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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER )C TOWNSHIP ACS- GkIti
SECTION T a CZ N-R / W
ADDRESS49.;? ? T~S~ k; ST. CROIX COUNTY, WISCONSIN
Ydl
SUBDIVISION LOT LOT SIZE,&F/2d? ,5
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
5
r
` INDICATE NORTH ARROW
BENCHMARK:Elevation and description:-1~42Z 5'k) aL1k)
Alternate benchmark
SEPTIC TANK: Manuf acturer d f~ S Liquid Cap. 1 2
Rings used: Manhole cover elev:fBD 5 Final grade elev:_Gop
Tank inlet elev.: Tank outlet elev.: 8 6 °
No. of feet from nearest road:Frontz-17, Side , Rear Ft.
From nearest prop. line:Front-/S?-/,Side , Rear Ft.
No. of feet from: Well k2Zd , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
' a
II
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: _Pump/Sigh Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pu off elev.:_Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance fro earest prop. line: Front, Side, Rear„_Ft._
Distanc from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: c~ Seepage Pit:
Width: _Length_. ~ Number of Lines: Z Area Built 900 cz~
Exist. Grade Elev. f On ~ Proposed Final Grade Elev.
Fill depth to top of pipe: Z i
No. feet from nearest prop. line:Front , Side , Rear,/
No. feet from well.)A_No. feet from building- &O
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: El ation of bottom tank:
Elevation of inlet:
No. feet from nea st prop. line:Front , Side , Rear Ft.
No. feet from* Well, building-, nearest road
Alarm Man acturer:
INSPECTOR:
DATE : PLUMBER ON JOB
LICENSE NUMBER:. I 992Z2~? V
6/90:cj '
L
Q a
t Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Cnunty:
+,y and Human Relations
Labor and
Safety and Buildings Division INSPECTION REPORT Lot 17 St. Croix
(ATTACH TO PERMIT) Prairie Vi ta ry Permit No.:
GENERAL INFORMATION SE, SE, Sec. 21 , T29-Rl 9, stagecoach Tr. 1 149244
Permit Holder's Name: ❑ City ❑ Village T] Town of: State Plan ID No.:
Patrick Leverty Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
L020-1260-30
TANK INFORMATION ELEVATION DATA a//
3TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Q CoAQ Benchmark
,4 b~ 446 (1 09
Aeration Bldg. Sewer
[Holding St/ Ht Inlet 12.4 (o
TANK SETBACK INFORMATION St/ Ht Outlet 5 Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic NA D+-Be4-efn W. z
NA Header f~+i.. I ' . 87
Aeration NA Dist. Pipe 83~ -77
Holding Bot. System r
PUMP/ SIPHON INFORMATION Final Grade p
Manufacturer Demand
Model Number GPM
TDH Lift Friction System I Loss mead Ft
Forcemain Length Dia. Dist. Towels F_ _T
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S 80 Z DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING facturer.
SETBACK
INFORMATION Type m ,vnLF CHAMB
S
System: t~/Gflca, OR UNIT ER Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length -f= Dia. ~F- Length ~ , Dia. Spacing -1-2-- 2_
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.)
Ale,
P~2
Plan revision required? ❑ Yes No
Use other side for additional information.
P/
19
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
s
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
°...,..,.~.,e. St. Croix
STATE SANvITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ` / 7
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
AOPEBTY OWNER PROPERTY LOCATION
/J SE Y4 SE '/4, S 21 T 29 , N, R 19 xg (or) W
PR ERTY OWNERS MAILI G ADDRESS LOT # BLOCK #
61 t-:), "a 17 n/a
TY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
SS-I-Zg Prarie Vista
II. TYPE OF BUILDING: (Check one) ❑ State Owned E3 VILLLLAGE : NEAREST ROAD
Hudson Stagecoach trl.
❑ Public El 1 or 2 Fam. Dwelling of bedrooms AR L Ax N MB ( )
111. BUILDING USE: (If building type is public, check all that apply) _ a Co 0 - 30
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 12 ❑ 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 ❑ Mound 30 ❑ Specify Type 41 ❑ 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
600 780 780 .77 <3 96.98 Feet 100.48 Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank x 1200 1 Weeks C . P . FX1 [I F1
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installati f the onsite sews, a system shown on the attached plans.
