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FOT~" STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP t
SECTION T N-R . I u3 ` c -C>0y
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Elevation and description: Z ~~L.~+ S~ LeT'~o~p EI = (00.00'
Alternate benchmark--0 P ~ ~ock Fem. gr't; . o'r) _
T
SEPTIC TANK: Manufacturer: Liquid Cap.
Rings used:j -Manhole cover elev: ~.1Z Final grade elev: S,Co
Tank inlet elev.: q. !:~,_l Tank outlet elev.: ct,
No. of feet from nearest road : Front , Side X , Rear Ft .4 3 Z,
From nearest prop. line:Front , Side X , Rear Ft. -70~
No. of feet from: Well a5-" Building: Zoe
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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PUMP CHAMBER
Manufacturer: A/A Liquid Capacity:
r
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 : - g Trench : Seepage Pit:--
Width: Length gG' Number of Lines: Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side
Rear Ft .q-v
No. feet from well: '?-I' No. feet from building Z7
HOLDING TANK
Manufacturer: A A 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:
INSPECTOR:
DATE : PLUMBER ON JOB:-
LICENSE ,
NUMBER: ""j
6/90:cj
i t
PEPAFiTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
ISON Y/VI 53707 State Plan I.D. Number:
I'M P NE 4, Sec 16, T29-R19
,CONVENTIONAL El ALTERATIVE (II..igned)
Town of Hudson, Lot
Dald Holding Tank ❑ In-Ground Pressure ❑ Mound
Lanp
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
BENCH MARK (Permanen reference point) DESCRIBE IF Mfftl#ENi~%Z PLA : REF. PT. CST REF. PT. E
Ql~
n r- c ~ ~ pia u c1,b = >63 121' 3. «r iaq, 0
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
SEPTIC ANK/HQUXUGJJWK '7.,3 ar M~ r = . 0&' p'
MANUFACTURER: LIQUID CAPACITY: TANK INLET TANK 0ET ELEV.: WARNING LABEL LOCKING COVER
PRO IDED: PROVIDED:
$ Gj~r 2 5. / ~¢dJ~JC~t. 7.17 9 71 9e, YES ❑ NO ❑ YES NOS
t/ BEDDING: VMT DIA.: yW MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY' I WELL: BUILDING: VENT TO FRESH
r. ALARM: FEET FROM LINE: / AIR INLET:
t
S T YES ❑ NO ❑ YES NO NEAREST---► '70 E.
OSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN %FjT FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO N! T
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: ri cm e. J, = G, 1G
WIDTH: LEN NO. O DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
DEPTH:
BED/TRENCH
DIMENSIONS TRENCHES: MA ERIAL IT
DIMENSIONS f 7
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE MA ERIAL: NO. D STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET ELEV. END: / 4,,- ^ ~ 4!p PIPES: FEET FROM LINE: r , / AIR INLET:
1 EJ// 7 n G c~C NEAREST 00- 70 C~ s
MOUND SYSTE
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 OVER TRENCH/BED DEPTH OVER TRENER76E5__] DEPTHS OF TOP SODDED: SEEDED: 7MU ED :
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DE ELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DI E DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
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
etain in county file for audit.
Sketch System on
Reverse Side. gSURF: TITLE:
SBD-6710 (R. 06/88)
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SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUr
STATE SANITARY PER T #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 1 1 inches in size. Ch ZRI ion to previous 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
T IBLOCK N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # #
CITY, STA E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
[.l1Z S VW Z7 S a r
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAREST ROAD
=W OF: tt O 4-K
❑ Public 1 or 2 Fam. Dwelling~# of bedrooms R L AX NU ER( )
111. BUILDING USE: (If building type is public, check all that apply) z
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 9 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
• -o 61-5- el Y 8 7 Z L -3 ga.4W Feet 99- ~/d 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 Holdin Tank !O 00 ~-~JQ le✓
Lift Pump Tank/Si hon Chamber .-Z+- VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
S 4-1P- 51 z _7 3 Z
PI be 's dress (Str t, i , State, ip Code):
IX. OUNTY/ EPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signature (No Sta PS)
Surcharge Fee) f
,4Approved ❑ Owner Given Initial e"
a
Adverse Determination
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
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 Saritary 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, 6138-266-3815.
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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. Building use. It 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 kind/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.
Vlll. 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 fur monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
f
4
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I
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/conttactot,(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 Sae. iLt%l/ds~"
T -R / Y
Location of property &-Y)-1/4 1~-1/4, Section /4
Township „9Le d"
Mailing address
% n r, W Z 'S qQ
_4i" j Address of site K
Subdivision name :Hl-r k m,0.
