Loading...
HomeMy WebLinkAbout032-2089-50-000 0 Co Q 3 0 d r~ O O T 3 m ' m # \ 1 ~~y O 0 m o v U) o w v o cn °w • CD CD PO 3 C d CD d ` ur 00 N) CL V) CO C) _0 CD C:> r ro CCD C7 O N Q ~O1 O N ° C., Cl C a C U) ~ D CD I CD aD, a o o w 3 CL O o co rn V o b n o I ~ =A rt rt y rn m co 3 0 a N. v, o I~ o ~ o ° m 00 H J H oz o O d ~ c y D) r. r~ N U x I n c ~ a CA Oro F, z m o Ia o. M w o m LL £ N I K ' y C 3 =r 0 (D (n z m 00 Za7 O ~i O D j 00 CD co O W Nr~y CD (D N rt Z ~D (D W O. V ' r\ a 3 i Z co s w W A n rt £ N a A z o r3 Irt ~t O H- W w cn N. 0 CL r:> z ~ c 3 z o r,, o CD (A CD A rt (D N (D obi a rt 3 o a °o s - o' - o o Q c o N o o a :3 3 ~ y Q _ c ~ I my c 7 a CD x o a, 0 O N Q. X ti ~ yA ~ N wa a ti o A is dC V O O r O L ~ y i ~1 Parcel 032-2089-50-000 08/14/2006 10:43 AM PAGE 1 OF 1 Alt. Parcel M 15.31.19.882 032 - TOWN OF SOMERSET Current X', ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner TODD F & SHEILA R PARNELL O - PARNELL, TODD F & SHEILA R 539 UPPER 216TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 539 UPPER 216TH AVE SC 4165 OSCEOLA SP 1700 WITC Legal Description: Acres: 2.787 Plat: 2224-NORTHERN OAKS ESTATES LOT 5 NORTHERN OAKS ESTATES TOWN Block/Condo Bldg: LOT 05 SOMERSET Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31 N-1 9W Notes: Parcel History: Date Doc # Vol/Page Type 08/26/1998 585831 1351/491 QC 07/23/1997 1076/347 WD 07/23/1997 879/556 07/23/1997 736/330 more... 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/24/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.787 44,600 150,300 194,900 NO Totals for 2006: General Property 2.787 44,600 150,300 194,900 Woodland 0.000 0 0 Totals for 2005: General Property 2.787 44,600 150,300 194,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 204 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f to Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT ~A Fo - TOWNSHIP SEC. T,_?/ N-R -W D_~ 3 ST. CROIX COUNTY, WISCONSIN Sc~e~S•eJ` LJi r SUBDIVISION/!/ ,4..,,. Oc /rt LOT S- LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I,HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM it i A~" X00 " '0"eet Sy'/'2. ,i M C ei Sr ~ ~o04K'l ~t try Cove - i ' '5V'dz3eZ,,,,,5 "z' 90 ~ o~•-~ ~~~:reCd f ~auS ~ y5 `5~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Ta Elevation of vertical reference point: 10 r _ Z-0 O Proposed slope at site: SEPTIC TANK: Manufacturer: G✓e. r$r r Liquid Capacity: /p p p s~ Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: G ~r Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,QRear, O tp [(o tS / feet .From nearest property line Front,OSide,~Rear, 0 feet Number of feet from: well building: ~Z (Include this information of the above plot plan)( 2 reference dimensions to septic tank) i CF.F RFUVPQV CTr%V PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet Bottom of tank elevation: Pump off switch elevation: '.Gallons per cycle: Alarm Manufacturer': Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Y.- --Trench: Width: lZ Len$th: Number of Lines: Z Area Built: y Z c° " Fill depth to top of pipe: 30 Number of feet from nearest property line: Front, O Side, &Rear, 0 Ft. 0 Number of feet from well: Number of feet from building-;-- (Include distlances 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: fK 0_ ,2 License Number: /y►~' ~J irk 3/$4:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.U. BOA 7969 BUREAU OF PLUMBING MADISON, WI 53707 ` CONVENTIONAL ❑ALTERNATIVE slate Plan 1.0 Number n l .rssignerD ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE Curtis A. Sahnow Rt. 1, Box 97K, Somerset, WI 54025 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST HEf PT V Sz NWT, Section 15, T31N-R19W, Town of Somerset, Lot 5, Northern Oak fCJ N:un nl PI.