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HomeMy WebLinkAbout020-1159-10-000 q ' � \ ft � ( §o § % ( i 77 a) � cc � ) ) D 5 = � � LL / tm � B § z B z 2 § 2 } $ 7 7 § _ \ @ � ) 0 j G E e \ � z co \ \ z k A $ I � k - k ~ a § CL m ƒ - o • a ■ / K ; @ @ = o o a 2 3 m m \ 2 . w § § E r \ k § iL U) } 3 k � � a 2 2 IL cn R o ' k \ � \ ƒ � D _ § 6 2 \/ E2 d m ( k § \ § � \ < co o % c 4 ¥ @ � § E % \ ) / § n � � 2 2 = \ f S@ 8 E $ k E / \ S k 2 / / § 1-.- z 2 @ < /- § \ , } o z k / 2 � i kw a e a , £ L: CL CL ° 2 © § e c Q v L 2 j A k J Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. TN-R`Y W ADDRESS ,A�� ST. CROIX COUNTY, WISCONSIN /,%sue,,/ �✓� If SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 6 �o 0 t J� '4'e INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Q� fjj Elevation of vertical reference point: ° Proposed slope at site SEPTIC TANK: Manufacturer: 6:j�, Liquid Capacity: A�6y Number of rings used: _ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation- Number of feet from nearest Road: Front,C)Side,Q Rear, O /,� feet f� From nearest property line Front,O Side n' Rear,O feet Number of feet from: well A r building: a F (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE ' s 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, O Side, O Rear, Ft. Tc^" �,. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: 1;I,-, Length: Number of Lines: `- Area Built:�i l6 Fill depth to top of pipe: y/J Number of feet from nearest property line: Front, O Side, &Rear,0 Ft . 6-4�-- Number of feet from well: h 1� i Number of feet from building: (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 absorbtion sytems? (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: G Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON WI 53707 NE PSO-., Section 20 CONVENTIONAL ❑ALTERNATIVE lf state Plan I.D.Number. Ied) T29NR 19W ❑Holding Tank ❑In-Ground Pressure El Mound assign Town a4 Hudson - Lot 5 Pine Gt ove Hgt. NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION A ChAi,S HoMen R Hudson WI 5403,6 �'Z�—q,�, BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: FIL11F.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: W%�Qiam Schumake�f 5 382 St. ctoix 1112766 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELE V.. ITANK OUTLET ELEV_ WARNING LABEL LOCKING COVER r�� ` PROVIDED. PROVIDED IWO �( Z [�wES ONO DYES NO BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: fRCIPERTY WELL: BUILDING. VENT TO FRESH ALARM I I AIR INLET �' FEET FROM {� ❑YES O � ❑YES �'fV0 NEAREST v 11LL// v DOSING CHAMBER: MANUFACTURER 7INGS LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUF ACTIIRER WARN( G LABEL LOCKING COVER I D: PROVIDED ONO ❑Y O ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPER WE L t��;G 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 LENGTH DIAMETER IMA RI L AN ARKING or excavation. Of soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: ",I NGTH NO.OF DISTR PIPE SPACING COVER INSIDE DIA 11PITS LIQUID .r . BED/TRENCH TRENCHES I MATERIAL: PIT DEPTH DIMENSIONS S �. 6 + GRAVEL DEPTH LENGTH PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DI R. NUMBER OF TV WELL BUILDING VENT TO FRESH 'd► BELOW PIPES .INLET ELEV END. PIPE FEET FROM LINE II �( AIR INLET ;! 11 m �t�5 NEAREST JPROPER MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSE11VATION WE LLS DYES 1:1 NO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES. EYES — NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATE HIAL&MARKING ELEVATION AND ELEV. ELEV.. DIA.. ELEV.. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY R MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑ COVE ❑YES NO DYES ❑NO COMMENTS: JPERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING / FEET FROM LINE / [:DYES El NO ❑YES ❑NO NEAREST IN- 6 (, 3 G ref� Sketch System on Retain in county file for audit. Reverse Side. ` - ' TITLE DILHR SBD 6710(R.01/82) ) C �[�V�7L. Zoning Adm-inL z JLa otL i {� SANITARY PERMIT APPLICATION CO ' Y 'Z 01L HR In accord with ILHR 83.05,Wis.Adm.Code STATE SANI ARY PEFAM IT## —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER PROPERTY LOCATION L I'd eo �(/ /a $,�1/4, Sa6 Tag,Q, N, R E (or PROFfERTY OWNER'S MAILING ADDRESS LOT NUMBER SUBDIVISION NA E .f/ �✓� 6 S IBLOCKNUMBER ,,we a v-L � CITY,STATE ZIP CODE PHONE NUMBER CITY /NEAREST ROAD,LAKE OR LANDMARK VILLAGE : r.---� •— TnWKI fn II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): Ill. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. ® New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in#2) 1. a. Nconventionai b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. &eepage Bed b. ❑seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): d 3 �s _c, d r GS Feet JC Private ❑Joint ❑ Public VI. TANK CAPACITY Site in aallons Total ##of Prefab. Fiber- Exper. INFORMATION New xi sting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank l l F-1 Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I El VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) P PRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: l/ Vlll. SOIL TEST INFORMATION Certif' d oil Tester(CS )Name CST## a;2 gr le CST's AD SS(Street,City,State,Zip Code) Phone Number: d- a IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial .�l / n/� Surcharge Fee Adverse Determination n o�V o(J X. COMMENTS/REASONS FOR DISAPPROVAL: { Vam,_ SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION , TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly.maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; Ill. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground ter -.. included the creation of surcharges (fees) for a number of regulated practices which Wisco 1C1t .. a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried f ' SUfB is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) 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 b intended for resale by owner/contracttQv, ("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 CQl�I Location of Property A4�7 i it-, Section _, T N R 919f W Township .&&ds-a et/— Mailing Address 2 GcJ Subdivision Name Luc Number Previous Owner of Property Total Size of Parcel � E Date Parcel was Created 1- 4 y a23 A!-42 -A► 1 01-Uktl"i and lot 11 n.?-s identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume �2 d and Page Number �a2 as recorded with the Register of Deeds INCLUDE WITHyTHIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid 'deiays of, the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (We) eeAti.6y that att Atatement6 on tW 604m cute tAue to the but o6 my (ouA) knowledge; that 1 (we) am (cute) the owneA(a ) o6 the ptopeA.ty deaeiu.bed in athi,6 in6oA.mat%on 6o4m, by viv tue o6 a wa4Aan-ty deed &eeo&ded in the 066iee o6 the County RegizlteA o4 Deedb as Document No. �L/_ 17 y$r ; and that I (we) pvteaentty own the plopMcs' .si.te Son the 6ewa.oe "polo_ (o& I (we) have obtained an easement, to A.un wLt:h the above de,6eAibed pnopeA-ty, Son the con.6t&ucti.on os .eatid b y.6 tem, aad the came ha6 been duty neconded in the 065J`,=e 06 the Cou Regat o6 heeds, ass Document No P . Zw SIGNA E Ir OkJNER - SIGNATURE OF CO-OWNER (IF APPLICABLE) DA'Z'E SIGNEU DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 440748 BOOK 820 F�v r,520 REGISTER'S OFFICE ST. CROIX CO., WI RiCHARD 0. I STOUT , JANET P. STOUT Recd for Record and MAUD H. STOUT Al 1r, 2 3 1988 conveys an ratiioo CHRIS J. HOLDEN and KIMBERLY at 10:10 A. M w �A T , husband and wife Register of Deeds RETURN TO the following described real estate in St- Cro iX County, State of Wisconsin: Lot #5 , Pinegrove Heights Addition Tax Parcel No: to the Town of Hudson, Section 20, Township 29N, Range 19W. -MP�N TER 3 14� FEA This is not homestead property. (is) (is not) Exception to Warranties: Dated this 19th day of August` ,1988 (SEAL) t r�l i# Still-L U,1- (SEAL) Richard 0. Stout Maud H. Stout by Richard 0. Stout., P.O.A. (SEAL) (SEAL) r Janet P. Stout AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. r.. C` . '" 7`d; ,, St. Croix County. authenticated this day of �` ^ °' 1 �1 , ,` Personally came before me tthLi* 19th day of '�• 3' ° 19 ttSS the above named Richard . Stout and Janet P. Stout Pi IRI TITLE: MEMBER STATE BAR OF Sy8 'N$IN °°•° , (If not, P to me known to be the person k who executed the authorized by§706.06,Wis.Slats.) for oing i rument and ac nowledge III same_-- THIS INSTRUMENT WAS DRAFTED BY JANET P. STOUT �- Patricia A. Dotseth 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: Dec. 10 _' 1989 Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms,P.O.Box 1075,Green Bay,WI 54305-1075 Form No.2—1982 I� ` G H r ST C - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT . o St . Croix County z d a OWNER/BUYER ROUTE/BOX NUMBE � lOf Fire Number CITY/STATE 1&40t) Z I P ��a PROPERTY LOCATION : �4, �14, Section T 2'? N , R W, Town of— �y St . Croix County , Subdivision Lot number_. • I 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 septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix County residents may be eligible to receive a grant for a maximum of 60% 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 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 0 I/WE, the undersigned,, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth , herein , as set by the Wisconsin Depart- w ment of Natural Resources . Certification form mus e o pleted and returned to the St . Croix County Zoni Of . i e wit 30 days of the three year expiration date . SIGN D D A'r 1,26,00 St . Croix County Zoning Office P . O. Box 98 Hammond , WI 54015 715-796-2231 or 715-425-8363 Sign , date and return to above address . r ° ,I TIi w�Or .REPORT r V sA lNDUSTR r; � ' r YIst a LABOR AI ' '`' ' ; PERC I 115 .Box 7 �HUMAW RE, $ ` 4 // ryry g�y�rs' 4A W1 53707 T $ IP/ OT NO NOS. S � 9 (or1 w :a he MAILING DD, � �� ;x4 ,�, ,�i< , sr.• ,� 1 Richard Stout' �St �,� ,I,ritf l^ � RtR � � � a r Li E�, acs ^6 $5 A! tr � IR/1TIN0. "t =1sib urWuftaAtetaKr tp =�j Tltaia�a}�j FAMEN COMMENDIEDXYSTIMR1 S U ®S rc�U WS U conventi+�c>tal�i•, Alt x !' - j} 6 "If P,Kcolat*Tot& NOT tNquirtd,!:a-1 a DESIGN RAT i tiY If aHy, Lion of the tested Oren is in the e,41 undM S.H63,A6(. ' irate: C18s3 1• , ={ Floodplain,indicate Floodplain_plevotiot► iY' FILE"DEkR1PT10111&I# P$ 158; WO-RING NUER i S A WITH S, LE�AWN ' RV D !F 069ERVED(SEE ABSRV.ON B ; w j3. 1 6.83 : 100.76 . none >6.83` 8361. : TSb .si1. .33bn.l.s. 4. taa.&gir. , �,. & 2 7. ?p�.�, 102.17 none >7.17 83b1.1,, A2bIn.sil. .42bn.1.s. 5..5�i.e.s!.&gar. ; A & 3 6."!5' 102.40 none >6.75 .83bi k.1. 5.92bn.c.s.&gr. t •''� I „ N;! .;: B. 4 6. � 102.15 none >6.59 .75bn.s 11 .4 bn.l.s. 5.42bn.c. ,> � . & 5 6.34�r 101.02 noneb .92b1.1.:VS( Sn.s1 ':67bmr.`l.s 4 p POICOLATI TESTS ' TEST DEPTH., l WATER IN HOLE TEST TIME V - RATE MINUTES NUMBER INCHES =AFTERSWELLING INTERVAL-MIN': rERIOD I PERIOD 2 PERIOD 3 PER INCH p �a P- P- lesign ME- 71 p. P- , i .i�c r. ate"•.' i . a ¢ PLOT PLAM:..;Shovr locations of percolation tests, soil borings and the dimensionsf of itliteble soil areas. Indicate scale or distances,9sKalbe what are the hors- zontal and eis�ation roference points and show their location on the plot plan. Show the'surface elevation at all borings ss�!thidirection and percent # 98.65 SYSTE LE"ilATiON k ` N ::its Al ` .r r Vi ii Ei Y \111 Vf i • I,the undersigned,hereby certify that the soil t ad on t re made by me in accord with the procedures and methods spsdfied in the YIF Administrative Code,and that the,data recorded and 1 o are correct to the best of my knowledge and belief. NAM (print): .; f3 tr TESTS WERE COMPLETED ONvC4 IN* ` / �+ Vary L. Steel i-, ,, 5-6-87 ' AD SS: CERTIFICATION NUMBER: PHONE NUMBER optional): � r 988 N. Shore Dr. New Riclimond, Wi. 54017 2298 - T SIGNA a � 618TRIBI.Jilb tt Orin t { t nsl and one copy to Local Authority,Prgperty a�r and Still Tsaar,, ;-' •` ' "'� ,V � DILHR-SBD4395(R.02/82) OVER 3 g , r _ r i RRf \n G Q _ 2 c�.s --e-