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Parcel 020-1151-80-000 02/01/2005 04:58 PM
PAGE 1 OF 1
Alt. Parcel 29.29.19.826 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
THOMAS A & JEANNE L AKERS ' AKERS, THOMAS A & JEANNE L
719 GLENNA DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 719 GLENNA DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.202 Plat: 2356-PRESIDENTIAL ESTATES
SEC 29 T29N R19W PRESIDENTIAL ESTATES Block/Condo Bldg: LOT 17
LOT 17
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 957/307
07/23/1997 757/164
07/23/1997 671/379
2004 SUMMARY Bill M Fair Market Value: Assessed with:
48912 271,500
Valuations: Last Changed: 06/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.202 29,600 180,400 210,000 NO
Totals for 2004:
General Property 1.202 29,600 180,400 210,000
Woodland 0.000 0 0
Totals for 2003:
General Property 1.202 29,600 180,400 210,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 149
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
w
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 51'auc Jo~~v~ Son TOWNSHIP i...cl~sO 1, SEC. T N-RW
ADDRESS 7 Z S+- C✓~~ N ST. CROIX COUNTY, WISCONSIN
14 J5 LU
SUBDIVISION a.r 7" OT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- !ta Di. vo_,
S f = vd So lea , S o ~Q
32
- S
c f
2a ~ ~
i T
Ho4 sar
2gX pro' ` I U
a 14 XZ9i/
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 1"e, L"
Elevation of vertical reference point: ~
Proposed slope at site: 1-.2 oXe, 5 (,J
SEPTIC TANK: Manufacturer: GfJa t'S !!,Y Liquid Capacity:
Iffioutl
Number of rings used:
Tank manhole cover elevation: 99,t~n ~
Tank Inlet Elevation: /
Cp,q0 Tank Outlet Elevation: 9&.05"
Number of feet from nearest Road: Front,O Side,O Rear,
feet
From nearest property line Front'',O Side,O Rear, ®
feet
Number of feet from: well building:
r20 F, rm, N U1 C_: kdv. 11~ t-o o w.. Loa c.
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
I
SEE REVERSE. STDE
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:
Ft .
Number of feet from nearest property line: Front, O Side, O Rear,
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: (,p r. J cvt+ rn. ( Trench:---
Number of Lines: 3 Area Built:~.'f
Width: Length:-"
Fill depth to top of pipe: Z
Number of feet from nearest property line: Front, O Side, Rear,0 Ft . ? _
'
Number of feet from well: 150
Number of feet from building: 3S ,
(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: ~T 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: ~'7~+-^^/` J7
Plumber on job:
Dated :
License Number: !u`
3/84:mj
EPARTMENT rfFANDUSTRY, INSPECTION REPORT FOR '
ABOR&,HUMAN RELATIONS SAFETY & BUILDINGS
.o.~BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
AOISON, WI 53707 BUREAU OF PLUMBING
RICONVENTIONAL OALTERNATIVE rr=
Holding Tank O rn-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER.
INSPECTION DAfE-
Sam Miller (Darrell Lewis) Rt. 1, Box 282, Hudson, WI 54016 f UAT ,
BENCH MARK IPermanenl reinaote pomtl DESCRIBE IF DIFFERENT FROM PLAN
REF. Pt. ELEV.: CST IEEE PT II
SE SW, Section 29, T29N-R19W, Town of Hudson, Lot 17, Presidential Es
II Pturnlwr.
MP/MPRSW No.. County- SannarY Per m,t Number .
Dou las Strohbeen 5432 St. Croix
EPTIC TANK/HOLDING TANK: 83849
MANUFACTURER` r e / Q
(J~J(s J/' LIOU CAPACITY TANK INLET ELEV. TANK OUTLET ELEV WARNINDED G LABEL
PROVI LOCKING COVER
ONO Y BEDDING VENT DIA VENT MAIL. 111GHWATER YES ONO I~JYES ONO
n ALARM NUMBER OF ROAD: PROPERTY WELL BUILDING VENT TO FRFSH
YES NO FEET FROM L'NE
❑YES ONO NEAREST CP V
DOSING CHAMBER AIRLET
:
MANUFACTURER 8FDOING LIQUID CAPACITY PUMP MODEL PUMP SIPHON MANUF ACTIMEH
WAHNIN(~LABEL LO
❑CK ING COVER
YES ONO PROVIOEU PROVIDED
GALLONS PER CYCLE--.-UMPANDCONTROLSOPERATIONAL OYES ONO ❑YES LINO
(DIFFERENCE BETWEEN NUMBER OF PHOPF IIIy WE L( BUn DIN(, VENT TOfH(SII
PUMP ON AND OFF) O FEET FROM LINE AIR INII I
SOIL ABSORPTION SYSTEM. Check the soil moisture at thedepEh of pl owinO NO (NEAREST->
or excavation, (If soil can be rolled into a wire, construction shall cease until FORCE t1 IF 14 "nl "1'At AND 10ARk IN1.
