HomeMy WebLinkAbout040-1287-40-000 Wisconsin Department of Commerce Count
Safety and Building Division , � + PRIVATE SEWAGE SYSTEM St. Croix
INSPECTION REPORT Sanitary Permit No: 405144 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:
Miller, Sam I Troy Township 040 - 1287 -40 -000
CST BM EVev: / Insp. BM Elev: BM Description:
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
- L' p.Z_ !10'
Dosing ��� AIt.BM I �� 3,(� 02� 6
o n 7
Aeration Bldg. Se§ver If q
Holding SU Inlet 7 1 G T (
1 0 d
TANK SETBACK INFORMATION S Ht Outlet 2 1 . 9 9 -7 , ` - 6
TANK TO P/ L WELL BLDG. Vent to Air Inta a ROAD Dt Inlet f _,
Septic �- 1 Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding B t. System �r It
� i; s Ia .
PUMP /SIPHON INFORMATION Final Grade .5' -CIS
Manufacturer Demand t over 31
Model Nu er
TDH Lift Iction Loss System Head TDH Ft
Fore ain Length ia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIM�PI810TdS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS v o( 9 Lf ']�
SETBACK SYSTEM TO l P/LM JBLDG JWEL LAKE /STREAM LEACHING Man urer. `
INFORMATION CHAMBER OR
Typ Of System: f ! !� UNIT Model Number: r �
DISTRIBUTION SYSTEM, IQOr'
Header /Manifold Distribution I x Hole Size x Hole Spacing Vent o Air Intake
iy 4 V n
L Dia Length 1 Dia 14 S acmg 1
SOIL COVER x PIressure Systems Only zx Mound Or At - Grade Systems Only C*A
Depth Over Depth Over xx Depth of eded /Sodded xx Mulched
r
Bed/ Trench C enter 7 5 f Bed/Trench Edges Topsoil ❑ Yes [] No [�] Yes [] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: (0__/ Inspection #2: I /
Location: 621 Glover Road Hudson, WI 54016 (NW 1/4 SW 1/4 15 T28N R1 9W) Glover Prairie Lot 4 Parcel No: 15.28.19.1630
I IF s f �k W44 5� its P (o t �,., a(,�. Nw.a. 4 �,r4�i 5� cGnW d�
1. Alt BM Description _ /
2.) Bldg sewer length = 2 (P
- amount of cover = //
Plan revision Required? ❑Yes L,Ao J �� ������ -- � G�a�
Use other side for additional information. V (/ / vI
SBD -6710 (R.3/97) Date Insepctor's Si gnature Cart. No.
i
oi
I ►
s
nS�
5 "�
County
=M&diWMQ i,►gs 1)ivisioa ve., P.O. Box 7162
i sconsin 3707 - 7162 � ��' S �/ 4P7 li De artment of Commerc sanitary Permit Number
Sanitary Permit Application
In accord with Comm 83.21, Wit. Adm. Code, personal information you provide ❑ Chock if Revision
rm be used Pri Law 815. 1 m State p� I.D. Number
L APPliadm �OD jd° - pwm MA All Infacmatioa
Parcel Number
Property Owner's Name
J property Location
Owner's ldailiiK Addrea
COUNTY t(/ 1f 5 Y/u' S t T,�- N
/ -c;-/ zip Code FFI Number J 1%wA Num ber
City. Stars Subdivision Name CSM Number
U. TM of Building ( all that app4) Ovdl ge
1 or 2 Family Dwelling - Number of Bedroom room D
0 Public/Commemia► - Dowsibs Use Nearest Road
❑ Stag Owed 3 9 3. use). Complete tine B if applicable)
- 7 S' - 5 L a �W -
III, Type of Permit: (Cb�eck only one boat on line A (numbering
acheaae for Internal
or Camut7 use
A 1 New 2 ❑ Replacement System 3 ❑ Repent of 6 ❑ Adttition to
Tank OW stem Date Issued
Issued Permit Number
B. 0 Chock it Sanitary pew Pr�vi�y S
ttcbeme b for internal use) �3
IV. Type of Permit; - (Check all that )(numbering so ❑ constructed Wetlud SA +� 31.1
210 Mound 47 ❑ Sand Filter
44 410 ljoiding Tank
- 48 0 Single Pass 51 0 Drip Line �
22 J Q
0 � zan�o
45 ❑ Ar-Grade 46 0 Aerobic Treatment Unit 49 ❑ Rec' 30 COI Other
/'YC4/�►
V t Area Information: Soil Application Percolation Rate System Elevation Final Grade
Dispersal Ara Elevation
Design (tom) Dispersal Area proposed Ratc(Ga18JDsys/Sq.Ft.) (MinJlnch)
t� !�0 � S p Site Steel Fiber P►zstrc
Total Number Manuacturfer Gl.0
