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HomeMy WebLinkAbout028-1030-50-000 s o y a C. c Op o a cu 0 0 cu O a x 7 N w ' c .o o co o .o h a o o m a~ E X o Q N in o N 'D L N C C U U O " co 'p Q. CO N N N p ~ O O U O c c Vl (D Co 3 C6 CL 'O p LL N 'O (n C .0 a) N y cu 5 3 U) p O U O :2 .O Q N C m N 3 (`7 a> z m ~ 0 0 z a m co w a co N F- Z O 2 d C a ~ O N avi Z d' ~ ~ I m F- r N (D E N co p 7 p N 1~ N O O •y L ? - O a U M N o Q J N ® Z F- Z O N Zo -p y ~ 7 I i E o c _ a° `m w m` ~i a N N y °O D Q a 3 a~ 0 0 0 •~N~r.ya C a a a ■i a 3 o v1 m rn 04 N In cn J 0 m m m N FUyv ~ (t: N N L O O Q1 ~ d 2 m O d Q Z Oli N 3 1 O O p l - N C °o co 0" o c E co en O c N w :3 6~ O 6 co Q O O ©"r O ~ D O N C E r :.r N O O N N O Ix O O t N C N m N 1 > ~ N I\ I` Z co r \ ik Y ID v a CL 'iv ~ ~ 'c I c m ~ I r~ E 3 'o1 A co a 11 o in co LOCATION: RUSH RIVER 24.28.17.189B,NE,SE,24,HWY. 63 , Wisconsr epartmentof Industry, PRIVATE SEWAGE SYSTEM County: ?-ab uman Relations INSPECTION REPORT Say uildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 149269 Permit Holder's Name: ❑ City ❑ Village)V Town of: State Plan ID No.: VANBEEK DANIEL RUSH RIVER CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: I T X50' GJ /eltd.,D m 028103050000 TANK INFORMATION ELEVATION DATA A9200115 7 2 7 AZ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic' Benchmark Dosing Aeration Bldg. Sewer Holding St/ bif Inlet TANK SETBACK INFORMATION St/ W Outlet ' TANK TO P/ L WELL BLDG. Aiir intake ROAD Dt Inlet Septic ?56?~ 2 NA Dt Bottom i t. Dosin NA Header /Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade anufacturer Demand 4cp Model Number GPM TDH Lift I Loss Friction Syst TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 64) DI EN t N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Man urer: SETBACK INFORMATION Type O q" CHAMBER OR OMIT Mo a Num System: e S DISTRIBUTION SYSTEM Header 1 ,r Distribution Pipe(s) eI ? 7 x Hole Size x Hole Spacing Vent To Air Intake Length ` Dia. Length / Dia. Spacing it SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over / tI Depth Over V xx Depth Of xx Seeded/ Sodded xx Mulched 9," /Trench Center Be46Trench Edges L Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)' 04-< •_z,_-, 78 ds- 79 Q~ g;7- Plan revision required? 0-1-es ❑ No Use other side for additional information. 7 Iq~i Q1 q SBD-6710 (R 05191) Date Inspector's Signature Cert. No. J ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , t EITIDILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY st C, ` STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /q g F 8% x 11 inches in size. Check if rev Sion to prey us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Dal, \Za b eR NF_ %a F_ S ~ll T , N, R or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # D RT CITY, S AT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER U!E h DD 915 I; Sy~3z,0 11. TYPE OF BUILDING: (Check one) El State Owned ❑ VILL GE NEB REST ROAD P IJ OWN OF: ❑ Public N1 or 2 Fam. Dwelling-# of bedroom _ P BER 3T CM III. BUILDING USE: (If building type is public, check all that apply) ©28 1D3~T 1 ❑ Apt/Condo 0)_g' 1030-0-000 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/school 80 Mobile Home Park 120 Service Station/Car Wash 50 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.~g New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 R Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 420 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 REQUIRED sq. ft.) PROPOSED(s ,q. ft.) (Gals/day/sq. ft.) (Min./inch) qd,9 ELEVATION I f 15'00 0• S R1 Feet 9~ o $/F et VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New lExIsting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank rPC~,S Lift Pump Tank/Si hon 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: &Aaa~~ ~0&, I Rrw b n w~ 5 rip 667 3 '7 ~ls y 30~~ ISTumber's Address (Street, City, State, Zip Code): E,7- 3 o t'Ct~~vr~~~ ~S V01 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (Includes Groundwater 'Date Issued Issuing Agent Signature ( Stamps) r Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber ..r 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 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 & 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. 