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HomeMy WebLinkAbout016-1077-70-000 ry o ~ ° I o p v> I h c v a w ~ I o o ~I N a (~I co c 1. v h a> I o~ c I 0 o ~ r T I N O O = c Z a P LL o~ 00 c 3 v v o I U " I z ~ € y a I LO °m a co aci m F- (n ~ o I E z c ~ ~ o 0 o w m z c ° VJ F- o € o I m a CY) '9 N C a~ c N c 0 0 CL L) a c O w O Z H Z N z _ C c ° R w .0 ' L• 16 a> CL m to y T a a~ °O I d G G a E r m N h^ VENN Eo CL En Zo • a a a a a N 3 C co LO LO M O I to J V p 0) 0) Z :z Z Q N 0) 0) U O O _ 'O E c, I 'I 7 n C Cl) 9 61 Q Z fn f0 04 p o 04 7 `•4 ° O y c U) _ O c u 0 O co p u y N N co 13 O M H L N C C V d p p l T N N a 'It 00 CD n o M c > oo c v -6 -5 • O O m !n N O z Z Z 2 Cn CC at E a a ~dt a `ate i • a m m r`Iwv E c _1 A c0 ao ',vici Parcel 016-1077-70-000 03/22/2006 04:46 PM PAGE 1 OF 1 Alt. Parcel 35.30.15.533B 016 - TOWN OF GLENWOOD Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - STODOLA, JOSH JOSH STODOLA C - CLARK KELLY CLARK KELLY 1223 RUSTIC RD R3 GLENWOOD CITY WI 54013 - - = Districts: SC - School SP - Special Property Address(es): Primary Type Dist # Description * 1223 RUSTIC RD R3 SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 6.240 Plat: N/A-NOT AVAILABLE SEC 35 T30N R15W PT SW SW N 450' OF W Block/Condo Bldg: 600'OF SW SW 6.240AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 35-30N-15W l Notes: I Parcel History: Date Doc # Vol/Page Type 'zf t~ u Vtx S t~ t~ 06/28/2001 649683 1670/203 QC 09/03/1999 609771 1454/156 `73 06/29/1999 605873 1438/070 S QC 07/23/1997 1145/325 WD more... 2005 SUMMARY Bill Fair Market Value: Assessed with: 89696 159,700 Valuations: Last Changed: 10/06/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.240 20,000 114,600 134,600 NO Totals for 2005: General Property 6.240 20,000 114,600 134,600 Woodland 0.000 0 0 I Totals for 2004: General Property 6.240 20,000 114,600 134,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 519 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 `Wiscons+r*Department ofIndustry, PRIVATE SEWAGE SYSTEM County: Labor arid Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI SEEGER, FREDRICK X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: *9200457 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Ventto TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet Septic NA Dt Bottom Dosi ng NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Ff Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Glenwood.35.30.15W, SW, SW, Rustic Road 3 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: i t • oea Safety and Buildings Division ~~■LInIR SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 81/2 x 11 inches in size. SO • See reverse side for instructions for completing this application State Sanitary Permit Number 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 / Propert Location P e / e e!v e 1, 1/4:?4 1/4, S_7S T3p , N, R ,-der) W Property Owner's Mailing Address Lot Number Block Numbe^ 17,23 Rd City, State Zip Code Phone Number Subdivision Name or CSM Number G~eN trove ..5` a 1 di 41(4W I >a6s = .z II. TYPE OF BUILDING: (check one) ❑ State Owned El City Nearest Road ❑ Public 21 1 or 2 Family Dwelling No. of bedrooms ~ [X Town of 19 4fA(Q., Yf101J'f1 (i Ae, 3 '00~1 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo O /X- /a 70 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. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Q6 Reconnection of 5. ❑ Repair of an System System Tank Only Existing 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~ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 1 ❑ 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) Elevation ,007~2,03Feet ,57 Feet V11. TANK Ca in gallons allo s Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank f C GLJ IN ❑ 1:1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ~ ~ Ej ❑ ❑ 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 Signature: (Dip Stamps) MPA11141111R9yofllo.: Business Phone Number: A .e Plumber's Address (Street, City, State, Zip Code): 21, IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa tary Permit Fee (Includes Groundwater ate Issued Issuing Age t ;ature (N Stamps loved Surcharge Fee) App F1 Owner Given Initial ffG Adverse Determination X. CONDITION ' OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS .s 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- It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. 