VL Tank Into Gallons Galbot of Tanks /vD area Constructed
New Esisdof
Taob Tab
So* or Haiti% Tack - I Z C W s
Doses Cbfakber ,
VU. R btli Statement - I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
MpIM[PRS Number Business P�h Number
plumber's Name (Prim) phrntber'e Signature 3 K'n 2-
Piumber's Address (Street, city. State, Zip )
/ Issu ens S' o S
V camps)
M Coun Me ent Use Od
Sanitary Permit Fee (includes Groundwater Dace Issued
Approved 0 Disapproved &udwg Fee)
0 Owner Given Initial Adverse�� S, ("I/, (�
Determination
Coodi ApprovaURarsoos for Disapproval
/ >e- �G��cl ''"
V f r►�¢P.f� r r+� 3 �f3
I-E
oe7 l vz— PC C`4 t " a l.ebes r abe
Pismo' 06 the Y) SO am
SBn -6398 (R 05/01)
h Z 2 �7�
c:LC�Y rte'. ' e, .d1f_y
" Ar ? 1
kv
F �
L� -�� �.AayrF•t
LL
`lit
i
S
R t
is t
s
s �7
7 CIO '
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Diyision of Safety and Buildinas
in accordance with Comm 85, Wis. Adm. Code
`County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must u 'ST. C-1 MX
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information viewe by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner P � i � ��DT Property Location
C /O 7 bb'ID STt` 3� T R&f EA:sL 1 � -3 Q 1/4 SLU 1/4 S\ S T Z H N R 1 q E (or )W
R;epeAY - Gwaeds Mailing Address Lot # Block # Subd. Name or CSM#
l o b e cz•�S'T- t� -tom i U t y Gov P�zca -t 2 t E
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
HUDSpiv W1 sgOL16 ( L.3) 38 6_3oSI I GLU
Q New Construction Use: ® Residential / Number of bedrooms �— Code derived design flow rate b 0 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent rr terial G -PCC.L ir'r l p U) PI-S Fj Flood Plain elevation if applicable A • ft,
General comments
and recommendations: iz� 1t"'t'i-Z)Qp Z C-k S � eft \} 3 `X 0 13.'ls l.Ard G W,/ lS Vru IT OF
t '�LGI�} e�l`f `/ S! DEInJllvtSt?12 LL�4 _C�4IpLstz
ZQoTI - U M OF Ct'- g 'tO gt LstLU , 9 Z o
a Boring #" . ❑ Boring
® pit Ground surface elev. q$• �J ft. Depth to limiting factor t t9 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. - Eff#1 - Eff#2
Z �z -�,1 I.o`t2' - s) I 2�sbk m`f�- e S - • S - E3
3 1n 1 9 Z vn S b k rn
a Boring # ❑Boring O�F\G�
® Pit Ground surface elev. R g 3 fL Depth to limiting factor 7 L ZZ
1 Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary _ Roots . GPD /ftz
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. _.. teff#1 •Eff#2
t3- ti I b -I Iz 3 L Z s z`�S b ►z wl`�L- �+.v l f. • S • 6
Z. 1'Z i �•SYiiZ3� — ti--1S O S V44
O s ►tit 1 — -� L- z
• Effluent #1 = B00 > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signatige CST Number
Arthur L;" Wegerer fi =0J -y 220254
Address W e g e r e r Soil Testing & Design Service
Date Evaluation Conducted Telephone Number
421 N. Bain St. River Falls, WI 54022 1 - U O1 715 -425 -0165
Property Owner l ax T Parcel ID # l� ��1 n1 G Page Z- 3
3 Boring #
[� Boring 9 of
°18. S Z
.® Pit Ground surface elev. ft. Depth to limiting factor 7 t Z- in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft=
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
D -�Z lb`'1231Z — s t I 24S6>, wtf i-. a 1'F .-3 . 8
�C m W
S9
2.0 - 7V// /(/"
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 • Eff#2
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
In. Munsell Qu. Sz. Cont. Color . Gr. Sz. Sh. •Eff#1 •Eff#2
i
Effluent #1 = BOD, > 30 < 220. mg/L and TSS >30 < 150 mg/t, " Effluent #2 = BOD < 30 mg/L and TSS < 30
_ mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777.
sso4330 (a.woo)
PLOT PLAN Page 3 of
Scale 1' = SO '
I
6 Lo E go flvD
a� �z
so 1 TO r
1 6 .3 I I �'W — - -!
