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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS /`l~~ d so 3 -h~61~
SUBDIVISION / CSM# d oral (Y lrs- LOT #
SECTION T N-R W, Town of M,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
` CG l~•a u e ~f o m2
;2-0
t S /'Perr~o t~ //~v~' 71
e -re- 7-1 14r,-A04-4 7-e
7-1
M ~s
INDICATE NORT ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
STC - 104 .'\'"y~ ~'93;~^~~ •r
D~ AS BUILT SANITARY SYSTEM REPORT
OWNER
r¢'ICC ~f
ADDRESS /y',~-~
SUBDIVISION / CSM ~C/~, 1i LOT
SECTION T N-R Ile W, Town ofG
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a
1
i
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
l
c `
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: yl c~
Setback from: Well--37,,,l - House .6 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length-7---5,-- Number of trenches
Distance & Direction to nearest prop, line:
Setback from: well:. 4 /P'-- House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
j~
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR:
c
3/93:jt
VV' I ,)nsln Department of Industry, PRIVATE SEWAGE SYSTEM County: ST. C:ROIX
Labor and,Human Relations INSPECTION REPORT
Safety and Buildings Division Sanitary Permit NO.:
(ATTACH TO PERMIT)
GENERAL INFORMATION
p
TIM Wig It N3~LRCHARD ❑ City ❑ Village [Town Of: State Plan ID No.:
CST BM Elev.: Fol. Insp. BM Elev.: BM Description: Parcel Tax No.:
,yycL
d0~
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic ~ /00.
Dosing
Aeration Bldg. Sewer 909, 3. S
Holding St/Ht Inlet gR.7q~
TANK SETBACK INFORMATION St/ Ht outlet
vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Air
Septic 7as ya p~ NA Dt Bottom
Dosing NA Header / Man. i
Aeration NA Dist. Pipe /d •39' 9•-qo
i a, 5
Holding Bot. System i ` c)2-
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System =TD Ft
mead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER
Model Number:
INFORMATION Type Of ,~U, OR UNIT
System:
DISTRIBUTION SYSTEM
[Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Dia. Length Dia. - Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over F pth Over xx Depth Of xx Seeded Sdded xx Mulched
Bed /Trench Center d /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19Wt NE NE, ORIOLE LANE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. L9 1-1 j(.
Date spvct s Signature Cert No.
SBD-6710 (R 05/91)
Safety and. Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County ,
than 8 12 x 11 inches in size. r
• See reverse side for instructions for completing this application State Sanitary Per it Nyper
tr io .
The information you provide may be used by other government agency programs E] Check it revision to previous application
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
_ 114,41Z_- 1/4, 5 T 2¢ , N, R / E (or)~ . pi Property Owner's Mailing Address Lot Number Block Number
3 -d Yd
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned it~ge Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ❑ VIIa Town OF a[,l a d VV dA e, 4eCdJe--
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo 6 2 d 13a~ - 5`d
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1- R& New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System Tank OnlyExisting System ---------Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 KLSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill -
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) rf,, 5r-d Elevation
Feet ` Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er_
Ing INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p
New Exist' structed glass App.
Tanks Tanks
Septic Tank or Holding Tank / t /o, rf p ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatur (No Stamps) M /MPRSW No.: Business Phone Number:
C3
Plumber's Address (Street, City, State, Zip Code):
P G G Sc
v, S'a~-rte x'!11
415~
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San, ary Permit Fee (Includes Groundwater ate Issued Issuing Agent Sign ture (No Stamps)
Approved ❑ Surcharge fee)
Owner Given Initial /vl
Adverse Determination Ao,
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Ruildings Division, Owner, Plumber
INSTRUCTIONS v
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever .
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of '
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls,- dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
a -
Wisconsin Department of Industry, SOIL AND SITE ~YALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety to Buildings in accord with IL 345, WIS. Adn),. Code
COUMY
Attach complete site plan on paper not less than S 1/2 x 11 inches h r£zp: Plan must include, I }f' PARCEL L0.
not limited to vertical and horizontal reference point (BM), direction a Y%of-slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
10111IL- j 0 ,t/ GSA/~.N y GOVT. LOT A E 1/0 1/4,S 27 T Z, N,R /,f E (or) W
PROPERTY OWNEWS MAILING ADDRESS LOT s BLOCK # SUBD. NAME OR CSM /
336 )Zs.,PoB~'TS ST ~ e2 }{UMRixD H1'0-5 (Plt/1$~L
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (~PtSWN NEAREST ROAD
.
r uG /Y/V 55/0 yz2-5ss5 +tUDSo"J o,P/oL 44-1
New Construction Use ( KResidenlal I Number of bedrooms Addition to existing bulking
I I Replacement ysa I I Public or commercial describe
-
Code derived daily flow Sao gpd Recommended design loading rate ~ bed, gpd/ t2 ' trench, gfdfit2
Absorption area required bed, ft2 1030 trench, ft2 Maximum design loading rate ✓ bed, gpd/ft2 , ~ trench, gpd11I2
Recommended infiltration surface elevation(s) J`-,W- P • 3 It (as referred to site plan benchmark)
Additional design / site considerations Lo,v ,rr ;RoeD w ~ e;(tlS
Parent material Flood plain elevation, if appliFable 4f%54- ft
ble for system O ❑ U IN [1 U PRESSURE AT G E[] U SYSTEM S M ❑ HOLDIN S 'I
S
U - = Unsuitable for system el 91 I BS F M
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon In. Munseil tau. Sz. Conl Color Gr. Sz. Sh. Bed iendh
0-13 /o ye y/i s. / a f ,s~6.(~ iw+ fle s Zf S . C~
S a0,~
Ground 3 ~ -lc( ~ a lie y • 's-
elev.
R-1'L it
Depth to
limiting
S't
factor fora tweet 9904
7 ~
Remarks:
i
Boring # / jtq- .S// 2 7~S6ie ~r►fii° ~S 2 f , S
2- _76 411 7~e
13
.3 d-yy /o y - S// 2 Jlk 44175 qs S I
Ground /olo~"~
elev.
y~.1 40
ft.
Depth to
limiting
factor ,r
r ,
r
PROPERTY OWNER SOIL DESCRIPTION REPORT Page .2-of 3
PARCEL I.D.
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD/ft
In. Munsell Glu. Sz. Cont Color Gr. Sz. Sh. Bed *O
4-8 /11) 3 i S z s~,f vfit' q S f. s
2- 19-36 Z Sri dy d cs - .
Ground "9G 75 y S. G~ S 7 ~d
a~ ft. ~
Depth to
limiting
factoorr~
Remarks:
Boring # Z f Jriw
Ground /
elev. 1- to yx OU it. S S . D S
i
Depth to
limiting i
I
factor
3
Remarks:
Boring Al / D -10 /D 2 L - .si~ 2~5~~ ar, f ~ S , :S ~ • ~
z /0)//C 2,12- - S1/. lffi.x"
Ground
elev. y- y S D, S . S
ft. i
Depth to ;
limiting
7f iI
19 01
Remarks:
Boring # _
i
13
Ground
Clow 1
E(EUhTcOt.)S f . 3 A 3
l`y2Z
13 z 5/' Z
/33
/3 y
/3s 93.36
S CA 30
fi
y
J I
a~ 30
v ~
L
r
4f
30
3 q.5
.
.01
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15.Q0' ` 205.00' 6I 7 34~
gyp 220.00' 332.34'
_ I QO 70
65.00'
LOT 4
2.82 ACRES -,R
422,949 SQ. FTo 0
~ 00 o
2 *46
ACRES_, `900 - _ CD -
,Aq T OS
~q ~~-rte 4 LOT 39
SF 3-68 ACRES
'liF~ cyi \ 160, 2.79 SO. FT.
f 00~
cf' DL
198.57'
4S
268.5 7
ORIOLE - W 002
39°49'46"E p
26$.38 _ g
s
OT 42 h v
2.17 ACRES: - RL•w \ "''r°s
94,642 SO. FT.
h LOT 43 r \
40 ~i c~ \ ro r
2.34 ACRES ° 101,995
~ S0. FT.
S0O 4, 4 I \
2 CRES j ~ i
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n ~S r tiP ;i l
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\ ~9\ 2.82 ACRES
O \ 122,949 SQ. FT.
