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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER f3 � 10,jl� TOWNSHIP SEC. T N-R W
ADDRESS I�/( a� ST. CROIX COUNTY, WISCONSIN
SUBDIVISION AI A LOT NA LOT SIZE ZZQ A CAO _S`
PLAN VIEW
Distances and dimensions to meet requirements of I•1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
AW
V
�J
i__r_i Q
19x'53 r
a
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04 'W rop
NO�.Ses r,U�L�
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used T ,9 f� /e400-QAa 94 9,4
Elevation of vertical reference point: &&714) Proposed slope at site:
SEPTIC TANK: Manufacturer: &J,6P K Liquid Capacity: 1!2,0 c>
{�
Number of rings used: Aldmg; Tank manhole cover elevation: ! a .,
Tank Inlet Elevation:
Tank Outlet Elevation: .L J
Number of feet from nearest Road: Front,W Side
,O Rear, O 33 '1 feet
From nearest- property line Front,OSide, Rear,O feet
Number of feet from: well _, building: f
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
nufacturer: Liquid Capacity:
" Pump Pump/Siphon Manufacturer: ump Size
Elevation of in Bottom of tank a ation:
Pump off switch elevatio G ons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest operty line: ont, O Side, O Rear,0 Ft.
Num of feet from well:
ber of feet from builu'n g:
(I ude distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: Len$th: `R Number of Lines: —3 Area Built:_ y
Fill depth to top of pipe: ��
Number of feet from nearest property lioe: Front, Side, O Rear,O Pt .
Number of feet from well: 946
Number of feet from building: _
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
quid depth: Bottom of seepage pit elevation:
Area t:
Has either a drop ox O or distribution box O been used on any the above soil
absorbtion sytems? (C ck one).
HOLDING TANK
Manufacturer: C city:
Number of rings used: E1 tion of bottom of tank:
Elevation of inlet:
Number of feet from n est property line: rout, O Side, O Rear, OFt.
umber of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector•
Dated: 11_ / Plumber on job:
License Number:
1
3/84:mj
512-PARTKN_tNT 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 State Plan I.D.Number:
SE 4;NE 4,Sec. 17 ,T 3 0-R19 (If assigned)
❑ CONVENTIONAL ❑ ALTERATIVE
Town Of Somerset ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
16 4h O IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N A E:
arb Cook R Somerset WI 54025 _3_ /p 0
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Donavin Schmitt 3205 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
i..7 PROVIDED: PROVIDED:
J
-0 6 t( ES ❑NO ❑YES NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM. FEET FROM INE, AIR INLET:
E:1 YES 0 C L F-1 YES '9 NO NEAREST---* 1113
to00 83 1
DOSING 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 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 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:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER PIT INSIDE DIA.: #PITS: LIQUID
TRENCHES: I MATERIAL:
DIMENSIONS hs 91>5 IA-0 I
GRAVEL DEPTH F DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV.I LET: ELEV.rEyN (� PIP S: LINE: AIR INLET:I FEET l\ .1. I d�
NEAREST�♦
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 ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
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 I ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
Z ❑YES ❑NO ❑YES ❑NO NEAREST -
v
Sketch System on Retain in county file for audit.
Reverse Side. SI ATURE: TITLE:
SBD-6710(R.06/88)
Zon�r3G m l/'ti s
+D�LHR SANITARY PERMIT APPLICATION cou
=
In accord with ILHR 83.05,Wis.Adm.Code
. t✓
STATE SANITARY PERMI #
—Attach complete plans(to the county copy only)for the system,on paper not less than // 3 5 `7
8%x 11 inches in size. ❑ Check if revts�to previous application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.
PROPERTY WNER PROPERTY LOCATION
60c)r 5,cF y4 E'/a,S T N, R If E(or)
2 Ma
PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK#
CI S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
NEAREST ROAD
10 .1 II. TYPE OF BUILDING: (Check one) ❑State Owned
CITY 1`f (/
❑ Public 1 or 2 Fam. Dwelling-#of bedrooms 7 PARCEL TAX NU BE )
III. BUILDING USE: (If building type is public,check all that apply) r�_ It 5- - Ll d
1 ❑ Apt/Condo
2 [] Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Service Cation/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 El Off ice/Factory
13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. N 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 El SpecifyType 41 [:1 HoldingTank
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. ELEVATION GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch)
Y5-0 9 Op ft, Feet Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks structed
Tanks Tanks
r
Septic Tank or Holden Tank P El
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Business Phone Number:
Plumber's Name(Print):
Plumbed gnature:(No Stam s) /MPRSW No.:
y 6 1
if
Plumber's Address(Street,City,State,Zip Code):
IX. COUNTY/DEPARTMEN USE ONLY Issu'n A ent Signature(No Stamps)
❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued 9 9
Surcharge Fee)
Approved ❑ Owner Given Initial // oa r
Adverse Determination `l'
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 Sanitary 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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. 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.
III. Building use. If 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 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 all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plLniber 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;
0 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 for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398(R.11/88)
7 69 413
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 j d"Iz'
Location of pro rty /9 �_1/4, Section _, T„�(LN-R W
Township
Mailing address 0 S'yroZS_
Address of site a t 5 '12'3^
Subdivision name
Lot number
Previous owner of property Q az.,-,� �
Total size of parcel /Z 0
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes *' No
Volume and Page Number S as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A VARRANTY 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
1(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
7 this information form, by virtue of a warranty deed recorded in the Office of
6!IK- the County Register of Deeds as Document No. 4V4 A j*,JV4r- ; and that I (We)
S� 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 t County Register of Deeds, as Document No. ) .