11. 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// 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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) STC - loo This application form is to be completed in full and the owner(s) of the property being developed. Any in equacies will only result in delays of the issuance. s development be intended for resale bytowner/contr ch or t d 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 .~ah va" Qe~k Location of property= l/4 S 1/4, section T 40 N-R 17 W Township Ptecs-61W I fC ICe'Y Mailing address _ 200 H,1 63 Roctfe 2- QId ~h s o~ r~ W02 Address of site Jc~trre subdivision name W n Lot no. Other homes on r oPe V P rtY? yes X No Previous owner of property f'IM C( ~L h P Total size of parcel 60 Q Gr9 5 Date parcel was created 0 C f 25 l 9f Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)?_Yes X No Volume 120 and page Number 2 5 3 as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUVITY DEED which includes a DOCUMENT NUHBER, VOLUME AND PAGE NUMDER & THE SEAL OF THE ZREGISTkR 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 the property described in this information f(are) the owner( orm, by virtue sofoa warranty deed recorded in the office of the County Register of Deed, as Document No. and 82 own the proposed site fo- r the-sewage di p salt system) orr Ie(we) obtained an easement, to run the above described the construction of said system, and the same haso been duly recorded in the office of County Register of deeds as Document No. 17q'0 S-2 Signature of apflicant Co-appl cant \F:3?1- CI O\ Date of Signature Date of signature 5A* - N..... N.•.....»«»»... N•Nw•N.., i'. ' - ~ •.••N~.NM.,'.•.NN. NwNNw•,•• NMN~NN•M•~ N ..•,N ••NNiYMNNN. R .M »•NN•NN..w.i....,•••. N.NM.N.•••M• S n' ti\' y, - w•......•.... N...........N,••»•.•M..•• y ,t ~N.•M••N'~MMN»N»»»N•N».»»»a•N........ N•NHN•N•• } •.•..MMM~,M••••NMMM••••.......» N................ ...«w.M..•»••• r .dN • ee*ww se r Sd¢ o..rN.••.w•.NN•••«.•«.»»•N. N.......••.........•.... r • y.Y.. ..,as..►••M• • A 11~ •[1.•YM.•11~•• •..N•N•pN•.•••NN•» •••.•N....,.. jityM~y.ls,•..~NN•.• w•w~:••N ".ry MNl•q .,h~~ ,I+Iwrri eiiMb M Tax Pw and Noi r 41 at b Y ~x ~IIIIII_~ iIIM~~, ' loiP pT{~ a (208 ~ r }'may a,{ s~ 3i'• s am 41 d 4 'hie bean"" . y. N ~ tie wec) dds N,. a" of pCtolsr 19 ......»....N.... w . A.. SEAL) t$ Y. ~ . . ,L,.• V46 Seek •N•.N••,N.•~... «Nw..NN a. q ...•....(SZAL) ...N. AVT=I WTICATION AO=NOWLSDOMXNT -TATS OF WISWNSIN " ......»»N....N...«.......... ...............wN..........................»w... .F ~4....................cern . -•deY'it 25 !!„91 Pen mHy eras bd se M t)►b , loll . !fie abate named ABM..YllI1NQ~lRk ..........................N...N.......... S N ..............w....... ..s..N......,,•.:...r..c. if~ «..................•i. ....«.«w».»• .+t•..'} 'E Fp 47 1.. qm knew to m be the paws tMM 4 F .~ngceiK inateerwN wA eevnrkl#t. eeeln• . - .Sheron J Strom , ' _ , , r3. ~A • F • ~ y 10 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER- Da h Yah BeeK Q41dwIN~Wl5C9MI'1~ i ADDRESS:- 260 Hwy 63 Pouffe 2 FIRE NO: LOCATION:- NE 1/4, s F- 1/4, SEC. 24 T 2 g N-R 7 W,__ TOWN OF:_ 10 (egtpew, Y a [ey ST. • CROIX COUNTY SUBDIVISION:- N /A LOT NO. 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 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning officer within 30 days of the three year expiration date. SIGNED: NN~ a~ I. ' DATE : St. Croix County Zoning Office 911 4th St. - Hudson, WI 54016 SechAoti r~° pO✓f ~ ~ III Sod evA)gtt~'6n I T-owkl S~'1 Da„ VG PI Bey 7 Y tC7yl beyr~ I roc u Fcd ~ p)-e asp~ LA/ S Y, NE 'Al S E I /y T 2 N 17v/ Qun UGC ~ Pe T 2.. (~c~i~Wih ~ V`/iSCOn5r1 0 m 2 ~ST Bruce ~o I P 52 I c~ t' vu,- (j e e K betiveo, cwvli,,- oi~ fi^ehAes I'~v P.f r <c CA of I~P'/4o 5rb SE ~q dF s '/N oa sic ? ~UV Not- be Qit^oupt- ~J T 8 N R 17 w V PleaS.~hValley 1 tit JU I ~"v'"' 5 y5f pq TDwn$~i'p o{ fi st c~ o -~7 a ctl~wratp a-rQq,.. 