HomeMy WebLinkAbout020-1349-02-000 Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 338987
Per %t„tldUT, N KIC El _Q e,- Town of: State Plan ID No.:
CST BM Elev.:- Insp. BM Elev.: BM Description: � Parcel Tax No.:
!� � .9 �G 6
TANK INFORMATION ELEVATI�NXXTA
TYPE MANUFACTURER CAPACITY ATION BS HI FS ELEV.
Septic; fC f �v enchmark q . Z D
Dosing /� Qv t
Aeration Bldg. Sewer
Holding V Ht Inlet ,(
TANK SETBACK INFORMATION &/ Ht Outlet
TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet
Air Intake p �Z•6 2 Q d
Septic .f O / >✓ NA Dt Bottom W
Dosing 4- 70� A /,4 Al NA Header / Man.• 7Z 9
Aeration A Dist. Pipe / GS
Holding Bot. System T2
PUM SIPHON INFORMATION .� Final Grade
Manufacturer 0 � S 4V Demancl
Model Number cp) GPM
TD H Lift A& Friction gq System_ TDH } eFt
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/ T Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME � DIMEN I N
SETBACK
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: INFORMATION Type C CHAMBER � n �_ Model Number:
�
System: � ,� (J '¢ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length �— Dia. Length / Dia. �7 Spacing �D� LIZ 'Z � L A.14
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: HUDSON 26.29.19,SW,SW 707 A &B BLUE JAY LANE
t• Z d'fu/e "^- (�r) $XSf
Plan revision required? ❑ Yes No
Use other side for additional informs ion. Z ZZ b
SBD -6710 (R.3/97) Dat Inspect Signature Cert. No.
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 s x Washington Avenue
In accord with ILHR 83.05, Wis. Adm- Code
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. s�
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ Check it revis o revlous a lication
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
AP-' knd sw /4 1/4, S T a� , N, R J
E (or)
Property Owner's Mailing Address Lot Number Block Number
Z — [ City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned n Cit Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms �O C] V own of Q`l•CG't lot,vG
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo OZ2 O' r le 7,2 _ G�
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 E] 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. E] New 2 Replacement 3 E] Replacement of 4_ ❑ Reconnection of 5. 0 Repair of an
L ystem System__ Tank Only__ Existing System Exl sting SLrstem
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 ❑ S epage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12 El
Trench 22 ❑ In- Ground Pressure / 1 42 Q Pit Privy
13 E] Seepage Pit (4 Q 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) 7tyD. 4 d Elevation
No— .6 Feet 494,6 Feet
IF Cap acit y
VII. T ANK
NFORMATION in gallo Total # of Manufacturer's Name Prefab. Con- steer Fiber- Plastic Exper.
New Existin Gallons Tanks Concrete structed glass App.
Tanks Tank
Septic Tank o ing Ta k `s� /�f E Y/�T/ ❑ ❑ ❑ ❑ ❑
Lift Pump T amber D d / ! r t ❑ ❑ ❑ ❑ ❑
ESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatu : (No Stam s) /MPRSW No.: Business Phone Number:
7 7 E
P lumber's Address (Street, City, State, Zip ode):
r
IX. COUNTY/ DEPARTMENT USE ONLY
Fm 7 Q Disapproved Sanitary Permit Fee (Includes Groundwater Egate ue I ssuing Age i n ure (No Stamps)
Approved ❑ Owner Given Initial surcbargeree) Adverse Determination C3(j g
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
1
INSTRUCTIONS
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 -3151.
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.
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.
V1. 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 81/2 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.
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PAC,I G F
PUMP CHAMFER CROSS SECTIOU AUFj SPECIF ICA"TIORIS
VCUT CAP
`"C.I. VENT PIPE _
WEATHERPROOF APPROVED LOCKINIG
> ?_5' FROM DOOR, JUMCTIO" BOX VMARIHOLE COVER
-
WIMDOW OR FRESH 92 M1U.
AIR INTAKE I
I
GRADE I
I 4' MIM.
