HomeMy WebLinkAbout014-942-27-2411-SAN-2023-194 �''` '"�- Industry Services Division County
�� , 4822 Madison Yards Way ,S�iw y P� �
: ., _' = Madison,W I 53705 Sanitary Pemvt Number(to be filled in by� 7
_ _ P.O.Box 7162 �
,�'�` Madison,WI 53707-7162 (,p s ( D� S r�
State Transaction Number �
Sanitary Permit Application !
In accordance with SPS 383.21(2),Wis.Adm Code,submission ofthis form to the appropriate govemmental�nit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffetent than mailir►g a� ..[
the Departrnent of Safety and Professional Services.Personat information you provide may be used for secondary A
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ��'�� '7�� /�n`�6��N
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�;� �ll;s GIH-4'y�-,27� �`�lll
Property Owner's Mailing Address Property Location
�7� D'� f0►`� /11/t Govt.Lot
City,State Zip Code Phone Number r
S j / �.� �/�U �`��� �, J C %.,�'/., Section�Z
II.Type of Building(check all that apply) � Lot# � T y�- N R E or
,$'�1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use �
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
3 gl9 S �q( �LTown of Le-�.-��i
IIL Type of POWTS Permit:(C6eck either"New"or"ReplacemenY'and other applicable on line A. C6eck one box on line B.Complete line C i
s licable.
`� New S stem
� y ❑ Replacement System ❑Other Modification to Existing System(explain) ❑Additionai Pretreatment Unit(explain)
B' �Holding Tank ❑ In-Ground ❑ At-Grade gn ❑ Other Type(explain)
❑ Mound ❑ Individual Site Desi
(conventional)
C• ❑Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Applicafion Rate(gpd/sfl Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation
300 l+-� �t r /�-r ItT
Capacity in Totai #of Manufacturer
Galbns Gallons Units � o 'd ^
Tank Infonnation � �
New Tanks Existing Tanks � c � " � � � `�
0
a. U ii� �, vs u, C7 Ci.
Septic or Holding Tank 3�OO ��'� ' �it✓�es r,�
Dosing Chamber
V.Responsibility Statement- I,the andersigned,assume respoasibi6ty for installation of the POWTS shown on the attac6ed plans.
Plumber's Name(Print) Plumber's Signature �� MP/MPRS Number Business Phone Number
GP��,�� ���.�� i '� � ��..—� �S�t�i ���5�-sr�—��3�
Plumber's Address(Street,City,State,Zip Code) �
i :3S-o �w �������I 2d ��� wH.� w1 s���3
VI.County/Department Use Only
l Permit Fee Date Issued Issuing Agent Signature
�A m e ❑Disapproved U
��w' ❑Owner Given Reason for Denial $ -Cd�� y �I��� 3 ��'k'(�'�,�Q-��
Conditions of ApprovaUReasons for Disappmval � a� �
C" � � 1 � , � i.
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a ,
SAWYER Ct��T•51-1'
ZCNING AD�,11N,�rr�a:�,OPJ
Attac6 ro complete ptaos tor t�e system aad sebmit to the Counly oety on paper not less than 8 trz a 11 inches m size
NQ REFU�vDS�'►FTER t-I�f(r ir�i
SBD-6398(R.03/2t) I�SUE OF F��T
Sawyer County Zoning & Conservation Administration
�������� 106]0 Main Street, Suite 49
� �R CO �� Hayward,Wisconsin 54843
�'� - —��fi �� (715)634-8288
��� � �`Z � FAX(715)638-3277
r Q/ \.�/
��� . _ {� wwwsawYcrcounty�ov.ora
� o , � �o � E-mail:sanitarian c�sawvcrcount m.org
I� � ='` _ ._y/`�= Toll Free Courthousc/Gencral Information 1-li77-699-4110
I LL��,�=�
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp �B / �� / �3
Parcel ID#o ( `�- `T�f�-�2�7-.2� / (
II. Plot Plan:
�Property Lines 4�Benchmark BM ♦
�Site Address �North Arrow
�Structure � Scale
Well �<25' to Service Road
�Legal Description �Nearest Road Intersection
�Setbacks to: Property Line, Well, Structure, Water bodies, Roads
III. Required Plans:
�Index Page with Original Signature
Management Plan/Contin�ency Plan
Servicing Contract
Holding Tank Agree�nent Fonn ($30 to ROD)
IV. Holding Tank Specifications:
'� Tank Cross-Section: Manufacturer: �,,,�es-e.r Gallons:
3�000
�Tank Anchor Calculations [SPS 383.43 (8) (g)]
�Locking device, chains/locks
Alarm, electrical per SPS 383.43 (8) (e)
3" Bedding Material < 1/2 "
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: ��i S Plumber: SaY �.