$ignature 'of Own Signature of Co-Owner (If Applicable)
Date of 3 gnature Date of Signature
�y
402885 ,VOL 714 PAGE 501
STATE OF WISCONSIN CIRCUIT COURT ST. CROIX COUNTY
------------------------------------------------------------------
i
In Re The Marriage Of:
I PORTION OF
GERALD JOHN COOK, JUDGMENT
Petitioner, AFFECTING TITLE
-and- TO REAL ESTATE
BARBARA JEAN COOK, Case No. 81 FA 63
Respondent.
------------------------------------------------------------------
The judgment of divorce entered in the above entitled action
on May 14 , 1985, contains the following provisions pertaining to
real property and secured interests in real property:
The real estate owned by the parties shall be divided between
the parties as follows:
A. To the petitioner, Gerald J. Cook:
1. The one-half interest of Barbara J. Cook in: The
South One-Half of the Southeast One-Quarter of the
IIr Northwest One-Quarter, and the North One-Half of the
Northeast One-Quarter of the Southwest One-Quarter,
Section Sixteen (16 ) , Township Thirty ( 30) North,
�•�Jf r Range Nineteen ( 19 ) West, in St. Croix County,
c`, JUN 12 IJ35 Wisconsin, containing 40 acres more or less.
2. The interest of Barbara Cook in: The South One-Half
�rciC�urts...•
s+.c=ca c r%W of the Southwest One-Quarter of the Northeast
One-Quarter and the North One-Half of the Northwest
One-Quarter of the Southeast One-Quarter, and all
that part of the Northeast One-Quarter of the Southeast
One-Quarter lying northerly of the town road, Section
Sixteen (16) , Township Thirty (30) North, Range
Nineteen (19 ) West, in St. Croix County, Wisconsin,
containing 58 acres more or less, and subject to the
one-half interest of Warren E. Cook in said property.
B. The respondent, Barbara J. Cook, a/k/a Barabara Jean Cook,
a/k/a Barbara Cook:
1 . The one-half interest of Gerald J. Cook in: The
R€6MTER5 OFFICE Southeast One-Quarter of the Northeast One-Quarter,
Section Seventeen (17 ) , and the Northwest One-Quarter
ST. CR04X CO., WIS. of the Northwest One-Quarter, Section Sixteen ( 16) ,
Recd. for Record this 21st and the Southwest One-Quarter of the Northwest
day of June A.D. 19 85 One-Quarter, Section Sixteen (16) , all in Township
8:30 A
%&Iw of Deeds
Vd! 714 PAGE 502
Thirty (30) North, Range Nineteen (19 ) West, in St.
Croix County, Wisconsin, containing 120 acres more
or less.
I hereby certify that the foregoing portion of judgment of
divorce in the above entitled action is true and ccurate.
Dated at Hudson, Wisconsin, this day of
1985.
CLERK OF CIRCUIT COURT
r ite M., s arc 4rg c
M j
�i
itate of Wisconsin a + ,��' • _
County of St. Croiidi's�
hereby certify that, f4siaiacur �•. �flf��ii/ Jw_
e`t5ri r:ai on f�l !,=
true and correct cop".'ta�,�► !;► � _ �►,
bnd of record indhd3il°� e�a`,
tornpared by mz ;
Attest,_.J_jo—Zday
Sue to Kobylarczy'k ark of C
DOAR, DRILL & SKOW, S.C.
P. 0. BOX 69
103 NORTH KNOWLES AVENUE
NEW RICHMOND, WI 54017-0069
(715) 246-2211
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER BA x,
ROUTE/BOX NUMBER Ti FIRE NO. / /V
CITY/STATE �) �f � S`S' T jA�„ - ZIP 5�
PROPERTY LOCATION: 114 _1/4, Section � , T_ 0 N, R ' �' W,
Town of �`st?��7L=FK�='T , St. Croix County,
Subdivision /`/A , Lot No. I.
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
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 X
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEIIARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
DIVISION
INDUSTRY' P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707
HUMAN RELATIONS (1-163.090) &Chapter 145.045)
TO WNSHIP068dwaITY: LOT NO.:BLK.NO.: SUBDIVISIO RAM E:
SE 11VE 11 17 /T30 N/1k9xE(or)W Somerset n/a n/a n/a
COUNTY: O E NAME: M R
St. Croix Barbara Cook IR.R.#2, Box 280A, Somerset, Wi. 54025
USE DATES OBSERVATIONS MADE
NO.I 3MS : COMMER A DESCRIPTION: I R O TS:Resince n/a ❑New Replace 10-13-8.9
RATING:Sa Site suitable for system U=Site unsuitable for system
rONVENTI NAL: MOUND: IN-GROUND-PRESSURE:rE:]S*OU TEM- N-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
�S ❑U [IS ❑U EaS ❑u ❑S 12U conventional
If Percolation Tests are NOT DESIGN RATE:required It any portion of the tested area is in the
under s.H63.09(5)(b),indicate: clas$ 2 Fioodplain,indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 34 HsB
BORING TOTAL DEPTH TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTF)M, ELEVATION OBSERVED- EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-1 7.09 98.33 none >7.09 .92bl.1. .92bn.sil. 2.33bn.c.s. 2.92bn.s.sil.
B-2 7.17 98.70 none >7.17 .00bl.l. 1.25bn.sil. 4.92bn.l.s.
B-3 7.08 98.40 none >7.08 1.00bl.l. 1.33bn.s.1. 2.75bn.l.s. 2.00bn.s.sil.
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCHES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. D P
P-
P-
P-
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 94.90
i :
f � f t i i
C) _
i j
fieJ
I ,
V
.�._ _
—
I _II___ _ t}
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:
Gaa L. Steel 10-13-89
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
88 N. Shore dr. , New Richmond, Wi, 54017
CST=E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER -
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