18' mill.
COIJDUIT `�'-
18'P11N. v -- - - -- --
INLET PROVIDE
AIRTIGHT SEAL
A i I i I
*J
I ALARM
i I
c *APPROVED i ow
JOINTS WITH
ELEV. FT. APPROVED PIPE -_�
3' ONTO PUMP -- OFF
D SOLID SOIL
CONCRETE BLOCK
RISER EXIT PERMITTED OIJL'J IF TAWK MAMUFACTURE.R HAS SUCH APPROVAL
SEPTIC f SPCCIFICATIOUS
DOSE
TANKS MAU UFACTUREK: 227 a1 LS?- e*';-/ IJUMBER OF DOSES: PER OAS
TAR1I( SIZE : _.� ®� GALLONS DOSE VOLUME G
ALA MAUUFACTURER: �eGefa y INCLUDIMG 15ACKFLOW: 26 0 GALLONS
MODEL WUMBEK: CAPACITIES: A= INCHES OK GALLOQ5
SWITCH TYPE:
/ B = �� INCHES OR &Z GALLOWS
PUMP MAMUFACTURER: �Gl� C = _._Z/f_IAICHES OR as GALLOWS
MODEL UUMBER: - 1 le Q0 D- INCHES OR °?-�� GALLOWS
SWITCH TYPE; /ne(-- C MOTE: PUMP AWD ALARM ARE TO BE
MILSIMUM DISCHARGE RATE._ GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID DISTRIBUTIOM PIPE.. 42 FEET
+ MINIMUM NETWORK SUPPLY PRESSUR77�E//, FEET
+ .200 FEET OF FORCE MAIN X 2__L F /p p rLFKICTIO J FACTOR < /4 FEET
= TOTAL DyRJAMIC HEAD - /G ZD FEET
INTERNAL DIMEWS101.3C OF TAUK: LEIJGTH ;WIDTH ;LIQUID DEPTH
i
I
91GRIF 1-):
i
A'
Goulds
Submersible
o Effluent Pump
C
3871 EPO4
EP05
APPLICATIONS * • Fully submerged in high ■ Motor Housing: Cast iron
Fasteners: 300 series grade turbine oil for for efficient heat transfer,
stainless:steel.
lubrication
Specifically designed for the . Capable of running tion and efficient strength, and durability.
following ses: dry-without damage to heat transfer. ■ Motor Cover:-Thermoplas
g ry tic cover with Integral handle
• Effluent systems components.'`' Available for automatic and and float switch'attachment
• Homes Motor: manual operation: Automatic
points.
• Farms EPO4 Single phase: 0.4 HP, models include Mechanical
115 or 230 V, 60 Hz, 1550 Float Switch assembled and Power Cade rier ere dut y
•Heavy duty sump • Water transfer RPM, built in overload with reset at the factory. rated oil aril Wesistant.-
• Dewatering automatic reset. P ■ Bearings: Upper and lower
• EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing
SPECIFICATIONS 115 V, 60 Hz, 1550 RPM, construction.
Pump: EPO4 built in overload with ` ■ EPO4 Impeller: Thermo -
• Solids handling capability: automatic reset. plastic Semi -open design AGENCY LISTING
3 /maximum. •Power cord 10 foot with pump out vanes for
•.Capacities 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP• Canadian Standards Association
• otal heads upto 24 feet... with three prong grounding a EP05 Impeller: Thermo- (CSA listed model numbers 1.
• Discharge size:; -1'/2 NPT. plug. Optional 20 foot plastic enclosed design for end in "F' or "AC".)
length, 16/3 SJTW with
• Mechanical seal: carbon- improved performance.
rotary/ceramic- stationary, three prong grounding plug a Casing and Base: Rugged
BUNA -N elastomers. (standard on EP05): thermoplastic design provides
• Temperature: superior strength and
continuous i
104 OF (40 c , corrosion resistance.
140 °F(60 °C) intermittent.
