The URL can be used to link to this page

Home My WebLink About006-1054-20-000 0 C) O ti 3 0 h O N 4 c C n O O N a N I' C i I r N N O C Z 7 f0 c LL 3 0 a N N I' Z E v o Z ~ I' `m m i Nazi ° 00 C G O 0 Z - co ~ o rn ° c - Z E a M .C 0) -~V N N N CL) • c ►ei a ~ L o O C O L Z°mz U z N d G N r Al) 0 O D d n ' _o Q fA fn N Z ~ N C) F- c) - o dI N 3: o v (L M a. a v v N J U m rn rn } La ~ N N N e o o - O E L •a m N C d _m N ~1 r y C ~V c co O o co N E r- U N M 3 L CO w ~ C m A C O Cr" C C f~ N Z 7 N 0.0 (6 00 • Fri O N U Z N O U O ~ - 2 H ~2 cw/) r V ~ ~i =E Of) ~ - E vt a 4) a a m u m rrww y E ` •G G 7 'o1 A uo(Lm ',Oinci Parcel 006-1054-20-000 01/24/2007 11:43 AM PAGE 1 OF 1 Alt. Parcel 24.31.16.367B 006 - TOWN OF CYLON 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 JOHN R MARTIN O - MARTIN, JOHN R 2037 250TH ST DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 2037 250TH ST SC 1127 CLEAR LAKE SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 20.390 Plat: N/A-NOT AVAILABLE SEC 24 T31N R16W PT NW SW COM W1/4 COR Block/Condo Bldg: SEC 24, TH S 86 DEG E 33.01' TO POB; S 86 DEG E ON N LN 1272.84'S 2 DEG W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 641.4' ON E LN TH N 89 DEG W 1271.22'N 24-31N-16W SW NW 1 DEG E 707.44' ALG ELY R/W TN RD TO POB & INC PARC DESC AS COMM W 1/4 COR; TH S more... Notes: Parcel History: Date Doc # Vol/Page Type 12/01/2005 813331 2937/111 QC 10/11/1983 388448 8758/03 LC 03/15/1979 355644 591/027 WD 2006 SUMMARY Bill M Fair Market Value: Assessed with: 144550 177,100 Valuations: Last Changed: 09/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 50,000 45,600 95,600 NO PRODUCTIVE FORST LANDS G6 18.390 55,200 0 55,200 NO Totals for 2006: General Property 20.390 105,200 45,600 150,800 Woodland 0.000 0 0 Totals for 2005: General Property 20.390 105,200 45,600 150,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 547 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1 ~/I TOWNSHIP {~L SEC. TO/ N-R / C, W ADDRESS X/ 10 3 ~ ST. CROIX COUNTY, WISCONSIN 6" SUBDIVISION } LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i c I O i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: 0 / Number of rings used: 0 Tank manhole cover elevation: - 66 Tank Ii.ilet Elevation Tank Outlet Elevation: j / J-z- Number of feet from nearest Road: Front,~Side,a Rear, O feet From nearest property line Front,0 Side,n Rear, 0 feet Number of feet from: well ` ' 5 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEF. RFVF1v,SF S H)F PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: P p/Siphon Manufacturer: Pump Size Elevation of inlet: % Bottom of tank elevation: i Pump off switch e~-f-,vation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of,-`feet from nearest property line: Front, O Side, O Rear , Ft.~ _ Number of feet from well: Number of feet from building: / (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: ' Width: r Length: Number of Lines: Area Built: J Fill depth to top of pipe: .yi~<- Number of feet from nearest property line: Front, O Side, Rear, O Ft 1 22- Number of feet from well: i Number of feet from building: (Include distances on plot plan). i SEEPAGE PIT j / Size: Number of pits: Diameter: e Bottom of seepage pit elevation: /Areauilt: been used on any of the above soil Hbox O or distribution box O a? (Check one). HOLDING TANK Manufacturer: - / Capacity: Number of rings used: Elevation of bottom of tank: Elevation of filet: Number of fi/ t from nearest property line: Front, O Side, 0 Rear, O Ft. i~ Number of feet from well: i Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated : 7~~ -I-,er on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. BOX'r369 PRIVATE SEWAGE SYSTEMS DIVISION WADISG,"J, WI 53707 BUREAU OF PLUMBING XCONVENTIONAL ❑ALTERNATIVE St.,.Planl.D.Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Uf assigned) NAME OF PERMIT HOLDER . ADDRESS OF PERMIT HOLDER. John R. MaAti.n R. R. 1, Box 103B, Deets Pack, wI 54007 INSPECTIOND TE t firs BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. ~ v. NW SW, Section 24, T31N-R16W, Town a4 Cyton REF. PT ELEV. CST REF PT ELEV Narne of Plu rnher_ MP/MPRSW No. County Sanitary Permit Number: Gahy Steet 3254 St. Ctcoix 49487 SEPTIC TANK/HOLDING TANK: MANUFACTURER: (y~ LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER i, ~{~l /1 / 61 Qr 7 PROVI ED. PROVIDE =1N v, v-! / E❑NO ~NO VENT DIA.VENT MATL HIGH ROADPROPERT Y WELLVENT TO FRESH IF— NO FEET FROM LINE r r~AIR INLET DOSING CHAMBER: NO NEAREST / LAG 5 J MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL . PUMP PHON MANUFACTURER WARNING LABEL LOCKING COVER ❑YES ❑NO PROVIDED PROVIDED: GALLONS PER CYCLE: PUMP AND CONTROLS OPE ATI N L ❑YES ❑NO ❑YES ❑NO (DIFFERENCE BETWEEN FEET FROM OF PROPERTY WELL BUILDING I VENT T FRESH FEET FROM LINE AIR INLET E PUMP ON AND OFF) ❑YES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nc;TH DIAMETER MATERIAL 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 WIDTH LENGTH NO OF DISTR PIPE SPACING COVER TR ENQh~ES INSIDE CIA -PITS LIQUID DIMENSIONS G/- / "'A AL PIT DEPTH GRAVEL DEPTH FILL DEPTH DISTH PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. D T BE LOW PIP S AB VE COVER ELEV INLET ELEV. END NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH PIPE FEET FROM ' LINE: AIR ET. x.76 Z-- C. NEAREST--s 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 PERMANENT MARK E R S OBSEHVA TION WELLS DEPTH OVER TRENCH,' BED DEPTH OVER THENCH~BED ❑YES ❑NO ❑YES ❑NO CENTER EDGES. DEPTH OF TOPSOIL SODDED SEEDED MULCHED I ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE TRENCHES: FILL DEPTH ABOVE COVER. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION AND FLEV ELEV CIA ELEV' PIPES DIA: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS COMMENTS: PERMANENT MARKERS~YES El SE ❑YES ❑Np OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: C LINE ) ❑YES ❑NO ❑YES ❑NO NEETF OM C S - I~~ ~ 7S `Lj J / Sketch System on 17 Reverse Side. Retain in county file for audit. SIGNATUR TITLE DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT '(PLB 67) COUNTY UNIFORM SANITARY PERMIT # a~l~ oERRRTmEnT of ' ~ InOUSTRV, LRSOR 6 HUmRn RELRTIonS / ? Y?;Z -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: VILLAGE: l 1/4 1/4, S T,N, R (or) W TOWN OF: - LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER K r,TYPE OF BUILDING OR USE SERVED C~/ 1 or 2 Family Number of Bedrooms. Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System El 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: 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): [r] Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. n Name of Plumber (Print): Signature: MP/MPRSW No.: Pho e Number: Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved /:m' j y ❑ Owner Given Initial 4y 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 pipes). 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 r01,' SAN I TA!:Y PI~;RMIT S1rC- too hi.s application form is to be completed in fu l! and signed by the owner(s) of the i)rOperty hehig, developed. Any inadequacies will only result in delays of the permit i.5suance. Should this development be intended for resale b owner/contractor " Y ~ ( spec lu~use"), 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 112 Al Location of Property ~4, Section , T N - R W Township Ma i.'•_ i_ng Address's Subdivision Name Lot Number_ a Previous Owner of. Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? -T W Yes No Is this property being developed for resale (spec house) ? Yes T- No Vo!_ume and Page Number / as recorded with the Register of Deeds INCLUDE ` ITt1 TPTS APPLTCATTON ONE OF THE. FOLLOWING: Warranty Deed Land Contract 3. Other recordings filed with the Kegister of Deeds O' lice in addition, a certified survey, if available, would be helpful so as to avoid delays (0 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) ee~-ttif y that a-(' 6tatement,6 on this 4oAm ane true to the. beAt o{ my (o«-.a_) h,now&dge; that I (we.) am (aAee) the owneA(,5) o() the pAopeTty densc'ribed in. -this i .4oAma,';i.on AoAm, by viAtue oA a wa,hanty deed Aeco4ded in the, OAAice o{j the County Regq i~s,teh o (j Vee.6 aA Doeume.nt No. and that I (we) p-7.e~e~ztCy own the pAopo6ed Aite {oA the sewage 7o6a F,~y,~tem (oA I (we) have obtained an eabement, to Aun with the above dmcAibe.d pAopvuty, KoA the const)uetion oo baid Ayd,tem, and