Loading...
HomeMy WebLinkAbout020-1188-20-000 ~ III O 3: C Q O1 O O C :E O O N O II i 7 Gy F+ II N I O O C Z L 6 LL O O a 3 Cl) v N Z y Lll E Z O Z N V co FN- (n d m C O O z c V ~ ~ p w m H N z C -O III O N Cl) N N N ~1 C ~ O CL N ~ y N ~ c • 1~) (n L O Q O = Z co z w v, z E N - ~~l m C N "C V N - N w E • 0 ty0 w ~C C - N 2 ~ ~ O m caCL - U) U) (a E U iA I o o •N aa0a z a c fn J U v rn rn N r } CV N N O o N O a i?s o N O O "O i~ 'o N N m N d a } c5 o ml N 0 a n 72 co N C E p O 04 LO Cl) o 3 0) r°n v a o °o rn CO E N v f0 e- N C M N N 70 O N C N • N co 7 yCl) O C E t6 U O O N 2 O 'O z N V - dat c €a • ` a am.~ md' `1V E ` E rr~~ `~1 A vaM 0U)0 t " Parcel 020-1188-20-000 02/10/2005 10:03 AM PAGE 1 OF 1 Alt. Parcel 28.29.19.1179 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * EUGENE W & JUANITA B GEISZ GEISZ, EUGENE W & JUANITA B 786 HARLAR CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 786 HARLAR CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.013 Plat: 0153-CEDAR HILLS ESTATES III SEC 28 T29N R19W NE 1/4 LOT 51 CEDAR Block/Condo Bldg: LOT 51 HILLS ESTATES III 2.013ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1213/482 WD 07/23/1997 808/564 2004 SUMMARY Bill Fair Market Value: Assessed with: 49219 386,900 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.013 40,100 259,200 299,300 NO Totals for 2004: General Property 2.013 40,100 259,200 299,300 Woodland 0.000 0 0 Totals for 2003: General Property 2.013 40,100 259,200 299,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 158 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 • Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. TN-RZW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION C-t tL,:~ r', 'ts LOT LOT SIZE c ~Vc. PLAN VIEW D ~ 1 1 ~ ZO ~Q~~ I Distances and dimensions to meet requirements of II-HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i A's tj 'n 1 1~'a 11 r 41 r thc' x f4~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used. Elevation of vertical reference point: Proposed slope at site: -j%e SEPTIC TANK: Manufacturer:/ Liquid Capacity: G t,~-' Number of rings used: C Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road.: Front,O Side„ Rear, O feet . • From nearest property line . Front.0Side 10 Rear, 0 2e, feet Number of feet from: well c-! ~4uilding:.(Include this information of the above plot plan)( 2 reference dimensions to septic tank) l PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: " Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, 0 Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width:_ j2 Lengkh: S- 2 Number of Lines: Area Built: G' C Fill depth to top of pipe: i /-2,1 Number of feet from nearest property line: Front, O Side, O Rear,© Ft. r Number of feet from well: s Number of feet from building:i (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorb tion s terns? Check one Y (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job:,/,.,..- License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 p State Plan I.D. Number: St'~,,NE',, Sec.28,T29-R19 L (If assigned) Town of Hudson Zin NVENTIONAL ❑ ALTERATIVE ❑ HolTank ❑ In-Ground Pressure ❑ Mound 5 0 NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION D ME: S On _,t Rt. Huci , WI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT LE1L ST REF. PT. ELEV.: - 76~ , 0 ~ Gv . b Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: ~T.4. Schumaker 6382 St. Croix 135433 SEPTIC TANK/odgilloMS MANUFACTURER: LIQUID CAPACITY: TANK INLET l5kfV.# TANK OUTL ELEV,~ FINING LABEL LOCKING COVER OVIDED. PROVIDED: 94 ~ ~ YES ❑ NO RtE2$7E0 NUMBER OF ROAD: PROPERTY WELL'/;1 BUILDING: VENT TO FRESH BEDDING: VENT DIA.: VENT MAT L.: HIGH WATE I - ' ~ : ALARM: FEET FROM i LINE UJ AIR 4249, ❑ YES NO NEAREST ~ 75 MANUFACTURER: BEDDING: LIQUID CAPACITY: JPUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑ YES ❑ NO ~ I ~ ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: UMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF P ❑ YES ❑ NO NEAREST 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: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS ' Q/ GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: 1,40. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH LINE: ,,tAA r AIR INLET: BELOW PIPES: ABOVE COV ELEV~ ELEV. PIPES: FROM .a 9 I~i3 3rI3 mrr- She. CFO IFEET NEAREST ^','J rlr ~.;5 (/S. • MOUND SYSTEM: 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 TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO [__1 YES ❑ NO El YES E__1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER BED/TRENCH : TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL] NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: 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-411- x too Q S.T. ,en~ae~P -of F Pt &rQ.ef t,. a+ Q. Ccr dV+ LJ. -6 de (a.614A4. Sew~'~ 96.17. (D uj, 00 r. Maz y d ~u c~ e%do a .•►~a. y°*Ift Ex,;,., o~ /1 c cry = 950. 9~GU' ~,>rra, n ~v'n •~1~yc o Ir o,F~S P'PSSketch System on Retain in county file for audit. Reverse Side. TITLE: 112-2. SBD-6710 (R. 06/88) ~]Z~ DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COU/NTY v "Y .3 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 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. PROPERTY OWNER PROPERTY LOCATION T S r T' , N, R/ E (or f t A --e (2 9 6'42 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE G^ S~~ jo =N ❑ Public 91 or 2 Fam. Dwelling-# of bedrooms PARCEL T U R III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo- 20 Assembly Hall 60 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. ® 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 1_/' ~a :/S- 4__; ell Feet 1?. Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Hoidin Tank C 10, El El El Lift Pump Tank/Si hon Chamber El 1 0 1 R41~ 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) AMP MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTYIDEPARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) _ Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for tw.o (?).,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 ;he erFnit issuing aythority. ...er 4. Changes in ownership or plumber Fequ resygSgnit*!yPermit Transfer/Renewal Form (SBD 6399)to be; submitted to the county prior to installation. . 5-. Onsite sewage systems must be-properiy. maintained. The septic tank(s) must be pu" ed. by: -ticserrssd pumper whenever necessary, usually every 2 to 3 years. 6. If-you-have questions, concerning:your onsite sewage system, cortlact,your local code administrator orthe- State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanita wd., ry Permit apPNcyition must Include; , I. Property owner's natne andmailing address. Provide he legal description and parcel tax number(s) of y. where the system is to be installed. r° 1tf x - It. Type of building being served. Check only one and-."plete # of bedrooms if 1 or 2 Family Dwelling y, 111. Buildi,ng,use. If building type is Public, check ail appropriate boxes-that apply. IV. ,Type=of permit: Check only one in line A. 6pa>ptete,jhM B if-permit is for tank replacement, rexanne , or repair... _V. Type otsystem. Check appropriate box depending on system type: Vt.` Absorption system' information. Provide all inldrrW[ n'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. Vill. Responsibility statement. Installmg 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 plaits and specifications not smaller than 8% x 11 inches-Must be submitted to the county: he` plans must include the following: A) plot plan, drawn to scale or witWl d6mplete dimensions, location off` holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/wi et'senvi streams and lakes; pump or siphon-tanks; distribution boxes-soifabsorption systems; replacement tem 4reas; and the location of the building served; B) horizontal and vertical etedati'bn reference gotrAs;" -C) cdMplete specifications for pumps and *mtrolsi;dose volume; ele;+ation 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. GROUNDWATERAURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which cab effect groundwater. The monies collected,.through these surcharges are used for monitoring groundwater, ground- water contamination (Investigations and establishment of standards. - , SBD-8398,11/88) 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 property1/9 X1/4, Section a , T 22N-R lp W Township Mailing address /yeti dsr• w S~`/~ / Address of site Subdivision name 6tcl b- /ls' 4 5 Lot number 15--/ Previous owner of property Total size of parcel f 6- VR Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes ~4 No 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, 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. ; 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 Register of Deeds, as Document No. Z' x Si ature of Owner Signature A Co-Owner (If Applicable) 19U Date'of S gnature Date o Signat re G t:i f STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER rc~». p 5 J se0 l ROUTE/BOX NUMBER VZ ~ ~ sa_ ✓ f h'D c C FIRE NO. CITY/STATE u. dSi~N 1~ ZIP ; r /G PROPERTY LOCATION: S ~ 1/4 X 1/4, Section T g 2N, R_Zy W, Town of St. Croix County, Subdivision Lot No. 157 . 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 for a MAXIMUM of $3000 of the cost of 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 systems properly maintained. The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE Z St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 425-8363 Sign, Date, and Return to above address INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRYY, , DIVISION LABOR AND P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.09(1) & Chapter 145) TOWNSHIP/ TY: T NO. BLK NO.: SXBDI i NAME: L vJ 1/4 NE 1/4 'n /TZ9 N/RIq gu&sd v Sr' C.&44 ILLS EV Ttf COUNTY- MAILING S~C~2olx plf_t, aIQw1:~~ CLi•N uL-4, s t 540/ USE X New OBSERVATIONS MADE Q foResidence LA Nz_ Ia.INew ❑Replace ma t••o 7Z 794: uR a El l la cT RATING: S- Site suitable for system U- Site unsuitable la for fo► SO/L5 Bx V system ibY ( DED O S ~U : IMOUIR: QU IN S DU L1J S • N•FI L O[LDING TANK: RECOfuj OYV V ST 614 t4Lionaq If Percolation Tests are NOT re ired DESI N RATE: ~ If any portion of the tested area is in the under s. ILHR 83.09(5)(b), Indicate: WS-e- Floodplain, Indicate Floodplain elevation: jJ PROFILE DESCRIPTIONS BORING -TUFA-L ELEVATION QECIU 12 Q 01-11 R•INCHES CHARACTER IL WITH THICKNESS. COLOR. TEXTURE. AN DEPTH NUMBER DEPIHZlI• TO BEDROCK- IF OBSERVED SEE ABBRV. ON BACK.) -OBSERVED ESTi B- ► z 1)4.0+ >9.z< , "$r_c.Ts2~'$aN+'hs il'' c. ray 5$"tt3aNrtS B• Z 9.%3 96.43 N y 9 ~3 a'BccTS 1Z" aN ~8r$aNCS,I re 6g+ QNM-s B. 3 9.7~ 96..0C No 7 9.75 l "&a /1"84.1 L I NS4 -z4 Q,, 1' B- 4 ,~3 93.74 t4 > 9.r63 /6"1kLC•rs "e <,4- /z"' tSd4~32~$i2NCS40" A15 B- S 9.33 943o > 3 L7S z6'" S,C.~FGtz 14'%QNCId&t '9C ROM 60 B- PERCOLATION TESTS TEST DEPTH WATER INHOLE TEST TIME RA MMUTES NUMBER l&AQMS' AFTER SWELLING INTERVAL-MIN. PER INCH P. i ,QO 04•7.Z> > x > > P- ? s0 6 3 > Z >'Z ? c 3 P. 4,40 tjowe 94 o6 3 > • - > L. <3 P. P• F-LE44't14M A-r k'L P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sale 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 r I i 1 r R : - -1 ! 1- - ___S _ 1 N + r I , I~ N Li - -4- A* t I , • I 1 ~ i Ktr - 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord wi R1e pr d nd 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 go and belief. l t ` - 3 NAME print : T ST WERE COMPLETED ON: rd NBY , 14 SOS, AY C FeAR R Y 2- ADDRESS! X940 407 CERTIFICATION NUMBER: PHONE NUMBERloptional): N a /4u kaaN s 3 +W ~6U- 46Ya CST SI TUR DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. 1 wed y (s I- s T T~~ s ~~~s a ,y Sll S o? 8 Ta p ~!u d9o,~/ Grp, ` a T ~5-/ v J V1 3 0 ~ b L 3 5`