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Parcel #: 040-1019-20-000 11/03/2004 PAGE E 1 AM
1 OF 1
Alt.Parcel#: 04.28.19.63F 040-TOWN OF TROY
Current XX ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units
00 0
Tax Address: Owner(s): *= Current Owner
* MAILAND,JEFFREY M
JEFFREY M MAILAND
511 OLD HWY 35 S
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *511 OLD HWY 35 S
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 5.100 Plat: N/A-NOT AVAILABLE
SEC 4 T28N R19W 5.1AC IN SW SE COM ON E Block/Condo Bldg:
LN SW SE 761.4 FT N OF SE COR,TH S 205
FT,TH W 1051.2 FT TO HWY 35 R/W, NWLY Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
ALG R/W TO PT W OF POB TH E 1120 FT TO 04-28N-19W
POB
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1147/218 WD
07/23/1997 800/501
07/23/1997 706/87
07/23/1997 689/570
2004 SUMMARY Bill#: Fair Market Value: Assessed with:
295,600
Valuations: Last Changed: 07/15/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 71,500 255,800 327,300 NO
Totals for 2004:
General Property 5.000 71,500 255,800 327,3000
Woodland 0.000 0
Totals for 2003:
General Property 5.000 48,400 236,100 284,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 115
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
'PUMP ."TIAMBER
Mav facturer: Liquid Zcturer:ty: •
Pump Model: Pump/Siphon Ma Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet om nearest property liner 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 k„. Trench:
�3� �4_ �S
Width: ��-� Length: S Number of Lines: -2— Area Built:
Fill depth to top of pipe: OWES- `�/� 67-- CAST "�'O � 8 " a.4- was T-
sd
Number of feet from nearest property line: Front, O Side, O Rear,Oit .
Number of feet from well: 4 01= 2- .50
Number of, feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: of p Diameter:
Liquid depth: Bo
Number
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: Capaci
Number of rings used: E ion of bottom of tank:
Elevation of inlet:
Number of from nearest property line: Front, O Side, O Rear, OFt.
z Number of feet from well:
{
£ Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
i
i
A/4 ✓r �< Inspector
Dated: ` Plumber on job:
i
License Number: I
.,,
HOMESITE SEPTIC PLUMOINGCO.
RT,3 O'NEIL RD,,HUDSON,WIS 51016
ROBERT ULBRICHT
VA9 *"R PLUMKR LIC.NO.33107 M.P.R.
3/84:mj ilNN.INSTALLER&DESIGNER LIC.NO.DOW
Form - S T C - 104
i
• e AS BUILT SANITARY SYSTEM REPORT
OWNER
6 YA) A�f2 TOWNSHIP T Q-o y SEC. T ZQ N-R W
�r. .3 Hu,y 35
ADDRESS ST. CROIX COUNTY, WISCONSIN
I-�-u DJo y 4j f5
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•ZHR 83
i
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
EI E V,fTtnNS ,
-rop 0i Sot(& #EADEz . Q� y/ �E 3
v
-rop e- pee;, N,wrfold� : q�33 ' CA
sysrem : 96. 5o' I
Keen"
To Step defeu Fy, y�t„
40 Puc
StI►'tt RPPR6Vlp FROST �Rap S- tS•SZ
PRO? BOX. Q�1� SO
►NLrt h Rt 90' tk " j
BFNO nowa �� Rok . 5��"�R
17•' 5y SET,
----------- --------- C/o
�— ,f r
oae
0 �
1
s s' 4
o i
/O'u SIo�ES
1 S�o f
^' \ So. for Lk%r
VEBT•' 'QEF, ?T., ToP e f S o Qty yoQ S
.1" tj?r or So, (or Lo'%h C , elau,= /00.D i
INDICATE NORTH ARROW
s-e- IDT- coRatR .
