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HomeMy WebLinkAbout032-1007-70-100 ti M 0 w erj C C C ! M O) p O N ~ L o I •3 ~ o i E v F- 0 4) 41 E o co c 0. I m m 6 3 A? Z Q c LL C E N 3 ~ T U) L 01 I Q S U.- I V y M I I Z W o, w 0 O z d I a~am i O z w~~II 4' a~ 5 E ~w N O CD 0 WJ C N N y y 4) r- C 4~O 0 0 0 CIJ •I~ d O V •U o0 O N Q w O _N Z oo z Z Z o M l0 O L> co }y d U') a w o 3 Z ~n > ' 0) FN- Iy- H o 3 3 3 a LL • 4i I E a a a a 2 CD 7 N m' U y rn rn } LO co "Oft-) Q N~ 0 0 C) 0 0 C O O 'a a E N N N = = O m C (L ! 04 N N O N W ! LO (V LO N Q U> O O Z' Vl V! O O O 30 r2 H C O C C E v CO U ' H T N C 7 0) C, V N d m O O C O A12 p r co r- O O c 7 N Q1 C N N M E III Y F w 7~~ •O o o in !'I ~C ~ o Z~E E t g in 4j r: V] a w ca a C • d d ~~~w C C a+ FORM - STC - 104 y AS BUILT SANITARY SYSTEM REPORT OWNER ~4c:z::, TOWNSHIP ~~-I- SECTION 3 T~N-RW ADDRESS ~ ST. CROIX COUNTY, WISCONSIN S^ y~ S<i SUBDIVISION LOT Z' LOT SIZE__ _ QGcea/ PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM . fie' rarf 0 ;z q INDICATE NORTH ARROW BENCHMARK:Elevation an~esLrip . n: i ~9d• O y~ Alternate benchmark" -*2404 SEPTIC TANK:Manufacturer: c, k,- Liquid Cap. / axz Rings used:,ILManhole cover elev: 7. inal grade elev: 97.,o Tank inlet elev.: 3 .,;LL/ Tank outlet elev.: 9',. JPV No. of feet from nearest road:Front , Side_Z', Rear Ft.- COD From nearest prop. line:Front Side , Rear Ft. > O&W" No. of feet from: Well _iiow- , Building: 19 f ---,get (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: 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: ✓ Trench: Seepage Pit: Width: / Z Length G y Number of Lines: _Area Built ;7 ylg Exist. Grade Elev. 97.5- Proposed Final Grade Elev. 5'S-.g 5"' Fill depth to top of pipe: y No. feet from nearest prop. line:Front , Side , Rear Ft.2/04 Weft No. feet from well: No. feet from building 3o St HOLDING TANK 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: Well , building , nearest road Alarm Manufacturer: 10 INSPECTOR: DATE:- zap & PLUMBER ON JOB: J LICENSE NUMBER: 6/90:cj A 91 oo i >&iscorsir4, Department of Industry, PRIVATE SEWAGE SYSTEM County: • Labor and Human Relations Safety and Buildings Division INSPECTION REPORT St. Croix - SW,SE,3,31,19W (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Lot - #2 232nd Ave. 149148 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Marty & Mary Link Somerset CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: A, 6 ' 032-1007-70100 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ' 6016 i Septic k_)2t Come . P,jjc/ a27d 04. Benchmark O 66 o z~YO' / 00, ;L ('0, Aeration Bldg. Sewer Holding St/1g Inlet 7, D~ Z~, TANK SETBACK INFORMATION St/ F}t► Outlet 0244 S/ •97 Verit TANK TO P / L WELL BLDG_ Airl to ntake ROAD Dt Inlet Septic NA Dt Bottom D NA Header / Man. 102,0' • 9,3, 0/ ' Aeration NA Dist. Pipe 102. ZVI, 79 v?• ~ Holding Bot. System go?, 1.2 PUMP/ SIPHON INFORMATION Final Grade oz,9 7 (1 ' Manufactur Demand T~ 7oz,r.G' 98• Model Number GPM TDH Lift Friction System TDH Ft Forcemai n Length Dia. hi Dist. To well J-1 I SOIL ABSORPTION SYSTEM BED /TtENIGIR Width / Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS aZ 6o~/ EN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O or{ V. Model System: (y0 -E oZ ~Sb OR UNIT DISTRIBUTION SYSTEM Header/Manifold „ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length (.0' Dia. Length _f_ Dia. Spacing ~D SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 14 C) 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 p_reejent, etc.) a S. c vr1~ . Slo r EC . 10,26 ~ , iCi. r✓1. /o,• I . )LU be j use % Plan revision required? ❑ Yes E~ p a 9~ S-~ Use other side for additional information. / 2o 2 -1, SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. la - R DILHR SANITARY PERMIT APPLICATION COUNT In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ `t' 8% x 11 inches in size. eck 1 re sl n tc previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY WNER PROPERTY LOCATION % '/4, S 3 TN, R 9 E (or PROPER OWNE 'S MAI G ADDRESS LOT # BLOCK # 2 L ~t r c 1= w Q CITY, STATE ZIP CODE P ONE NUMBER SUBDIVISION NAME OR CSM NUMBER 7 d II. TYPE OF BUILDING: Check one CITY NEAREST ROAD I~ ( ) State Owned O ILLAGE : ~ . _e z -7 2~ ❑ Public I~ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL X NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 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. EN