Lot number
Previous owner of property IJ.~m,,
Total size of parcel -Z: !P Ae o✓-j
Date parcel was created `I- Y-Ib$
Ara all cornets and lot lines identifiable? _Yes __J10
is this property being developed lot resale (spec house)?~,_Yes __No
Yoltls:a 9040ind Page Number SB77- as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION T11E FOLLOWING:
A WARRANTY DIED which includes a DOCUMSHT NUMBER, VOLUME AND PACE 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 Ceitilied Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(Me) cattily that all statements on this form are true to the best of my (out)
knowledge; that t (we) am (are) the owner(s) of the property described In
this Information form, by virtue of a warranty dead recorded In the Office of
the County Register of Deeds as Document No. 413 SYtI&/• 1 and that I (Yel
presently own the proposed site for the sewage disposal system (at i (we) have
obtained an easement, to tun with the above described property, lot the
construction of said system, and the same has been duly recorded In the office
of the County Register of Deeds, as Document No. 4,03 sy VV
SI9nature of Owner Signature of Co-Owner (If Applicable)
~
Date of Signature Date of Signature
- T C rq1
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Quarter of Section 16a Nortl+
lotraebip 29
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Meet+*St:"Cze"'Camttpe - plaoomesa zzczpr Lots i throve 4.' lmdmelve O
~filed J11147 439 1984 "!a Vol. 05"e PaM 14479 Doc. No. -'I15024
eat to the C•alarWA m 'o! tlotoctiw'Cowaaato dated tebrmry 15."all85;t loo
t4 o!ltoe:O! the.8e81etel of Deese an Eebnww la. 1985 la Vol. 706
No. 39!800. Un
f eat to cos eulusiw eaeemeate o! record for ' use of the toot road heal
x)70! the 66 above maatimed Certified 8umy Maps
R to ~tM ` ft tltlca Fee" 'fit betwen the State of Viscon eim
of 8~da~al`Deeousoee amd Mea " hera dated September 159 1979, recorded
28,'197! Lt'~o1. "601"e pap 639; Doc• Nos 360128 for the mautemamce o!:
! t~;,SY k of u k Of Sectloa 9-29.19 amd NM As of Ni k of
it , M1~ 'r 4
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litsnalno(a) STATIC OF 1PItil70NSIN
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, "UmeL by
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weeMd "n q,.jo K aekeowtsdtpttl. !loth Hp COmmi+tdmt in
es<piratlen
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STAT19 aAtt OM wlXCO*MN
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County 'J
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OWNER/BUYER
o:
xt-
ROUTE /BOX NUMBE Fire Number
d
CITY/ STATE ZIP ! yo %G
sow t~~ _ r
M
PROPERTY LOCATION: Section 11A T_2:~f_N, R_
Town ofSt. Croix County,
Subdivision Lot number /
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed 'se tic tank um er. What you put into
the system can affect the function-of t e 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,
whit 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'inew 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
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, asset by the Wisconsin Depart- w
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE 9
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
INDUSTRY, DIVISION
-LABO WAN HUMAN REDLATIONS PERCOLATION TESTS (115) MADP.O.ISONBOX
WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/MtfA1+C-FP~ctifi?': OT NO.:BLK_ NO.: SL~(VISIOQ
AME:
r4 J/4 N /T29 N/R /°I E (o W Aso - 1"A~ K ,
oy ~bb
COUNTY: MAILING AD RESS:
-ST C~ I x 'LAM 141 L LEA.
I ~pVT oK 1,
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: My~ 71TUrTa DESCRIPTION A I TESTS:
;4R 2 New ❑Replace
U +~.1'L ~vL.Y I7, ! 9 g D 7L,r...y /e'.2796
RATING: S= Site suitable for system U= Site unsuitable for system k~ y S t $ S Q
COCCoENTIpaNAL:MOUND: IN-GROUND []U RE: SYSTEM-INO-FILLHO0LDING TANK: RECQQMMND~~T,~a(optt~l
IS XS
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: CLdSS ( Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH-4, ELEVATION OBSERVED S I HE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- I 16 `iz to /\in NJ jr > 8,9~ 21 ""8LL Zo" L r~"2b$eNAe>'l6,0 4'k"$f? M!' 4e f,
B- 9.0% 9 0~ t46E Zo'90-SL ro"2a$QN~►SdC,~ 64'~~N 111SY4,e
B- 'j.9Z l0/.0% 4 L- > $.g~ Z9 g~c1s Zz''BfetiSIC.t3°tQa$a M~~EG~ 3 R M~tG,~
B 9,7~ X03 Z6 JJoNkC > 9 r3"ec STS t " a L "BRNGe~ S ~Z✓e,~N Ir'c,,~
B- $ .'A p . z dofvl~ s 8 i r" 8LcTS , z" &~JL v►rs U
LB-__ PERCOLATION TESTS
TEST D~F T~H WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
UMBER IIVbiES AFTERS WELLING INTERVAL-MIN. PERIOD 1 P RI D2 PERIOD PER INCH
P_ r 5776 Nth la~7t) Z ~.S
P. 3 . r o ..Qj 99.10 Z > '2 > < 3
P-
P ~~Jd \ IAN ;Q
-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 ~b o0
S _ . qZl _ z
Al LoT Scb~e tN
i . S r 8-3 s4'
\ I
- - 7o Q~n~11 M rtQK. ~ Pa c.
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord wit 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 k wledge and belief,
NAME (print): TESTS WERE COMPLETED ON:
3oWN50N JauNsc ,`>u d %rh, t ~UILy /g tg90
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
4o-7 ScU>N~ flsoil" ar 38~- ~o€Q
CST SI TURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R, 10/83) - OVER -
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