I cAI r
1yp' A Q /
S LTA LS LEv�L � -- Go�v�vlZS 0"
Sit 8.1
Kj
r
0
9
e1. "00;0' onl SPtlrzl-: -? �1'ri30UET GRftU� 1111 t�iwfslZ
1w`4 _o1 715 -425 -0165 220254
CST Signature Date Telephone No. CST No. . Job No.
�t
rr rr rr rr rr rr
All
BioDfffuse'r- icdti6ns
HOO
r r
Churbw
Hoo
1
4'Kn
Universal 1 1
Av cdlable
Si zes Chamber 11" Stan• 14" High Capac ty
Dimensions dard Capacity
gy n .�v '' �„ ,:,�'
�, t7h 7' � ' � 1 �i ` �I.1rt k' . • 4 � /���D{Y�V/ �/' Tb. s� .�
i
CD
O S W Cv W
'" 6 i� ❑ W, n P.— p x t N n
p o p p 0 N O
a co �e N
ct
PS N
o pp
N
K 0 o
tv
nil co I H o
0.
gn o f a '
5 v� w a. U.) n o
co
A o' a °` N
0 CD CD
CD
ON 00
N r+ w r+ r+ : O
r-+ Vl' 01 N �o ON W W
� C
aq
QQ �'
LA N 00 ► O ? J J O N 'O '�' n co
co
o�
,. � 8
5 . ch cn �n cn to w v� cn °°
w LA in %'o Lh to �10 1 .0 °O v W O p ' c' CD •
o O
O M CD
�.
fD
' to LA (A A cn iA in in a o C d
oop ?po go po gpo zz �,
{ o o c o 0 0 o y o o r? d
i
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number d /
Numb of Bedrooms
Design Flow - Peak (gpd) Cao o
Estimated Flow - Average (gpd)
Sept Tank Capacity (gal) f, z So
Soil Absorption Component Size (W) z
Type of Wastewater Dordestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design - ) ham.
Maximum nfluent Particle S' a (in) > 1/8
Maximu s mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the se and outlet filter shall be assessed at least -,
once every 3 years by inspection. Toutlet filteO shal be c leaned as nec essary to e nsur e �`
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
11
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm, 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
(r,17 Z
ZO/;hq
3
1
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address � l l 0 of le —
(Verification required from Planning Department for new construction)
City/State H V L4 _'l IAJ 1 Parcel Identification Number
LEGAL DESCRIPTION
Property Location '/., =' ' /4, Sec. t . T N -R own of T2o
bdivision 1 �- , Lot #_.•
Certified Survey Map # 4 P S 42 ` ; Volume , Page #
Warranty Deed # r40(4 �' , Volume / . Page # y
Spec house yes ❑ no Lot lines identifiablbl yes ❑ no
SYSTEM NANCE
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, 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.
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 St. Croix County Zoning Office within 30
da s the a ear expiration
ATURE O J PLICA DATE
-;' iQWNER CERTIFICATION
1' certify that cer that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the own er(s) of
ed above b 'rlue of a warranty deed recorded in Register of Deeds Office.
t DATE
ATURE O l'LICANT
,
• * * * ** 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.. 82 4pA6I 447 (�
WARRANTY DEED 6695$4
STATE OF WISCONSIN — FORM 2 K(O HLEEN H. WALSH
REGISTER OF DEEDS
DOCUMENT NO ST. CROIY Co., WI
RECEIVED FOR RECORD
This indenture, Made this 25th day of January A /I,! 2092', 01 -29 -2002 8:30 AN
between McDona I d Homes . Inc a Minnesota WARRANTY DEED
Corpora ion 1,1 p duly EXEMPT d
organized and existing under and by virt ue of the laws of the Smte of �Ji�c6t(,4 M,d at CERT COPY FEE:
Inver Grove Heights, MN `�,{y{V party of the first pan, and C'DPY FEE:
Sam E. Miller, a single person, RECORDER FEE: 11
RECOkDING FEE: 11.00 .00
PAGES: 1
part V of the second part.