-h r. IMP/MPRSW No.. Count, ESL. Sanitary Permit Number Michael Wilson 6388 St. Croix 83828 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK LET ELEV. TANK OUTLET ELEV WARNING LABEL LOCKING COVER P II ZNG PROVIDED ~~Z<1?.~~ ICT7 v~C03 9(~JYES ❑NO ❑YES KNO BEDDING VENT DIA. VENT MATL. HWATER INUMBER OF ROAD: PROPERTY WELL BUILUWG VENT TO FHE 911 ALARM FEET FROM u~G~ n~ TAUT wLEr L4 C ❑YES NO ❑YES ❑NO NEAR EST (p (f p( DOSING CHAMBER: _ MANUFACTURER BEDDING LIOUIUCAPACITY 1PUMI'MODEL IPUMP.StPHONM - AC 1t) WARNING LABEL LOCKING COVER PROVIDED PROVIDE. ❑YES ❑NO r ❑YES LINO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL] UMBER OF PH(1{'ER1Y WELL HUEL OF N(t (VENT TO FHE'It (DIFFERENCE BETWEEN FEET FROM LINE AIHINLET PUMP ON AND OFF) ❑YES ❑ NEAREST-30 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowin ENr'TH IDIA111 IF II 111AII lung AND a)nHKIN(, or excavation. (If soil can be rolled into a wire, construction shall cease un FORC MAI the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH JLENGTH NO. OF IDISTR PIPE SPACING COVER IN"')' I)In API IS I.I OUID BED/TRENCH G TRENCHES I" Ar unu PIT OF 1'1" DIMENSIONS (01AVFL DEPTH FILL UEPiH UlSilt PIPE UISTR PIPE DISTR. PIPE MATERIAL NO. DI R NUMBER OF PROPERTY WELL HUILOING VENT TUFltl"ll 1HF LOW PIPES AHOVE COVEli f INI F I E V U` PIPES LINE i L FEET IF -SO, 51 11 1 Z7 NEARESTO . ~8 O 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 ❑NO SOIL COVER TEXTURE 1PITINIANI NI MAHKI HS t) [I SI 1I VA I I() N WF 1 I S - _ ❑YES ❑NO _ _❑YES LINO DEPTH OVER THE NCII BED ID E PT11 OVF H TRENCH BEU IDIPTI, OF TOPSOIL ISOOD,D SEF OFU h111LC1/1U CFNTEH EDGES ❑YES ❑NO ❑YES ❑NO ❑YES LJNO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH IT[ LOW PII'I F It L- DEPTH ABOVE COVE It DIMENSIONS MANIFOLD PUMP MANIFOLD UISTR. PIPE JMMATERInL NU UISTR I:ISIR 1'IPF UlSili llitlllON l'll'( "'All ltlnl 74 M11nItK INIi ELEV ELEV DIA ELEV. PIPES UTA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHRF C I I V CDVFR MATERIAL VE PI WAI I II T COHHF SPONDS TO APPROVI U PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS. 777TIONWELLS. NUMBER OF PF30PERTV WELL BUILDING FEET FROM LINE ❑YES ❑NO ❑YES ❑NO NEAREST I Sketch System on Retain ' county file for audit. Reverse Side. SIGNATURE ~ TITLE DILHR SBD 6710 (R. 01/82) , ommmonm6 w,sconsin APPLICATION FOR SANITARY PERMIT r COUNTY DILHR (PLB 67) UNIFORM SANITARY PERMIT # ~ OEPRRTTEnT OF InDUSTRV,LABOR 6NUTRn REIfiTIOnS f Y. if'R -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 7-.-7 0 SGT+nr7 R OX 2: 0 J+„ p+~ 5 L,l a tam d .S PROPERTY LOCATION CITY: '1 _W/va)1/4, S , T., , N, R j9 E (or) VILLAGE: 7' LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST AKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED ig 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ~!_9 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 Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: tr a M r t, r 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): C .r 4110 L/a U K 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: 1, a G.✓+ J: o C, 63 0 .s' (2~~ ).1G a.:.i_? 7 Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signat re of Issuing Agent: Fee: ~ DaQte: 4 ❑ Disapproved 0- /O`V U J~/ Olp El Owner Given Initial Approved 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 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 pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. i 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 C L i-L t Location of Property S jz / 1%, Section T . , N-R19 W Township Mailing Address f a""11~ 2 Z L Address of Site 9 7 1:4e Subdivision Name e r ( k-< C ~5 / G ZC e Lot Number Previous Owner of Property L 5 Total Size of Parcel 722 Acre Date Parcel was Created 2_ O r 00Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume __73 6~ and Page Number 33 0 as recorded with the Register of Deeds. KJv~e 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) eentiby that ate statements on this bonm ane true to the best ob my (oun) knowledge; that I (we) am (ane) the owneA(s) ob the pnopexty de cx3ed in th.ia inbonmat.ion boAm, by viktue ob a wakAanty deed necanded in the Obbice ob the County Register ob Deeds a3 Document No. q-16 , and that I (we) pnesent.Cy awn the pnopos ed .6 to ban the sewage diS pas AyStem , • (on I (we) have obtained an easement, to nun with the above descAi.bed pnapeAty, ban the conatnuction ob said system, and the dame has been duty necanded i Deeds, ab Document No.- n the Obbice ob the County Regi,aterc ob SIGNATURE OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H • cn H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d a OWNER/BUYER Li 1- 1-S I4,/ ROUTE/BOX NUMBER Fire Number .CITY/STATE n klj e 45 e_ ZIP ' ~ PROPERTY LOCATION:,; r,, -AL k, Section T~31 N, RW - 1=7 Town of _~S6tti~c~~".5 c' St. Croix County, ~rtl,ern Subdivision Oaks E &Lf- 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. 0 E 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 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. v ' r w = m 7D m cn t\ 1 ( ~ ~D ► V1 cn N (A w ~ N ~p a (D 7r O A n (D O 0 003 o c O w w w o ~ -H c co ~ `c o `e v cm' 'o am cu 0 o? C4 ~a= 00 ~w ,°o, w m~'Coo 0 '00) OF CC (D D CD a N w? 'a I gr co = a O A 3 a OC) cD (D 0 > > cp o w O w 1 =r _ = O 3 o co c c w o w 3 Z~ col< cr ao w w ~ f 0 cc N_.c~u w u*v, ~wcD o~oC, ca = co D 3~ w A m 'co o CD N c cn c ? ° C O A S D w A A C G) CL M Al 0 ~a w Q~ a~i O f _ m Z w 0 0 v w w 0 C D Z rA -q < to v M C=D ca z acChu m mJ? n A 3 cc o sr CA m m \ v ? o o w N w w C m w 01 CDc? c0. ova 0 a(o g w aw = a -1 N p c fn O< oA. _ coo p~ o OZ co v 3 a c Qo c p► ao f 0 c c aw o m aO m a_ao-a.... G) CA m c a. -1 0 (0 -4 G) 9 3 cp A c cp `<p) (D cD O Y a o 7 09 a C cn a cw ~m-ICDCCD ~s A'"r aca scmw A m 3 0 5.0 0 acCDD 0 0 3 m N 3 a 0< 3 ffi c° CCD o Z O low DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I N DUSTR•Y, DIVISION LABOR-AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SEJCTION: Q y~ TOWNSSHIP/PAWN1CIR-0,L •TY: LOT NO.: BLK. NO.: SUBDIVISION NAME: / 5 /T,3 N „J (or) fl J YY► f~ ~n COUNTY: OWNER' BUYER' NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MA 15E NO. BEDRMG.: COMMERCIAL DESCRIPTION: IPROFI E DESCRIPTIONS: PERCOLATION TESTS: ,Residence &kNew ❑Replace Il RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: I" F -GROUND-PRESSURE: SYSTEM-IN-FMEND YSTEM:(optional) s❑u s❑; s❑u asSu os®u 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 Jd BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEeTk#~{ . OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B 0-7 ©1l7 ,Cow , vo B 4// c 60 It9o0 7 41 to c, l-ige.~.-S Sgi3n B- 3 83 /L)d /L) S3 B- -9 0 acs p a >Ca , 7.615-, d° . 7~ • 17 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 PERIOD PER INCH P- P- P- 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. SYSTEM ELEVATION C? I ~L= Lv4 E - , , 1 GO h 7 °'I~ € zst1 \ I r 5 E E 3 , i E f E E . I it t 1, 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): ` TESTS WERE COMPLETED ON: V~Gr~/' - © CJG ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 9,9, 60 CST SIGNA OR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - i t Tlf}N FOR Vi LL FC 15 - S - 6395 --il test, Y('-' ,---ort ,,asst inclu, e: a residence project; 3. fined; 4. 5a. t. A n neat; . - E :6mp- fir 10. J A r N s ci a o ~ P yn ti p Q t~ r Dz C ^ l/1 1/! N e 4 o Q (3 '1 O by n $ i n' ~ ~ ~ ~ ~ ly e p 10 J 9 10 N ff. / S T Ff i . N c- ?I °0 P- o 0 o $ 4 a r A 3 o o a _S o r w n~ ~ ~ s s tj ~ a m ? 9' t