FOR TAPa - 6ALy cENTER of
BENCHMARK: Describe the vertical reference point used Sol • fRoor EST} X00(Z
Elevation of vertical reference point: Proposed slope at site:
IN i ESEl� Z�
SEPTIC TANK: Manufacturer: CO /00 Liquid Capacity:
Number of rings used: Ze W,0 Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
7o WeS7- �Vi J�-Op
O
Nuihb f bf `filet from nearest Road: Front, Side Rear, feet
From nearest•,.property line: : Front 10 Side,O Rear,0 7✓ feet
Number of feet from: well 50' building: /0
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
DIVISION
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
P.Q.BOX 7969
MADISON,WI 53707 �q State Plan I.D.Number:
SW�,SE4,S4,T28N—R19W OCONVENTIONAL El ALTERNATIVE (It assigned)
Town of Troy ❑Holding Tank ❑In-Ground Pressure ❑Mound
Hwy. 35
INSPECTION DATE:
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER:
John Mailand 25024 Itasca Ave. Forest Lake, MN 5502
REF.PT.ELEV.: CST REF.PT.ELEV.:
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN:
Name of Plumber:
' MP/MPRSW No.: =County: Sanitary Permit Number ob Ulbricht 3307 92554
SEPTIC TANK/HOLDING TANK: LOCKING C
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: PROVIID DLA EL PROVIDED:OVER
DYES ❑NO OYES ❑NO
NUMBER OF ROAD: PROP E RTV WELL: BUILDING:(VENT TO FRESH
BEDDING: VENT DIA.: VENT TL.: AL RMATER LINE AIR INLET:
FEET FROM
OYES ❑NO OYES ❑NO NEAREST
DOSING CHAMBER:
PUMP/SIPHON MANUFACTURER g WARNING LABEL LOCKING COVE
MANUFACTURER. BEDDING: LIQUID CAPACITY: PUMP MODE L. PROVIDED: PROVIDED:
❑YES 4❑NO OYES ONO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPER ATIONAL NUMBER OF Y WELL' BUILDING. VENT LE FRE SH
AIR INLET(DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST
LENGTH'. MATERIALAND MARKING
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: INSIDE DIA SPITS ]LIQUID OVER
BED/TRENCH WIDTH LENGTH NO.OF DISTR.PIPE SPACING !NO.ATERIAL: PIT DEPTH
TRENCHES
DIMENSIONS
NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATEHfAL: ISTR_ LINE'. AIR INLET.
BELOW PIPES: ABOVE COVER'. ELEV.INLET ELEV.END: FEET FROM
NEAREST
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES El NO
PERMANENT MAHKE RS. OBSERVATION WELLS
SOIL COVER TEXTURE
❑YES ❑NO - YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED
SEEDED MULCHED
CENTER'. EDGES:
DYES 0 N ❑YES ❑NO ❑YES :EZ]
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR DIS7R.PIPE DISTHIBU 710N PIPE MATERIAL&MARKING
ELEV.: ELEV.: DIA.. ELEV.: PIPES DIA_:
ELEVATION AND
DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
OYES ONO 1-1 YES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO YES NO
NEAREST
5 (4 Le
Sketch System on Retain in county file for audit.
Reverse Side. siGNATURE: TITLE'
Administrator
DILHR SBD 6710(R.01/82) Zoning
i
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
Y
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment,30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis.Adm. Code will be applicable.
10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size,separating distances,distances between beds if appropriate,tank locations,effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems
must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning
your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
r_ra wi$cons,n w�' �Q� � v
� DILHR (PLB 67) COUNTY
�OEPRRTmEnT ov UNIF RM/�SANITARY PERMIT#
-InOUSTRV,LRBOR 6 HUMRn RELRTIOnS /5,_�/
—Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNE/R MAILING ADDRE�SSS`�('/L ryA &8/ r'j— `L
PROPERTY LOCATION
51V 1/4S£1/4, S , Tl�N, R E (o W TOWN OF: /
LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, ARK STATE N I.D. NUMBER
3S !V
TYPE OF BUILDING OR USE SERVED
1 or.2- —dTT y Number of Bedrooms: J ❑ Public (Specify):
THIS PERMIT IS FOR A:
KNew System F-1 Tank Replacement El Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnectipo,,Z Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. V SMQ,S
r r � ,
;1,Seepage Bed Il X S1 ❑ Seepage Trench ❑ Seepage Pit Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
�����/,/� Gallons Tanks Concrete Constructed
Septic Tank Capacity /�'
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: !ES D N.
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THI CK: ❑ Mound ❑ In-Ground Pressure
al
*of Prefab. Site Stee Fiberglass Plastic
Gallons Tanks Constructed
Septic Tank Capacity �
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION ABSORPTION AREA WATER :Y:
(MinSper inch): REQ quare Feet): PROPO (Square Feet):
/yrx '2r Private ❑ Joint ublic
I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): HOMESKE SEPTIC 1�/MPRSW No.: Phone Num /
Rt: y VNEIL RD.,HU nN,W,100.
3 30 7 (715')3 (9 /F
Plumber's Address: HT
Name of Designer:
��
tl "MN PLUMIER LIC,N0, 3307 MARS.
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: F e: Date: ❑ Disapproved
p ❑ Owner Given Initial
Approved Adverse Determination
Reason T'In Disapproval:
K R p v,,z oed 6 y i"c-ry ter, NJ`�"k it-S
Alternate course(s)of Action Available:
D I LH R-S8 D-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber
""s`°"_"' SANITARY PERMIT
D'L H R County
���■—,J�,,,JJJ�••. GROUNDWATER SURCHARGE E r
�N'IOIJSTFIV,LgBOq 6 MIJflVYIAELAT101'15
Sanitary Permit No.