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 informatior requested for numbers 1 through 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 al!,,eotic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental ,oroduct approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate orefix (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 10 x 11 inches must be submitted to the ccunty. The plans must include the following: A) plot plan, drawn to scale or with complete dimensior•s, location of hclding tank(s), septic tank(s) or other treatment tanks- building sewers; wells; water mains/water ser,,ice; ,tre,iris z n lakes; pump or siphon tanks; distribution boxes; soil absorption systems- replacement system areas; and the loc,itior, cfthe building served; B) horizon al and vertical elevation reference points; CI complete sped fication,. for pumps and controls; dose volume,- elevation differences, friction loss; pump performance .urve; pump model and pump manufec!urer; D) cross section of the soil absorption system if required by the county, soil test data on a 115 iorm, and F) al 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. -Se : : r . I t I - a Reel - j o l l l --4116 l - - I I - 491 C7 'L - -1 _ I _ ~ ~ I I + I r t-- I _ j I i ! i r ' ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE ' 911 FOURTH STREET • HUDSON, W154016 _ 715) 386-4680 EXISTING SEPTIC SYSTEM AFFIDAVIT The existing septic system which serves the dwelling being added on to must be inspected by a licensed soil tester for compliance with high ground water and/or bedrock seperation requirements as set forth in s. ILHR Chapter 83.10(2) WI. ADM. CODE. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is ,properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as setforth in s. ILHR Chapter 83.10(1). Property Owner (s) A- Property Mailing Address: 42 ;2-.~ 671eN .ooe Property Legal Description: Loti__=CSM/Subdivis ion 5k,-'114 6wl14, Sec. , T-70 N., R. 4 W. , Tn. of G.CeNwoeW I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property. Notary Public Subscribed and sworn to before me on this date: J6~~7 Signed: C7- V4 /-3 Sys Date:. My commission-expires: JEAN R. JOHNSTON County Approval: econem My commission ExOse November 10, IM Date• SOIL AND SITE EVALUATION REPORT Page.. for . HR In accord with ILHR 83.05, We. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but /'Y not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. « dimensioned, north arrow, and location and distance to nearest road. O /Z- le 2 G APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT,S"GU 114S40114, S T .3© N,R 13' AM W PROPERTY OWNER.'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE KIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD /V Z010 0 d (y31 7 s d New Construction Use ]X ] Residential I Number of bedrooms (J Addition to existing building Replacement ( ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _!~_Ibed, gpd/ft2trench, gpd/ft2 Absorption area required bed, lt2 qD D trench, ft2 Maximum design loading rate -bed, gpd/1`12trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design 1 site considerations Parent material 6-' A 1,4, 44 L Flood plain elevation, if applicable ft for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK L=SU Suitable Unsuitable for system ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botx>dary Roots GPD/ft in. Munsell Du. Sz. Cont. Color Gr. Sz. Sh. Bed Tm o- 7 0 2 z - S/ L ..r I, Z Ground -7 /4 L 6f 5 6 AfF _V I V~ 4' Aj7* ' elev. 94~Ll Depth to limiting factor - - Remarks: Boring # 4Y'F? Ground elev. it. Depth to limiting facto 1-17 Remarks: CST Name:-Please Print G _Aj Phone: 71,5_ Address: ? iii ,20 G e N4100 d &P' 74 Signature: ~ ~ Date: ~6_ 9~~ CST Num~erj~~, _~-_i-.