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CROIX COUNTY ZONING PAGE 1 07/27/92 08:50 REQUESTS FOR INSPECTION WORK SHEETS FOR: 7/27/92 AREA: JT -Actfvity: A9200115 7/27/92 Type: CONVSEPT Status: PENDING Constr: Address: RUSH RIVER 24.28.17.189B,NE,SE,24,HWY. 63 Parcel: 028-1030-50-000 Occ: Use: Description: 149269 Applicant: VANBEEK, DANIEL Phone: Owner: VANBEEK, DANIEL Phone: Contractor: WEBSTER, BRUCE Phone: 594-3080 Inspection Request Information..... Requestor: BRUCE WEBSTER Phone: Req Time: 15:07 Comments: J& Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, G DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (1-163.0911) & Chapter 145.045) LOCATION: SECTION: WNSHI OT NO.: BLK. NO.: SUBDIVISION NAME: 5 '/a a s /TSB H/R ~ 7,, (or► W ~ Y N 0- 1 JV IV COUNTY: OWNER'S BUYER'S NAM : MAILING ADDRESS: 57, Cro" Dart/ Vah .9'ee~ 448 0.o'-yuew K'( Rdb.ris W6 S40ZC USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DE CRIPTIONS: PERCOLATION TESTS: Residence XNew ❑Replace on site (!y 31rN tlor.rsov 8/9/q, RATING: S= Site suitable for system U= Site unsuitable for system CON❑VENTION~ . MM OUN s. IN-GROUND URE: SYST M-IN-FILLHOLDING TANK: RECOMMENDE~YSTEM:(optional) SS ® S U ❑S OU DS 01 P'`flU IV If Percolation Tests are NOT required DESIGN RATE: ( If any portion of the tested area is in the under s.H63.09(5)(b), indicate: N# CIQss 2 Floodplain, indicate Floodplain elevation: U PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) q0 O-lo, k- 5.) 7op5o l lo- I 0 Gy ern S )8 -06 Qr$C raot7/s.T ze 0,,j e B- I ] .Q N 26-.58"RJBn SCl 0-L" 131%A 7opsa, l -70&7& 5CLLao-49 134 SC nrn054r4a" B- 2 5o 17.4 Mori e -4a '49^"601' (2,Q Qn SC11- p-4" G/ 8L 5;1 7' It S"i) 4-ZI ay Be SGLL 21-'q Qn 5C w.9 B- -3 4S3 q .ln o>ut 3 'M o~<<s aY 3--t„ B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 P R PER INCH P_ I O TV ovu-C 3 O 1 4/ / P- 2 20 YO rV e o I % 1 a 7 P_ o TC o N 3 0 P-_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 7 • i i j - 01 L-4 f_ r - I ~f lo` { T7 i a ; i 7 I ? ~Wr I I 1 , ( A oiL w ' _ i 0 ~r 411+o1je„ , { i - I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: ADDRES : CERTIFICATION UMBER: PHONE NUMBER (optional): ~ I J Q s vuiu1os, r. 1V-0 C. I' 33' CIS-4ZS-2,->s CST S GNATURE: / DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - AW INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To and accurate soil test, your report 1. C ascription; 2. TP t clearly in- 'ether this is a r ~ or commercial project; 1 MAXI. f',edroom rnmercial usf 4. Is this gent sy,, 5, Complete i rating bo :yrs. A SITE IS SUIT-BLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTC:` RULED OUT BASED i SOIL CONDITIONS; B. PLEASE use the an' nations shown here for ..1 srofile descriptions and completing the plot plan; 7. MIKE A LEGIBLE --am accurately locatir y test locations. D . wing to scale is preferred, A ,ir hate sheet may v if desired; S st your benchn irk and vertical elevatio iE., point a _ r shown, and are permanent; 3 A e all appropriate boxes as to dates, names, addresses, flood pl data, percolation test exemp- Eppropi We; itormatio- Basch as flood plain, elevation) does not apply, plu-- in the appropriate box; 11. i the form acrd i 'sce your current address and your certification nu 12, Make legible c t rd distrillu + as require, ' ALL SOIL TESTS JST BE FILED WITH THE LOCAL ~ U l Y WITH!" YS OF _ 'LETION, ABBREVIATIONS FOR CERTIFIED. L TESTERS Soil Separates,! Textures Other Syn <)ols St - Stone { 3"? BR I I cub - t d") SS ~ ne gi, 3") LS Li ne s - id p - med s rid fs g Bldg Is L<. > C Than `sI - L < L in ~l Lan - B r S Im B! l si _ t Cy - G~. ~cl- Y Y `l(~ sc l „rtrn R - F siCl irn 11,101 ;x4c C £a p t - 3' m M~-;k level, six 'irns lit ater n >al - - Referen TO THE OWI ."r g a sanitary pertnit, The )u t' y of v rr, it may re.rfuest Dr to permit issrr ins r r ,r rrie private must be suhmitted -E order to a permit. T - it must be obtained ar 4 of r ` J ST. CROIX COUNTY WISCONSIN ~ h ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 - (715) 386-4680 Oct. 9, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite investigation of the Dan VanBeek property, located in the SE 1/4 of the SE 1/4 of Sec.24, T28N-R17W, Town of Rush River, St. Croix County. This onsite revealed suitable soils at 24" with 12" of sand fill making this site suitable for a mound septic system. Should you have any questions, please feel free to contact this office. Sincerely!, James K. Thompson, Assistant Zoning Administrator cj I'