Plumber's Name (Print): Plumber's Si re: (No Sta RIO No.: Business Phone Number:
Gary L. Steel !y ~ ( 3254 715 246-6200
Plumber's Address (Street, City, State, Zip C de)
54017
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sa itaryPermit Fee (Includes Groundwater a sue Issuing Agent Si nature (No Stamps)
Approved El Owner Given Initial f
Adverse Determination / - X. Surcharge Fee)
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
STC-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 nc
and SW 1/4 of SE 1/4
Location of property__UIL1/4 SE 1/4, Section 21 , T 29 N-R 19 W
Township Hudson, St. Croix County, Wisconsin
Mailing address 1150 East Seventh Street
St. Paul, Minnesota 55106 Phone: 776-7423
Address of site 571 Stage Coach Trail
subdivision name Prarie Vista 2nd Addition Lot no. 17
Other homes on property? ves XX No
Previous owner of property Verlyn E. and Catherine A. Benny
Total size of parcel 2.606 acres
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes XXNo
Volume and Page Number 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 & 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. , 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 County Register of deeds as Document
No.
'Su f applicant Co-applicant
MontaRari Homes, Ipc. - President
November 12, 1991
Date of Signature Date of Signature
Rf ~R rye;
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41
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER MmTtnTr- s, Inc.
ADDRESS: 571 Stage Coach Trail FIRE NO:
an or 1/4
LOCATION: NW 1/4, SE 1/4, SEC. 21 T 29 N-R 19 W,
TOWN OF: Hudson ST. CROIX COUNTY
SUBDIVISION: Prarie Vista 2nd Addition LOT NO. 17
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 complete and returned to the St.
Croix County Zoning officer within Q days of the three year
expiration date.
S I G N E Mo ahari Homes, Inc. - Vice President
DATE: November 12, 1991
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
pzf
DEPARTMENT O REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'INDUSTRY, ~ . DIVISION
P.O. BOX 76
LABOR AND- PERCOLATION TESTS (115) MADISO
N WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIPCITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
SE 1/4 SE 1/4 21 129 NCR 19Por) W Hudson 17 n a Prarie Vista
COUNTY: GMVX11 S BUYER'S NAME: MAILING ADDRESS:
St. Croix Patrick Leverty 16827 7th. St. N., Oakdale, Din. 55128
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRO DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 n/a ~vew ❑Replace 10-8-91 10-8-91
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: MIS TEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional)
0 S ❑U E S ❑U 0 S ❑U ❑x U ❑ S EU conventional
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a I Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS Page 58 BxC2
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED ES GHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.17 100.48 none >7.17 .67bl.1. 1.50bn.sil. .67bn.l.s. 4.33bn.c.s.
B-2 7.17 100.18 none >7.17 .67bl.1. 1.33bn.sil. .50bn.l.s. 4.67bn.c.s.
B 3 7.67 100.86 none >7.67 1.00bl.l. 1.67bn.sil. .50bn.l.s. 4.50bn.c.s.
B 4 7.08 101.04 none >7.08 .67bl.1. 1.58bn.sil. .58bn.l.s. 4.25bn.c.s.
B-5 7.42 101.28 none >7.42 .75bl.1. 1.75bn.sil. .42bn.l.s. 4.50bn.c.s.
B-
decimal' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES -FERLQ NUMBER ]NHS AFTERSWELLING INTERVAL-MIN. I t D
PER INCH
P-1 3.50 none 3 6 6 6 <3
p-2 3.20 none 3 6 6 <
P_ 3.88 none 6 6 6 <3
P-
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 96.98
a~ !
a,
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to
1
t i F ~ t 11
B
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N
I
t
1,S_ C, Z I f i,k
D
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ito
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:
Gary L. Steel 10-8-91
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. AVe., New Richmond, wi. 54017 2298 715-A6-6200
CST Sl /17
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR•SBD-6395 (R. 10/83) - OVER -
GUARANTEE
In consideration of the Addendum to the Land Contract entered
into between Verlyn and Catherine Benoy and Patrick and Marilyn
s
Leverty, on the terms and conditions thereof, the undersign
guarantees the prompt payment of the Land Contract at a date *et-eAO
vT early then January 31, 1992, and in accordance with all the terms
and conditions of the original Land Contract and the Addendum, and
agrees to all the terms and conditions of those documents and
affirms the waivers and contents contained therein.
The liability of the undersigned to enter into this guarantee
shall be direct and not conditional or contingent on the pursuit of
any 'remedies against either the Benoys or the Levertys or against
they real estate at issue here and more particularly described as
follows:
Lot 17, Prairie Vista Second Addition to the Town of
Hudson, St. Croix County, Wisconsin.
Notice of acceptance is hereby waived. This shall be a
continuing guarantee, extended to any notes given in extension or
renewal of this Land Contract, notwithstanding that the original
Land Contract may have been surrendered provided the liability of
the undersigned shall not be increased over the amount contained in
the original Land Contract as of the date this guarantee is signed,
plus accrued and unpaid interest.