the same hays been duly Aeeon.ded in the 0{()-ice' o(~ the County RegiA teA o{ Dee.dA- , aL$ Document No. ) . S NATURE. OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H y N C~ y >,lIIC 'TANK MAINTENANCE AGREEMENT St. Croix County z r~ Y OWNER/BUYER_ ROUTE/BOX NUMBER _&.X 4!r~ Fire Number - CITY/STATE ZIP x i PRO?'EP.TY LOCAT r0N : ' N S e c t 1 o n R W, own of_~° yLQ ~!St. Croix County, Su1)divisiOn Lot number ~I Improper use Ind 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 U0 cn 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 <ind returned to the St. Croix County Zoning Office within 30 days of the Lhree year expiration date. S I G N E D I~ (Z DATE i i I St. Croix County Zoning Office ?'.0. Box 227 Hammond, WI 54015 71-5-796-2239 ~ S-i.gn, date and r(- iirn to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iN USTRY, DIVISION LA RAND PERCOLATION TESTS {115) P.O. BOX 7969 Hl''" RELATIONS vo~ MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION/: SECTIpN:T r < t ~ ~1 N/R C (0r1 TOWN SHI/MWiW IPAttTY: OT NO.: BLK. NO.: SUBDIVISION NAME: y J Zo N T Y~: OW ER'S BUYER'S NAME: MAIL ADDf?ESS: USE _ DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER AL ESCRI0TI N: (O New DES IF ITIO=ER TI NTESTS: r~Residence (ONew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system - _l CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING ANK: RECO ME DE/D SYSTEM joptional) OS DU ESF~UI S❑U ❑S U ❑S~U ri DESIGN RATE: / If Percolation Tests are NOT required / 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 ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH W. OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) o a -B- 97, s B- q -7 -/Y B- 7 0 ' - j? 1. 7 2zo _ r - Qr _ 7R - y PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD_1 PERt D PERIOD PER INCH P- / P- i P- P- P- P- LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori )ntal 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 f land slope. ;YSTEM ELEVATION i r t~ 5 r - - scat - 4;, ~ , - i WII ,~1a~eQ~ ~.s~ sv - - r _ i L - - - - e n s t✓ a L' C, 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 dministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. AME.(print): 7 / TESTS WERE COMPLETED ON: D DP4-S 8: ? C Rl IFICATION NUMBER: PHONE NUM~ER(optional): CST S Gf~IATURE: ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ILHR SBD-6395 (R. 02/82) - OV1ER _ / + _ I 401 e , DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 . I MADISON, WISCONSIN 67701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS i Towrnshi or M,rP--iPaldty 1110. Section Tjl N, R E (orK~J P T. ~ d , _ -County - Block No Sing Mdless CIante other f'rVk OF OCCUPANCY. Hesi - FFFLUENTDISPOSALSYSTEM: NEW. A//No.ofBedrooms _--ADDITION- ....-_-__.REPLACEMENT PERCOLATION TESTS _L-~ 11ATESOBSERVATIONS MADE: SOIL BORINGS ;OIL MAP SHEET SOIL TYPE PERCOLATION TESTS r 1100Rf WATERIN TESTTIM! IN PM TER LEVEL, INCHE%1 RATE TEST pEFfH CHARACTER OF SOIL SINCE HDIE LE AFTE INTERVAL MIN/iN i NON- INDIES THICKNESS IN INCHES 1ST WETTED SWa LLING IN 1ala11ffEL PER" 1 PERIOD 7 PERIOD 1 0 p k2 L61 ~ P-3 SOIL BORING TESTS F -TEST TOTAL DEPTH DEPTH TO GROUNDWATER. INCHES CHARACTER OF SOIL WITH THICKNf L'. INCHES (DEPTH TO dEOROCK IF OI, COI 'NUMBER INCHES OBSERVED ESTIMATED HIGHEST e - I-L i6 s PLANVIEW ILoou P.-Iii tests.wd bor. hot.+ and 11, .bit wll arses.) Indlcau on the piers the location and sVuua 1 of sun le r)nu. Indicate number o1 square feet ut atnor{n'on arse needed for y hutlret scale and oceupa-y Ir-'5 - 1-:r _ / ,ie type Sc. 9/r or d~stanLes. Gi Give hor zontal and vertical reference points. In rats dope. o0 1 I I' + %-t- -1- 1 ~ i tN + tf 1_, 1 F ! l j Z.r ` 1- J -J 1, the undats,gnekd, hereby certrty that the sod tests reported un thn form were made by me in accord with the procedures and methods specified in the Wnw nsln AdrnlnlsbaGve Code, and that the data recorded and location of lest holes are correct to the best of my knowledge and Lehef. Nana (Print) C.rnfication No. SS S L Address ~--Name of installer If known CST Signature COPY A -LOCAL AUTHORITY _ - s e. ~ \ l 1 f 71- Z ~ ~ ~ t y i 9t n r 1a C' i4UuoloG~ ;C)." a n I ti ~,r Syr ~~k v I 1 c__