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HomeMy WebLinkAbout032-1054-10-025 w ~ 0 Old 3 d o d 1 3 I 7 Pill, ID 11 1 n -4 0 C1 p~ O N Vi ~ O 41 N H ~'S C4 3 0 ~ W (D W O. N DI N n N n cn cn 7y n c m (D o to oo O o m o rt °'3 ° ai ocNn~ I-d (D cn v a ~i H. rt co ro y ai a o 0 _0 rt CL VP y 1 3 O ~ofD I ti v H t~1 1 a r~ o r z w yr o rnrnm'' ~orY rc-r H z O O O 1111 CI)~ z y D, Q ;(A CA (ft > vv_NI ~ tQ u' eD y cr N 1 0 CD (D ' m lit Cy 01) I m 3 oyi (nn ON w~ N rD I N C> I 7 = 7 N Z ! F- 0 ^^ll 011) p z o CD ID 0 (D lv M "D F- 'a cn O 01 O C> o n c m Q 1 rt (D N o rb rt \ rt p Z A Z 0 n rj) N a (D 0 rv a p rt o. ~o 3 m H z A CD I w~ 0~1 a c CD fl1 G O CD a O CL 3 w c 00 O OZ CL CD I a s O H I I ~ a 3z O A N O c o 7 0 I o b N CD ti ~ w C) `o b I o a 01/25/2007 02:54 PM Parcel 032-1054-10-025 PAGE 1 OF 1 032 - TOWN OF SOMERSET Alt. Parcel 21.31.19.269A-10 ST. CROIX COUNTY, WISCONSIN Current XApplication # Permit # Permit Type Creation Date Historical Date Map # Sales Area Apph O = Current Owner, C = Current co-owner 00 O Owner(s): Tax Address: O - HOFF, TODD A & KATHY E TODD A & KATHY E HOFF 485 210TH AVE SOMERSET WI 54025 * =Primary Districts: SC = School SP = Special Property Address(es): * 485 210TH AVE Type Dist # Description SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 6.494 Plat: 4522-CSM 17-4522 032-03 SEC 21 T31N R19W PT NE NE CSM 17-4522 Block/Condo Bldg: LOT 01 40 1/4 160 1/4) LOT 1 (6.494 AC) Tract(s): (Sec-Twn-Rng 21-31N-19W NE NE F tory: T e Notes: Doc # Vol/Page yp 4 754809 2513/515 QC 3 744426 2441 /64 AFF 10/10/203 743355 2433/473 WD 06/20/2003 726682 2283/27 more 2006 SUMMARY Bill M Fair Market Value, Assessed with: 145384 345,700 Last Changed: 07/14/2004 Valuations: Total State Reason Description Class Acres Land Improve RESIDENTIAL G1 6.490 65,400 196,800 262,200 NO Totals for 2006: 6.490 65,400 196,800 262,200 General Property 0.000 0 0 Woodland Totals for 2005: General Property 6.490 65,400 196,800 262,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 0910712005 Batch 05-7 Specials: Amount Category User Special Code Special Assessments Special Charges Delinquent Charges 00 0.00 0.00 Total Form - S T C - 104 f AS BUILT SANITARY SYSTEM REPORT OWNER /(L STD TOWNSHIP SEC. T N-R W ADDRESS / ST. CROIX COUNTY, WISCONSIN GCJs SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7W WAE~ ~d I, N ~ po ~o use ~ /~9t. d0 C/tL .5Fp7tC Tk1v11 L f~ 0M floes p l i to~x5~ ~ S,~E~,gG~= l3E4 I-J e w 4 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 1/2" P/'a'g;- O/V' BAs; !~i/? ZlAdr Elevation of vertical reference point: ld~c 1) Proposed slope at site: SEPTIC TANK: Manufacturer: CULa'~: ~'S` Liquid Capacity: Number of rings used: Tank manhole cover elevation: 102,13 Tank Inlet Elevation: Tank Outlet Elevation: NRE Number of feet from nearest Road: Front, Side 0 Rear, O 70 feet .From nearest property line Front,O Side, Rear, O feet Number of feet from: well , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER ` facturer: I Liquid Capacity: Pump Mode Pump/Siphon Manufacturer: ~umpF Size Elevation of inlet. Bottom of tank ation: Pump off switch elevation: lons per cycle: Alarm Manufacturer: larm Switch Type: Number of feet from near property line: Fr O Side, O Rear, © Ft. umber of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width:_jZ Length: Number of Lines: _ Area Built: y Fill depth to top of pipe: 30 Number of feet from nearest property line: Front, O Side, ® Rear,O Pt.