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HomeMy WebLinkAbout020-1170-60-000 St. Croix County Zoning Tuesday, December 14, 2004 at 7.•59.26 AM Detail Sanitary Information Page I of I Computer 020-1170-60-M SublPlat: Edgewood Estates III Section: 7 Parcel 07.29.19.1062 Lot: 88,89&90 TNIRNG: T29N R19W Municipality: Hudson Township CSM: 114114: SW 1/4 NW 1/4 Owner: B & H Development 333 Edgewood Drive Hudson, WI 54016 State Permit: 79186 Issued: 06/10/1986 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 0 Installed: 10/03/1986 POWTS Detail: Bed (seepage) Bedrooms: 3 WI Fund: POWTS Pretreatment: Unknown Notes Ins or As Built Plumber Other Requirements Additional Notes Money Owed Harold Barber Yes Schumaker, William $0.00 Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/10/2005 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Parcel 020-1170-60-000 12/14/2004 07:56 AM PAGE 1 OF 1 Alt. Parcel 7.29.19.1062 020 - TOWN OF HUDSON Current 1K ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner THOMAS E & VALERIE L SCHMIDT *SCHMIDT, THOMAS E & VALERIE L 333 EDGEWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 333 EDGEWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.020 Plat: 1932-EDGEWOOD ESTATES III SEC 7 T29N R1 9W LOTS 88, 89 & 90 Block/Condo Bldg: LOT 88 EDGEWOOD ESTATES III Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 08/22/2003 737008 2385/564 WD 758/181 2004 SUMMARY Bill Fair Market Value: Assessed with: 49103 220,500 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.020 27,300 143,300 170,600 NO Totals for 2004: General Property 1.020 27,300 143,300 170,600 Woodland 0.000 0 0 Totals for 2003: General Property 1.020 27,300 143,300 170,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 121 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 O Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ..i. ' ~•~-'z TOWNSHIP /East ATo A/ SEC. ~ T A~ N-RZ? W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION sd LOT ~yK9'D LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L %t f. C~ r INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Soy a S ,~Iy Elevation of vertical reference point: /dJ Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: /000 Number of rings used: Q Tank manhole cover elevation:';` SI Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side 0 Rear, ® ' - feet From nearest property line Front 10 Side,0 Rear, O feet Number of feet from: well &Z building: .12C (Include this information of the above plot plan)( 2 reference dimensions to septic tank) , SEE REVERSE SIDE 4W " "*W 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, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Len$th:_ Number of Lines: 3 Area Built: //,1`10" Fill depth to top of pipe: yo Number of feet from nearest property line: Front, O Side, O Rear, (2 It '2 S` Number of feet from well: .S3 ' 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, OFt. Number of feet from well: Number of feet from building: Number of.feet from nearest road: Alarm Manufacturer: InsPector• Dated: d ~T ►f Plumber on job: License Number: p~ 3/84:mj 'DEPARTMENT OF INDUSTRY, ' INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING MADISON, WI 53707 ENCONVENTIONAL ❑ALTERNATIVE Stale Plan I.D. Nurn • (lf asvgntW) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound p 6 -1170 -(~'go NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE: B & H Development 836 St. Croix Street N., Hudson, WI J 3 d76 'd.1A BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.. SW NW, Section 7, T29N-R19W, Town of Hudson, Lots89-90, Edgewood Est. Name of Plumber: JMPIMPRSW No.: Co."" Sanitary Permit Number: Bill Schumaker 6382 St. Croix 79186 SEPTIC TANK/HOLDING TANK: r"s MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKI NG COVER PROVIDED: PROVIDED: ~7~ 77 S DYES ❑NO ❑YES ❑NO d2 I BEDDING: !EN T DIA.: VENT MATE ALARM TER NUMBER OF ROAD: fROPERTY WELL. BUILDING: VENT TO FRESH k Q ALARM IN AIR INLET FEET YES ❑N0 ❑YES ❑NO NEARESTOM 31. ro fJa DOSING CHAMBER: / T MANUFACTURER. BEDDING: LIOUIDCAPACITV JPUMP MODEL PUMP/SIPHON MANUF ACTUREH WARN ING 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 I I NC,I H JD1111AT11HAL 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: BED/TRENCH WIDTH LEND TJJ}~~~ NO OF IDIST11 E SPACIN(V COVER JINSIDE DIA -PITS LIQUID THENS EHIAL: PIT DEPTH: DIMENSIONS ~v GRAVEL DE TH FILL DEPTH UIS7 H. PIPF DISTH PIPE DISTR. PIPE MATERIAL DISTH NUMBER OF PROPERTY WELL. BUILDING: V NT TO FRESH BELOW PIPES gBOV~COVER ELE INLf ELEV~ENU ES FEET FROM LINE / AIR INLET: (/L~~J ' GI'•~~ NEAREST--r MOUND SYSTEM: 91, 9a 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 ❑ NO meets the criteria for medium sand. TIONS MEASURED. SOILCOVER TEXTURE 1PIRMANI NI MAHKIRS OBSERVATIONWELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH RED DEPTH OF TOPSOIL SODDED SEEUFU MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIOTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL INO DISTH JUISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELE V.. ELEV. DIA. ELEV. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS. PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING: FEET FRO3 LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SI NATU E: TITLE. DILHR SBD 6710 (R. 01/82) wlsconsln ~ APPLICATION FOR SANITARY PERMIT COUNTY ~ DILHR J'Itevisoo (PLB 67) OEPRRT TEnT OF UNIFORM SANITARY PERMIT # InOUSTIRY, LRBOR 6 HUR1Rn RELRTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: S--01/4,444/4, S , TAI N, R / jE (or TOWN OF ,,4/ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER T OF BUILDING OR USE SERVED X.1 o Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench F-1 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 OAC Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 3:2 - 112 Jd' j/2-s- ❑ Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): SignatuuX P MPRSW No.: Phone Number: 4 V `{t f ~f j ).SFri Plumber's Address: Name of Desi ner: 26- LLgw lv S COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved L ❑ Owner Given Initial v Approved Adverse Determination Reason for Dis ro . Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 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 pipes). 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 STC-100 This application form to 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 louse"), then a second form should be retained and completed when the property is soya and submitted to this officewith the appropriate deed recording., - - - - - - - - - - - - - - r T - - _ - - - - - - - Owner of Property B. & H. Development Inc, Location of Property _SW NW ,~i• Section 7 T 29N - R 19 W Township Hudson Mailing Addreso P.O. Box 541 Hudson, Wisconsin 54016 Subdivision Name Edgewood Estates 88-90 Lot Number Previous Owner of Property B. & H. Development' Inc. Total Size of Parcel Acre Plus Date Parcel was Created December 1985 Are all corners and lot l aes•identiflable? X_ you No is this property being developed for resale., (spec house) ? x_ Yes No volume 685 and Paso 'Number 44_...5 as recorded with the Register of Deeds INCLUDE WITH THIS PLICATION ONE OF THE FOLLOWING: 1. Warranty Dead , 2. Land Contract , 3. Other recordings filed wits the Usiater of Deeds Office 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 the Certified SurVoy Nap shall also be required. . .R. . PROPERTy OWNER CERTIFICATION I (We) ceAti.6y that aP,+L e.t,aateWAU on thiA onm ane tn.ue to the beat 0j my ( sun l knuwredge; that I (we) as (ane,) the ownen(e~ o6 the tAopenty deecAi•bed in th.ca -tn ju4nwtion 6onm, by viA tue oo a weal deed Aeed in the 066ice o6 the Cuurat y Reg,.eteK o6 Ve,edb OA Document No. 392420 and that I (we) pnebeituy own the. propoeed bite bon the aewaga poeaZrbyatem (sn the have obtained an easement, to )UM with the above deaaaed pkwpenty, 60 coryet4uction o6 said aptem, and the tame has been duty 2~2eeconded in the 066iee u6 .tile County Regi-6ten 06 Deeds, ab Document No. 39 ) 12 SIGNATURE O 0WN R SIGNATURE OF CO--OWNER (IF