New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E] 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 ySD 4 Feet Feet VII. TANK CAPACITY Site INFORMATION in allons Total #of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank (s ~ - 4a' & 7 ::R I . M F 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. Plu er's Name (Print): Plum s Signature MPfMPRSW No.: Business Phone Number: y 17 P umber's Addr (Street, Ci , State, ip Code): O~ Z:" 41.,,41 Zoof I OUN /DE A TMENT S ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue king Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASON$ FOR DISAPPROVAL: SBD-6398 (formerly Plb$7) (R. 11/88) 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. ---------------------------,-~----------/---I----,-,-/---------------------------------- Owner of property Location of property 1/4 s " 1/4, Section 3 , T 3 1 N-R_t q_W Township S Mailing address S 2Z P/ G~~LC~ ~I d GUl,~'Jb Z( ?s li"CI 19M Address of site Subdivision name ~~11 Lot number LU 7- S 41 ~~C 7l (~q Z C ~o 01 Previous owner of property ~ZG lGf SC'y( Dom' Total size of parcel ~y Date parcel was created `y d 2 Z 9 Are all corners and lot lines identifiable? _J(-Yes No Is Is this property being developed for resale (spec house)? Yes 1~ No a6- y% Volume ~nd Page Number j--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. `/762660 • ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Regist of Deeds, as Document No. Signature o Owner Signature of Co-Owner (If Applicable) Date of Signature Date o i nat re DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 14, STATE BAR OF WISCONSIN FORM 2 - 1982 pow 472600 L 9 12PAGE2M REGISTER'S OFFICE ST. CROIX CO., WI David M Helget and Debra L Helget husband and wife Recd for Record as joint tenants AUG1 61991 Gt 11:30 A. M conveys and warrants to Marti n 1 I i nk and Marv F_ I i nk q~~ f/ a'..A hughand and wife as tiirvivnrchin marit41 prnpPrty Register of Deeds RETURN TO Century 21 Somerset Box 416 the following described real estate in St. Croix County, Somerset, Wi- 502S State of Wisconsin: Tax Parcel No: Part of the SW 1/4 of SE 1/4 of Section 3, Township 31 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 2 of Certified Survey Map filed September 27, 1989 in Vol. 118", Page 2156, Doc. No. 451894. TOGETHER WITH and SUBJECT TO a 66 foot private roadway as shown on said Certified Survey Map. T SS h FEB This is not homestead property. (0y (is not) Exception to warranties: Recorded easements and rights of way -1991 Da is day of July (SEAL) (SEAL) • David M. Hplgpt (SEAL) (SEAL) f * Debra L. Hey,t AUTHENTICATION ACKNOWLEDGEMENT Signature(s) STATE OF WISCONSIN ss. St Croix County. Personally came before me this 31 day of authenticated this day of ,19 July ,19.1.-the above named David M Helget and Debra L. Helget. husband and wife * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person S who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY e * Gary H Baillargeon Gary H. Bai l l argeon Notary Public St Croix County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: - _„may H, BAR I -18 ,19 94 *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN WISCONSIN REALTORS@ ASSOCIATION FORM No. 2 - 1982 4801 Hayes Road, Madison, Wisconsin 53704 STC - 105 H SEPTIC TANK MAINTENANCE AGREEMENT ~ St. Croix County ? ~Gf9~ ~~GrilL OWNER/ BUYER 0 ROUTE/BOX NUMBER 5'222- Fire Number :3 ~11 t7 CITY/ STATE , OV~4 ZIP rt m PROPERTY LOCATION:'.'~546-" S~Z Section , T 3 IN, R I q W, Town of 5 6At&a f T St. Croix County, Subdivision Lot number _Z 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 licensed septic tank um er. What you put into the system can affect the Function o 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 60% 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 systems 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. H 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 b and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INGUSTRV, 1 c DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/tTTY: LOT NO.:BLK. NO.: SUBDIVISION NAME: SW 1/4 SE 1/4 3 /T 31 N/R 19 E Somerset MIX xxxxxxxx COUNTY: /BUYER'S NAME: MAILING ADDRESS: St. Croix Mart tr Ma Link 22 Pierce, Elmwood. wi 5474o USE _ DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: ®Residence ®New ❑Replace 1-3n-Q1 3 xxxxxxxx X-C 6-29-91 r RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN_ -GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ©S❑U 0S DU C~J S❑U ®S DU 9SOU 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 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 104 96.0 none 104 1.3'Blsl 1 'Bns 1 1'Rd 'B m B- 2 74 95.8 none 74 .9'Blsl 2'Bnsil 3.3'Bnms. B- 3 96 96.8 none 96 ' ' B- 4 104 97.5 none 104 .7'Blal 1I_A'RnjYsj1 I'Rdls 5_2'Rnms. B- 5 84 97.1 none 84 -7'Rkln ' 11-81TIMMot- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- 1 48 none 3 .5 P- P- 58 none 3 than 6 n 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 hor - 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 perce t of land slope. SYSTE .M ELEVATION 92 m .0' 232nd. Ave. m; E e E , E 301 kale 1" 40' - _BM; base of "ttee,, top-of r X X _ nail assu*e 10010.. ~x boring. 2% cty 8* _basswood _t>ree.. Hy 7 I 11 . Q.16L;$ _ 2 r Staked _but1 . Not'. Certified survey snap house H , attached. 4 Borings staked to facilat:ate y~ locatin ~8~- 2 71 3 E E 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. NAME (print): DAVE FOGERTY PLUMBING TESTS WERE COMPLETED ON: Licensed Perk Tester & Plumber ADDRESS: pass ruav CERTIFICATION NUMBER: PHONE NUMBER (optional): Fogerty Heights Road PARISCONSIN 5Q93 Phone 749-3656 CST SI ATURE~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - .CERTIFIED SURVEY MAP Located in part of the SW4 of the SE4 of Section 3, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. 0 N s ° 4wj N} Corner of o Section 3 SCALE IN FEET N b 1" Iron Pipe Found _ 0 100 200 300 o CO ~0 . 1 U 0 c W N v N L O~ w o w 0 ^ C- W 0 0 Unplatted Lands c a. z b ° Centerline of Town Road 3 0 _ C3 N89009'16"E 638.16' 232nd AVENUE 41 t- 605.29' _ N O I M I Cn M C o Ol .,J ~ >1 U I W1 Ln N N N . .01 1 4 ICJ kO 01 Z1 1 O Ln b 17 `1 CI1 x ' ° LOT 2 d•. I N 1' W U~ N v I _0,1 01 't o (0 Area Including R/W: ~ > 421,985 Sq. Ft. 0 0 >a 9.69 Acres o 1 1 1 L I o f ti N QI 0 w l ~ 1 O Area Excluding R/W: o 0 %10 380,308 Sq. Ft. U 2 1o 8.73 Acres L 33' 33 - ~ - 33.02' 608.05' --j S890361 39"w 641.07' cc"~~'`r!~' Unplatted Lands A N C OWNER o - t i-.G Harold Schachtner ° 568 232nd Street o LEGEND 9 f UDSON. Somerset, WI 54025 Wis. Found Section Corner <q,`+.,,M,~,..~••''.1' • 1" Iron Pipe Found O 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per Isk Corner of linear foot. Section 3 Aluminum Cap in Concrete Found C~j Ale? This instrument drafted by Fran Bleskacek Ire No. 86-15-189 ~D . 03 - 1007- 707 100 h -}I Ci I` 'n M - M T O S I po V K J14 4t h Z~ N o o 3 v►~z,~ o- ~s \ o 00 _ M N r J~ L ~ZM C LM ~Co o tfi W c co • • Y J N N~ e O d dC'S ~y~uiQ ` LL. L co ~ i I' I I ,i 3 • A j d • t ~ Y . C9MMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 C3 ~6,~ 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.: 31231/01 PAGE i ST. CROIX COUNTY REPORT DATE: 10/23/92 COURTHOUSE DATE RECEIVED: 10/21/92 HUDSON, WI 54016 ATTN: THOMAS C. NELSON OWNER: Martin Link LOCATION: 565 232nd Ave., Somerset COLLECTOR: J. Thompson DATE COLLECTED: 10-20-92 TIME COLLECTED. 2:34pm SOURCE OF SAMPLE: Outside Tap DATE ANALYZED: 10-21-92 TIME ANALYZED:2:00pm COLIFORM: 0 /100 ml INTERPRETATION: Bacteriologically SAFE NITRATE-N: 5 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. CoLiform Bacteria/100 mL Nitrate-Nitrogen, mg/L ~ 9 1p l , G~ GZ 90 LAB TECHNICIAN: Pam Gane - WI Approved Lab No. 19 ` t Means "LESS THAN" Detectable Level Approved by: ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse ~a 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion SLf this for-,m I& gssentjal, &Q that t ha property pAn D& located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received., WATER TESTING----------------- -------FEE: $ 35.00 (For nitrates and coliform bacteria) WATER TESTING FEE: $185.00 (For VOC'S) SEPTIC SYSTEM INSPECTION FEE:. $25.00 (Determines if system is properly functioning at.time of inspection) rr ' PROPERTY OWNER'S NAME: ctk+(r1 PROP. ADDRESS: X65 ~23QIOO14U CITY Legal Description 1/4 of the 1/4 of Section A T_at_N-R/ Town of ~or►.,,~c~-"1~ Lot Number o2 Subdivision: FIRE ER Gar 5 csm~jdgob 3 Z - l vv -7 LOCK BOX - 7~ - l0&``f 711 Color of house ealty sign by house? by house? /JOIf so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A NAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER .TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone Number REPORT TO BE SENT TO: oZ U + t.1 CLOSING DATE: Signature