HomeMy WebLinkAbout020-1264-90-000
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER,,,? TOWNSHIP Wa Z~ e,-1
SECTION_aff _T_.Ef N-R_fff
ADDRESS Ro,i'' QZ ST. CROIX COUNTY, WISCONSIN
f 6e ho h C'k,"T T- y
SUBDIVISION cue ('P' LOT--.93 LOT SIZE
PLAN VIEW
SHOW RVERYTHING WITHIN 100 FEET OF SYSTEM
b~; way
I
s A EAl 10CJ. p~
S w d//
~e 5 10 p
a 6,X SO • p
® N, w, lot !aT- [-1 cnr
• INDICATE ORTH ARROW
L~r'"zY
BENCHMARK: Elevation and description: J ✓o=R e < ,f
Alternate benchmark
SEPTIC TANK: Manufacturer: U-) g-!_ S - r Liquid Cap. 1Q0 0
Rings used s ZManhole cover elev: ,S Final grade elev: Tank inlet elev.:=_ Tank outlet elev.:
13, la
No. of feet from nearest road:Front,_,_, Side,!, Rear_,Ft.
From nearest prop. line:Front Side, Rear•,X_Ft. sS
No* of foot from: Well &o' , Buildings Z Z
(Include this information in the above plot plan)
(2 reference dimensioonnss ttooVseptic tank)
SIDE
PUMP C 1MMER
Manufacturer:Z/4 Liquid Capacity:
Pump Model:__Pump/Siphon "Manufact.:
-Pump size_
Elevation of inlet:
Bottom of tank elevation
Pump on elev.:-.Pump off elev.:`-Gallons/cycle:
Alarm: Man : Switch Type: Location
Distance from nearest prop. line: Front-,, side-,, Rear .Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: a Trench: _ Seepage Pit:
Width: Len th / 4o 9G Number of Lines:~_Area Built~y~r
Exist. Grade Elev. ~
Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line: Front
3ide,C , Res ,_Ft.
No. fet9t from well:-IL, No. feet from building
HOLDING TANX
Manufacturer:- Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line: Front Side.,, Rear _Ft._
No. feet from: Wellbuilding__., nearest road _
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB: n / w
LICENSE NUMBER:- ~1 h' S 3 Z
6/90:cj
w.
P" '
I as l
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
L,BOR & RUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
V ~SO l 53707 State Plan I.D. Number:
0-,~N 4,Sec.29,T29-R19 CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Hudson, L 23
Ross in Ct View Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PER T HOLD R: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 14
Sam Miller Box 282 Hudson WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM LAN: REF. K. ELEV.: CST REF. PT. ELEV.'
'o f
Name of Plumber: MP/MPRSW No.: Coun Sanitary Permit Number:
Doug Strohbeen - 5432 St. C x 128882
SEPTIC TANK/HOLDING TA $"fr11 , c J~f = e / - /t
MANUFACTURER: LIQUID CAPACITY: TANK INLET EV.: TANK blOTCET ELEV.: WARNING LABEL LOCKING COVER
n / f PROVIDE PROVIDED:
ES ❑ NO ❑ YES
WELL: BUILDING: VENT TO FIRESH
BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ' ROAD PROPERTY AIR
ALARM: E NE
NAREST LIt-:',a, i / INL
❑ YES O C 6 5A ❑ YES 64NEAREST .
DOSING CHAMBER:
MANUFACTURER: BEDDI LIQUID CAPACITY: PUMP MODEL: N MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GAL NS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF RTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARK .
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTEM( /y 39 C S ' z ` , ~C~
BED/TRENCH WIDTH: L NO OF DISTR. IPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
DIMENS IONS / ✓ v0 3(4 f TRENCHES: MATERIy~ PIT DEPTH
OY
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE MATERIAL: NO. I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW P~PES: ABO 1E/ C VEU: E V. IN' i ELEV. EN PIPE FEET FROM LINE: AIR INLET:
o. NEAREST
MOUND SYSTEM j? b
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
[DEPTH OVERT H/BED DEPTH OVER TRENCH/BED HS OF TOPSOIL: SODDED: SEEDED: MUL ED:
TER: EDGES:
❑ YES E] NO ❑ YES ❑ NO YES ❑ NO
P SURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPAC GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE C ER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: DISTR. P BUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST----*
Sketch System on a county file for audit.
Reverse Side. SIGNA RE: TITLE
sBO-6710 (R. osiss) ~m /
CILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COO,N~i
Now
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than El /,c ~J~~
8% x 11 inches in size. c i r ~s n o previ s application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRIN ALL I RMATION.
PROPERTY OWNER PROPERTY LOCATION
s. A r✓ him, /a S o2 Ta., N, R 7 E (Or
PROPERTY OWNER'S MAILING ADDRE T BLOCK #
v XCII Z Z_ -2,3
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
w L s o i 3 c. 7 r, Qo5 i V: euJ
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) ❑ State Owned ❑ VILLAGE ~ 4 O r\ a ~
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX u ( A ► ~l
111. BUILDING USE: (If building type is public, check all that apply) I Z 97 0 4(e, q ` go
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. MP 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
~/So G~is- syE~ (oyg S?I~ (j, L G 3 9~'ad Feet /0 2. S Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App.