• Fasteners: 300 series METERS FEET
stainless steel.. 10
• Capable of running 9 30
dry without damage to
components. 8
Pump: EP05 25
• Solids handling capability: o 7
%" maximum. W
• Capacities: up to 60 GPM. 6 20
• Total heads: up to 31 feet. 2
• Discharge size: 1 1 /x" NPT. z 5
• Mechanical seal: carbon- c 15
rotary/ceramic- stationary, a a
BUNA -N elastomers. o
• Temperature: 3 10
104 °F (40 °C) continuous
140 °F (60 °C) intermittent. 2
5
1 _
0 0 10 20 30 40 50 GPM
6 S 10 12 m' /h
0 2 4
CAPACITY
Effective May, 1995
'
0 1995 Goulds Pumps, inc. 83871
Wisconsin Department of Commerce ,.=L._AND SITE EVALUATION
Division Safety and Buildings 1 Page L_ of
Bureau of Integrated Services , "trl 46r. &f� 60�vv ih,s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less ftian 8 1/2 x size F'Ita rnust County
P ..
include, but not limited to: vertical and hori�o6stal refere t 4 dire6l i6 �nd St . Croix
percent slope, scale or dimensions, north 4rroW, and location and distance toy est road. parcel I.D. #
T98
APPLICANT INFORMATION - Piease print a�( ` Reviewed by Date
Personal information you provide may be used for Secondary pg }
Property Owner Property Location
Richard Stout ' Govt. Lot 5kj 1 /4 114,S a T„ t? ,N,R / E (or)ff
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
1353 Awatukee Trail 2 Brown's Ridge
City State Zip Code Phone Number ❑ City ❑ Village [j Town Nearest Road
Hudson WI 54016 Hudson I Meadow Lane
® New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 4r; Q gpd Recommended design loading rate . 7 bed, gpd/ft . 8 trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate ' 7 bed, gpd /ft ' 8 trench, gpd/ft
Recommended infiltration surface elevation(s) 7 __ s It (as referred to site plan benchmark)
Additional design /site considerations �'�` Z T/ , td /� ��/. I
Parent material rac ial Di -pnSit Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system [2 S El 0 S ❑ U [2S O U ®S ❑ U El S [ U EIS W U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
1 1 0 -1 10 r3/2 Sil 2mbk mfr cs 2F .5'.6
yof 2 .10-40 10 r4/6 Ls 2mbk mvfr cs .5;.6
Ground 3 40-S6 1 0 r4/6 Ms osq ml . 7 , 8
Depth to
limiting
factor
9 6 in. �ti
Remarks:
Boring #
1 0-1E 10 r3/2 Sil 2mbk mfr cs 2F .5 .6
2 2 18-(0 10 r4/6 Ls 2mbk mvfr cs .5..6
a / d 3 60-110 10 r4/ Ms osg ml .7:8
Ground
Depth to
limiting
factor
1 1 (1 in. Remarks:
CST Name (Please Print) Signature Telephone No.
William Schumaker (715)386 -3121
Address Date CST Number
1070 Scott Rd Hudson WI 54016 ,S? 7 7 'qr1
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT I,
Page a' of 3^ '
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 -24 10yr3/2 Sil 2mabk mfr cs 1F .5 .6
c�Q 2 24-45 10 r4/4 Sil 2mabk mfr cs .5 '.6
Ground 3 46/1 00 10 r4/6 Ms 0Sg ml .7.8
elev.
t.
Depth to
limiting
factor
f-
Remarks:
Boring #
1 r 2 Sil 2mabk mfr cs 1F .5 6
4 2 0 -6 10 r4 4 Sil 2mabk mfr cs .5 .6
3 52-110 10 r4 6 Ms 0Sq ml .7 '.8
Ground
e lev.
ft.
Depth to
limiting
factor
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # 1 -8 1 0yr3 /2 Sil 2mabk mfr cs 1F . 5 : 6
5 2 -36 1Oyr4 /4 Sil 2mabk mfr cs .5 .6
y� 3 36-95 10yr4/6 Ms osg ml .7.