Application Review Date: _ b g/�'� ( ��a- 3
POWTS Reviewer: `
�� � �
Name
�� � �� Rev. 4/27/2023
Credential#
PAGE 1 OF 4
Holding Tank Plan
index & Cover Sheet
Co o nt Manua!Design References:
Version ,SBD-10855-P(N.03/07;R 01/12) 'a�_�"7)
Pg 1 of 4 ,1 Index&Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map(if appticable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
Owner Name(s): Neil Ellis Phone:
Owner Address: 572 Dayton Ave St.Pau1,M� Z�p: 55102
Project Address: �2797N Anchor Ln
Govt Lot: SED 1/4 of NW 0.1/4,Section27 ,T42 N-R9 E�or W�
Township: Town of Lenroot County: Sawyer
Project Parcel ID#: 074942272411
Designer Information
Designer Name: Gerald Froemel Phone: ��15�558-1138
Designer Address: 13502W Froemel Rd Z�p; 54843
E-mail: Jayfroemel@gmail.com 7'his space rese�ved for�pproval stamF:.
License Number: 950111
Remarks:
Signature:���� Date: $�17/23
Original signeture iequired on each submitted copy.
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PAGE 3 OF 4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproot 12"Min.or 2.0 ft above
Junction and APPro�� EstaWished Flwd Elevadon
Alarm Box Vent Cap (typical)
Elec[rical must comply with 1 Approved Lodcing Manhofe
SPS 316 and NEC 300 4"0 Vent Pipe � wilh Waming Label Attached
Conduit >10 ft from (typ��l) 4'Min.or 2.0 it above
Building Eslablished Flood Elevafion
. - . . . . � (A'Pical)
-- �Airiigh[Seal
° Finished Grade �
18"Min.
(�YPica�) <
1 ` ' a ".
. a
Inlet Inle[Invert
Watertight
Approved.bints unth _ � Plug
Approved Pipe 3 ft onto Max. 12'or 90%of total volume
Solid Ground ' if more than one tank
a
A Alarm-0n
:
HOLDING TANK
VOLUME = 3,000 9al
e'
a ' . 4 . � � . . . . . , n .
3"Approved Bedding Material Beneath Tartk
TANK MANUFACTURER: Wieser Concrete
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Baliast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)- Ibs.tank.wt]x 1.5
Holding Tank exterior dimensions in inches: (Length_"x Width "x Height ")/1728=0.00 ft3
Ballast Weight= [( 0.00 cu.ft. x 62.41bs/cu.ft x 1.5) - Ibs = 0 Ibs
PAGE 4 OF 4
Holding Tank Management Plan
IAAPORTANT:
The owner of this holdi�g tank(s)shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52 (2), Wisc.Admin. Code, this holding tank(s)
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc. Admin. Code.
Estimated Daily Wastewater Flow= 300 gpd
Inspection Checkiist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanical malfunction(i.e., pumps,vabes, switches, floats, etc.)
o material fatigue(i.e., leaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o electrical components(i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o surface discharge of effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s)shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats.
when the wastewater in the tank(s) reaches a level of one foot below the iniet invert of the tank(s).
Disposal of contents shall be pursuant to NR 113,Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unk in accordance with SPS 383.55 Wis.
Admin. Code. Report any component fallure or malFunction to:
Name of individual or company: �ayS SeptiC Phone: - !�� 'S Sr�S���-��l
Local govemment unit: Sawyer County Zoning Phone: ��15) 634-8288
Local government unit address: 10610 Main St, Ste 49 Hayward, WI Z�P; 54843
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacement of failed or maliunctioning components shall comply with SPS 383,Wisc.Admin. Code.
No product for chemicai or physical restoration of the POWTS may be used uniess approved by the department in
accordance wfth SPS 384,Wisc.Admin. Code.
Continaencv Plan
In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a
pian submitted to the appropriate agecy for review and approval.