Dated at St. Paul , Minnesota , this _1day of
November, 1991.
Montana x~ omen, Inc.
ar o anar ras en
y`i1?✓91 16 s l6 WALL & M i l LEt2
I
~►DDft tJM '~+D ki C OUTPUT
veryxn S noy and Catherine BenpY and patriok and Marilyn
Laverty, the, patties to a land controot filed with the Bt. Croix
County Regiatar of Doods Office as Cco• No. 471122t and describing
the following real estata►t
Lat 7.y, Prairie Vista seoon4 Addition to the Town of
Hudson, Oo Crolx -Caunty#
hereby make this Addendum for good and valuable Gon#iftration. The
land contract shad be amended to provide that building construction
may be aormonoed on tha property befQtre the payment of the oohtroot
is We in fNll under the following cotditionst
%a That the payment of the land oontraot in full is guaze►mtead
by Montanari Komar, Inc, by the pr#oideot of the corporation jUrt
Montahari, to pay the full purchass price no later than aanuary 3t,
19929
2s Conbtruat ton opt a hone on the property nay- comraor e►e
imzadiataly, as long as the ihatallmsht poymaht• are current and
closing taken place no later than Ja=ory 31, 1903.
3, This Addendum in no way affoota the sellerls forealooure -
and lien rights as set forth in the original Land Contract, This
Addendum is ahtored into for the purpose of allowing the buyers,
patldcR And Marilyn Leverty, to c+orilpl+ate Construation of housing on
the property by January 31, 19021 It is rmrther intohdsd that the
Levertys shall advance to the Benoys in Whange for a warranty
deed, the Cull payment for the Lend Contract at the closing on the
house to ba constructed by MQntanari Hone, lnot
.
Dated this ,.,.day of November, 19511
a r c Y
er yn E.
~Anoy
a~ ns . en0y ax ► ~X Y
91
STEEL'S SOIL SERVICE
Gary L. Steel 988 N. Shore Drive
C.S.T. 2298 New Richmond, WI 54017
MPRSW-3254 (715) 246-6200
t
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDi7STR1(, P.O. BOX 71 69
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHI ITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
SE 1/4 SE 1/4 21 /729 N/R 19;~or) W Hudson 17 n a Prarie Vista
COUNTY: 5ftVNWS/BUYER'S NAME: MAILING ADDRESS:
St. Croix Patrick Leverty 6827 7th. St. N., Oakdale, 11n. 55128
DATES OBSERVATIONS MADE
USE
PROF I LE DS: PER OLATION TESTS:
1)0 - NO,BEDRMS.: COMMERCIALDESCRIPTION: ~lew ❑Replace 3 n/a 10-8-91 10-8-91
Residence J
RATING: S= Site suitable for system U= Site unsuitable for system
OMMENDED SYSTEM:(optional)
ONVENTIONAL: MOUND: UIS PRESSURTEFIL Dnrconventional
ES ❑U ~ S ❑U ❑U El S EZ U El S EIf Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. I Floodplain indicate Floodplain elevation:) n/a
LHR 83.0915)Ib), indicate: n/a
decimal' PROFILE DESCRIPTIONS page 58 BxC~
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, OLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. O BACK.)
B-1 7.17 100.48 none >7.17 .67bl.1. 1.50bn.sil. .67bn.1'.S. 4.33bn.c.s.
B 2 7.17 100.18 none >7.17 .67bl.1. 1.33bn.sil. .50bn.li.s. 4.67bn.c.s.
B 3 7.67 100.86 none >7.67 1.00bl.l. 1.67bn.sil. .50bn.l.s. 4.50bn.c.s.
4 7.08 101.04 none >7.08 .67bl.1. 1.58bn.sil. .58bn.lli.s. 4.25bn.c.s.
B
B-5 7.42 101.28 none >7.42 .75bl.1. 1.75bn.sil. .42bn.l.s. 4.50bn.c.s.
B-
decimal' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER MEMES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERI6OD 2 PE 6 <3
P-1 3.50 none 3 6 6 6 <
p- 2 3.20 none 3 6
P- 3 . SO 8 none 3 6 6 <3
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or gist orta ibe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at al ri n t ion and percent
of land slope. JJ
SYSTEM ELEVATION 96.98
F e
E
e
.
F E
' f
e
J L
1. 80 Lbo-
,ko
3
e _
T_
T
E~
E o
t
ti
- - f ~ ~4
_ I
71, T -T
IS6 _ 07 e
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 belif.
NAME (print : TESTS WERE COMPLI TED ON:
Gary L. Steel 10-8-91
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. AVe., New Richmond, wi. 54017 2298 715-,9146-6200
CST SI
J
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -