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PUMP CHAMBER V
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,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: / Q � Length:-'B 4 Number of Lines: Z _ Area Built:lo y�
Fill depth to top of pipe: y z
Number of feet from nearest property line: Front, O Side, Rear,Oltt .��
Number of feet from well: x(00 �
Number of feet from building: DL
(Include distances on plot plan).
SEEPAGE PIT
Size: t� _ 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: /��l 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: j
3/84:mj
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Form - STC - 104
W
AS BUILT SANITARY SYSTEM REPORT
OWNER So-In /1'f,��G/ TOWNSHIP Ile, /5 p/7 SEC. T N-R W
ADDRESS 04, /24'r/ doX -172- ST. CROIX COUNTY, WISCONSIN
11t, 3 0►1 GCJ y o / G
SUBDIVISION -Saco b S �a �r %�3 LOT S LOT SIZE • `�� c Q ✓
CS✓► �/ �-1 �-J
PLAN VIEW
Distances and dimensions to meet requirements of I•1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
S,—CL ice ��q /0
N
A
u5
acy1-1 (va�4 ft
s yr�Al
d lz0
I
yw
° A-230'No se-.&/,,) INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used AJ;6 Tsd n„ 5octn lok--1w
Elevation of vertical reference point: 160.0' Proposed slope at site:. S co
I
SEPTIC TANK: Manufacturer: (,UQ;Sc{ Liquid Capacity:
Number of rings used: Tank manhole cover elevation: 9 �a�
Tank Inlet Elevation: �640C) Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side,QRear, (D feet
From nearest property line Front,0 Side 10 Rear,O /
feet
i
Number of feet from: well 'Z8 , building: tiz tok 5E lo,x'ty C���1'o HeLLf,0_
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.SOX 7969 BUREAU OF PLUMBING
MADISON WI 53707
SW SW, 2]_,29,19 CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number:
Town Of Hudson El Holding Tank ❑In-Ground Pressure El Mound
Lot #5 Jacob's Landing
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller Rt. 1, Box 282, Hudson, WI 54016
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW N..: r,"my. Sanitary Permit Number:
Doug Strohbeen I5432 St. Croix 92473
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:P LIQUID CAPACITY: TANK I- ET ELE V.: TANK OUTLET ELEV., WARNING LABEL LOCKING COVER
P V DED: PROVIDED:
� �YO � YES ❑NO DYES ENO
BEDDING: VENT I VE7AJL.: HIGH WATER NUMBS OF ROAD: �r PROPERTY WELL: JBUILDING:,4AENT TO FRESH
IIALARM. FEET FROM LI� / IR INLET.
DYES NO DYES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ONO ❑YES ONO I [—]YES ONO
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) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth Of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVE INSIDE CIA. #PITS LIQUID
BED/TRENCH TRENCHES r MA(F� IA q PIT DEPTH
DIMENSIONS r \l 111
GRAVEL DEPTH FILL DEPTH D PIP' DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELLBUILDING: V NT TO FRESH
BE LQ`W,pIPEtS" ABOVOVER: 'INLET.ELE V.END/ —7 C PIPE �J FEET FROM LINFj. ^ AIR IykE
/\(J 2 l// c'�] // lJ 1\ NEAREST--► (/ V (}�� V (�
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
❑YES ONO meets the criteria for medium sand. TIONS MEASURED.
OIL COVER TEXTURE: JPER"ANINT MARKERS OBSERVATION WELLS
1:1 YES 1:1 NO F-1 YES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED
CENTER: EDGES:
DYES ONO I DYES ONO DYES 1-1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF H LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE IMANIFOLDMATIRIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEVATION AND
ELEV.: ELEV.: DIA.'. ELEV.: PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING:
® FEET FROM LINE:
S ❑YES El NO S NO NEAREST
11� r1 �� 91�A
Sketch System on � Retain in county file for audit.
Reverse Side.
SIGNATURE / � TITLE:
DILHR SBD 6710 IR.01/82) l//
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 syste:rl, 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;
ll. 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'h 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 Ater
included the creation of surcharges (fees) for a number of regulated practices which Wiscorsin`s
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re sure
is used in your building is returned tc; the groundwater though your soil absorption o
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--
terec: by the D�epartment of Natural Resources. These funs are used for monitoring ground- f
-eater, groundwater contamination investigations and establishment of standards. Croundwat€: ,
it's worth protecting.
SBD-6398(R.03/86)
=:Ewl H S ANITARY PERMIT APPLICATION COU
In accord with ILHR 83.05,Wis.Adm.Code
� STATE SANITARY PERMIT#
e q-
,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
_-501, 5G()%,S,2/ T , N, R !(or
PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BL2>7BER SUBDIVISION NAME
CITY,ST TE ZIP CODE PHONE NUMBER 7n CITY NEAREST ROAD,LAKE OR LANDMARK
Q/ / - 161 VILLAGE: Gh
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. P1 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. gConventional 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. X Seepage Bed b. ❑seepage Trench c. ❑ seepage 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):
41/11— G V $ 8/•9.�Feet X Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank X ❑
Lift Pump Tank/Siphon Chamber ❑ 1 ❑ ❑ I ❑ ❑ ❑
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) MP/MPRSW No.: Business Phone Number:
6,,0, 32, 33
Plumber's Address(Street,City,State,Zip Code): Nam f Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#�S
! LA/V 14. {IoW CIVITT
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
❑ Owner Given Initial /} /� Su charge Fee
Approved / //►
Adverse Determination V V �
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
Form - S T C 100
Owner of Property ��
Location of Property 5W SGc) �, Section o2 / T-&aN Rl9
Township
Mailing Address ,� `�
nX z s Z
Subdivision Name
Lot Number
Previous Owner of Property_
�r soYr
Total Size of Parcel �d (�� G¢Y3
Date Parcel Was Created__
Are all corners identifiable ? _Yes
* 7 70 ) j�--- 6,3 Z_ No
Include with this a lication one of the followin
. Certified Survey Map
. eed
. Land Contract , or
- Other legal Document which describes the property
PROPERTY OWNER CERTIFICATION I
1 (We) certify that all statements on this form are true to the best of m ,
knowledge; that I (we) am (are) the owner(s) of the property described inothis
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. Z 303 ;and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an 0asement, 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. X& 4� =3 ),
SIGNATURE OF OWNER SIGNATURE OF CO.OWNER (IF APPLICABLE)
-- •3 r I -
PATE sIGNEO
DATE SIGNED
l
H
' Vf
H
a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
/� a
OWNER/BUYER _5ZM Alellel- M
ROUTE/BOX NUMBER 2_e2__ Fire Number
.CITY/STATE _ /&/a S-Oh Gdr ZIP ,S'-yeD
PROPERTY LOCATION: S� ,5� It, Sectionc;'/ , T —�� N, R ZY.6 ,
Town of St . Croix County,
Subdivis Lon Joe d6 khd/HS 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 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. .�
0
I/WE, the undersigned , have read the above requirements and agree z
N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Toning Offlge within 30 days
of the three year expiration date.
SIGN
DATE
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.
DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982 TNIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
REGISTERS OFFlCE
423033 E00K 770 pmt 632, ST. CROIX C09 WI&
Recd. for Record ft . 5th
This Deed, made between ._..yirg�11i3__M.__Hanson1_ a day of March A.D, 1987
single woman 11.45 Aa Md
-•-•- ---
ot
---------------------------------•----• .......................................................... Grantor. James O'Connell
and....................Ssm__M ller,-_.ddb/a/_:Sa .Miller-'Construction_-'_ ^' . . 1W � �
7y
-------- --------------------------------------------------------•--------------••---•---•------••---•----- deputy
............, Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
................QJie._do ar-.anti--other--valuable-•consideration• _
conveys to Grantee the following described real estate in :. RETURN To
County, State of Wisconsin:
s
Tax Parcel No: ...................................
Part of the SW+ of the S144 of Section 21-29-19, described as follows:
Lots 5, 6, 7, and 8, Certified Survey Map filed November 19, 1986,
in Volume 11611, Certified Survey Maps, page 17+7, as Document #419479.
Subject to recorded easements, reservations, and rights of way.
Ov
This ---------iS--AQt....... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And..........Virginia M._ Ha n son
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
no exceptions
and will warrant and defend the same.
Dated this ........... .4th ....... day of March 7
. ----•---•....... ........ -- ..... --............... ----................,
-------------------------------•-------------------------------------(SEAL) .... '
��crG .!/.l-1� .. ............. SEAL)
nia M. Hanson
.................................................................. t
.......................................•.............................(SEAL) ..... . .........................(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) .._...Vgll�.1_.I"L...H�I} QA STATE OF WISCONSIN
............•-••• ........................................................•-•--- St. Croix
ss.
......................................County.
j
authenticated this Ath.day of.....March........... 107_ Personally came before me t is .......day of
March , 19.. . the above named
Vir inia M Hanson
Eric--J� l
-•Lundel
- •---•------- ---------
----
TITLE: MEMBER STATE BAR OF WISCONSIN ....................................... .................... ...................
(If not, ........... ;1
authorized by § 706.06, Wis. Stats.) ............................................. - -
to me known to he the person .-- -�,r�- who exec uted the
1.foregoing instrument and tckno- %ledge tro same.
THIS INSTRUMENT WAS DRAFTED BY � .�'
Eric J. Lundell
New Richmond WI__5�+01'� ,.-u -•------ ----r'1........... -�
--------------- _ Notary Public -_......a.t.j...Croix Coitntyl'Wis.
(Signatures may he authenticated or acknowledged. Both MY Comrnission is permanent. (If *npt% ��toite; expiration
are not necessary.) /�
date: ---J_[_��4.4t_.. .U-•--•-• .....................
*Names of persons signing in any capacity should be typed or printed below their signatures. J
H.C.Miller cornpany fry-11 STA'rli iIAR OF WISCONSIN
''°'t,t No. 1--1982 Stock No. 13001
DEPARTMENT OF REPORT Oil SOIL BORINGS AND SAFETY&GUILD ION p ;
INDUSTRY, DIVISION
UM � PERCOLATION TESTS (115) P.o.gox 7e09
HUM4NAN REL ATIONS REL MADISON,WI 53707 .
(1-163,090)&Chapter 145.045► '
LOCATION. 5 s N: TO NSHIP/ tCt Y: OTNO.:BLK ]SUBDIVISION A
ell 'T 9N/R G i(o M1
COUNTY: W E 'S MAILING
USE DATES OBSERVATIONS MADE
RI TIO - p
New ❑Replace v
RATING:S-Site suitable for system U-Site unsuitable for system _
MSEA- 10SOU ]ENfI NA L: MOUND: IN-GROUN R M- -FILL rE]S []a1I OLDINGTANK:RECOMM RECOMMENDED YSTEM optional)
M OU ❑S ®U
If Percolation Tests are NOT require DESIGN RATE: if any portion of the tested area is in the
under s.H63.09(5)(b),indicate: /�5 Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
ORR D P R UNDWATE -INCHECHARACT ER SOIL WITH THICKNESS,COLOR, R ,AND DEPTH It, ELEVATION BS RV D
TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- 7
B- y _
B- 7 4� ,
s. •
e.
B-
C. PERCOLATION TESTS
TEST DEPTH . WATER IN HOLE TEST TIME D A TER LEVEL-INCHES RATEMINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PER INCH
P. G S.- / 7
P- r -sue }
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of,(uitable soil n 'cate scale or distances.Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot in. he surfa avail n at all borings and the direction and percent
of land slope.
r SYSTEM ELEVATION
•— t - I
al - i
- .
41Qaaf
i— -
I,the,undersigned,hereby certify t tlz soil tests po ted 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.
NAM (pri t : TESTS WERE COMPLETED ON:
A S CERTIFICATION NUMBER: PHONE NUMBER(optional);
CS G TU E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester• 1 /�
' DILHR-SBD 6395 IR.02/82) OVER- `' L�� �� c-s r �1
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