-e - - - 4 'j 2-~ ! ~1/ - - - - - - _ i I_-- BAR __Alf _ 1 i I ! r > I I 1- I ! i . I I I ! L I I ~ I ! i ~ I I ~ I i I r - ~ I l-- I ' I { I I I I C I` I . I i 'I ~ I I 1 I I L I I ~ ~ I I i I I I i ~ I I- - ~ I TEL J t ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving Slv ; , S4~ ; , the LAC:6 R/C/f- SSc e 9 c,R residence located at: Sec. T,3o N, R 1„4' W, Town of G~eNc~ood , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced 9~- Did flow back occur from absorption system? Yes No_)L (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: / a--" Construction: Prefab Concrete Steel Other Manufacturer (if known) : Lv /e!i-~ S o R Age of Tank (if known) : y x (Signature) (Name) Please Print P,-1 410 ,l e q MP '~5-v 9o (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP/M~ S~ 90 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ SC e g e?, MAILING ADDRESS / 2 Rd G~eIy coo 04/ ~i 1`rL~i~yoi3 PROPERTY ADDRESS Sf},r.1 L° (location of septic system) Please obtain from the Planning Dept. CITY/STATE CAI Gt1 o c d C ~y, i Jr!f PROPERTY LOCATION S 1/4, SI-t/ 1/4, Section T_,Z~2 N-R W TOWN OF eN 6"o D o d ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , 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. UWe, 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: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo 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 1'xeol Rle 4 $4 S~ A'fe'y .See 9 e Location of property S_I1/4 1/4, Section ,?,6- T _?o N-R_ r" W Township G14 e -iv wy o d Mailing address 1.2 2 3 'gLISJ`"i c 6EZe& woCP d GZltk Address of site .Sf m L° Subdivision name Lot no. Other homes on property? Yes No Previous owner of property e /Z-Ax p y d e Total size of property / A C R e Total size of parcel / '-f d' e Date parcel was created IT7 Gf Are all corners and lot lines identifiable? Yes XNo Is this property being developed for (spec house) ? Yes Z_No Volume LW and Page Number lo?-69 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 I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (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. 7X' a 6 , and that I (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 Applica Co-Applica 9 /5' ~S - - s Date of Signature Date of Signature • + DOCUMENT NO. WARRANTY DEED THIS SPACi'. :'.~SEnVED FOR RECORDING DATA jl STATE BAR OF WISCONSIN FORMR 2 -1982 l sss~s 4JPAGE i VOL 10 120 REGISTER'S OFFICE Bet_ty.._Blihovde...------- - - - - - Sr. CROIX CO., WI Reed for Record - _ - - - - - - - - - - conveys and warrants to __Fredrick _J. Seeger _ and 11 :00 A. I, i Sharon.. L._ _Seegeri._ husband.-and_- wife-. as-------- survivorship_.marl.tal__prop erty_-_.__.._- _ - . - - --RETURN TO ,I Francis X. Rivard - - - - - P. 0. Box 9 - - - . - ----CountY, Gl.@nWOA61--:_ - -WI -54.4.13 the following described real estate in _ St. Croix State of Wisconsin: II Tax Parcel No_ ~I Part of the Southwest Quarter (SW4) of the Southwest Quarter (SW4), Section Thirty-five (35), Township Thirty (30) N, Range Fifteen (15) W, St. Croix County, Wisconsin, described as li follows: Beginning at the Northwest corner of said Southwest Quarter (SW4) of the Southwest Quarter (SW4), said point assumed to be in the centerline of the public highway, thence South on the West line thereof, assumed to be the centerline of the highway 450 feet; III thence East parallel with the North line thereof 600 feet; thence North parrallel with the said West line 450 feet to the North line of said Southwest Quarter (SW4) of the Southwest Quarter (SW 4) ; thence West on the said North line 600 feet to the point of beginning. l i F1 This -..-_--__1S_homestead property. (is) (ie let} i Exception to warranties: Subject to easements and rights of way of I~ record, if any; municipal and county zoning ordinances. i, Dated this - c day of - - , 19..93... II r - .~~~pq~GX (SEAL) - --------(SEAL) Bet y Blihovde j' - -------------------------------(SEAL) - - - -------(SEAL) i ~j i AUTHENTICATION ACKNOWLEDGMENT Betty Blihovde Signature(s) STATE OF WISCONSIN ss. nty. Co authe tic ate thlsa_ ay f____ ptember•-, lg---93 Personally came before me this ________________day of 19-------- the above named F ncis X and TITLE: MBER ST TE B R OF WISCONSIN (If not, - - authorized b y § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Francis X. Rivard Glenwood City WI 54013 Notary Public .----------------------------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration I are not necessary.) date: •Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wisconsin