Tanks Tanks structed
Septic Tank or Holdin Tank ~~GO Gc/a r s'w
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:
Nth- S4 3 Z apt i
St, VX-J."-^ I k)"
Plumb s Address (Street, City, State, Zip Code):
r~s
elo -3 ,,K, Ik" c / M.6 X
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent ai No S
Approved ❑ Owner Given Initial Surcharge Fee) / a as
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
APPLICATION FOR SANITARY PERMIT
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
Location of Property i(%Section ~IN-R /
Township
Mailing Address
Address of Site A7'
Subdivision Name _'o~s:,LQ le4 i✓ ~/;.~ty
Lot Number _2 3
Previous Owner of Propertyo r r~'t F R o~ _
Total Size of Parcel 2.00 ~ee~i3
Date Parcel was Created 11-17-
Are all corners and lot lines identifiable? , Y Yes No
Is this property being developed for resale (spec house) ? /r Yes No
Volume -7.5-7 -,and Page Number 91f as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Wg4ranty 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
1 (toe) ceAti6y that att statementa on this 60,cm ake true to the best o6 my (ouA)
knowt.edge; that 1 (we) am (aAe) the owneh (b) o6 the pupeh ty du cAibed in thiA
.in6oAmdti..on 6o4m,.by vi tue o6 a wa Aanty deed neconded in the 066ice o6 the
County RegiateA o6 Deeds a,6 Document No. 'Ig 1.•2 o ; and that I (We) phehentfy
own the pnopoeed site bon the zewage LpoA a yAs em (on I (we) have obtained an
easement, to nun with the above debcA bed pnopeAty, bon the condtnuc ion o6 said
system, and the dame had been duty keeakded in the 065.ice o6 the County RegidteA o6
Veedb, a8 Voeument No. Is 2 Z 3 0 ) .
SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
A
f•_ - ! (PASS
DOCUMENT NO STATE BAR OF WISCONSIN FORM 11-itllsa~.`-1a space are[RVtO ►oa R[COROINO OaTA
LAND CONTRACT REG.=TER'S Ot-OCE
IaO.Weal and V-porala
rr,~~f~ yv ITO R!: USED FOR AL1. TRANAAPTIONS WTIF.RF OVFR
a»tinno IS FINANURD ANU IN OTItrit NON-CONSUMER ST. CRoix CO., W1
AI•T THANSACTIONS1 Rc: ,c.1 trot Pnord
ContraCt, b1 and between . FgXX~l3i.. .a...R4flR.~pS.Bnd
..KutZY...Rft11gY.>-. a sin(;le woman Ci 1:25 P M
("Vendor",
whether one or more) and..S4la.1;....I'1,111.C.C Register of Deods
("Purchaser". whether one or more). ol.wj
Vendor sells and agrees to convey to Purchaser, upon the prompt and full per-
formance of this contract b) Purchaser, the following property, together with the
rents, profits, fixtures and other appurtenant Interests (all called the "Property").
in......SC....GXO1>1 County, State of Wisconsin: Rarunn To
West one-half of Northeast Quarter (140004)
except the east 8 rods, and the Northwest
Quarter of Southeast quarter (NW!~SEI>.), except Tax Parcel No
the south 6 rods, all in S..ction 29, T29N, 19W.
Z NSoc?
r-
$ FEE
This . is,not . homestead property.
8191 (is not)
Pure.hnser agrees to purchase the Property and to pay to Vendor at .208 8th St. , Nudson, WI
the sum of =.256,,150x00 . in the following manner: (a) $.ZQr.OQQ..QQ......
at the execution of this Contract; and (b) the balance of ; 23C~s.150.•.QQ together with interest from date
hereof on the balance outstanding from time to time at the rate of.nine..1:9x11 per cent per annum
until paid in full, as follows: Interest to January 11, 1988 shall be limited to $1,320.29.
$80,000.00 plus interest on the unpaid balance on January 11, 1988.
$50,000.00 plus interest on the unpaid balance on January 11, 1989.
$50,000.00 plus interest on the unpaid balance on January 11, 1990.
$56,150.00 plus Interest on the unpaid balance on January 11, 1991.
The above payments shall be made in addition to any payments made for the conveyance of
lots until the total price is paid in full.
All payments shall be by 2 checks, one to each Vendor for 1 of the full amount.
A )pot tedlehase Aggemnt h~~ adlso been sli l~dpo•I~ this dateb 11th
rove t• ow•ever, a rot ire outs ail Ing ha once s I e al In u on or efore the day of
....jliutumty 19..91.. ( the maturity date).
Following any default in pa) inent, interest shall accrue at the rate of .lo....... % per annum on the entire amount
in default (which (hall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
Purehweert unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay rennonahly antici-
paterl annual t-amw. aprrial a.,a~nw-its, fire r.nrl required insurance premiums when dice. To the extent received I.r Vendor*
Vendor agrees to 4.pply payatents to thoss obligations when due. Such amounts reeeiveti by the Vendor for payment of
taxes, aaaEaamonta and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest
unless-otherwise required by law.Any amount may be prepaid on principal at any time.
Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any-
.amount may be prrpaid without premium or tee upon principal at any time Rfter 19....... (OR)
there-iinay be no prepayment of principal without permission of Vendor." ".`,-40008
In :he event of any prepayment. this contract shall not be treated m in default with respect to payment !to long
as the unpaid balance of principal, and interest (And in such case accruing interest from month to month rhall he treated
as unpaid principal) is less than Vie amount that said indebtedness would have been had the monthly payments been
:Wade sus first specified Above; provided that monthly payments shall be continued in the event of credit of any proceeds
of insurance or condemnation, thr condemned premiser being thereafter excluded herefrom.
Purchaser states that Purchaser Is satisfied with the title as shown by the title evidence submitted to Purchaser
for examination except:
Purchaser alrreett to Pay the root of future title evidence. If title evidence is in the form of an abstract, it shall
be retained by Vendor until tl,- full purchase price is paid.
Purchaser shall beentaledto take possession of the Property on the daft lu•reuf If
I '
LAND :ri~TRACT-Indivdual and ST 11: Polo fit' WIFr-nVdl% tc-o n 1.•r.l niank r•.. It.,
Corporate i-nNtl II oTSt \I,,.• tt,a.
t..
" SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
014NER/BUYE n
o
L
ROUTE/BOX NUMBER Fire Number-----_ :J
ZIP
CITY/STATE `g 'kr=
PROPERTY LOCATION:' Ql ',~/1 _k, Section, TAN, R_1176t)
Town of lAz l&,.... St. Croix County,
Subdivision,,sS,,,<~4yfy 1/1, , Lot number Z-3
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licens'ed' 's*e t'ic tank um er. What you put into
the system can affect Elm-function of the-septic tank as a treat-
ment'stage in the waste disposal system.
St. Croix County residents'-may be eligible to recieve a grant for
a maximum of 607, of the cost.of replacement of a failing system,
whic 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 sys't'ems agree to keep their system properly
maintained.
The property owner agrees to. submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic'•tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year•expiration. y
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with N
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed V
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
a
SIGNED
DATE 229
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION.
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 7969
ON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145) a
LOCATION: SECTION: TOWN SHIP/Mb"tCTP`AT OT-NO.:BLK NO:: SUBDIVISION NAME:
Nw N E 29 /TZcir N/R `'9 (or) f /uasa~ Z ssfN4 -r►2y ► w
COUNTY: MAILIN ADDRESS:
ST cP,o,z 1,6idm -fefxr, $QOcl Y- lf~A:L l /Iu4syj
USE DATES OBSERVATIONS MADE
~~yy~~ NO. BEDRMS.: COMMER IAL DESCRIPTION: I PROFILE DESCRIPTIO A TS:
a1JResidence V NV 'New ❑Replace FE$ rc /7?/ f e e /6 /7C~ ! /
RATING: S= Site suitable for system U- Site unsuitable for system -PRESSUR r ONVENTIONALU ors : M~UjVS. 0 U IN G®s ~u E: SYSTEM-INQUL DS G TANK: RECOMMENDED
COwV S fOUx1(l. do alb)
If Percolation Tests are NOT requ ired DESIGN e RATE: / If any portion of the tested area is in the /v
under s. ILHR 83.09(5)(b), indicate: Ct ~tS~ Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
Qz:C ;-r
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTI-ItV. ELEVATION OBSERVED EST. H T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 11.17 110.73 ~ON 11.17 54' ,•80c Z4" G6 Cw 49`<A 60
e- Z 10. CIC> 107.4 o m > Io' oa Ce a «Trs 3,,z L -z siG b 6m &u csIG
B- q .L-7 Ion 4 / ►Not4 9 6-7 ge" the -Ke 56"ate ~,~G ~c b
B- 4 11.-1 ~ /OZ-S3 /NONE > 1 ~S L z " Ms Cs~ 30" CSdCaPCab~ati 7~ $Q.,►+~
B- 'i I, NO At ~wOKA. ~t~SYG~P ~~~~f44N IIIS /,3wt34.,.a4(-e ~BR ~F~ SA 4N~Sc~R
;tea
TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER L V L-IN HES RAPER INCH ES
NUMBER FWS AFTER SWELLING INTERVAL-MIN. P Rt D t P Rt D PERIOD 3- P_ -Z.7o 4 U-7 /01.76 3 > a2 <
P_ ~ - Go f10-2-LO 3 >Z
P- 3 ~o X05.40 3 > 2 7Z > 2
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.
i
6T1
Y
« A3~ v n ! A~TE~N~?~ ~ ~
DF~
a
• (OS =
i
2 Lucv~rc
1, 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,
iNAME (print): TESTS WERE COMPLETED ON:
ADDRESS CERTIFICATION NUMBER: PHONE NU BER(optional):
,407 co &)t S 1-1 ubsd N I 54 r 3 M6_
CST SI ATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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