 4 u " 3 / �aS k v Ground $ Q /�(S &J 4 .� 6.7 7 elev � ft. mot- 9� • sv ' Depth to limiting factor > / 16 in. Remarks: CST Na me (Please P Signat a Telephone o. ff)aivs:v VO Add/fts / Al -&5wV ate CST Number S46) ZZZ_Z�7 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of, « PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench - 73 t R 4 sr �s m l cs I �, ,7 Ground ley ft / �1- S -- ° 7 Depth to limiting factor Eo7 in. Remarks: Boring # S4 e �6 D� il� Ground Depth to limiting f to ��in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 4 ®_ lbk o8 / 5 ;h Cr rn I 54 r17 s rn _ $ Ground Depth to limiting f ctor in. Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) rr 7 31 "S NJ In 184 E-U V�� G- RBI P-1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS Owner A&W y Septic Tank Capacity - p a l ❑ NA Permit P Se tic Tank Manufacturer C3 NA +� 30 12 " DESIGN PARAMETERS Effluent Filter Manufacturer - O NA Number of Bedrooms C3 NA Effluent Filter Model �- ' Ot 2 ❑ NA Number of Public Facility Units M NA Pump Tank Capacity g ® NA Estimated flow (average) gal/day Pump Tank Manufacturer IS NA Design flow (peak), (Estimated x 1.51 gal /day Pump Manufacturer m NA Soil Application Rate al /da /ft a Pump Model m NA Standard Influent/Effluent Quality Monthly average" Pretreatment Unit 0 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter D Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA O Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) C3 NA Biochemical Oxygen Demand (BOD 530 Mg /L M In- Ground (gravity) D In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA O At -Grade D Mound Fecal Coliform (geometric mean) 510 cfu1100m1 ❑ Drip -Line D Other: Maximum Effluent Particle Size Ys in dia. ❑ NA Other: M NA Other: M NA Other: fil NA "Values typical for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency month (Maxirrturn 3 yeas) O NA Inspect condition of tanks) At least once every: ® earls) Pump out contents of tank(s) When combined sludge and scum equals one -third I%) of tank volume 0 NA Inspect dispersal COWS) At least once every: D month(s) (Maximum 3 yeas) 13 NA ® earM! Clean effluent filter At least once every: - ❑ month(s) 0 NA ® ear(s) month(s) 0 NA Inspect pump, pump controls & alarm At least once every: O earls! O month(s) 0 NA Flush laterals and pressure test At least once every: D year(s) Other: O months) 13 NA At least once every: O y ear(s) Other: 0 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: S Inspector; POWTS Maintainer, Septage Servicing Operator. Tank l r Plumber; Master Plumber Restricted Sewer; POWT Masts l eaks. in or broken hardware, Identify any cracks or le . o identify an missing include a visual inspection of the tank t y Y ins actions must � cud p P 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 cells) 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 (Y3) 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. All 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 (4101) qq Page It of pt. STAR) UP AND OPERATION 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 cellls). 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 cellls) in one large dose, overloading the callls) 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. O 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. 0 The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to lacers a su itable re p lace ment area. It no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. O Mound and at -grade soil absorption systems may be reconstructed in piece 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 Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name A r nor Phone Phone This document was drafted in compliance with chapter Comm 83.2212)(b)OHM &(fl and 83.54{1), (2) & (31, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer M li K r 2 fe �' l Mailing Address Z {7D S ' !�W �' &::'t e NA Y Property Address (Verification required from Planning Department for new constructs ) City/State u -s>AN arcel Identification Number 0 2- 0 1 3 7 `I -" 16 LEGAL DESCRIPTION Property Location J'E 1 /4, sw 1 /4, Sec. /A. , T : 9 N -R 90 W, Town of Ao icub.✓ - Subdivision S IO IL NA1QQA' , Lot # Certified Survey a # Volume — Pa e # Y P � g Warranty Deed # 22 7 Z P Z , Volume , Page # Spec house ❑ yes 10 no Lot lines identifiable 0 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 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 Zoning Office within 30 days of the three y r expiration date. SIGNATURE OF LICANT DATE I 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 the property descri ed above, by A a of a warranty deed recorded in Register of Deeds Office. / Z- 03 SIGNATURE OF PLICANT 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 06/13/03 FRI 14:08 FAX 715 386 4687 REGISTER OF DEEDS IM002 J 2272P 629 7aZ5 si.a STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Docun>entNumber ST. CROIX CO., WI This Deed, [Wade between Landsted, LLC, a Wisconsin limited RECEIVED 'FUR RECORD liability company, 0 6/12/2003 10:45AK WARRANTY DEED Grantor, and Mark Wagner, EXEWT # REC FEE: 11.00 TRANS FEE: 387.80 COPY FEE: CC FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum:) Lot 1 Plat of Starr Wood in the Town of Hudson, St. Croix County, cousin Rccording Area Namc and Return Address Valley Abstract & Title, Inc. P Box 149 son, W1 54016 020 - 1374 -16 -000 Parcel Identification Number (FIN) This is not homestead property. Exceptions to warranties: (tia) (is not) Easements, restrictions, and rights -of -way of record, if any. Dated this Zw day of June , 2003 I.ANDSTED, LLC r * By. AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF 'WISCONSIN ss. S.T. CROIX County ) authenticated this „ day of ' Personally came before the this 0 !* 2 day of June 2003 the above named - fC Landsted, LLC, a Wisconsin limited liability com any NotapL Pi 61' jT — f B TITLE: MEMBER Sstatwd W4000” (If not, to me lm to bell sons) who executed the foregoing authorized by $ 706.06, Wis. Stats,) ins wedged the same. THIS INSTRUMENT WAS DRAFTED By Brent R. Johnson - Lommen, Nelson, Cole & Sta eber , P.A. Notary Public, State of WISCONSIN Hudson, Wisconsin 54016 M o ission is a anent. (If not, state expiration d te: (Signatures may be authenticated or acknowledged. Both are not neec=ry.) �j•/3 ) am Nes of persons signing in any capacity must be typed or printed below th signature. �"—� WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 -2000 INFO -PRO (A00)635.2021 www,infoprolorms.com ao�cta4aoa �ca ,tiu' ° OWNER BMW rAAeOra VA suns a a � �� 0o aleleYlMreNWe IOMTIIk/IAIE / 9 / 6�L9 cdna>r,11DN1alalrruao \ Pm«/PrEFU" • ?w«/PPEF«1r0 ! l 0 rx2rnONArEWE0ea11.13us P9,t6EMFoarwr / O ?t 37 e01/ FIFE SEr VVEMOM 3A61ffi P9tllIFMFDOf �/ \ �/ • .1. 1 •• 1 MM: AtLOT611orCDm/®me10NLWM W7mrt2rwoNAfew9smw DETAILA • • • . • . • • • • an a//+raelelLxtl/E tASe/wM / Norm arAE PWPds®«NE LAiE — - — 1 - / , 12467 MV20 Yr ' 2 NSrI959"M 2466 SIDIIYNwi91tliB1111DNNEA 3 Ne, .M n 10.67 lU, w•�- D*YMTDH V*%I E . Horan" tam a Norlsa6w 10.19 NDAEA - 7 pm-B 117 W GWMWq TMTWOIaDALTER"CJ VC" . e Nm'W.OW 6171 0F"9lQNVAlMF*lEMnMA FA IS PFAA*N m - - BUU* 16MEPN01idt VPM - 1 TEs101WVw7mr& - n inD1/MFA e . 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Oorlhd to WMo«Wn DspwWwt d Trarrpona W, for more etormd«L The phone mmtw may be obtained W offu rq the CmM HVhv Y Del - TM bb d Die 1Md dhhbn mM mmeNnOD noble at IwNS slcedlrp DD bYW In t Tram 406.04. T" 1. Then WNW"baud an IdWrN Wrldmda Owwe d &me bb we mopOmmbb br WbWG . nabs m Admt b plod SO" bq. elm anam SHEET 2 OF 3 SHEETS . 71n IIIailUr.81f«W7®sY12Vp Me NR MIA DA763.1140