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO F Dlslw PIPE SPACING CO
DIMENSIONS T1+EN' TE IN.SHniil.i zpiS 110011)
PIT DEPTH
r,Hn VIL OF PTH FILL UEP 111 UIS 111 PIP! .Sri 111- III LOW PIPE ABOVE)VkN "IV INII I DISTq. PIPE MA TERIAL
ELEV NO NO DISIR NUMBER OF PHOPEHIY WEL1. HUILUING VENT 111!111 tar
i PIPES ~j FEET FROM LINE
AIR INLE f
OUND SYSTEM: NEAREST--,p~~
M
Mound site plowed perpendicular to slope
and furrows th Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
thrown upstope: mound systems to make certain that it . ON REVERSE SIDE. SHOW ELEVA-
OYES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TFXIUHE
Pf HMANI NI MAHKI HS Olist I+VAlIr1N WI t I s
UFPTHOVEH TH{NCH RED DEPIIIOVFH TNENCH BED OYES
LINO
CrN T ER EDGES ONO DYES -711,
I)EV111 OF iUVSOII. SODU") SfFUIO MY PRESSURIZED DISTRIBUTIONYSTEM: YOYES DNO ES DNO
BED/TRENCH WIDTH LF Nulli NO.OF LATERAL SPACING r;HAVfL OF P71/NILOW
DIMENSION, TRENCHES 111 L DEPTH ANOVI COVE H
MANIF 0I D POMP MANIF 01.1)
ELEV
UIS/H PIPE MANII OLI)MA EHIAI NO OISTH =:;:%#,Ipl ELEVATION ND E
LEV o1n ELEV
DISTRIBUTION
INFORMATION HOLE SIZF HOLE SPACING DHIL( ED(:D/iHl CITY
COVER MATERIAL VF Ht ICAI 111 I I;()FiNf SPON US 10 nPPlinvl U
❑YES PANS
COMMENTS: PERMANENT MARKER ONO OYES LINO
OBSERVATION WELLS. 1
NUMBER OF PROPER
Orr WELL BUILUING
YES ❑Np OYES FEET FROM LINE
ONO NEAREST
Sketch System on
Reverse Side. Retain in County file for audit.
SI iN T E '
II LE
DILHR SBD 6710 (R. 01182) L~
y
7g
E::E
_
DILH a SANITARY PERMIT APPLICATION ISTAT
R In accord with ILHR 83.05, Wis. Adm. Code
NITARY
pERMIT#
.Attach complete plans (to the county copy only) for the system, on paper not less than S~L7 9
8'/ X 11 inches in size. STATE PLAN LD, NUMBER
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. jRARIANCE ❑
PROPERTY OWNER ❑ Y PROPERTY LOCATION ES NO
PROPERTY OWNER'S MAILING ADDRESS Z , N, R E (o W
QE / LOT NUMBER BLOCK NUMBER SUBDIVIE ~1-
CITY, STATE _ ZIP CODE PHONE NUMBER
IT NEARESAKE OR LANDMARK
Wy S B 1r O VILLAGE: 4
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family_ OR
❑ Public (Specify):
111. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. X New b. E1 Replacement c. ❑ Replacement of d. ❑ Reconnection of e.
System System Septic Tank Onl ❑ Repair of an
2. ❑ A Sanitary Permit was previously issued. Permit Only an Existing System Existing System
3. ❑ An Existing System has been inspected and soil conditions meet minimum rDate Issued
equirements.
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. Pnl Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. 1:1 Pit Privy d. 1:1 Vault Privy e,
In-Fill Tank ❑ Mound f. ❑ IGP
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. Seepage Bed b. ❑ See a e Trench c. El 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):
Co / X Private TANK CAPACITY Feet 141 Private ❑ Joint ❑ Public Site
INFORMATION in allons Total # of New xisting Gallons Tanks Manufacturer's Name Prefab. Con- Steel Fiber- p.
Plastic A
Tanks Tanks Concrete glass A
structed pp.
Septic Tank or Holding Tank OOQ LL) a, 1, 4<✓ ® ❑
Lift Pum Tank/Si hon Chamber ❑ 1:1 ❑ ❑
VII. RESPONSIBILITY STATEMENT F-1
❑
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:
T) Lc
Plumb r Address (Street, City, State, Zip Code): 1 S Z. + 3-7•~.7
Name of Designer:
VIII. SOIL TEST INFORMATION 1 ^ n a~ l~
Cert'fied Soil Tester (CST) me 1 ~l [`~j1 Q
/r% S o CST #
T's ADDRESS (Street, City, State, Zip Code) r G? ~
P e
111!11, jaw."
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater
Approved ❑ Owner Given Initial Ile
S rcharge Fee ate Issuing Agent Signature (No Stamps)
Adverse Determination ~4e- •
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
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-I 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:
1. Property owner's name and mailing address. Provide the legal description where the system ;;s tcl be
installed;
Il. Type of building or use served: Ii 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;
III. 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
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license
form. r winh appropri me prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only; application is disapproved.
