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HomeMy WebLinkAbout030-1018-40-100 C d li 3 d O M co~ c I 7. 3 H• CD 1 .0 w ~ 3 \ 1 a gz °mc I ~~°w `c • C1 y O ` NO F•y 3 N 8 3 Q N Z n W I D (D C N r~ 1 a- 3 O O 00 N O OO 0 S O-1 n y o C) O p = N i to (n d A I O"' f ~ m a a 0 v V 3 0 ~ 8 CD N W = "ft" a ID co yl n r N CD 00 00 N o c N O O N. fT c Z I Z Z O O gOg o N~II o Nz `~Q co Lo v v, o ' 3 I~ FD' cp m P o m co Z-lz D oo m M o' =r @ y "*A • Z (A N Z N 7. v N ca fo a CD a 3 ? Z 7 I A Z m n a A Z m O o : (p N CT m CL z 3 o I Z N j O z a f W I =s a C I N y ~ G O N CD o Z C. = v o o m m N i cn ~d ,I fi Dm ~ y 5D 0 oo a oo t O fi ? A co ti a v X o o O A o CD 0~ N C V ti cjn O O I ti O ~ Parcel 030-1018-40-100 02/17/2005 05:07 PAGE 1 OF 1 F 1 Alt. Parcel 05.29.19.77C 030 - TOWN OF SAINT JOSEPH 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 * TUMA, TIMOTHY E & PATRICIA N TIMOTHY E & PATRICIAN TUMA 1167 ROLLING HILLS TR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1167 ROLLING HILLS TR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 10.010 Plat: N/A-NOT AVAILABLE SEC 5 T29N R19W PT SE NE LOT 2 CSM Block/Condo Bldg: 6/1648 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 05-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 739/408 2004 SUMMARY Bill Fair Market Value: Assessed with: 4855 307,300 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 10.010 121,900 180,400 302,300 NO Totals for 2004: General Property 10.010 121,900 180,400 302,3000 Woodland 0.000 0 Totals for 2003: General Property 10.010 71,400 131,500 202,9000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 205 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER mnT,l Y Tt~nt q TOWNSHIP M SEC . T AN-R_2W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7e cL. Q e g C, 31S wZ W2 S 1U lu v4 z z (AJ 2 2 ~DUSE tU INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: 1D010 Proposed slope at site: a SEPTIC TANK: Manufacturer: k5 Liquid Capacity: (;A)1QA] Number of rings used: --0_ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,kV Rear, O / feet .From nearest property line Front, 0Side QRear, 0 feet Number of feet from: well - A4M--, building: ti Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE STDR r ~ 7 UMP CHAMBER facturer: Liquid Capacity: Pump Model. Pump/Siphon Manufacturer: p Size Elevation of inlet: Bottom of tank elev on: Pump off switch elevation: Ga s per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from neares property line: ront, O Side, O Rear, 0 Ft. mber of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: _ Trench: Width: Length: ~i Number of Lines:-- Area Built: 24111 Fill depth to top of pipe: /g Number of feet from nearest property line: Front, O Side, Rear,0 Ft. ~ Number of feet from well: IZ I_ Q, Number of feet from building: 6 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: iquid depth: Bottom of seepage pit elevation: Area uilt: Has either a dr box O or distribution box O been used n any of the above soil absorbtion sytems? heck one). HOLDING TANK Manufacturer: Capacity: Number of rings used: vation of bottom of tank: Elevation of inlet: Side, O Rear, 0Ft. Number of feet from n est property line: ront, O umber of feet from well: Number of feet from building: Number of feet from nearest road: rm Manufacturer: : Inspector. Dated: C Plumber on job: - License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. BOX 7969. PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ ALTERNATIVE State Plan I.D. Number: s ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (lf assigned) NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER Timothy Tuma Rt. 2, Hudson, WI 54016 INSPECT_ ION DATE. BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. _ r~ 14 ~ REF. PT. ELEV.: ILST REF. PT. ELEV.. SE NE, Section 5, T29N-R19W, Town of St. Joseph, Lot#2 Name of Plumber: MP/MPRSW No. County Sannary Permit Number Donavin Schmitt 3205 St. Croix 79161 SEPTIC TANK/HOLDING TANK: MANUFACTURER. n LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: BEDDING: VENT DIA.: VENT MAT( HIGHWgTEH