Svstem Abandonment
If use of this tank(s)is discontinued, it shall be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
HOLDING TANK SERVICING CONTRACT
Contract Datc: � / f�/ .2
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
/VPi � ���i f .SCO�1 "/��{'
Parcel identification Number:
(12 Digit Legacy ID) v I � - � �( � - �- � - � � ( �
1 . The owncr agrees to file a copy of this contract with thc governmental unit, Sawyer County,
which has aecepted and recorded with the OfCice of ti�c ►'�egis[cr or Deeds, the Maintenance
Agrecmcnt for a Holding Tank required under the Sawycr County Private Sewage System
Ordinancc for the issuance of a Sanitaiy Pcrmit for the installation of a holding tank(s).
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to
permit the pumper to have access and to enter upon thc property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-wcathcr access road or drive so
that the pumper can service the holding tank(s) with the pumping equipment. The owner
further agrees to pay the pumper for charges incurred in servicing tl�e holding tank(s) as
mutually agrecd upon by the owner and pumper.
3. The pumper agrecs to submit to the Governmental Unit, Sawycr County, a report for the
servicing of the holding tank(s) as required undcr SPS 383.55, Wisconsin Administrative
Code and the Sawyer County Private Scwage System Ordinance. The pumper further
agrecs to include the following in the report:
a. Thc name and address of the person responsiblc for scrvicing the holding tank;
b. Thc name of the owner of the holding tanlc;
c. Thc site address of the holding tank;
d. Thc date the holding tank was serviced;
e. Thc volumes in gallons of the contents pumped from thc holding tank for each servicing;
f, The dic}�osal sites to whac�h t�� confents from rhe holding t�tinl< were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In
the event of a change in this contract, the owner agees to filc a copy of any changes to this
servicc contract or a copy of a new scrvicc contract with Sawyer County within ten (10)
business days from the date of change to this service contract.
Owner's Namc: (Print) Owner's Signanirc: �oniy one o«�ner s�gnature requ�rea>
�er � �� � i� 1���
� �
Pumper's Name: (Print) Pumper's Signature:
,SCD �-T � ��' � ���
P � � `�� ,
Pumper's Rcgistration Number:
�! �I 3
Rcv. 03/2C/13
.. ..
- USE BLACK INK ONLY -
�I��I fl I(I I'I ( II (I�i(I IfI I�I
���I :8072954
POWTS MAINTENANCE AGREEMENT ix:4046864
For Holding Tanks 44596�
PAULA CHISSER
Owner's Name(s)as shown on deed: REGISTER OF[}EEDS
SAWYER COUPlTY, WZ
�QI l �'�, �/�C10�� �i��l � • l�� � �$/i�j2Q23 4R_1$�!M
Parcel Identification Number: Q RECORDING FEE 3Q.flU
(12 Digit Legacy ID) U ' �- l -( 3- o�-� - � � � �
— PAGES: 2
Legal Description of Property:
- SEE ATTACHED SHEET -
We acknowledge that application is being made for the installation of a holding tank(s)on the
property described on the attached sheet.
Return To:Sawyer County Zoning and Conservation Administration
10610 Main St.Suite 49, Hayward,WI 54843
As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the owner is
responsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to all
applicable requirements of SPS 383,Wis.Adm. Code relating to holding tank management, including the following:
1. The owner agrees to contract with a person who is licensed under Ch. NR 113,Wis.Adm. Code, except as provided by
Section 281.48 (3) (d), Stats., to have the holding tank properly serviced and to file a copy of the service contract with the
governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service
contract,with the governmental unit within ten (10)business days from the date of change to the service contract.
2. The owner agrees to contract with a person licensed under Ch. NR 113,Wis.Adm. Code,who shall submit pumping reports to
the governmental unit in accordance with SPS 383.55,Wis. Adm. Code, for the servicing of the holding tank. In the case of
exemption under Section 281.48 (3) (d), Stats.,the owner shall submit the report to the governmental unit. The governmental
unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the
holding tank is not being properly maintained.
3. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit to prevent
or abate a human health hazard as described in Section. 254.59, Stats.,the governmental unit may enter upon the property
and service, or cause the tank to be serviced. Pursuant to Section 145.20(4)Wis. Stats., a governmental unit may assess the
owner of a private sewage system for costs related to the pumping of a septic or holding tank.The charges will be assessed
as prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the governmental unit for
inspection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate
any human health hazard caused by the holding tank.
4. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems
certifies that either a soil absorption system that complies with SPS 383;Wis.Adm. Code, or a m��nici�al sewer sen,ec thQ
property. In addition, this agreement may be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
5. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit
the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will
permit the existence of the agreement to be determined by reference to the property where the holding tank is installed.
-Only o wner s' natur uired- ACKNOWLEDGMENT
Owner's Signat .
State of: ���d+ s,�
County of: _ �a w`�� �
Owner's Name (Print .
�,�u�ribed and sworn to before me on this
,.�Py�� ZL ��''''► ay of >�1`/ c , 20 a 3
Date: .�`� '
; . •'By(d'vurl�jFi��Same): /V 1 �//,• 5 _
.' �QJc�t'�rQ�u.bli ignature: '�
Drafted by: ) I " �t�fic Notary ame (Print)� S�.�r �oZ(cc,.JK.'
f� �— �^�-t�lGtti�— '����f'cnmi si n expires on: �/ a� �_
.� 9. .�
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S��yI,II„Ff,��",M�
Personal information you provide may be used for secondary purposes[Privacy Law,� 15.04(I)(m)] Rev.03/26/13
�
Con2�
Lot 1,of Certified Survey Map No.8691 as recorded in Volume 38 of Certified Survey Maps on Pages 95-
97 as Document No.443192,being part of Lot 4 of Certified Survey Map No.8400 as recorded in �
Volume 36 of Certified Survey Maps on Pages 95-97 as Document(do.419661 and located in the
Southeast Quarter(SE'/a)of the Northwest Quarter(NW%)of Section Twenty-seven(27),Township
Forty-two(42)North,Range Nine(9)West,Town of Lenroot,Sawyer County,Wisconsin,
7/13/23,824 AM Novus-Wisconsin Access rev. 13.1108
Real Estate Sawyer County Property Listing Froperty Status:Next Year
Today's Da[e: 7/13/2023 Created On: 2/ll/2023 238:54 PM
�Description Updated: 2/17/2023 � Ownership Upda[ed: 2/ll/2023
Tax ID: 44689 NEIL E&ABIGAIL M ELUS ST PAUL MN
PIN: 57-014-2-42-09-27-2 04-000-000110
Legacy PIN: 014942272411 Billing Address: Mailing Address:
Map ID: NEIL E&ABIGAIL M ELLIS NEIL E&ABIGAIL M ELLIS
Municipality: (014)TOWN OF LENROOT 572 DAYTON AVE SR DAYTON AVE
STR: 527 T42N R09W ST PAUL MN 55102 ST PAUL MN 55102
Description: PRT SENW LOT 1 CSM 36/95#8691
Retorded Acres: 1.830 � Site Address *indicates Private Road
Lottery Claims: 0 12797N ANCHOR W ' HAYWARD 54643
First Dollar: No
Waterbody: Nelson Lake .J p�aperty Assessment Updated: N/A
Zoning: (RRl)Residential/Recreational One
ESN: 400 2023 Assessment Detail
Code Acres Land Imp.
N/A
�� Tax Districts Llpdated 2/17/2023
1 State of Wisconsin 2.year Comparison 2022 2023 Change
57 Sawyer Counry �and: 0 0 0.0%
014 Town of Lenroo[ Improved: 0 0 0.0%
572478 Hayward Community School District 7otal: 0 0 0.0%
001700 TechnicalCollege
. Re[orded Documents Updated: 1/28/2022 .�property History
O CERTIFIED SURVEY MAP Parent Properties � � �� Tax ID
Date Recorded: l/31/2023 443192 5�_014-2-42-09-27-2 04-000-000030 40080
O TRUSTEES DEED 57-014-2-42-09-27-2 04-000-000100 43665
Da[e Recorded: 10/18/2019 420616
0 EASEMENT DEED
Dafe Remrded: 10/7/2019 420325
O CERTIFIED SURVEY MAP
Date Remrded: 8/30/2019 419661
O CERTIFIED SURVEY MAP
Date Recorded: 8/26/2008 355542
O WARRANTY DEED
Date Recorded: 6/25/2001 291925
O AGREEMENT
Date Recorded: 8/7/2000 285658
O WARRANTY DEED
