HomeMy WebLinkAbout038-1167-20-000
~ 1101 Ca 7
STC - 104 '
AS BUILT SANITARY SYSTEM REPQ
OWNER
ADDRESS,, Z>'S
SUBDIVISION / CSM#LOT #
SECTION4,,~T - N-R~ W, Town of S.~~l
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- 4
~r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
I
BENCHMARK:
ALTERNATE BM:.
~'s_~.La, y Q7
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: 44~ J
Setback from: well:- House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system ~S,97
Existing Grade Final grade _11_)e1__5_
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: _
INSPECTOR:
3/93:jt
Wiscon$in Department of Industry, PRIVATE SEWAGE SYSTEM county:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
224649
Pe+ §gbtr : PAUL ❑ City ❑ Village [R Town of: State Plan ID No.:
Star Prairie
CST BM Elev.: Insp. BM Elev.: BM D cription: / Parcel Tax No.:
emr ,GAD /G~. G~i' G1.`_: /3(d-6_ A9400275
TANK INFORMATION ELEVATION DATA 2 /9
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Lt_,1kz& C G Benchmark
Dosi n
~,~r,' X67
Aeration Bldg. Sewer SQ
Hol St/ Inlet ?
TANK SETBACK INFORMATION St/y( Outlet 7,~9'
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic <2)' '
(Q d NA Dt Bottom
Dosing NA Header14g 7~ C
Aeration N Dist. Pipe '
Holding Bot. System ~Ze
PUMP/ SIPHON INFORMATION Final Grade
Manuf rer Demand
Model Number GPM
TDH Lift Loss ction System Ft
mead
Force Length Dia. Dist. To Well I F
SOIL ABSORPTION SYSTEM
BED / TROksk- Width Length , No. Of Tre ches pl No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Spa DI E N
-Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREA EAC
INFORMATION TypeO " n HA o e Num er:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) „ x H Size x Hole Spacing V o Air Inta
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste
Depth Over „ Depth Over i/ xx Depth Of xx Seeded / Sodded xx
Bed / Troelftenter Bed /ages Topsoil E]
Yes No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Star Prairie.28.31.18W, S , NW Lot 1~, 10 th Street
,
i
Plan revision required K ❑ Yes [y-N~o
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signatur Cert - No.
- 1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: '
I
II
I
L - ~
SANITARY PERMIT APPLICATION
UILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
swmws
esu..wu~s.sw.w„rnvr
ST~~
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PERMI
8% x 11 inches in size. ❑ Check if revision to previo s application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP WNER PROPERTY LOCATION
'/a '/4, ~Jf T N, R ~(or
/
, ~ r f PROPERTY OWNER'S AILINgADpRESS LOT # / BLOCK #
Cl , STAT ZIP CODE PHONE NUMBER SUBDIVISI NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) F] State Owned VILLLLAGE I NEAREST ROAD e
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) ~,-,-,?o ev0
1 ❑ Apt/Condo
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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.20 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ~ Seepage Bed 21 El Mound 30 El Specify Type 41 El Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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
1 ZI& '1_7 A) REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
/ Feet n Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank hVIO I B;q I [A - I I F1 I LJ
'
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for install!!' n of the onsite sewage system shown on the attached plans.
:lumb'e's Na a (Pript): Plumb r,s S n ture: (N Amps) _ MP/MPRSW No.: Business Phone Number:
I tuber's Ad ress (Street, City, State, Zip Code):
-?ew 40
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanit ry Permit Fee (includes Groundwater a ssue Issuing Agent Signature (N
urcharge Fee) Z
19
Approved ❑ Owner Given initial I C//1~
Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2 Your sanitary permit may be renewed before the expiration date, and at the 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 :suing authority.
4. Changer; in ownership or plumber requires a Sanitary Perrnif Transfer/Rer.owai For f F?rt 63E,9) to be
subrnilti=;l to the county prior to installation.
5. Onsile sewage systems must be properiy maintained. The p t: rank(s) must be l•u •.-nt ,y licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage systern, contact your local code ad°i~ nistratot, -or the -
State of Wisconsin, Safety & 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.
If. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family i;welling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, . aconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requestrlr' in ##1-7.
Vll_ Tank info? elation. Fill in the capacity of eery new and/or existin", ,k, list the Iota` ~ 'i, o:,:, of
tanks and v~ anufacturer''s name. I•F)uicate prefab or ,ite construe~e t and tank rnatc:r iK.l err r~ F :;r all .
septic, puinp/siphon and holding tanks for this system. Check ex.F r!rr,c. ltal approval c W! ryas received
expenryie r.al product approval from DII_HR.
