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Form - S T C - 104
y AS BUILT SANITARY SYSTEM REPORT
'"--r pr'h/.Nrnso"SEC. /2 T W
OWNER te
ADDRESS /1/ ST. CROIX COUNTY, WISCONSIN
/~rt~, r r y roNE e„ 9-P
ro 1 G ~
1111al)SO'." L'zu' S410)6-- CC)
SUBDIVISION T. /24sx LOT LOT SIZE
('tATSyni
PLAN VIEW
Distances and dimensions to meet requirements of ItLHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- _
0 ~°eo~o/mq / OPo2Ty N _
yQ 6/1-= ToP yr CrOatr TE A5 D, \ 20A0
lS 6LV. =J00, 00
p / ,mom
:VENT STACK
6T ~
0
/'/iot'Eni Y I j
,~r
14LT. SS?F /
r \
1
0
I
IVEW
/Cnarriey "
i
/ LANE
~ 1Z.Ad
//toPoSEO In/tLL ~ ~ /
f,
3°
~r
y- NIP J~owf2 So U7/J PAOPE&TY Lr~ E_ INDICATE NORTH ARROW
mow.
BENCHMARK: Describe the vertical reference point used C,'64 T-.y. 12ox
Elevation of vertical reference point: 20,0 0 Proposed slope at site: .9- %
SEPTIC TANK: Manufacturer: W~aE(z' Liquid Capacity: L
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road.: Front, Side Rear, Q 0 feet
-From 'vearest-preperty line': Front 10 Side 10 Rear,0 ?c9,- feet
Number of feet from: well S~ , building: //"9-
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
t
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: Lenth: Number of Lines: Area Built: C b
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear, 0irt.
Number of feet from well: C'> L7
Number of feet from building: y~
(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: ~oC ~b Plumber on job:
License Number: ~1J~,f ~,Da
3/84:mj
pp-
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 - BUREAU OF PLUMBING
,=MADIS&N, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan I.C. Number:
(
Holding Tank ❑ In-Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDERI ADDRESS OF PERMIT HOLDER: INSPECTION D TE
Jim Stewart Krattley Lane, N. Hudson, WI 54016 ' 3~Z c
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
NE NW, Section 3, T29N-R20W, Vill. of N. Hudson, Lot#24, St. Croix Sta
Name of Plumber: IMP/MPRSW No. JE7 I,.. Sanitary Permit Number:
Gar Za a 3300 Sun t. Croix 75019
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL JLOCKING COVER
J q r ' P OV ED: PROVIDED:
1 I 95, a2 5 l S 0 L~ YES ❑ NO ❑YES NO
BEDDING: VENT DIA.. VENT MATT HIGH WATER NUMBER OF ROAD A PROPERTY WELL: BUILDING: (VENT TO FRESH
ALARM FEET FROM I✓ LIN AIR INLET.
❑YES O ~e C- ❑YES ❑NO NEAREST-
DOSING CH MBER:
MANUFACTURER BEDDING: LIQUID CAPACITY JPUMP MODEL 1PUMP,11PHON MANUI ACTIIREEi WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
[:]YES ❑NO [:]YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: rMP AND CONTROLS OPERATIONAL NUMBER OF I'HOPERTY J WELL BUILDING I(DIFFERENCE BETWEEN FEET FROM `l NE AIR INLET.
PUMP ON AND OFF) ❑YES ❑NO _ NEAREST -0.
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing - JOIAMIT111 111ATIRIA1 ANDMARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYS7 EM:
WIDTH. LENGTH NO. OF MIPI SPACING, COVER [NSIOL PIA -PITS LIQUID
BED/TRENCH r.ENCHES TERIAL PIT DEPTH
DIMENSIONS I L4 Ir
UHAVCL DEPTH FILL DEPTH PIS7 H. PIPE UISTR PIPE DISTR. PIPE MATERIAL NO DI NUMBER OF PROPERTY WELL. BUILDING'. VENT TO FRESH
BELOW PIPES ABOVE COVER JEL hNtf I EL V. ENU PIPES FEET FROM LINZ5 0 AI INLsET.
-7 C~ NEAREST
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PEHNIANINIT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH 1111, PE PTH OF TOPSOIL SOP DE II SEEDED MULCHED
CENTER EDGES
❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIOTH. LENGTH NO.OF LATERAL SPACING GHAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH UISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA. ELEV. PIPES DIA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLAnIs
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE.
❑YES ❑NO [:]YES ❑NO NEAREST
C3
01/
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE r~ TITLE: /
DILHR SBD 6710 (R. 01/82) ~/J
un5mn51n APPLICATION FOR SANITARY PERMIT
COUNTY
DILHR (PLB 67) UNIFORM SANITARY PERMIT #
~ DEPRRTTEr1T OF
-mmom' In...TRILRBOR 6..rnRr1RELRT,on5
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAIL NG ADDRESS
F / ✓
PROPERTY LOCATION 'OFF""
.E 1/4f✓1~-1/4, S -3, IA J, VILLAGE:
N, R A2L7E (or) W teWra-eF: v~T J
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
■ 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
N New System ❑ Tank Replacement ❑ Repair
D Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A,CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
N Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
Ell 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 As- '
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: /Z
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):
U 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): Signature: /MPRSW No.: Phone Number:
vv (2)S ► .3P6-.2rsa
Plumber's Address: Name of Designer:
Gs .r. s"
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: ID ate: ❑ Disapproved
rj J ~p f ❑ Owner Given Initial
!i ~„d CX~(v O YApproved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
a w 1~
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 r '
A
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
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 5-L.
Location of Property , Section l N-R 20 W
Township A (a O ",<T fi 12 ~Q6!"
