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HomeMy WebLinkAbout030-2084-10-000 n cn O o 0 "E C: o : m (D o ID v * c (D 3 a ri, S S N O W W awn ° N CO ` W O N f] O- O_ N v' N ~ C N CO W ~O ? ~ ~ ~ A N N i a a [O W A O O O I e O O O a' o (n ` 3 N o = O C N O ~ py (D C d Lo p vOi', c! a 1 T'i (p O O O v ( O W N J N N O O i;- J N O ~ r C... (D CO LJO N c O C cc ~c 0 C 0 m 9 ~ s O O O o _ S ®~I 'i D O C7 Cn P'R Ct °O O (D O Q 0 O Z 03 Z ? D (D o M N = a 7 O 0 (D s 0 o (D m rn I~ o m Cm (D (D Q -I G 00 A Q A Cn -I W 00 v m O) (D o a ~ z ~ o r-j O o Z (D A Cl) 0-0 "O co u "O G 'O N (D O (D (D -O (D (D O O- 3 OR (D < n - ~ a; T (D 0 0 0 0 0 5 0 - 3 C w 3 n J o - Q O F"O o- = m N CD ~F Q ~ O Q N CL O O O O O O (D "O 00 a O N Q O , N `L ~ ~ N v O O, O N co 0 O co o Q = (D (n m c a O c . v o o_ 7 o o m m S'41 0 (~,acn p 00 (Q o C -0 77 (D m N o N o <n ti O d c- ? N cQ v _ o c (D CL CD v ° v 0 Q a o im - 4. 0 N 0 m m 0 c d M CD v' c .r I D) CD (D 3 r+ 0 a~ O N O W `C• L O r, C 1 0 N) 3 C) N) c v co `D "O ? Q 1 00 ~ No u n W C M v o A CD h N 7 O Q !a N l~r ~ O1 N (T a X a ° o m C N CD 0 0 m Cl o a c i O N) N N N -4 -4 v L.. n r- C cn M Q o OZ 0 0 0 0 • 0 0 ~ aQ CD CD C O) N CD (D 4) w 0 O N N Z W Z O zzh o D a 0 ~ J S (D (D • N l~~ll (D N C CC N C (D CD W 7~ Q 0 ~ cn o A Z CD s O v d A z C) M W C4 W (D M G A 0 Z 0 3 O ai Z CD A w a CD Fn- n ccD_ c x-0 o - N (D T CD v C v o a m (D w (o - m o o ~ x CD CD m CD CD (D N CL o o ~ N 0 0 cn A ti CD v 6o ° o o c 04/07/2005 12:48 PM Parcel 030-2084-10-000 PAGE 1 OF 1 Alt. Parcel 36.30.20.714 030 - TOWN OF SAINT JOSEPH ST. CROIX COUNTY, WISCONSIN Current X Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner BROOKS, RODNEY B & SUZANNE T RODNEY B & SUZANNE T BROOKS 259 RED PINE TR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 259 RED PINE TR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.030 Plat: 2323-PINE TREE MEADOWS SEC 36 T30N R20W PINE TREE MEADOWS LOT Block/Condo Bldg: LOT 11 11 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 36-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 783/182 2004 SUMMARY Bill Fair Market Value: Assessed with: 6423 240,300 Valuations: Last Changed: 07/12/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.030 72,600 163,800 236,400 NO Totals for 2004: General Property 2.030 72,600 163,800 236,4000 Woodland 0.000 0 Totals for 2003: General Property 2.030 42,500 135,600 178,1000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 501 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges 0.00 0.00 0.00 Total P F~Sne7~-ee I'S ~ r 'k E R•L.S, i embossed gook 7i't ShcB•S1''E S G BSc. +i ii ~ c g o p # eoo" o a W x 6 CC. I e3 This instrumant was 2 0 41 £ drafted by James R. Grubb, R.L..£ 7t 2,✓qn. p 7,1976. LLJ to o VF a2 -th n day ' - `e` « i JI Revised this IJ' < i2.T3 A Pw M o f March, 19 76. 86 W 1 State of Wisconsin) County of.St Croixj" a ice: o I, being the du/y a/acted, quo% To ifiad and acting town treasurer of -the Tawn of bra` 17,/ a5 p, StJoaaph, do haraby carfify that in occordonca S 3 with raCerds in Pny offiaa, +he.re. era PTO un- ses••ra b $ paid •toxes or unf.aid spacio/ asJllarnanfa as of 1976 on any of the /and in- cluded in +ha p/a+ of Pins Traa Magdows. LLJ I• Dated: , 1976. ase.a: Town Tisgsurar C= cry P 5tgta of Wisconsin SS 2 County of St Croix t r--------- o I beiny the duly a%ctad, qua/- 4 o 33 c ifiad and acting treasurer of Sf.Croix Cow" Fy,do u o ii J y hereby eortify that Me.recorw/sin my officeahew © y O 2.27. no unpgrd taxes Or spaoia/ asssrsmarfts 90 of i~ M ^ aPr ,/976 affecting the lands inC/udad 1 o a in the p/qt of Pin. 77-ea Meadows. Iw tI Dated 1976 Q 1 I ,~v ~ yu 5 Co,4nty Treasurer ¢ s~7 "ReaelVed, that the p/at o4 Pine Tres Magdoms Q= ` 's• in tba Town of ,W-losoph, K. B.Prriztar Real Q °s Eltgte,Sn,C., Laa/ie Lin•tlom, and Anna Lou 2 i Linstrom, ewnars,is hereby appro VOO/ by the St. Croix County Board.' 