VIII. Responsib0ty statement. Installinn plumber is to fill in name,- licerr--,e number with 3!)r>roo,i, - prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form
IX. County, Department Use Only.
X. County/ Department Use Only.
Comr!'Oe p =tns and specifications not s-tiller than $'/s x 11 inn l: z -wji-t be `:.ubr7 itl~' I : th- ;county The
plans rnt ~f i,,ciude the following: A) plc . p'an, drawn to scalp: n.f c,-iiplel n d;rn atiorr of
holding septic tank(s) or other t ea'ment tanks; builder ; n t.~~ ; wat-1 .Vii service.
streams anti lakes; pump or siphon tanr< ; distribution boxes, ~ t,=I'tiotr systern- • r,;5 i system
areas; and the location of the buy ,`frog served, 3) horizonta ar~,J' icai ~alev3tion ;,),(_~rF i-., z
C) complete specifications for pumps and controls; close volume; elevation differences; fr icti<_ rr loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorp°ion 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 Inciudsed ':fie creation of surcharges (fees) for L; r°um:?e r r.
re, ul3te r . I t I (-J-. ; r: . Ii tt grnuncfw8tw r
,o
Tee Jni~c. + C?ed througl.~ ~ 3e sr,rcha, ge t '..'s~'c for r;l_.. :n
wetter' :ontammi;tion n.vesii9 tio;is anti +.'.Stclt?11 i ~ of standlards. -
SBD-6398 (R.11/88)
y r
Sly'
2
PAC, t or
. fm" Ak Mhas 411 0~~~~~~Uo11 Pipe
(~~Awevsd Veal got
• MW+wr ld4~e•o i .
f9de
♦-C••1 4M1 i.•'•.
1. 11.•1'414410 v.1 Py•
' My1~ IN• 01 {~~~Mik C•••rln• '
174' A90001616
ago Pit*
~IP• T•• •
• ~•N•1~ Ili• • ?wostel•• Pipe YNw
• ~C•yrle{ iv••1••Ib! As
~ ••11•~ 01 ~/►Hw
Pro .,o't 0 Pm#-' 9 rh
WIL rILL
.10I3TKIBUTIOI.1 PIPC
APPRO`rcp S.(NT}aETIC COVE
2"0f 1~GGRffi!►1F --•-~r `'-ltA7CR1^L oft 1' OF STKA1•
OR MAK•1. N,Ay
9/Oz +ol,.~ONYt -LI/s AG GK cr. ATE.
~P ~
FEET, =1&i
OISYRIpUY10M PIPt.TO DC AY I=Chi1T _ IWCHCS BCLOW ORiWWA1, •,rAp~
AQU AT LCAiTZO IWO:HGL OUT 140 MOKC THAW yZ IWcHCi pCLOW rl►JAI. CJINOC
,r
M1 IMUTA DEPT•N OF F-XcAVt\T101J F OM OKItW,\L 6RAv~ WILj- 5L - 1uc.Hes
rvfrIMM OEFni of EACAVATID" rA0P% 0.'4INAL CRAPF- wlt•L 5C , INCHCS
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division sf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix'
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
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. 038-1167-20
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Paul & Melissa Wittstock GOVT. LOT SE 1/4 NW 1/4,S 28 T 31 N,R 18 xf (or) W
PROPERTY OWNERS MAILING ADDRESS LppT # BLOCK # SUBD. NAME OR CSM #
255 W. 6th. St. 11 na Red Pine Estates
CITY, STATE ZIP CODE PHONE NUMBER OCITY CIVILLAGE tjOWN NEAREST ROAD
New Richmond, WI. 54017 (715)246-3867 Star Prarie 107th.
[x New Construction Use)tx] Residential / Number o~fedMgmi m / ° ' [ J Addition to existing building
j Replacement [ J Public or commerci"eWft
Code derived dairy flow 450 9pd / Recomtrloi4ddiiign loa pg to • 7 bed, gpolft2 - 8 trench, gpolft2
dltt2
Absorption area required 643 bed ft2 563 ~ 112 J MOTurh desj load rte • 7 bed, gpd/ft2 •8 trench, gp
~r
Recommended infiltration surface elevations 96. ft erred to site plan benchmark)
fir; n
Additional design / site considerations
Parent material outwash ain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND N-b40 M ESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
Unsuitable fors stem MS ❑ U 06 ❑ U ~M'S ❑ U 0% [3U ❑ S ®U ❑ S ® U
U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed rertctt
w l 1 0-8 10 r3/4 none sl lmsbk mvfr 2f .4 .5
4M 2 8-18 10yr4/4 none sl lmsbk mvfr gw if .4 .5
Ground 3 18-31 7.5yr4/4 none sil lmsbk mfr gw if .2 .3
elev.