Witnesseth, That the said party of the first part, for and In consideration of the sum of
$367, 500. 00 ---------------------------------
to It paid by the said part Y the second part, the receipt whereof is hereby confessed _ THIS SPACE RESERVED FOR RECORDING DATA
and acknowledged, has given, granted, bargained, sold• TtmlSed, TCICased, aliened, conveyed NAME AND RETURN ADDRESS
and confirmed, and by these presents does give, grant, bargain, sell, remise, Alen, convey and Fir st Federal Savings Bank
confirm unto the said pa nt.__ of the second part, _ his heirs LaCrosse— Madison
ane ass',gns forever, the following described real estate, situated in the County of 201 Second Street
_fit . Croix _ State of Wisconsin, to-wit:
Hudson, Wisconsin 54016
040- 1061 -60 a nd 040 - 1061 -50
PARCEL IDENTIFICATION NUMEER
Lots 1 through 7, inclusive, Plat of
Glover Prairie in the Town of Troy,
St. Croix County, Wisconsin.
(IF NECFSSARY. CONTINUE DESCRIPTION ON REt'FR5E SIDE)
Together will all and singular the hereditamcnis and appurtenances thereunto belonging or in any wise appertaining, and all the estate,
right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of,
ill and to the above bargained premises, and their hereditaments and appurtenances.
To have and to hold the said premises as above described with the hi!Wdimments and appurtenances, unto the said par of the
second part, and to his heirs and assigns FOREVER.
And the said McDonald Homes, Inc. a Minnesota Corporation,
parry of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said partl__ of the second part,
— his heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises
afxace described, as of a good, sure, perfect, absolute and Indefeasible estate of inheritance in the law, in fee simple, and that ;he same are free and
clear (tornall mcumbrances whatever, _ except easements, reservations and restri
of record
and that the above haigeincd premises in the quiet and peaceable possession of the said Part l of the second part, hi
ne!rs, and assigns, against all and every person or persons lawfully claiming the whole of any part thereof, it will forever WARRANT and DEFEND.
in Witness Whereof, the said McDonald Hom Inc., a Minnesota Corpor
hart,w the fast part , haseaused these presentstobesignedby Todd A Bjerstedt its Vice President,
��/r,<,.�id�.fl1. �td l�tl;,4v( /////////////////. / / / / / / / / / /// / / / /i �v�$r ; � c Et�c� y �
v Hudson __, 1Visconsm, and its corporate seal to be hereunto affixed thu
dayoi January ,A, D., / 20 02.
SIGNED AND SEAI.F:D IN PRESENCE OF
Mc NA H O S _ sota
CO poste ,�
lice President
ODD A. JE T
COUNTERSIGNED.
-- — Secretary
state of Wisconsin, 1 f
St. Croix Count)', „
Personally came before me, this 25th day of January AD ,f 20 02
Todd A. Bjerstedt. Pn• side„ tl /w y- /!////// // /1/ -Z//Z/ 1 2LZZ/N Q l 1 1(41
of the above named Corporauun, to m e )ns who executed the ng instrument, and to me known to he such President
and Secretary of said Corporation, an wled Ill e .eecuted the for ins tnnent as such officers a e decd of said Corporation.
by ns authority.
THIS INSTRUMENT WAS DRAFTED` — �( p — - - - --
�+ NO 0.r r0.(A \\ �-' R EF -b: -T
L `Z'
Notary Public:, St • Croix County, Wis.
_,___ STEP HEN
J. DUNLAP � Nly commission (expires) (is) 1a _ X00
Hudson, Wisconsin
5 It 1'11 1 \ 5.I J II In JJ IIII - pI' I P I)
5•�i ;,, da th ey, , u, A, r~r: . hu.,r xc. c . l,I ,, ,rp itch. dr.�h.J h L,unr,. ;� - JI L, , � Icn.nl
- pr ,.J )Pxnn., ry< ,h,n„ .uhphi,
STATE OF %VISCONIIN w,scon;ln Legal Blank Co, Inc.
��',tkRA,�TI' DI:FD - fl.' cnrpurallon Iv— No. 2 Mih aukee, Wis
r
t `
me r
4
9�
"' I I TCH IJNE
I
►� J -
ff 55
w 1 � I . 6
I t
.Q .
` 01
U l
QL
f .
I '
y �R,
m
�p
a l l,
fTj Ira' -�
(� 1 zl re
w; I
fA wm r.�t�m
tl�l r —
®d ®V 3A