~ Number of feet from well: Number of feet from building: 0 (Include distances on plot plan). EEPAGE PIT e: Number of pits: Diameter: Liquid pth: Bottom of seepage pit elevation: Area Built: Has either a drop box r distribution box O been used on y of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: apacity: Number of rings used: vation of ttom of tank: Elevation of inlet: Number of feet from arest property line: Front, ide, 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: License Number : ,B{ b 3/84:mj PIJI~ CHAMBER facturer: Liquid Capacity: Mode Pump/Siphon Manufacturer: ,.----'PumSize Pump Elevation of inlet. Bottom of tank ation: Pump off switch elevation: lons per cycle: Alarm Manufacturer: larm Switch Type: Number of feet from near property line: Fr O Side, O Rear, 0 Pt umber of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ) Trench: Width: Length: Number of Lines: Area Built: y Fill depth to top of pipe: c7 D Number of feet from nearest property line: Front, O Side, ® Rear,O it Number of feet from well: I Number of feet from building: (Include distances on plot plan). EEPAGE PIT e: Number of pits: Diameter: Liquid pth• Bottom of seepage pit elevation: Area Built: Has either a drop box r distribution box O been used on y of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: apacity: Number of rings used: vation of ttom of tank: Elevation of inlet: Front, ide, O Rear, 0Ft. Number of feet from crest property line: Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ( SAFETY & BUILDINGS DIVISION LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 63107 ~y State Plan I.D. Number CONVENTIONAL ❑ALTERNATIVE (ffasslgned) Ia.~.. r ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N CAT ` Michael Casto Rt. 1, Somerset, WI 54025 REF. PT. ELEV.: CST REF. PT. ELEV.. BENCH MARK (Permanent. reference point) DESCRIBE IF DIFFERENT FROM PLAN NE4 NE4, Section 21, T31N-R19W, Town of Somerset IMP/MPRSW No.. County_ Sanitary Permit Number: Name of Plumber: Donavin Schmitt 3205 St. Croix 79132 SEPTIC TANK/HOLDING TANK: ill 7 MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: j _ i~OD 1 / YES ONO DYES ONO BEDDING VENT NIA. VENT ATT NUMBER OF ROAD: PROPERTY WELL BUILDING VENT TO FRESH HIGH WATER AIR INLET / ♦ ALARM FEET FROM ~f 7D l LIN~~ ` YES ONO 6/ , DYES ONO NEAREST DOSING CHAMBER: PMANUF ACTIIHEN WARNING LABEL LOCKING COVER MANUFACTURER. BEDDING: LIQUID CAPACITY 1PUMP MODE I . PROVIDED: - ❑YES ONO OYES ONO DYES ONO ---]PUMP AND CONTROLS OPERATIONAL NUMBER OF PH( EHTY WELL BUILDING IV ENT TO FRESH GALLONS PER CYCLE: LINE AIR INLET. (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) OYES ONO NEAREST-00 'H ";AM[ TEH MATEHIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUID INSIDE UTA -PITS DEPTH'. BED/TRENCH ,VIDTH. LENGTH NO. OF DISTR PIPE SPACIN(, COVER IAL' IT TNFNC S DIMENSIONS NUMBER OF PROPERTY WELL BUILDING VENTTO FRESH C H.AV EL DI PT II FILL DEPTH UISTR PIPE DISTH PIPE DISTR. PI E MATERIAL SISTN LINE AIR INLET: eELOwPIPES ABOVEypvER El V NLt r ELE D FEET FROM a~` ~/0 NEAREST- CZ 0 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. DYES ONO PENMANF Ni MAHKF HS ~BS ATION WELLS SOIL COVER TEXTURE DYES NO YES ONO SEGUED MULCHED D EPTH OVER TRENCH BED ~DEPT H OV FH TRENH HEDEPTH OF TOPSOIL SODUFI) CENTER ES DYES ONO DYES. ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE covEN 'WIDTH LENGTH jNEL0LFE LATERAL SPACING (iHAVEL DEPTH HE LOW PIPE BED/TRENCH NCHES. DIMENSIONS MANIFOLD PUMP NIFOLD DISTR. PIPE MANIFOLD MATERIAL Imo FIPESISTH DiSATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. . ELEV.' ELEVATION AND DISTRIBUTION COVER MATEHIAL VERTICAL LIFT CORNESPON DS TO APPROVED INFORMATION HOLE SIZE HOLE SPACID CORRECT LY PLANS DYE S ONO OYES ONO PERMANENT MARS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE D YES ONO OYES ONO NEAREST- - Sketch System on Retain in county file for audit. Reverse Side. uRE TITLE DILHR SBD 6710 (R. 01/82) ' ry~ Q E UJISCOnsin APPLICATION FOR SANITARY PERMIT OUNTY X-C DIL-HR OUNTY n OFF (PLB UNIFOOOyyRM SANITARY PERMIT # InDUS TR ~I nDUSTRV, LR O LABOR 6 NUR1Rn RELRTIOnS N -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. PALE SE PRINT PROPERTY OWNER MILING ADDRESS ~L~ PROP RTY LOCATION CITY: VI LAGE: E1/4 X1/4, S,Z , T N, R /E (or WN OF- LOT NUMBER BLOCK NUMBER UBDIVISION NAME INEARESI ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ~A, JJ TYPE OF BUILDING OR USE SERVED Ail 5C' 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ Tank Replacement ❑ Repair % New System ❑ Privy ❑ Replacement Soil Absorption System ❑ Revision ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench [J Seepage Pit ❑ Holding Tank ❑ ❑ System-In-Fill El In-Ground Pressure El Vault Privy Pit Privy issued ❑ Existing, For Which A Previous Permit Is On File, Permit # ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Plastic Total #of Prefab. Site Steel li Gallons Tanks Concrete Constructed Septic Tank Capacity ~s Lift Pump Ta A 44 nk/Siphon Chamber Holding Tank capacity i 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): /~/~Ji 6;Z ' Private El Joint El Public C~ I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Signat M Phone Number: Name of Plumber (Print): Name of Designer: D"A4zmt Plumber's Address: B ~ COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ 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: e 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 CA S`/ C Location of Property IF 3%, Section T IL N- R W Township Mailing Address 11 /r Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel -=L Date Parcel was Created rtpw Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes Ne No Volume and Page Number 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) eeAti,6y that ate. sZatementd on Chid 6onm ane VLu.e to the bed.t o6 my (ouA) knowt.e.dge; that 1 (we) am (ane) the owner 1b 1 o6 the pnopen ty deA cA bed in th.i,d in6o4mati.on 6oAm, by vi&tu.e o6 a waAAa.nty deed neeonded in the 066ice o6 the County Reg-iA teA o6 Deeds " Document No. Ll 97 j I and that I (we) pnedentt.y own the proposed 6 to bon the sewage pas system (on I (we) have obtained an easement, to nun with the above de cAi.bed pnopehty, bon the eondtkucti.on o6 said system, and the same had been duty recorded in the 066.ice o6 the