9�s
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly 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 included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
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-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Ground
Si
s ur
e of Issuing
Agent:
Groundw ate r Fee:.
Date: Wi
sco
buried'
C)'C
7
DILHR SBD-7289 0.N !84)
( 5
t,
c
-
• 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'6 w !�
Location of Property 540 1% S� it, Section / , TV N-R �� W
Township 1;`
Mailing Address 1S O Z
F0O� ST !i�¢IC.e S $ d 2 S—
Address of Site 1 T -3 3 o 5'
s
Subdivision Name
Lot Number
Previous Owner of property
Total Size of Parcel
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 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) centi,by that att statement6 on this bonm ane true to the beat ob my (out)
hnowtedge; that I (we) am (ate) the owner(.a) o6 the pnopen ty dens cx bed in th,i,a
inbonmation bonm, by vchtue ab a wa�vco. deed n anded in the Obb�.ce ob the
County Regizten o4 Deed4" Document Na. � ; and that I (We) pnea entty
own the proposed z to bon the .6ewage dispoz ixt sys em (on I (we) have obtained an
easement, to nun with the above de4n bed pnopeA,ty, bon the eonstnucti.on ob aa.i.d
6y6tem, and the .name hab been duty recorded in the Obbice ob the County Regizten ob
Deeds, as Document No. ) .
&ATUOF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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STC - 105 9
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SEPTIC TANK MAINTENANCE AGREEMENT p
` St . Croix County z
d
OWNER/BUYER 76 #A1 14f4i 1A
ROUTE/BOX NUMBER Z SLR L/ '���`�C� Fire Number
CITY/STATE ) �0)67 G/¢ ZIP SS0�S
SW �9
PROPERTY LOCATION: SW 3%, S k, Section 1d, T N , R ` W,
Town of 7-W,611 , St . 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 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 H
three year expiration. o
E
' z
I/WE, the undersigned, have read the above requirements and agree C,
to maintain the private sewage disposal system in accordance with H
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 Zoning Office within 30 days
of the three year expiration date .
SIGNED
DATE
St . Croix County Zoning Office
P.O. Box 98-
DEPARTMENT OF REPORT ON SOIL. BORINGS AND SAFETY&BUILDINGS
INDUS` `•-,�; DIVISION
LABOR AND
. PERCOLATION TESTS (115) �" MADISON
HUMAN RELATIONS
LOCATION;, SECTION: , OWNSHIP/MUNICIPALITY: LJC.NO.s SUBDIVI ION NAM
sw 1145f 1/4 y' /T 'N/R/�E fort W 7`00/
E' COUNTY: OWNER'S BU ER AME:- MAI LING
/P" � oh�,e r ThQMfis /%3 , ' ` `
USE DATES OBSERVATIONS MADE
NO.B DBMS. COM R A DE 1 TION: ,�•��yy
r
QResidence Z•,r tau New ❑Replace.
RATING:S=Site suitable for system U=Site unsuitable for system ,
S� ry S,1;rMr Je�M
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:S TEM-IN-FILL OLDING TANK:RECOMMENDS SYSTEM7leptional) :'
�s au o s au �s ou - a s ou o s u ���r�,�Q � o�341A) E �
I If Percolation Tests are NOT required DESIGN RATE: If any portion of the lot is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: .'/" f
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUP D ATER-INCHES CHARACTER OF SOIL WITH THICKN SS, L,OR,TEXTURE: ;
NUMBER DEPTH IN, ELEVATION OBSERVED TO BEDROCK IF OBSERVE SEE AaB.RV.ON BAGIL I
�- �' if"l�•B�•L, !2 "IQN,.G, /�► ''C1�"'L J�or�'' ..',�Sr' .; . ,
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME I RATE PER INC
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PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or 040noa, Owx1be^4141 SM 441 -"
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at ail'bq 84 00
of land slop. &)f0A4 of a.4P4W.&,0 740 Lrf EXrltyl�/ M
SYSTEM ELEVATION yZ " &Ia w AVI; A r F& v v f 3? 4e elc V. 4
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1, the undersigned, hereby.certify that the soil tests reported on this form were:made by me in acoord with the pr000dut�-ttNthodt apaafiad In`the W n'
Admimistrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
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NAME(print): TES: S WERE COMPLETED ON:
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DISTRIBUTION:Original-Local Authority,2nd page-Bureau of Plumbing,3rd page-Property"Ownar,4th papsSoN Tsswc
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