0 2 Dgte /97i. APprn ved 2E 0 o l Chq,rman •{.1 ° 4 rv89•orw I Dote Il7i. S,ynad _ TT JOO /5.20 G Cllglr e *rti1 I hereby carfify that *he foregoing is q copy of = c 0 5 ' q reee/ution adep'tad by the St Croix County F'~ ~I 9 M1•b 1_, Board. h Q ` p0 =E 1 3 N 31~ County Clark II o 'Resolved,*he+ the pp/o+ of Pine Traa Meadows as 4 I 'bo in the Town of St. Joseph, K e. Priaster Raal LL_ II 3 2 P'Pe Estato, Inc., Leslie Linstrom, and ,gn174 Lou m~ ~2 Linatrom, owners is haraby app"Ved by the W I c= ° ° dig.n St. Joseph Town ecard " Q II t b /ong, gate zz 0, I Q~* r a n Date v h e i 1 0+ c n I haraby certify *he+ +ha foreyyoing is q z" Cn al 2 °r y I ° of o resefu+ion adopted by the 3t J07eph 7bwn eo ° u5 ~\g '~i Doard. Q~ I~'uivauora flffidavit Town Clark State of Wisconsin)al UnE County of Pierce ff 1 I, Ja.nas R Grubb, ayrvayor do ;YOix County; Stgis of Wisconsrn22sa r" M divided, and mapped PineTree°a,Dap-tMentef county of StCrorxJ 4SV,4 of SWti ofSaci-,-36, r z4w "fn!a!4 of AtrveHe/ly egma.befera r". +his day of Geunty,Wls., fvrfhar deacrib and Soca21 1976, KB. Piieeter, Piesidanf, and Terry E. e e n~ ! qugr>ar corner ofsgrd Sea Set a///ota Pirrw,Sacre+qry of *he above nomad ear' W o v~ 1 said See. SG o dratonea of Fansea, nor porgtion, qnd Las/r'e Linatrom gndAnnq 9° a o,cSTN. 35; -thence o/any said" r7gra8 6 er Loy Linstrom, +o me known +e be the par- e! (~y feat; thence N69'07'W /5.20'110 e.xprass/y sons who executed fha foregoing instru- ° w 'I leaving zoid R•OV~ S88'S5~'E g rearric- man?', and ~o r~7e krloeun t`o bG~ such +he.ncaN81'85"E 262.e9fee.t93 of•tv's. officers &10 said caeporgtion bnd ock- O N/'0011 2957S0faat;S88S*Et A4'-q'7--WY hew/adgad that they exa.cuta.d said iR7- thanceN88%l'W~f7L89faet; t9 6trymant as officers, or owners, as the whose chord bears 518 S8-Wcutad fha dead of said corporation, by its gytt,or,ty. f%*+; them S6S•09'E S3Yagao/ Eatate, Notary Pub/ic Chance N00'39E 250.00 feet; / K. S.A-iests , Hudson, Wis. N Y4'11'W $00.OSt'e.et; ths,frw, rfs Ptrmana nt COmn'7i.i%OH. John 1] Haywood whose chord begrs SWOOo Td', seal to be feet; 1'h6nca 500'49W2L5.00 ~•In praserpeOA point of beyinnmg.7 cerfrf division, and plat by the c~-- ~ Secretgr ` - flkk -COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 4wjCAw '4', 715-962-3121 800 - 962 - 5227 CROIX ZONIN' T.' POW' 40,` 47 "01 ST. CROIX COUNTY REPORT IWE. 11/27/91 COURTHOUSE MATE RECEIVER! 11/26/9, ~G HUDSON, WI '4016 6-, 2~ ATTW. THOMAS 0-7 6-, Ce93'()'- '~cnam Rodney & Suzanne T. a ;'oks / r -A TON, 259 Red Fine 1'r a, 1 ~iiAs?t - ail ,3~ 2u, CTOR: M. Jei k i `aOJRCE OF SAMPLE'* K i t c l v- s 'OL.IFORM'o 0 /100 NTERPRETATION; Bacterioiogicaity SAFE 1 ppm ;ve 10 ppm exceeds the recommended Public W=-ter Standard. 4h i nic i na ifs! ~ ~ ~ { Fil 1LiHYIi Jri . rah L'3lre' C~ N Yy C ZO ( l®~ V 04,NDFDEI,r~EH 70 T, O` ~P V 1 heae:s "LESS THAN" Detectable Level. Approved by: o PROFESSIONAL LABORATORY SERVICES SINCE 1952 c, of ST. CROIX COUNTY ZONING OFFICE ~j St. Croix County Courthouse 911 4th Street j- y L Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix County Zoning office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning office, and mail, along with form to the above address. Testing will be done as soon as passible after fee and form are received. WATER TESTING----------------------------FEE: $ 25.00 Ll~" (For nitrates and coliform bacteria) WATER TESTING FEE: $127.00 (For VOC'S) j SEPTIC SYSTEM INSPECTION------------------FEE: $25.00 (Determines if system is properly functioning at time of inspection) Property owner's name I~[~DNL`7 ,J • SvZN~ -~?IL~ Property owner's address IZ-(n Pt ,4E I l L j Legal Description 1/4 of the 1/4 of Section , T N-R Town of _)uo~ ,o rj Lot Number Subdivision Name FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house? If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running :.he water fo sera.