YES ❑NQ ❑YES ~NQ ALARM NUMBER OF ROAD: PROPERTY WELL: BUILDINVENT TO FRESH ❑YES NO FEET FROM ♦LIN,~~ J~ gIRIN~ET ❑YES NO NEAREST /r DOSING CHAMBER: MANUFACTURER BEDDING: LIO UIO CAPACI rY PUMP MODEL PUMP:SIPHON MANUE ACiIIHEH WARNING LABEL LOCKING COVER ❑YES ❑NQ PROVIDED. PROVIDED GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES ❑ND ❑YES ❑NO (DIFFERENCE BETWEEN NUMBER M LINE arv WELL BUILDING (VENT TO FRESH FEET FROM NE AIR INLET PUMP ON AND OFF) ❑YES ❑NO _ NEAREST 11, SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing AAME TER MATE HIAL 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 wloTH LyH No of ulsrH PIPE sPACIjN o VER °1I THEN' FS INSIDE D I A ~PITS LIQUID DIMENSIONS {RIAU PIT (O DEPTH 71 "EL DEPT, FILL DEPTH DISTH. I DISTR PIPE DISTR. PIPE MATERIAL O DIS 9 BE LOW PIPE OCOV EH EI V INLF f NUMBER OF PROPERTY WELLBUVENT TO FESH PES FEET FROM LINE. AIR INLET N_EA R EST--o_ 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 ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER rexruRE PEHM11ANf Ni MAHKF HS rO( NATION WFLLS YES ❑NO YES ❑NO CENTER UEPTH OF TOPSOIL SODUFU ISE F DFU EDGES MULCHED ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BE WIDTH LENGTH TRENCHES ~O OF LATE HAL SPACING GRAVEL DEPTH BELOW PIPf . FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTHIBu-JeJ PIPE MATERIAL & MARKING ELEVATION AND ELEV. ELEV CIA ELEV PIPES DIA DISTRIBUTION INFORMATION HoLESIzE HALE SPACING ORILLEDCORHECI LY COVER MATERIAL VERTICAL LIFT COHRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: =FFEET UMBER OF PROPERTY WELL BUILDING: FROM LINE. YES ❑NO ❑YES ❑NEAREST Sketch System on Reverse Side. in county file for audit. I SIGNATURE:, TITLt DILHR SBD 6710 (R. 01/82) wmcons,n APPLICATION FOR SANITARY PERMIT D I L H R COUNTY - OEPggTmEnT OF (PLB 67) , mIXJGrq EnTgGWUmgnqELqTlons UNIFORM SANITARY PERMIT # -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 MAILING ADDRESS PROPERTY LOCATION CITY: VI E: .54.1/4 4'rt~~ N, R E (or) OWN OF: <S 1 IT,- S _ „ Xyl LOT NUMBER DIVISION NAME ST~ROA~D, LAKE OR LAN MARK STATE PLAN I.D. NUMBER ~ TYPE OF BUILDING OR USESERVED 4/0_l6) 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): 0 THIS PERMIT IS FOR A: 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 ❑ 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 Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity t e Lift Pump Tank/Siphon Chamber - Alt) Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks ncr to Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: Private -71 Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature- ) M MPRSW No.• JP3hone Number: 1 e sT Plumber's Address: Name of Designer r: Zr ~fV 6 4 COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Q' /1a~ ❑ Disapproved ❑ Owner Given Initial Approved Adverse Determination Reaso for ap va . Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber ' r INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 f f 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. s 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.-i, , Location of Property it ,/&F14, Section , T t' N - R W Township Mailing Address Subdivision Name . Lot Number Previous Owner of Property Al BA . Total Size of Parcel =U Date Parcel was Created ;j - - Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes- No Volume and Page Number -Ye Z as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register 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 Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) ee4ti.6y that att .6 to tementa on .th iA 6o, %m ahe tAu.e to the but o6 my (ouA ) knowe.edge; that I (we) am (cute) the ownen(6) o6 the phopeAty ducAi,bed in .th.ia .in6o4mati,on 6onm, by viAtue o6 a wa,4Aa.nty deed keco&ded in the 066ice o6 the County RegiA teA o6 Deed6 ad Document No. ; and that I (we) pnebent,ty own the ptopobed Aite bon the sewage d.Upoh dyd.tem (o,% I (we) have obtained an easement, to hun with the above de4cAi.bed pnopenty, bon the conzt4ucti.on o6 said dye.tem, and the tame had been duty teco4ded in the 066ice o6 the County Regia ten o6 Deed6, ad Document No. ZZLa , ~f SIGNATU F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H z . H STC - 105 r r ' a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 0 z _ d OWNER/BUYER ROUTE/BOX NUMBER Fire Number .CITY/STATE ~7CJ/7Sl7oV p~ ZIP PROPERTY LOCATION:_j'6~- 1, /VZ':7'14, Section_6 T,g Z N, R 2 W Town of 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 three year expiration. H 0 I/WE, the undersigned, have read the above requirements and agree £ z 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. SIGNED G' DATE St. Croix County Zoning Office P. 0. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. L , D N r C N ? f/1 Ul "33 O l< p 7 V 0 fD a 7r A n? 2 p a = 0 ~cc ~o coww~<l<< ccoco N m ~ o ' c N N N A 7 N1 m -a 0 X00 U * - 13 +(~Dp(O 0 CD c~D°ma0~ 0 Er CD CD -1 CD 0 ~r o 3 a c W m 3 E; (a :3 g oc ~.~co: ~ h 0 c c3 o a o 3 Z=r c`~ Qp p m o -•o a~ -at°o~v D << Q~co ao 0 cD N O D c m ~o 2=o ~0 C) c cc -.w _o _ ° o ° o a ' CD 0 cr 11, C m 'NC o(D Lo Z N U) l (D ID o 3::wn~ia D D am 0 3 cn ~w=ono m a~ ~NOa mv,~a~w N 'a ?w ac cD C m o ~!m 3cs vCD 3 7~ cn (D In 0 N i W W Q W ! w o= m ~19 0, in w ,n o ao a ccn c c caw o m w CL (D cr :3 r ~n l< co ? cD 3 co n to p !nUE S m m m c O y n fD O 7 c m' n C CL c CD a o a °c f° N " m '.ice =r o o a c a s c c w 3 0 -3 CL CD :3 0 - W a O < 3 CD CD p DEPAFfTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS LNDYJSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS • \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: OWNS UNICIPALtTY: LOT NO.: BLK. NO.: SUBDIVISION NAME: sp-UE'/a ~/a s TZ9N/R19Ecor s~V sos~ Z c,s•m. COUNTY: OWNER'S UYER'S NAME: MAILING ADDRESS: S7 • c ~A 1X 1J Q Iq v t2 ~.~`T~ Z ~Lv C1Z U~-S , w S ~I pZ.2. USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRI PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence _-3) I~' A. PTION: New ❑Replace I / 3_ 17~-8- a 6 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U OS ~U 1 IS ❑U ❑S MU ❑S MU 2nZe'u CHIES-G?\ Ct1 S'x 90 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: Floodplain, indicate Floodplain elevation: ' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER4 RI'~FIE•6 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH If. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- \ 6, 6' loy.o' »~JC 6.6' @S'Gvc1lTs;o•8'Bnsil;3.y'~,~\S; ~.9'Okt o• 6' an sil TS ; ~•9'ensil ; Z.S' B►, ~s;o•y'l3ns1 . B- 2 S l b3• o 7 6. 5 ©.-Z" Bh \ - 0 9' 8h Is 0.'1' 8>ns{1TS;o~'~~si);cs.8'Bt1G~si;Z.6' B- 3 6-y °l`1.S ~I > 6.y By%kS • 1.6'3 \S w s RN B- L/ 5 Ct • 3+ t 1 6. S O• °I 1 13 h S 1 1 T5 ; -Z, 3' 3 h s 1 1; l- 6' '8h S -VA t't-w SL~GIyTL DETaSF SI ,PO \.1' 3h 'FS I 0.8' 9nsil TS; -o' 8,, ls; 1.3'8rt Gv-lS; z_s' 13-S 6.S 1 0.3 tl 7 6• S Bn 5 O.9' t3 LCwZs1- stpr OF PIT- 1S T ER ST Stb of PtT~ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER 3 PER INCH P_ 30 110 3 0 1 1 ~S!/6 3 Z P_ Z 3 p 1v o 3 p Z 5/g Z 5/g 5sg P- 3 3® TJD Z Z ~/s 5 P P- 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. O 9 9 L ® 9n►'I~T ~RCE SO Cl~ k . p Jr►q, SYSTEM ELEVATION ®g a -7' g r;• 3 - t i ~ ~ R 8 $ 1:F 1, ~O -pro I'~ 2. w ap t J 1- Fr P. I I~$3 1. C i S1 IL _yd _ J E S W l CID ' to G ZZ S O 'Z'!1 s Ind i -4 I > i EP CyT ~I b i jP E I,.o 3 S E co } I 1 8»is 2 ~ ~ 1 , € R; _ L T3 S `t , L~j ITS L 1, f - ~ I t ~ i SCt~LE loo ~K-cE~T AS sttu~ 6 ~ C 5 I, the undersigned, hereby certify that the soil tests reported on this for rje by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of t s s r to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: t~ R'rN vR L . ~v E G 8- 8 ADDRESS: Q`~' l.~ ®X ZrZ(p rn ►"r'J CERTIFICATION NUMBER: PHONE NUMBER (optional): Er 1.~5 Lvo S to S-)6 113- 4 z S-6 J6Y Q tp CSTSIGNATUU E.* DISTRIBUTION: Original and one copy to Local Authority, Property Owne it Tester. DILHR-SBD-6395 (R. 02/82) - OVER - M ~ 1 i 7-- L • To be 1. Cc vial project, T b ALL, domplet Deg, A t; 'TH THE sic - Aft /60 - Ty ~'v ~2 l; I wo SPA /N o r 6 a. AST • jy ~ ~ _ `7 47, ~ DRW,/ 7 13 HO T yc9. 7' ~ Cvlv~- f j5.1- 80 ~ l s 7 5 DR4WIwC- FOR D1?Aa*;,,11v 6- /90 flT, -7-