23i 29S .
0 4~. 9\
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LOT 41
2.46 ACRES N
C\~
107,343 SQ. FT: F LOT 39
3.68 ACRES
~ Fqs 30\~~ 160,279 SO. FT.
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
SAh
PROPERTY ADDRESS 1
(location of septic system) Please obtain from the Planning pt.
CITY/STATE e IV /V 49
-7
ca_
PROPERTY LOCATION 1/4 1/4 Section T N-R W
TOWN OF UZ~ I~ ST. CROIX COUNTY, WI
SUBDIVISION 'I ) Y r C; l LOT NUMBER4_ n~
CERTIFIED SURVEY MAP _9 VOLUME , PAGE , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to, submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: `
DATE: b Kll~
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
' owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property \ V1S
Location of property 4:--1/4 :L 1/4, Section 7 ,T_~Z? N-R_ f W
Township CYY \ Mailing address ~
Address of site ~1 7-7? 69y e',11--e - k my-e
subdivision name y-\k.~ A L-16 Lot no.
Other homes on property? Yes_ o
Previous owner of property 7
Total size of property Z 2-- c`C-ZQo
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable?. x. Yes No
Is this property being developed for (spec house) ? Yes (---Nn
Volume l re and Page Number 6,3-? as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
-:r (we) certify that all statements on this form are true to the
best of wy (our) knowledge that 17 (we) a3a (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 5-IF-fa ff /7- , and that r (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
ignature of Applicant Co-Applicant
Date of Signature Date of S'gn ure
E
DOCUMENT NO. STATE BAR. OF WISCONSIN FORM 1-1982 TN 9aAtE.RJ T
WARRANTY DEED REGISTERS OFFICE
CROIX CO., G"v"1
• 5.44209 VOL 11 OFA~~O~,`3 _ .31
Rec'd for Rocord
F
a
This Deed, made between I - - - -
Humbi-rd--Land_Corporation,. a--Minnesota Corporation... MAY 2 4 1996
. - Grantor,
al,d._Richa_rd J. Kearnsand Michelle L. _Kearns~ _hu'sbandt 1:2~ P. M
and wife,+ I 1
- W
- - - -
Regisier of Deeds
- - - - - - - Grantee,
Witnesseth, That the said Grantor, for a valuable consideration-.----
RETURN TO ,
conveys to Grantee the following described real estate in 100 Ad,
County, State of Wisconsin:
Lot 40, Humbird Hills Second Addition,
Town of Hudson, St. Croix County, Wisconsin Tax Parcel No:
T A tD FER
r
This .....i.5_not.....------ homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And....-... - - " - - - -
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
Easements, restrictions and rights-of-way of record, if any
i
and will warrant and defend the same.
Hated this 15th day of May - - 19 96 '
- ' - - - -...---(SEAL) HUMBIRD LAND CORPORATION .-.....(SEAL)
- 4 Austin J. Bai 11 on its Pres
~C.I~:'~pde t
-------------------------------------------------------.(SEAL) _ (SEAL)
' "
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF Q()cWt7(p(KM MINNES TA
as.
Ramse
y--•-------_--- --------County.
authenticated this day of_____ I 19 Personally came before me this ...15th day of
May............................... 1916... the above named
Ay.i<~n-_J-t.• Bai l l on, resi-dent-•of
. . . Humbi rd--Land- Corporati on.....
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not by § 706.06, Wis. Stats.) -
to me known to be the person who who executed the
foregoing instrument and acknow ge a ^
T141S INSTRUMENT WAS DRAFTED BY
p UL A. BA LON
HUmk rd--Land-Corporation tdOTARYPURLC- NNESOTA
dVASHINGTON OUNTY
, aul Bailton ........--Comm- 1
• . 31, 2000
Notary Public Washi ngton.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, expiration -8
nre not necessary.) xpiration
date: JaIlUdCY---3j-................................. 40:._2000)
'Names of persons alanina in any opacity should be type.l or printed below their Oxnaturm.
WARRANTY DEED STATE OAR OF WISCONSIN W(s<onsin l.e¢al Qlank Co. Ins.
FORM No. I- 1982 w.;.