Date Remrded: 6/24/1964 118907
HISTORY�Expand All History White=Current Parcels Pink=Re[ired Parcels
O 7ax ID: 184ll Pin: 57-014-2-92-09-27-2 04-000-000010 Leg.Pin:014942D2401 Map ID:.8.1
O Tax ID:40082 Pin:57-014-242-09-27-2 04-000-000050 Leg.Pin:014942272405 Map ID: .8.5
O Tax ID:40789 Pin: 57-0142-42-09-27-2 04-000-000060 Leg.Pin:014942D2406 Map ID: .8.6
O 7ax ID:43665 Pin: 9-014-2-42-09-27-2 09-000-000100 Leg.Pin:014942272410
O Tax ID: 18411 Pin:57-014-2-42-09-27-2 04-000-000010 Leg.Pin:014942272401 Map ID: .8.1
O7ax ID:40080 Vin: 57-0142-42-09-D-2 04-000-000030 Leg.Pin:014942272403 Map ID: .8.3
44689 This Parcel Parentr Children
hrips:/Itassawyercountygov.orgl/Accesslmaster.asp ���
• I Illllil IIII illil illll �
DocId:8067273 443192
� Tx:4043207
PAULA CHISSER
REGISTER OF DEEDS
SAWYER COUNTY,WI
�' o�� �� o te � o O � O O • � OS/31/2023 09:30 AM
� w� � o m RECORDING FEE 30.00
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8025690
State Bar of Wisconsin Form 7-2003 Tx:4015916
TRUSTEE'S DEED 420616
DocumentNumber pocumentName PAULA CHISSER
REGISTER OF DEEDS
SAWYER COUNTY, WI
THIS DEED, made between MARGARET L. CONE 10/ 18/2019 01: 16 P M
RECORDING FEE 30.00
as Trustee of UNDER PRIVATE TRUST AGREEMENT DATED JUNE 7 2001 TRANSFER FEE 405.00
AND KNOWN AS CONE TRUST
("Grantor," whether one or more), and NEIL E. ELLIS and ABfGA1L M. ELLIS PAG ES' 1
husband and wife as joint tenants �
("Cnantee,"whether one or more).
Grantor conveys to Grantee, without wananty, the following described real estate,
together with the rents, profits, fixtures and other appurtenant interests, in RecordingArea
Sawyer County, State of Wisconsin ("Property") (if more space is Narne and Retum Address
needed, please attach addendum): Et�'tgg�e��arQy Tit9�
Lot 4 as recorded in Volume 36 of Certified Survey Maps, �� �°�` ���
�9�y�xas�d, FNI �b�
page 95, Survey No. 8400 as Document No� 419661 , located ���o �
in the Town of Lenroot, Sawyer County, Wisconsin, being a
part of the Southeast Quarter of the Northwest Quarter Part of 014-942-27-2406
(SC'/4iVW'/4), �ection 22, 7'ownship 41 P�orthj Rallge 9 WeSt. Pazcel Identification Number(PIl�
lD�� r � �,olg
Dated
, (SE.AL) //' �� �i/� (SEAL)
* �� 0/% * MARGARE L. CONE. Trustee
* �,�`°` ��P,. . .�..,;4���, �sE�,�
.• .
. > �
. �� <
� ^` � " "�7� •+ i
AUTHENT�ATION : ': I, l AC'KNOWL�DGMENT
5ignature(s) �.* � � � � � �.S'£t1TE OF !�C//5�UY1 S l/L �
_ . ,
. .
� o . �
� . � � . ) ss.
authenticated on y'
s �•� 1�f Ew e 4 ����. COLJNTY )
���'9•�'�. � .•'� ��ersonally came before me on �Ul� r l ��� / ,
* � �" " ` the above-named
i Margaret L. Cone
TITLE: MEMBER STATE BAR OF � NS I��,���
(If not, � �� to me known to the perso s) who executed the foregoing
authorized by Wis. Stat. § 706.06 ) �s nt an knowl ed e s e.
THIS INSTRUMENT DRAFTED BY: * a�,� ��
THOMAS J. DUFFY, HAINYARD, WI 54843 Notary Public, State of � I /L
Drafter advised he does not represent grantor or grantee. My commissaon {is permanent) (expires: � g )
{Signatures may be autheaticated or acknowledged. Both are not necessary.)
�iOTE: T'HTS IS A STA�TDARD FOIL�I. ANY MODIFICATION TO THI3 FORM SHOULD BE CLEARLY ID�ITIFIED.
TRUSTEE'S DEED �2003 STATE BAR OT NTSCOVSL�' FORM NO. 7-2003
+Type oame below signatures. iNFapRo� w�w,.�rcoP�nrorms.c�m
420616 1 of 1