County RegiAten o6 Deed&, ad Document No. © ~ 1 0-/Z,L,uf..a SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H . H a r ST C- 105 r a • y • SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a H OWNER/BUYER CJ~ f j F ROUTE/BOX NUMB i r e Number ER ~L .CITY/STATE 1- PROPERTY LOCATION: Section T N, R~ W, k, Town of ~/~`IL~SL St. Croix County, Subdivision Lot number 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 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 H three year expiration. ° E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with 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. 0. Box 98` Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. s • . Q CO) r • 9 ~ ~ to N N 3 Q CO) c m O rt ~ ~ (D 7c ~ n ? w N~ 00.3 °0 m _ CD vcCD N wfoN~~c~o _ V, ° a00 w ° w w~ CD g _ cD a U $ $ v ~mN~ • = w ? n o M CC CAD o 3 a o ..-~to~ w CC 0 ~w o 13: ° C- C FA* 3° c o S.3 9=aoo 3•Zco c-< v° f ° w ° c s 2-0 a -N m o w co o=cto- > o-.v•v o • w N A(a r- ° < CD A N N cc o D 5 0 a c" o =cam C°~ao* O wow o-. cr w C N M cc 7 =r -0 01 w CO Z a ~w ~ow5D *co 0 Z MN~ ~MCDm~a a a • a W 0 Cn to m uicm °w~0mro m Q Cl. CD m to a Co y a a C n CD C m m mc~ o°5 aS ~ui n mw m w Qw = -'I f ° ao me _C ~ m Cn 1 °m "C°0Cnw O Q o£ w c C a ui 0 m w a a a a =r 0 C7 CD 3 c CD v► 0 t0 7 N n N S m c S o m S \ CL 7 3 a= 3 3 ° a 0 m CD Q ~ t LDINGS DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, 1 P.O. BOX 7969 LABOR AND-4 PERCOLATION TESTS (115) MADISON, WI 53707 HUMAWR6 LATIONS 09(1) & Chapter 145.045) ` LOT NO.:BILK. NO.: SUBDIVI I N NAME: LOCATION: /4 SECTION:T -3)N/ (or) W COU T OWNER' BUYE 'S NAME: ! MAILIN ADDRES DATES OBSERVATIONS MADE USE PROFILE DESCRIPTIONS: PE ATION TESTS: NO.BEDRM 1,: COMMERCIAL DES RIPTION: ~p1ew 11 Replace ~7 8~ esidence 3 t C RATING: S= Site suitable for system U= Site unsuitable for system C VEcNTIONAL: MOUNcD: IN- 311YUNcDPRESSURE: SYSTEcM-IN-FILL111101 NG TANK: RECOMMEND D SYSTEM:(optional) R/! 1 ®S ~U CAS CU EIS ~ EIS 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 COI OR BORING TOTAL D PTH TO GROUND . HIGHESTS TO BEDROCK IF OBSERVED (THICKNESS, ON BACK TEXTURE, AND DEPTH NUMBER DEpq+f- . ELEVATION OBSERV EST ED Z_ B- 88 11L A) -S Zp y 9c" Uv 'v- B- B- B_ j f PERCOLATION TESTS TEST DEPTH WATERI HOLE TEST TIME DROP IN WATER L I HES RATE MINUTES N R INCH z P R I NUMBER 4A*H1IiS AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 3 PE P_ 1 P- 7- qc~ L P_ 0 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. Q SYSTEM ELEVATION 1 (2 - - a I S f 11~.S tit t -(fit - t~ 3 I{ 70 1 t t ) 3 C t ) E , 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. TESTS WERE COMPLETED ON: NAME (print ADDR CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIG T E: /J DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - r )I COMPLETING C ' 5 - SBD - 6396 4 A i ' a acv grail test, yoLar report HIL 9, iption; 2. must clearly irate whether th cornmercial 3 ber of be( ccarnm(: , 4, e a SITE IS T~` IOLDING TAIL C ALL RASED - 6 tin r ? e permanent; a test exemp- lace N.A. a )rohriate box; ~ i. Jon number; U; TESTS MUST BE EIL-D THE "S _ ESTERS E R'. t Sr B . Gj 4 F T( The county t r :y Ce J Pfs'CS_ EL _O r IVo Sc,~,C i 1 t i - • C. jJ ~ A' .r a v ce7~ rtiR dCh, At- goo 6bsC..f iT