Ground
elev.
e ft.
Depth to
limiting
factor
_9 6 in. Remarks:
Boring #
..........................
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer A c o v �� T
Mailing Address 135
Property Address '2a ;? el&e2f A eal e
(Verification required from Planning Department for new construction) sQi
City /State Parcel Identification Number D a? 6 4 �;Z
LEGAL DESCRIPTION
Property Location %4, V4, Sec. -� , T .29 N -RZW, Town of /4&, /_<r•el
Subdivision 4^o 4✓ , a f Lot # ::;2
Certified Survey Map # , Volume . Page #
Warranty Deed # �'- /'�t`� , Volume Page #
Spec house ❑ yes 94 no Lot lines identifiable 0 yes ❑ no
SYSTEM MAINTENANCE
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
n lumber, restricted lumber pumper verifying that (1) the on -site wastewaterdisposal system or a licensed um
master plumber, journeyman p p P P
e
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 the St. Croix County Zoning Office within 30
days of the three year expiration date.
�'90IAT s to/
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
* * * * ** 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 1.3.3' 3 PACE 4 7 J /00
STATE BAR OF WISCONSIN FORM 2 - 1982
X81439
WARRANTY DEED
i
DOCUMENT NO.
David
- -- -- - - ST, CRO!X CO., w1
conveys and warrants to Richard 0. Stout and Janet P 51Q 1 i JUN 2 2 1998
hu _abaLurid . wife,_,a __s worship —mari to __ 8:00 A
- - -- - - -- -- -- RA Lip of Q*pd•
--"' ` - - -- - -
S SPACE RESERVED FOR RECORDR-G �;ATA
_ Nw- LVD Q -TURN ADDRESS
the fullowing described real estate in _ St. Croi County Fb L-
State of Wisconsin. r
020- 1072 -60
%A.Z EL 'DENTiFCATION NUMBER
That part of S�SWk, Sec. 26- T29N -R19W described as follows: lot 2 of Certified
Survey Piap recorded in Vol. 11 of Certified Survey Maps, page 3036 as Doc. NO. r
538112. Together with a 66 foot access easement from Kinney Road to the Easterly
boundary of the above described property. `
-te
�TRANSFER �
y
This _— �. $_no - -.. _ homestead property e;
X= c: not �+
Exception to warranties Existing highways, easements and rights of way of record.
Dated this - - -__ day of — June _ _. A D, la 98
(SEAL) - -- (SEAL)
•D avid
- -- (SEAL) -- - (SEAL)
AUTHENTICATION ACKNOWLEDGSIENT
Y k
stgnalure(s) _ State of 'Wisconsin, r
ss :�
-- — — -- - S r c Gz_L V Coll t
authenticated thu —._ -- dal' of 19— Fersoeally :a•7e fore me this _ —_- __ day of �
19 98 the above mined
- - -- - -- -- - - - -- — Richard J . C.� 11eia� a si —
v.
M ;
111 LE. Mr -NIBER >lA', E B. \p. t1F \\ I5CONSlN - -- - - - -- -- - - -- —
Al nct, - - - - -- - -- — -- -- - — i
;utthorr_ed h) 00 Oh. \ \'i titat .} ,�;� \.��11 10 me ti;r
P AY P�/ I1 4 stntmert _r -d . die the same zr
THIS IN TRUMFNT V.'AS JRAFTE!D BY
AAAUREEN K
- 3(14 - Locust -S.tree t,._liudson, d f 5 YLIS of e _
nlaf'int If it:ani !stir
�ii;nautrs e11a`: he authen:l.ated of trot
—.
I•. I ,_ �L,r1. H. > >e of \,UCUN�t� :.....- .. ^., :,....;. ...
Form No.:
JMBIRD__H_ILLS THIRD __A__D_D__I_T_I_O_N BENCHMARK 66' BLUE JAY _
LOT _57 iLOT _58 EL. = 1015.97
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