100.56ft. 4 31-10 10yr4/4 none co s Osg ml na na .7 1.8
Depth to
limiting
factor
+105"
Remarks:
Boring #
1 0-9 10yr3/4 none sl lmsbk mvfr gw 2f .4 .5
2
2 9-16 10yr4/4 none sl lmsbk mvfr gw if .4 ~.5
k•' w~
3 16-2 7.5yr4/4 none sil lmsbk mfr gw if .2 .3
Ground
elev. 4 28-10 10yr5/4 none co s Osg ml na na .7 ` .8
100.01 ft,
Depth to
limiting
factor
+100"
Remarks:
CST Name:-Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 20 th. Ave., Ne Richmond, WI. 54017
Signature: Date: CST Number:
6-9-94 cstm 2298
2f 1wil
PROPERTY OWNER Paul Wittstock SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # 038-1167-20
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bafxl3y Roots GPD/ft
in. Munsell Gu. Sz. Cont Color Gr. Sz. Sh. Bed ITmr&
3 1 0-9 10yr3/4 none sl lmsbk mvfr gw 2f .4 .5
2 9-21 10yr4/4 none sl lmsbk mvfr gw if .4 .5
Ground 3 21-3 7.5yr4/4 none sil lmsbk mfr gw if .2 .3
elev.
99.06 ft 4 36-120 10yr4/4 none co s Osg ml na na .7 1.8
.
}
Depth to
limiting
factor
+120"
Remarks:
Boring #
1 0-11 10yr3/4 none sl lmsbk mvfr gw 2f 1.4 .5
ME=
4 2 11-23 10yr4/4 none sl lmsbk mvfr gw if .4 :.5
3 23-41 7.5yr4/4 none sil lmsbk mfr gw if .2 .3
Ground
96.ely ft. 4 41-90 7.5yr4/6 none co s Osg ml na na .7 .8
Depth to
limiting
factor
+90"
Remarks:
Boring #
1 0-8 10yr3/3 none sl lmsbk mvfr gw 2f .4 .5
':5 2 8-23 10yr4/4 none sl lmsbk mvfr gw if .4 .5
3 23-36 7.5yr4/4 none sil lmsbk mfr 9w if
.2 .3
Ground
96.1 ft. 4 36-90 10yr5/4 none co s Osg ml na na .7 .8
Depth to
limiting
factor
+90"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
i
Remarks:
SBD-8330(R.05/92)
' J
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
Paul & Melissa Wittstock
CSTM2298 SE4NW4 S28-T31N-R18W New Richmond, WI 54017
MPRSW 3254 lot #11-Red Pine Estates (715) 246-6200
T
N
1"=40'
BM=top of 3/4" steel pipe at el. 100'
Alt. BM= top of NW lot stake at el. 97.92'
U) %tevo
'
2e, 7' Z' 1,9 .5 -30
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Gary L. Steel
6-9-94
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STC-105
SEPTIC TANK
MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS l ~p
low
PROPERTY ADDRESS q (05 'A Ao
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 5 1/4, N VJ 1/4, Section 25 Tai_N-R_a_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION ,~Q 1
LOT NUMBER
CERTIFIED SURVEY MAP jVr-\ , VOL PAGE _jj)1q , 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: L
DATE: R3 f 8&b'1~
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - loo
This applicatid) form is to be completed ioull 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.
-----------------------------------------1---------------------------
owner of property T
Location of property 1/4_ 1/4, Section -p T ~N-R- W
Townshipaj.A PAD A--O- Mailing address
ItAn
Address of site a ('0
Subdivision name Lot no.
Other homes on property? Yes X No
Previous owner of property _
Total size of property 12J.3CO
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes XNo
Volume N9 and Page Number _5-71 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. 1- , and that I (we) presently
own the proposed site or 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~o~fcffice of the County Register of Deeds as Document No.
r O I
C1
gnature of Applicant Co-Applicant
Date of Signa ure *Dt of Signature
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR O WISCONSIN-FORM 2 - 1982
519781 W-1 ~gPAl3F57
REGISTERIS OFFICE
ST. CROIX C0.,1M
Dan McCulloch, a/k/a Daniel McCulloch, Recd for Record
AUG 2 1994
L
. . 11.30 A. M
.
conveys and warrants to ........Paul C. Wittstock and Melissa- A. a, to
Wittstock,..husband..and wife, .
Reps: of Deeds
RETURN TO
• (X0 "zV'R'
ooa
the following described real estate in St...-_.rO1X......-„.•_.County,
State of Wisconsin: Tax Parcel No:
Lot 11, Red Pine Estates in the Town of Star=Prairie, $t. Croix
County, Wisconsin.
r~ t ...Y
This is not . homestead property.
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of
record, if any.
Dated this .7~~ day of . y-.......... 9
` . . . . . . (SEAL)
.
..........................................•----•------..(SEAL)
Dan McCulloch, a/k/a Daniel McCulloch
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Dan McCulloch, STATE OF WISCONSIN 83.
a/k/a Daniel McCulloch.___.____•
......County.
day of
19 ---94 Personally calve before me this
authenticated this day of ---------July
19........ the above named
l
L~ t
•...-Kristina 0$land-•------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, .
authorized by § 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 -
Kristina Ogland-----•------..
Attorney at Law Notary Public ..........................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
)
are not necessary.) date: , 19.........
'Names of persons signing In any capacity should be. type,l or pl'Int.rd below thrir Nicnnfnrrs.
--V nAn nF aOrsrCINSIN Wisconsin Legal Blank C2. Inc. j