Mailing Address
Address of Site
~j f^~ U oSON ` W~5 T d ! (o
Subdivision Name 4, ~ Ieo tX :>I-A
Lot Number
Previous Owner of Property C) xj
Total Size of Parcel / d aCA44_"
Date Parcel was Created 2 2 ^ ( q
Are all corners and lot lines Vdentifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes_ No
Volumes and Page Number 12 3 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
I (We) ceAzi.6y that aft Statements on this 6oxm axe tAue to the but o6 my (ouA)
knowledge; that 1 (we) am (cute) the owneA(z) o6 the pxopwy descA bed in this
in6oAmation 6oAm, by vi4tue ob a watvcanty deed Aecoxded in the 046ice o6 the
County RegisxeA o4 Deeds as Document No. go 9 ZS 7 ; and that I (We) piesentty
own the ptopoded site sot the sewage dispoA system (oA I (we) have obtained an
easement, to tun with the above desc&ibed ptopeAty, 6oA the construction o6.6aid
.system, and the dame has been duty %ecoxded in the 046tice o6 the County Regi6teA o6
Deeds, as Document No. 1,097$ Z J .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
NED DATE SIGNED
i
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
d
_ a
OWNER/BUYER
f J +
ROUTE/BOX NUMBER Fire Number
:CITY/STATE H V t)r'G' Gv iS ZIP-_5 616
PROPERTY LOCATION:&E-'k, PiVk, Section, T N, R20 W,
UIlof q U ldco
St. Croix County,
/VO t~_~n)
Subdivision ST,C,901C ,57-4 UI(1 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. y
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- 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.
SIGNE c a L C f'✓;-t. /V 'L,
DATE
St. Croix County Zoning Office
P.O. Box 9B'
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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N O
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND' PERCOLATION TESTS (115) P.O. BOX 7969
yHUMALV RELATIONS \ / MADISON, WI 53707
y~ (H63.090) & Chapter 145.045)
L ATIOIQ: SECTION: T Y: LOT NO.. BLK. NO.: SUBDIVISION NAME:
NC '/4 13 /T29 N1112-0 E (or rY of i1/0ry, #vore4.) z yr j_ c ol•x $T~ri c,v
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
ST GRofx J'IM STEwhRT- TTvDS013 Ohio
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: P O FILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 pe KNew ❑Replace l~/~ G}Q~ TAN . /D 1986
wi vTfe cD.vD1Tio.VS S ov", y Vf "I';wv $7- 1 60
- -7~G
RATING: S= Site suitable for system U= Site unsuitable for system 'rUAwV ' 3 / - 31? 'F • /d -S&
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
lilS ❑U lilS ❑U D S ❑U ❑ S KU El S 2U ~'ovv>FVro"v~/ 4a
if Percolation Tests are NOT required DESIGN RATE If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: L'L/1'.ts Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS SC S S'~ f/u/3L3~4ipv S
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH TVMKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
' 133' cx-av. s /0' y~ ;e.
B- C 73 yz' ae R.?. s. .83 ",.6,v. s 610e 3.5 rw c
B-Z 193 9~.1 P > I& 6:,e-B,-/S, /.o' /s .2..0'd1f-edZ44 s
B-3 & 74-70 33' 8A,. S~ zs o,P ~ou.PSg
s.
/s 3, v lka
B- 1 •~D~ 6'P '6'V . s . &je . a.o
rm%wS - 3, , S-,
B-y 97 ,y > ~ •~3',Cfro•G,P. ',ems. IS 33" ezt't
s. -
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER meltES- AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ X3 loct- &
P-
P- v 3.7 Z
P-_
P-3 .2 L i iCP
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 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 percent
of land slope.
SYSTEM ELEVATION
Yo _ _ € e . l"T1~~Q~~F'1~• L a1r
(ob 7"4
I
o gyp' s' 5~ z6) -5CALI~7 30
So
' I 3
E
E
_ ~
i
Thit
for fete
E I
o
wry, ~ ~e
ptlb~ ten
1, the undersigned, hereby certify a e soi tests reported on this form were made by me in accord wi 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.
16 7
NAME (print): TESTS WERE COMPLETED ON:
20/3 ER7- 7,14d e . pq - / 184,
ADDRESS: , CERTIFICATION NUMBER: PHONE NUMBER (optional):
Rr-3 O Nell v ''~G~. Syd/(~ SSr6Zy~1--- I? S
CS SIGNATUR
')riginal and one copy to Local Auth t Z d Soil Tester.
9. 02/82) - OVER -
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L'^T O S For PLETIP' FORM 11 - S -
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ly i " silence project;
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Parcel 161-1094-50-000 01/03/2007 02:54 PM
PAGE 1 OF 1
Alt. Parcel 13.29.20.748 161 - VILLAGE OF NORTH HUDSON
Current X' ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
0 - MATEV, KAMEN G
KAMEN G MATEV C - MATEVA VESSELINA S
MATEVA VESSELINA S
273 STATION CIR N
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 273 STATION CIR N
SC 2611 HUDSON
SP 1700 WITC
Sir,.
Legal Description: Acres: 0.000 Plat:
ST CROIX STATION LOT 24 VIL NH Block/C
Tract(s) /4)
13-29N
~o a 3
Notes: Parcel History:
Date Doc # Vol/Page Type
08/25/2003 737271 2387/497 WD
903/274
731/123
2006 SUMMARY Bill Fair Market Value: Assessed with:
181788 473,000
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 112,000 315,300 427,300 NO
Totals for 2006:
General Property 0.000 112,000 315,300 427,300
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 112,000 315,300 427,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 313
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00