~? hours before the r several test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: 1st?' r~•r= TTytT-On Telephone Number--)15- SV-e- Sn j .-,016 REPORT TO BE SENT TO: _ PL S Tlye KC' Closing date l~ - t v a i Signature ST. CROIX COUNTY rx WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Nov. 26, 1991 Peg Starke First National Bank/Hudson 307 2nd St. Hudson, WI 54016 Dear Ms. Starke: An inspection of the septic system on the property of Rodney & Suzanne Brooks, located at 259 Red Pine Trail, Hudson, WI, was conducted on Nov. 25, 1991. At the same time a water sample was also obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Sin erely, Ma y-,J., Anki-is Assistant zoning Administrator cj Parcel 030-2084-10-000 11/10/2009 09:27 AM PAGE 1 OF 1 Alt. Parcel 36.30.20.714 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BROOKS, RODNEY B & SUZANNE T RODNEY B & SUZANNE T BROOKS 259 RED PINE TR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 259 RED PINE TR SC 2611 HUDSON SP 1700 WITC I Legal Description: Acres: 2.030 Plat: 04-022-PINE TREE MEADOWS SEC 36 T30N R20W PINE TREE MEADOWS LOT Block/Condo Bldg: LOT 11 11 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 36-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 783/182 2009 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/12/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.030 72,600 163,800 236,400 NO Totals for 2009: General Property 2.030 72,600 163,800 236,400 Woodland 0.000 0 0 Totals for 2008: General Property 2.030 72,600 163,800 236,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 501 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f Parcel 030-1020-60-000 11/10/2009 09 28 AM PAGE 1 OF 1 Alt. Parcel 05.29.19.87B 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BROOKS, RODNEY B & SUZANNE T RODNEY B & SUZANNE T BROOKS 259 RED PINE TR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 2 SC 2611 HUDSON SP 1700 WITC 73 ~ Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE SEC 5 T29N R1 9W PART NW SE NE CORNER AS Block/Condo Bldg: IN VOL 349 PAGE 480 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 05-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 685/603 07/23/1997 526/438 2009 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 99,900 70,700 170,600 NO Totals for 2009: General Property 5.000 99,900 70,700 170,600 Woodland 0.000 0 0 Totals for 2008: General Property 5.000 99,900 70,700 170,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT TOtTNSHIP,S': N~ SEC._ SIC TAN, ADDRESS` jf ST. CROIX CO', Y, WISCONSIN. IVISIOl3.~~ LOT__//_LOT SIZE , PLAN VIEW Distances S dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -F f ~_li I I fi II ( i I 1`7 -T-- `TTY--Y-~ I :I i -f it Indicate Nonth Antc.ow TIC TANK(S)MFGR. , _CONCRETE_ STEEL Scale NO. of rings on cover i Depth DRY WELL 'NCHES NO. of - width lefigth area r no. of lines widths lengtharea 4,, a~ ' depth to top of pipe U-. TE i. RATE AREA REQUIRED AREA AS BUILT -claimer: The inspection of this system by St. Croix County does not imply complete t-)liance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for :Item operation. However, if failure is noted the County will make every effort to _o_rraine cause of failure. ,;ASES AND OILS SHOULD N0. BE DISPOSED THROUGH THIS SYSTEM. 