APPLICABLE). DATE SIGNED ' DATE SIGNED x H a S T C 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County x d a OWNER/BUYER B. & H 'D C. ROUTE/BOX NUMBER P.O. B ox1 Fire Number • CITY/STATE Hudson zip wi• PROPERTY LOCATION; W ,1, 14, Section T 29 N, R 19 W, Town of 'Hudson St. Croix County, Subdivision Edgewood,Estates, Lot number 88-90, 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 ti tank um er What you put into he needed, em c by an a affect licensted he septic o -the 'septic "rank 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 cast of replacement of a failing system, which was in operation prigj;-zu. -a1- 1;-1-93-8-.- St-...,.Croix.-County accepted this program in August of 1980, with the requirement that owners of all new stems agree to keeptheir 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-pite 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 semt'approximately 30 days prior to three year expiration. 'j 0 • x; I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with M 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 Offioe within 30 days of the three year expir*3Jon date, SIGNED ff DATE y 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 SANITARY PERMIT ` IZIDILHR c oun GROUNDWATER SURCHARGE Sanitary Permit No. 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 ` ter S ature of Issul ent Grou^a~er Fee. Date: WiscO . .ce d S 6-- Q - buried DILHR SBD 89 N. 184) s -DEPARTMENT OF r REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INS, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (1,163.090) 111 Chapter 145.045) LOCATION: SECTION: TOWNSH / UNICIPALITY: ILOT NOAS K. NO.: SUBDIVISION NAME: 01 0 j / u~son~ r-10 - EA/mwOO& EST I >w 114W 1 z9 N/R1`~ COUNTY: MAIVIt: MAILING . CO RN N &E' LLOi\,kl -qT INC X36 STCI'o?x Noe TN ~UQSoN ► `~db16 ,atx E DATES OBSERVATIONS MADE [Residence 014K - xNew ❑Replace MARCu 7TS,19 V MAlcu 21,100 RATING: So Site suitable for system U- Site unsuitable for system M 0 V U IN L i K: RECOMMENOEO SYST (optional)(IMdR~1Tt ❑S o l:n1T~WdaLEr~, Y S ❑U S ❑U S ❑U ❑S U I K If Percolation Tests are NOT requi ESI GN ATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: CLKSS S Floodplain, indicate Floodplain elevation: fj :1 1 A I btcvr PROFILE DESCRIPTIONS BORING ELEVATION -IN H S HARA TER OF SOIL WITH THICKNESS, LO TEXTURE, AND DEPTH NIMER IM. B TO BED C OCK IF OBSERVED (SEE ABBRV. ON BACK.) 40-0.6 ALI.TS o.6-2•5 BjNS1L Z•15.7.S Lr$ItM M•S 7'S~ 95.4Z avt > 7.SG Z ' • 8 •SU x}7.34 1~oN L Q, , 0.7 &-SLTS 0.7.3.0 A2n/LS 3.v-7•S ~A 5 t61t B. B- 3 ~~3.g0 0.0•S PLtT'S O.S-5.3 $RNSiL 5.3-6•g ~~S to st' r T f, n 0-0 4 L 74 *Q 5t6R Ircch c M /'3 -3• ARN g 1 C s.4 7,40 89.67 7.4v 3 B- X300 `~7.7 ~©n►6C ~•-$.00 O-C3.5 $ttTL Q-%-/.7 $Q+vhL. /•~-4• Y R~► , 4,17 &LrS /.o-4.o leN L 4.o-1,< -Ra S T6Q B- z 4 4: •SD s- T z• p •c ~T PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME PER INCH MINUTES NUMBER 11>~S AFTER SWELLING INTERVAL-MIN. =-2=p I PERIOD 2 PERIOD-- P- A 1 :z< koNe r S $ SS 2. U P- Z S Z 1 t~otil k 91./► S Z P- 3 6'. 3% 142!ig { 97.25 3 Z /6 P _ - Eysi-I 10 &T 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 hod zonal 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 ~l•9 ` Ntti d U GQc~I-& U'S& & I ! i. i tJ$ i~~f IQ L YKSfiLt { St e+L ON I TOk1n1G-, a, rE R ~N Jas 6 klxs s I _-144 Alt • 1. 5 rtis l t t , rR : t { tp t I i ~ ~ ItY~ _ f h I I : • 6A N a:•e { A TFNaTLrf ■_[i- y~ 24 y a~/7 rR~c e 1 ~ i ;P Z ~ ` ! 1.44t Ohl% 3 N S__ L Hr 1, the undersigned, hereby certify that the soil tests reported on this form we d y' in accord with the procedures and methods specif led 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. A print : TESTS R COMPLETED ON: 1141kdI`Y Jol~ -:~a MAiNIA Zb ADDRESK CERTIFICATION NUMBER: PHONE NUMBER (optional): 407 SrcoNL ST I~lv So 5~a6 4%~ 3 6-40@0 CST SI ATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SOD-6395 (R. 022/82) - OVER - .~cS./...9.~'l."......~ ~o 'e ` • sGt/ ~ L+/ ~ ~ ~..n~ T~.J//lf~~ ~~o,i/ r s~ p~ h~ "Or s ` ~ dT Q~ 1161 A-,,/dUs-ed G"