X. Comment area for use by county or resaon given when app
Complete plans and specifications not smallrdthan 1/2 x 11 rawnto scale lorhwith complete d mensionsh ocationyof he
plans must include the following: A) plot plan,
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
commQnly known as-the groundwate~ protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground}gates a
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's ;
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried treasure
is used in, your building is returned to the groundwater through your soil absorption . l
ILD
system or the disposal site used by your holding tank pumper.
The monies collected through these sijic:i-targes a e credited to the groundwater fund adminis.. f 1!~
tered by the Department of Natural R-asources. These funds are used for monitoring grou d-
water, groundwater contamination investigations and establishment of standards. Ground\ ate` ,
it's worth protecting.
SBD-6398 (8.03/86)
.
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 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 SA /n 411,+14f f l Gt/ s
Location of Property ~jE
- 14, Section TQ?d' N-R W
Township &ee
Mailing Address ~ee Z-
Address of Site- Ig-vi na Dr.
Subdivision Name
jm
Lot Number
Previous Owner of Property S ld } S
Total Size of Parcel %./~r¢;r S
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 Y~~....~.. and Page NumberJ7 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
1 (We) ee tisy that att Statements on this Sotm ane true to the belt o6 my (oun)
knowledge; that I (we) am (ahe) the owner (,s) o6 the pro peh ty deg cA i.bed in this
insonmafii.on SoAm, by vi tue o6 a waAAanty deed recorded in the 066ice o6 the
County Regi step o6 Deeds as Document No. ; and that I (We) pta enemy
own the pnopoaed site Son the aewage di.6pod aye em (on I (we) have obtained an
eabement, to nun with the above descA bed pnopeAty, Son the eonatnucti,on o6 .baid
bybtem, and the aame hae been duty neconded in the 046i.ce o6 the County Regi6ten o6
Veedb, ab Document No. 3,J -7,1T_) ,
.SIGNATURE OV.OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE
DATE SIGNED DATE SIGNED
t
STC - 105 r
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
nn y/~ a
OWNER/ BUYER AECVt
ROUTE/BOX NUMBER Z9 Z.- Fire Number
.CITY/STATE ~-~Gr tl SD`► !~C/~ ZIP ~~Q/
PROPERTY LOCATION:-2'r_;4, 5_W''4, Section, T 2_1N, R ~ W
Town of 144 .Sn n , St. Croix County,
Subdivision rQ i OE ~ql Lot number/Z.
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 pelt 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 x
the standards set forth, herein, as set by the Wisconsin Depart-~v
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,
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
•
1NIT
DEPARTMENT OF REPORT ON SOIL BORINGS AN~,1/ SAFETY & BUILDINGS
LABOR d'ND PERCOLATION TESTS ( 1 1151 DIVISION
HU(fIIIAN•RELA'fiONS P.O. BOX 7969
(1,163.090) & Chapter 145,046) ` I MADISON, WI 53707
A I Ni ION: TOWNSHIPpLIGpyo,~[;
S'6 1/4 7/ A C/ IT27019 to OT+~NO.:BLK No.: SUBDIVISION NAME:
COUNTY: WNE s.~~. / YC t' t[
.BkliFEff'S AM MAT_ N AUMITSS:
cSf ~0% Mt~/tr ~~4Jll~ ud O w.S S Q
USE
NO, BE DRMS : M R L DESCRIPTIO DATES OBSER ATIDNS MADE A
NS'
[Jj ~esidence /V JNew ❑Replace R. ES S:
S
Ar /1,0
ig, S- Site suitable for system USig, 6 .C? X
B
41 1
ONVE q Site unsuitable for system
MOUND: i(~I•GR6UN FILL OLDIN TANK: RECOMMENDED SYSTEM: (optional)
r;;YIS ❑U ®S ❑u ❑U ® ❑S U /
F ercolation Tests are NOT required SIGN RATE:
er s.H63.09(5)(b), indicate: ♦i ~i If any portion of the tested area is in the
Al .'A Floodplain, indicate Floodplain elevation:
PR FI E DESCRIPTIONS
NUMBER DEPTHW ELEVATION BS
BORING TOTAL/ P HT R U DWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
TO BEDR CK IF OBSERVED SEE ABBRV. ON BACK.)
B- I ~ ~au~ ~ 7s,
Vie S/ 1 3 3 5
S S.
s~ is ns .3 cs
B- Y. If, P F' oil I/
/rkAi i 7 71! r .S /Jh / s O J( Qh S
B- . oZ-' fo,~tc 7 '
PERCOLATION TESTS
1 TEST
NUMBER DEPTH WATER 11.4 HOLE TEST TIME -DROP N WAT R L V -IN HES TES
AFTERSWELL_ING INTERVAL-MIN. I RATE IN H
P. / e %p PER INCH
P. ' /1101 G -3
P L.
P-
P-
EEHE=
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 pesoam
of land slope.
SYSTEM ELEVATION 9y. 7 '
(r, _
e
o~
Ci :of;
- a B j TN
a
J _
I
Opt
L
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 :
`J / i TESTS WER OMPLETED ON
: :
L/ t dVSJ►d ~L~jf -.2- -4pc
ADDRESS
ION NUMBER: PHONE NUMBER(optional):
7/s- 3J66 -
ST G TORE: r
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82)
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