'INSPECTOR DATED PLU' EWER ON JOB LICENSE NlaIBER R-POU OF IIISPI;CTI0:1--?. ;T 1DYJIlliJAL .,L,•)1'LCE llISPOSAI, oYS TEIS Sanitary Permit r State Septic T61,11ISHIP t. Cr6lx County SEPTIC TA7T1: Size gallons. `umber of Compartments Distance From: We 11 ft. 12% or greater slope fi. Building' ft. Wetlands f. Highwa.ter ft. DISPOSAL SYSTE:1Tile Field or Seepage Pit(s) Distance From: Well J `A ft. 12% or greater slope ft Building; ft. Wetlands f 1_ 1 FTP,Ln 7liphwater ft. Total length of lines ft, Number of lines - Length of each line --=_~ft• Distance between lines ft. Width of the trench -f t. Total absorption area sq, ft. Depth of rock below the in Dp-pth of rock over tile in. Cover -over. rock,,,,, Depth of tile below grade Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to around water ft. PITS Number of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: `yes no. Total absorption area sq. ft. _ Z~l Square feet of seepage trench bottom area required \ Square feet of seepage nit area required Inspected hY Title': . Approved Date 197 Rejected Date 197. j r.EH 115 • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AfdD PERCOLATION TESTS LOCATION: 5Ltl%, 51/4, Section T,~N, R 00(or)(l Township or Municipality S/. j~ Lot No., Block No. County 5 Cam" h~c~l y ~~~N-i iivision Name Owner's Name: ~ Mailing Address: A~w STS ~z~sr L`~t s S~`f°<~' TYPE OF OCCUPANCY: Residence No. of Bedrooms ,3 Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT p ~"~3 a DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN q p, Eee kil.,v- 02 i-I 3 c I /Z, ~7C P!~ 7 / 3 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) C/A a e- 91-11s, _72, 5k, 54 B- ft (f B ,e, iv". fs, 3J'- s/~ 5-1, , ~ > ~ - - 3 ~ •S~ ~ C~.~- SAC PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate n mber. of square feet of absorption area needed for building type and occupancy. 2 7 S L' ~ Indicat e scale or distances. Give horizontal and vertical reference <in n te slope. < . -e It e e A!1 ice r 73- tN I 1 i I f I 4- 1 I I . _ I I ~ ~ ~ ~ ~ ~ ~r • I i # ! ~ i i I i 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 location of test holes are correct to the best of my knowledge and belief. / JET ^ `f Certification No. 3 - /S Ir Name (print) ic. - Address e' e Name of installer if known CST Signatu - A. 1_ # 4 State and County State Permit LB 67 a: y Permit Application County Per # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: r- a ct I V t'r. I1 V Y'\ c- n L' / 1. -5 { -ja c~ i C' i Y l B. LOCATION: c.1 '/45 Section T .3 C' N, R Q- (or) W Lot# C~V y Subdivision Name, nearest road, lake or landmark Blk# Village -1 Township -4` C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D• SEPTIC TANK CAPACITY C C Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area .1 sq. ft. New X Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage BedAIMM Length q/ Width Depth -Tile depth (top) No. of Lines Seepage Pit: Inside ~iameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope - WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on H 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH 115 prepay d by the Certified Soil Test NAME S y~ rA 11r'IS~t sir -sue V-V C.S.T. # and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW#-~ Phone #f Plumber's Address l c `"'-e PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. r Gw l _ J U C- e v s n ~ e, a E t E . : x • Do Not Write in Space Below /FOR COUNTY AND STATE DEPARTMENT USE (9W) C/ Date of Application _5 JZ ~7 Fees Paid: State Cou t Date / Permit Issued/+kte,7d (date) 7 - Issuing Agent Name - ~ Inspection Yes ~No State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /78